Together, the cheek and neck can be considered as a single anatomic location because skin vascularity, texture and thickness are similar. The cervicofacial flap has been described as the treatment of choice for the cheek defect because of its good mobility and excellent cosmetic result. However, if the defects on the cheek are wider than the length of palpebral fissure of extended to the lower two thirds of the cheek, the conventional cervicofacial flaps would be inadequate in size without the benefit of expansion. Tissue expansion of the cheek and neck is distinguished by a particuarly high rate of complication. Prevention of various complications require careful planning and certain modifications in technique. We have used the following modifications and measures to prevent the complications and to maximize the expansion. 1) Whenever possible, expanders were placed over the rigid foundation such as mandible or posterior neck area after wide undermining. 2) Expanders were placed deep to platysma in the neck area. 3) Following optimal expansion, the further dissection extending to the clavicle and the posterior neck area was performed for optimal mobilization and draping of the expanded skin. 4) The expanded skin was advanced upward on the cervical portion and rotated forward on the cheek portion. 5) The flap should not be draped above the inferior orbital rim and postoperatively the pressure garments were applied to prevent drooping of the expanded skin. We experienced 21 cases of the expanded cervicofacial flaps with above surgical modifications and the expanded cervicofacial flaps can resurface the 95% of cheek defects with minimal complications and excellent cosmetic results.
Cheek* ; Clavicle ; Mandible ; Neck ; Orbit ; Skin ; Tissue Expansion

PURPOSE: Non-cement total hip arthroplasty for unstable intertrochanteric fracture in elderly patients is regarded as another surgical technique preventing complications such as non-union, long term limitation of weight bearing, pressure sore, pulmonary thromboembolism after open reduction or closed reduction with intramedullary nailing, or plate fixation. We would like to announce the short-term results of primary non-cement total hip arthroplasty with double strands and double loops figure of 8 wiring for unstable intertrochanteric fracture in elderly patients. MATERIALS AND METHODS: All of the 20 patients admitted to the hospital between April 2010 and February 2012 who underwent non-cement total hip arthroplasty with double strands and double loops figure of 8 wiring for unstable intertrochanteric fractures were evaluated. The mean age was 71.1(57-86), there were nine males, and 11 females, with an average follow up period of six months. The post-operative state was evaluated by Harris hip score. RESULTS: The mean operation time was 95 min, and the average blood loss was 800 cc. Mean Harris hip score at the last available follow-up was 92.7, and, among the patients, 15 had all functions of daily life without limitation of walking distance, one had hip dislocation, one had breakage of strands. Pressure sore, deep vein thrombosis, and pulmonary thromboembolism were absent. Radiography at the last available follow-up showed no loosening of the femoral stem in any of the patients, and 13 patients had osteogenesis around the fracture site, and there was no osteolysis. CONCLUSION: Primary non-cement total hip arthroplasty with double strands and double loops figure of 8 wiring in elderly patients with unstable intertrochanteric fractures showed satisfactory results. These results are expected to be useful for further studies with a long-term follow-up and in development of a reduction method.
Aged ; Arthroplasty ; Female ; Femur ; Follow-Up Studies ; Fracture Fixation, Intramedullary ; Hip ; Hip Dislocation ; Hip Fractures ; Humans ; Male ; Osteogenesis ; Pressure Ulcer ; Pulmonary Embolism ; Venous Thrombosis ; Walking ; Weight-Bearing

Fatal air embolism can occur during a variety of surgical procedures. We experienced a case of cardiac arrest due to venous air embolism during spinal fusion. A 63-year-old woman underwent spinal fusion for compression fracture on L1 and scolio-kyphosis. Anesthetic induction and initial intraoperative course were completely uneventful until precipitous blood pressure drop occurred, and accompanied by a significant decrease in heart rate and cardiac arrest after use of bone cement. Although more common intraoperative events were presumed and treatment initiated, venous air embolism was considered the etiology of these events when whirring noise was detected by esophageal sthetoscope and a transient decrease in end-tidal carbon dioxide tension was noted by capnometer. We performed cardiac resuscitation with external cardiac compression, various cardiotonic drugs, and removal of air through the right internal jugular venous catheter, but the result was unsuccessful.
Blood Pressure ; Carbon Dioxide ; Cardiotonic Agents ; Catheters ; Embolism, Air* ; Female ; Fractures, Compression ; Heart Arrest ; Heart Rate ; Humans ; Middle Aged ; Noise ; Resuscitation ; Spinal Fusion*

