Congenital Constriction Ring Syndrome

In general, excision of a constriction ring is not difficult when performed several months after birth, but care should be taken to excise the scar tissue in newborns so as to avoid neurovascular damage. Although Hall et al. and Greene described successful one-stage operations in cases of forearm and leg constriction rings, a two staged Z-plasty around the circumference of the constriction is recommended in neonatal balloon. The authors in this article excised constriction ring through a single operation with Z-plasty, and restored digital contour. In order to preserve neurovascular structures, the authors employed loupe(x3.5) and prevented inadequate sensation and cold intolerance, which may occur after surgery. A one-stage release of congenital constriction ring was performed for 5 constriction rings in four extremities(one patient). No wound problems occurred, even when there had been marked congestion of the extremity distal to the constriction ring. The one-stage release facilitated postoperative care, and there was no need for additional anesthesia or for additional operations, which are necessary when this problem is treated with a release performed in two or three stages.

Patient-Controlled Sedation for Local Anesthesia Patients in Plastic Surgery / 대한마취과학회지

BACKGROUND: Patient-controlled sedation (PCS) involves the patient self administering the sedative agent to the point at which the patient is satisfied with the level of sedation with the advantage to overcome the phamacodynamic differences between individual patients. We performed the PCS with two different dosages of propofol and compared the efficacy and side effects for local anesthesia patients in plastic surgery. METHODS: Thirty patients underwent propofol PCS with Perfusor fm (B. Braun, Germany) PCA pump during nasal inhalation of O2 3 L/min with continuous monitoring of SpO2. PCS settings were 10 mg of bolus dose, 30 mg of initial loading dose, 1 min of lockout interval, 100 mg/hr of continuous infusion in group 1 and 20 mg of bolus dose, 60 mg of initial loading dose, 1 min of lockout interval, 100 mg/hr of continuous infusion in group 2. All the patients received local anesthesia with 1% lidocaine before operation. Observer's assessment of alertness/sedation (OAA/S) scale, SpO2, mean infusion rate of propofol, duration of induction and recovery, recall of operative procedure, and patient's and surgeon's satisfaction were checked. RESULTS: The mean infusion rate (group 1; 32.2 +/- 19.4, group 2; 38.3 +/- 20.5 ug/kg/min), duration of induction (group 1; 4.9 +/- 1.9, group 2; 3.1 +/- 1.4 min), duration of recovery (group 1; 1.7 +/- 1.2, group 2; 2.5 +/- 1.3 min), and mean OAA/S scale (group 1; 3.8 +/- 1.6, group 2; 3.1 +/- 1.5) were not significantly different between the groups (mean +/- SD). Inadequate sedation occurred more frequently in group 1 (13%) than group 2 (0%), and incidences of respiratory depression (SpO2 < 95%) were more higher in group 2 (20%) than group 1 (0%). Numbers of satisfaction of patient and surgeon were 100% and 87% in group 1, and 87% and 93% in group 2. CONCLUSIONS: 10 mg or 20 mg as a bolus dose and 30 mg or 60 mg as a initial loading dose of propofol for PCS provided effective sedation and patient's and surgeon's satisfaction without significant side effect for local anesthesia patients in plastic surgery. (Korean J Anesthesiol 2004; 46: 583~588)

Traumatic Displacement of the Globe into the Ethmoid Sinus: Case Report

We experienced a rare case of traumatic displacement of the globe into the ethmoid sinus. A 66-year-old man sustained trauma of the right eye and orbit, which resulted in displacement of the globe into the ethmoid sinus. One day after injury, surgery was performed to restore the intact globe into position within the orbit. Ten days after the operation, light perception was noticed only when transillumination was placed into orbit. Trace test undergone 45 days after the operation, no sight were measured from right eye, and the movement of right eyeball was not possible in any direction. We believe that the nerve and extraocular muscles were severed against the floor of the orbit or severely traumatized as the globe entered the ethmoid sinus. This case is very rare and never reported in Korea. We treated by replacing the globe in the orbit surgically and reconstructing the orbital floor with acurate diagnosis by the Computed Tomography(CT) scan.