BACKGROUND: The purpose of this study was to find out the effect of hypnotics and analgesics on oxygen saturation by pulse oximetry in surgery patients under spinal anesthesia. METHODS: Sixty-five patients classified ASA physical status 1 or 2 scheduled for surgery under spinal anesthesia were studied. These patients were divided into three groups. The 22 subjects of the first group did not receive either midazolam or fentanyl. The 22 subjects of the second group received midazolam. The 21 subjects of the third group received midazolam (0.03 mg/kg) and fentanyl (1.0 microgram/ kg). Oxygen saturation was measured with a pulse oximetry. Measurements were made before spinal anesthesia, 5 minutes, and 10 minutes after starting of spinal anesthesia, 5 minutes, 10 minutes, 30 minutes, and 60 minutes after the start of the operation or intravenous injection of drugs. In addition, measurements were made on arrival in the recovery room, and 5 minutes, 10 minutes, 20 minutes, and 30 minutes after arrival in the recovery room. RESULTS: There were statistically significant differences in oxygen saturation at 5 minutes after the start of the operation or intravenous injection of drugs. The mean oxygen saturation for the first group was 98.2 +/- 1.8%, for the second group 97.9 +/- 2.6%, and for the third group 92.4 +/- 2.8%. Hypoxia cases at 5 minutes after the start of the operation or intravenous injection of a drug occurred in 4.5% of the first group, 9.1% of the second group, and 57.1% of the third group CONCLUSIONS: We concluded that oxygen saturation monitoring should be done routinely in patients receiving hypnotics and analgesics during spinal anesthesia, and oxygen should be administered to patients who develope hypoxia during spinal anesthesia.
Analgesics* ; Anesthesia, Spinal* ; Anoxia* ; Fentanyl ; Humans ; Hypnotics and Sedatives* ; Incidence* ; Injections, Intravenous ; Midazolam ; Oximetry ; Oxygen ; Recovery Room

BACKGROUND: Pulmonary vessels constrict when they are exposed to hypoxia, unlike other vessels. It is hypothesized that the decreased concentration of cAMP in the hypoxic condition causes this reaction, HPV (hypoxic pulmonary vasoconstriction). When cAMP concentration is increased by either activating adenylate cyclase, using adenosine, or inhibiting the cAMP hydrolysing enzyme, phosphodiesterase type 3, using amrinone, then HPV can be reversed. The aims of this study were to develop HPV in an isolated perfused rat lung preparation, and to investigate the vasodilating effects of adenosine and amrinone on HPV. METHODS: Isolated lungs from male rats (270 330 g) were ventilated with a normoxic gas mixture (21%O2-5%CO2-74%N2) or a hypoxic gas mixture (3%O2-5%CO2-92%N2) alternately, and perfused with calcium-containing perfusate solution. Adenosine (6 x 100-2 microgram, n = 6) and amrinone (5 x 101-3 microgram, n = 6) were mixed to perfusate solution, and the initial hypoxic pressor response { Pin = Pmax (maximum pulmonary artery pressure) - Pin (initial pulmonary artery pressure)} and hypoxic pressor responses after drug administration { Pdrug = Pmax (maximum pulmonary artery pressure) - Pbase (baseline pulmonary artery pressure)} were measured. Meclofenamate was used to block prostaglandin-mediated vasorelaxation. RESULTS: Adenosine did not decrease Pdrug compared to Pin. But amrinone inhibited HPV effectively a with a linear dose-response relationship (r = 0.842, P< 0.05). y = 26.72 x log (x) 35.79y: % relaxation = 100 [ Pdrug/ Pin] 100 , x: amount of drug, microgram, CONCLUSIONS: Amrinone attenuated HPV, and it can be concluded that increased levels of cAMP helpful to relax pulmonary vessels in hypoxic condition.
Adenosine ; Adenylyl Cyclases ; Amrinone ; Animals ; Anoxia ; Humans ; Lung* ; Male ; Meclofenamic Acid ; Pulmonary Artery ; Rats* ; Relaxation ; Vasoconstriction* ; Vasodilation