A Case of Cervical Necrotizing Fasciitis

Necrotizing fasciitis is a relatively rare disease which mainly affects the extremities, inguinal area, and the trunk area, and it is by definition a severe acute bacterial infection which affects the fascia. One can misdiagnose the disease as simple cellulitis, thereby delaying an appropriate treatment, and the disease can rapidly spread through the fascia, causing complication such as sepsis, leaving severe loss of tissue as a sequelae. Necrotizing fasciitis of the cervical area is even a rarer disease. Once a person contracts, the disorder can spread through superficial musculoaponeurotic system and cervical fascia, quickly infecting important vascular systems and mediastinum of the craniocervical and thoracic area, which cause a serious complication from direct spread unto main organs. Therefore, in case of necrotizing fasciitis of the cervical area, active surgical treatment such as wide excision of necrotizing tissue and proper drainage of abscess and early administration of broad range antibiotics are necessary in order to prevent serious complications in main vascular system, mediastinum, or craniocervical system. We have experienced a case of necrotizing fasciitis of the cervical region in 2002, and obtained satisfactory results from wide excision, abscess drainage, local flap with skin graft, and hereby report the case with references.

A Effect of Pretreatment Period on CO2 Laser Resurfacing in Guinea Pig Skin: A Comparative, Histologic Study

For the pre-treatment prior to laser resurfacing, materials such as glycolic acid, tretinoin, and/or hydroquinone have been widely used. However, the optimal duration of pretreatment is still controversial. The authors chose guinea pig skin which is similar to human skin, pre-treated it with tretinoin and hydroquinone with different duration, and examined gross and histologic changes after performing laser resurfacing in an attempt to study the effect of pre-treatment period on CO2 laser resurfacing. Sixteen guinea pigs were divided into four groups, and the dorsal skin was pre-treated with 0.05% tretinoin cream and 4% hydroquinone for 4, 8, and 12 weeks respectively while groupI underwent no pre-treatment as control. During the pre-treatment period, the authors observed gross skin reactions, and also examined the number of epithelial layers, thickness changes, the extent of epithelial regeneration, and collagen tissue change within dermis layer with skin tissue samples before and after laser resurfacing. Compared to group I(control) which received no pre- treatment, pre-treatment groups showed rapid epithelial hyperplasia and increase in the number and thickness of squamous epithelial cells and granular cell layer. However, there was no statistically significant difference in epithelial regeneration and number and thickness of epithelial cell layer between the 4-weeks, 8-weeks, 12- weeks pretreated groups. Pre-treatment with tretinoin and hydroquinone prior to laser resurfacing helped epithelial regeneration after resurfacing, but as to the benefit of long-term pre-treatment more than 4 weeks was not necessary.

Congenital Lacrimal Sac Fistula

Congenital lacrimal sac fistulas are relatively uncommon and are estimated to occur in 1 per 2000 birth. They consist of a dimple opening that leads to the lacrimal sac. Most of the fistulas are unilateral and are located inferonasally to the medial canthus. The patients may be asymptomatic and overlooked for some time after birth, or may demonstrate tearing from the fistula, the eye, or both. The treatment of those with symptoms such as epiphora and dacryocystitis is still controversial. In cases with nasolacrimal obstruction, performing dacryocystorhinostomy in addition to excision is appropriate. Therefore, it is necessary to determine whether nasolacrimal obstruction is present before or during the operation in deciding treatment method. But in most cases, treatment is possible with excision alone. From September, 1999 to February, 2002 authors treated 3 cases of congenital lacrimal sac fistulas without nasolacrimal obstruction and good results were obtained by the method of fistulectomy alone.

The Effects of Glucocorticoid and alpha-Lipoic Acid on Ischemia-Reperfusion Injury

During revascularization after ischemia, oxygen free radicals and cytotoxic enzymes are released and they have a role in pathogenesis of ischemia-reperfusion injury. Glucocorticoid decreases oxygen free radical formation by inhibition of arachidonic acid metabolism, and alpha-lipoic acid scavenges nitric oxide(NO) with inhibition of hydroxy radical formation. Author investigated the role of glucocorticoid and alpha-lipoic acid to decrease ischemia reperfusion injury in 24 anesthetized rats (normal saline-injected, n= 8; dexamethasone-injected, n=8; alpha-lipoic acid-injected, n= 8), subjecting a soleus muscle to 4 hours of tourniquet ischemia followed by 2 hours of reperfusion, and evaluated the concentration of NO, tissue edema, and neutrophil count of rat skeletal muscle as a indicator of tissue damage by ischemia- reperfusion injury. We obtained the results that glucocorticoid and alpha-lipoic acid treatment decreased the increase of NO concentration, tissue edema, and neutrophil count significantly. These results support that pretreatment with glucocorticoid or alpha-lipoic acid has a beneficial effect on the preventive management of ischemia-reperfusion injury.

Conjunctivodacryocystorhinostomy with Rubber-Tipped Jones Tube

One of the problems of conjunctivodacryocystorhinostomy which employs the conventional Jones tube is that the end of Jones tube has to be manipulated by the surgeon so that the tube resides within the nasal cavity while not touching the middle turbinate and the nasal septum. As a result, for most of the patients who have high nasal septal deviation, paradoxical curvature, or middle turbinate hypertrophy, there wasn't enough room within the nasal cavity where one end of Jones tube could rest. Such patients required either septoplasty or turbinectomy before they underwent conjunctivodacryocystorhinostomy. In order to overcome such a problem, the authors connected a 4 Fr. rubber tube to the conventional Jones tube, and helped the end of the tube to reside within the nasal cavity regardless of the anatomical variation of either the nasal septum or the middle turbinate. When such modified procedure is used, the conven tional Jones tube will make contact with the conjunctiva, lacrimal sac, and the nasal mucosa while the rubber tube remained afloat within the nasal conjunctiva. Such modification helps the tube to reside within the nasal cavity without foreign body reactions and granulation tissue complications, and there is no need to change tubes in order to make up for the loss of tube length due to post operative tissue contracture. Between April 2000 and August 2001, the authors performed conjunctivodacryo cystorhinostomy with rubber-tipped Jones tube on 8 patients with nasolacrimal duct obstruction, and obtained satisfactory results without complications.

Reconstruction of Lower Extremity Soft Tissue Defect using Gastrocnemius Musculo-adipofascial Flap

UUse of the gastrocnemius muscle flap has proven to be highly effective in reconstruction of knee and lower leg defect due to its easy procedure, anatomical consistency, and less donor site morbidity.The gastrocnemius muscle is anatomically spindle shape, the volume of the distal part of the muscle for coverage is actually quite small and also even smaller when disuse atrophy is accompanied due to trauma. Although the defect is inside flap's arc of rotation, it is out of gastrocnemius muscle flap's indication when the defect size is extensive, and even though the defect is small, it is also out of indication when the defect is a bit out of arc of rotation. There has been a lot of modification to increase the flap's arc of rotation or dimension. However, it is difficult to achieve satisfactory results due to limitation and expense in clinical application. Authors used, for soft tissue reconstruction on broader area, gastrocnemius musculo-adipofascial flap, rather than classical gastrocnemius muscle flap, based on the fascial plexus of gastrocnemius muscle. We obtained a good result in lower extremity reconstruction of 7 cases from March 1999 to July 2000 and report this result with several cases.

Submuscular periareolar approach to augmentation mammoplasty

No Abstract Available.

The Effects of ndomethacln on Edema and Eicosanoids Changes in Rat Skeletal Muscle after Ischemia and Reperfusion Injury

Ischemia and reperfusion of skeletal muscle occurs in acute vascular occlusion and revascularization, in elective vascular surgery, in upper and lower extremity surgery by means of a tourniquet, and in free transplantation of muscle containing cutaneous flaps. During revascularization of skeletal muscle after ischemia, lipid mediators, mainly eicosanoids are released that may have a role in the pathogenesis of reperfusion injury. The exact role of eicosanoids in the imposed ischemia-reperfusion induced functional deficits in skeletal muscle is still unknown, we compared tissue edema and the changes of eicosanoids and the effects of cyclooxygenase inhibitor indomethacin in the rat right hindlimb by application of tourniquet ischemia-reperfusionn injury. After 4-hours of ischemia, reperfusion was established 4 hours by releasing tourniquet. Experimental groups comparised ischemia-reperfused animals pretreated with indomethacin 20 mg/kg. The control animals received normal saline, 4 hours of ischemia without reperfusion. To assess tissue edema, wet/dry weight ratios were determined and the concentrations of prostaglandins and thromboxane were measured by the high performance liquid chromatography with UV detector at 195 nm. Ischemia itself did not result in muscle edema and did not increase the release of cyclooxygenase metabolites, but muscle edema(52%, p<0.01), and the relase of 6-keto-PGFalpha(151%, p<0.01), thromboxane B2(98%, p<0.05), and PGE2(127%, p<0.01) were significantly increased by reperfusion. Indomethacin treatment ameliorated limb edema(35%, p<0.05 versus ischemis-reperfusion control) and decreased 6-keto-PGF1alpha(65%, p<0.05) releases. These results support view that cyclooxygenase products may play significant roles in the formation of ischemic muscle edema and suggest that nonsteroidal antiinflammatory agents and eicosanoids antagonists might be beneficial to the management of acute limb ischemia-reperfusion injury.

The effect of indomethacin on the production of eicosanoids and edema during ischemia-reperfusion injury in skeletal muscle

During reperfusion of skeletal muscle after ischemia, lipid mediators, mainly eicosanoids, are released and may have a role in the pathogenesis of reperfusion injury. To validate the role of eicosanoids in the ischemia-reperfusion induced functional deficits in skeletal muscle, we compared muscle edema and the changes of eicosanoid concentration in the rat hind limb after ischemia-reperfusion injury by application of tourniquet. After 4 hours of ischemia, reperfusion was established for 4 hours by releasing tourniquet. To assess tissue damage, edema, and wet/dry weight ratios were determined and the eicosanoid concnentrations were measured by the HPLC. The muscle edema and the release of cyclooxygenase metabolites were not induced by the ischemia itself rather they were significantly increased by reperfusion. Indomethacin treatment ameliorated limb edema and decreased the release of 6-keto-PGF1alpha, thromboxane B2, and PGE2 induced by reperfusion. But the inhibitory effect of indomethacin on edema (35%) was relatively low than the inhibitory effect on release of cyclooxygenase metabolites (up to 69%) by reperfusion. These results support the view that cyclooxygenase products may play a significant role in the formation of muscle injury by ischemia-reperfusion and suggest that nonsteroidal antiinflammatory agents might be partially beneficial to the management of acute limb ischemia-reperfusion injury.

Target-Controlled Infusion of Propofol for Conscious Sedation Using BIS Monitor / 대한마취과학회지

BACKGROUND: Propofol has been found to be an ideal anesthetic for sedation during regional anesthesia with the advantage of rapid onset of action and recovery. Infusion of propofol by target-controlled infusion (TCI) has been shown to be effective in achieving conscious sedation. The purpose of this study was to define the optimal target concentration of propofol evaluated by bispectral index (BIS) which is necessary for conscious sedation in patients to achieve a local or regional blockade. METHODS: Sixty patients scheduled to undergo local or regional anesthesia were divided into 3 groups. 10 20 min after performing local anesthesia with 2% lidocaine 10 ml (group 1), spinal anesthesia with 0.5% hyperbaric bupivacaine 12 18 mg (group 2) or brachial plexus block with 1% lidocaine 40 ml (group 3), TCI of propofol was started at a target plasma level of 1 microgram/ml and the target concentration was adjusted in steps of 0.2 microgram/ml to maintain a sedation level comparable to an Observer's Assessment of Alertness/Sedation (OAA/S) score of 3. BIS, EKG, heart rate, noninvasive arterial blood pressure, respiratory rate and SpO2 were recorded during the operation. RESULTS: Group 1 had a significantly higher mean (range) target concentration [1.8 (0.9 2.8) microgram/ml] than group 2 [0.9 (0.2 2.4) microgram/ml] and group 3 [1.0 (0.2 2.6) microgram/ml]. A target concentration of 0.9 1.8 microgram/ml of propofol produced BIS 78.2 (group 1), 73.4 (group 2) and 75.4 (group 3). CONCLUSIONS: TCI of propofol with a 0.9 1.8 microgram/ml blood concentration produces safe sedation during locoregional anesthesia without severe complications.

New Technique of Flexor Tendon Repair with Endoscopic Exploration

Repair of injured tendon especially is still a difficult problem in hand surgery. The challenge is to restore the gliding mechanism of the tendon. Despite increasing knowledge of tendon healing and subsequently better postoperative result, the problem formation of adhesion between the tendon and its direct surroundings remains. It is now agreed that primary repair of both flexor tendon is the treatment of choice with preservation and resto-ration of the tendon sheath. The flexor tendon sheath plays an important role in flexor nutrition, especially for the volar part of the tendon, by secreting the synovial fluid. Although data to data are indications that it will lead to fewer adhesions. Tendon sheath are sometimes restored by autologous graft. It is excellent management that the tendon sheath and pulley system are restored during tendon repair. The method of minimal injury to tendon sheath and pulley is better than restoration of that. The exploration of divided tendon through wound margin with endoscope minimizes sheath and pulley injuries. The blunt extraction of divided tendon from invisible wound site is a risky method for exploration of tendon. This endoscopic method is less traumatic, causes less pain, and requires a minimal incision. And the patient with endoscopic tenorrhaphy can exercise immediately because less operation site discomport and can be discharged early. The new tenorrhaphy technique using endoscope is expected to give better result than conventional method.

The Antivasospasmic Effect of Arterial Freezing on Acute Damaged Endothelium

During the microsurgery or during the postoperative period, the occurrence of the vascular spasm increases the failure rate of microvascular anastomosis,and in cases of trauma, the thrombogenic possibility is increased by the endothelial damage. The author thought that the vascular freezing of crushed vessels could improve the patency rate of microvascular anastomosis. Vascular freezing destroys most of the cells in the intima and media. There by causing degeneration of adrenergic fibers. Even though regeneration occurs after 2-3 weeks, regeneration in the smooth muscle layer is still incomplete. So vascular freezing has beneficial effects on relief of vasospasm. Fifteen Sprague-Dawley rats weighing approximately 300 g each were inflicted with crushing injury on the femoral arteries of the right side and the crushing injury with vascular freezing on the femoral arteries of the left side. The gross and histologic findings, as well as the patency rates, were observed at the postoperative 2nd, 10th, and 30th day,and the results were compared between the crushed and crush-freezing groups. The left side (crush-freezing group) showed less vasospasm and less thrombogenesis than the right side (crushed group). There were no significant differences in the patency rate between the crushed group and crush-freezing group. Vascular freezing is suggested to be effective on a potentially thrombogenic, endothelial damaged vessel as a prophylactic treatment method against vasospasm. Clinical application of vascular freezing awaits further experimentation.

Scalp Extender for Hair Replacement Surgery and Treatment of Male Pattern Baldness

Scalp extension involves the continuous nonvolumetric expansion of the hair-bearing scalp, via biologic creep, using implanted surgical device consists of cutting a 5 cm wide strip of plain silastic (0.02 inch thick) from a larger 16x8 inch sheet, then gluing dacron-reinforced silastic strip (5x1 cm, 0.015 inch thich) to the distal ends. A stainless steel plate from hooks is then secured to each end of the extender. During the period from March 1996 to September 1997, 21 patients including 16 patients of male pattern baldness were treated for alopecia of the scalp using internal scalp extender in the department of plastic surgery Korea university hospital. All cases were successfully reconstructed without major complications. It not only reduces the number of scalp reductions and time necessary to totally excise bald vertex scalp, but also appears to decrease the amounts of stretch back and atrophic scarring that may accompany some reductions. Scalp extension appears to be a useful adjunctive technique in hair replacement and reconstructive surgery, and has distinct advantages over standard scalp reduction and tissue expansion techniques.

The Effect of Clonidine Added to Lidocaine on the Duration of Anesthesia and Analgesia after Brachial Plexus Block / 대한마취과학회지

BACKGROUND: When clonidine is mixed with local anesthetics, it extends the duration of both the motor and sensory elements of spinal, epidural, axillary, peripheral nerve block. This study was designed to determine whether the addition of clonidine to 1% lidocaine would produce significant extension of anesthetic and analgesic effect after axillary brachial plexus block and to assess the incidence and severity of side effect. METHOD: Sixty patients who were scheduled for hand surgery received 1% lidocaine 40 ml (Group L), 1% lidocaine 40 ml with clonidine 75 microgram (Group C75) or 150 microgram (Group C150) during axillary plexus block. Time from the performance of the block to 1) loss of pain sensation to pinprick, 2) return of pain sensation to pinprick, 3) onset of postsurgical pain and 4) time of first analgesic medication were recorded. Blood pressure, heart rate and sedation and pain score were checked every 10 min after block. RESULTS: The onset time of anesthesia in Group C75 and Group C150 were shorter than that of Group L (p<0.05). The duration of anesthesia and analgesia and the time to first analgesics medication in Group C75 and Group C150 were longer than that of Group L (p<0.05). Group C75 and Group C150 represented higher sedation score than Group L (p<0.05). CONCLUSION: The addition of clonidine (75 microgram or 150 microgram) to 1% lidocaine significantly prolongs the duration of anesthesia and analgesia after brachial plexus block and induces some degree of sedation without significant side effects.

HAIR TRANSPLANTATION FOR MALE PATTERN BALDNESS AND OTHER ALOPECIAS

The increasingly successful results of hair restoration surgery in the last years have developed the interest and the confidence of patients and it is the most frequently performed esthetic surgery among male patients. Currently, various kinds of techniques for hair restoration surgery including hair transplantation, scalp reduction, and scalp flaps are performed in our clinic. Among these, hair transplantation is the basic and the most popular procedure, which can be performed not only by itself but also in conjunction with other procedures. 123 consecutive cases of hair transplantations were peformed from Jan. 1995 to Feb. 1996 for male pattern baldness, traumatic alopecia, and female pattern baldness under out patient base. The authors introduced a new classification for male pattern baldness, which are the type M, O, C, U, M-O, and C-O after alphabet to make simple and easy for clinical application. The ancillary procedures were scalp reduction, preauricular flap, and scalp expansion. An ellipsis of hair bearing scalp taken from the occipital area was sliced into slit-, mega-, mini-, and micro-grafts. The survival rate of the grafts was over 90% with minimal complications. This hair transplantation technique enabled us to achieve a good density and more natural looking hair with avoidance of cobble stoning and apparent scar.

TISSUE EXPANSION FOR HAIR REPLACEMENT SURGERY AND TREATMENT OF MALE PATTERN BALDNESS

No abstract available.