BACKGROUND: Several Studies from western institutes were done on the clinical characteristics and long-term prognosis of patients with variant angina. In these reports, 61-92% of patients had significant coronary artery disease, and survival without myocardial infarction at 1 year was approximately 70-83%. These results differ from our clinical experiences with Korean patients with variant angina;however, no detailed study has been reported in Korea. The purpose of this study was to describe the clinical characteristics and long-term follow-up data of our Korean patients with variant angina. METHODS: Two hundred four consecutive patients with variant angina(M/F;166/38, mean age 53+/-10 year) were included. The diagnosis of variant angina was made by spontaneous spasm in 53, positive intravenous ergonovine(iv Erg) provocation in 52, intracoronary acetylcholine(ic Ach) provocation in 55, simultaneous iv Erg and ic Ach provocation in 48 and bedside intravenous ergonovine with 2-dimensional echocardiography in 33. The clinical and angiographic characteristics were examined in 204 patients and mean 1.5 year(6 month to 3.5 year) follow-up could be done in 165 for the evaluation of long-trem prognosis. RESULTS: The Korean patients with variant angina were characterized by relatively low prevalences of significant coronary stenosis(25%), myocardial infarction and rate of cardiac death. Futhermore, survival and survival without myocardial infarction for the entire group were significantly better in our observation(1 year survival without myocardial infarction, 98%) than in other studies. During the follow-up period, 4(2%) out of 165 patients died, 1 developed myocarddial infarction and ventricular fibrillation occurred in 2. Three of 4 death caused by stopping medication abruptly. Thirteen patients were angina free after discontinued medications during the follow-up. CONCLUSION: The overall prognosis of variant angina may be better in Korean patients. We believe that less severe coronary atherosclerotic disease and a high rate of treatment with calcium blockers may have contributed to the lower rate of cardiac death and myocardial infarction on our patients compared with those in previous studies.
Academies and Institutes ; Calcium ; Coronary Artery Disease ; Death ; Diagnosis ; Echocardiography ; Ergonovine ; Follow-Up Studies* ; Humans ; Infarction ; Korea ; Myocardial Infarction ; Prevalence ; Prognosis ; Spasm ; Ventricular Fibrillation

BACKGROUND: Transluminal balloon coronary angioplasty is one of the most widely used therapeutic procedures in the treatment of patients with coronary artery disease. However, restenosis remains a major limitation of percutaneous coronary angioplasty despite extensive efforts to prevent recurrence. We examined the immediate and long-term results of 516 patients (617 lesions) who underwent coronary angioplasty to evaluate the initial success rate, complications, restenosis rate, and the factors affecting initial success and restenosis. METHODS: The coronary angioplasty of 516 patients(M/F : 388/128, mean age : 57 years), 671 lesions was done with conventional technique and follow-up coronary angiogram was obtained 4 to 6 months after angioplasty in 168 patients. The angiographic restenosis was defined as >50% luminal narrowing in a previously dilated lesion, and the clinical restenosis defined as the recurrence of typical angina and/or positive tests of treadmill test, or thallium scintigraphy during follow-up period. RESULTS: 1) The coronary angioplasty was successful in 459 of 516 patients(89%), 604 of 671 lesions(90%). The success rate was significantly lower in subgroups with type C lesion(52.2%, p<0.001), right coronary artery (83.7%, p<0.05) and <3.0mm of size of lesion(81.4%, p<0.001). 2) The procedural complications were as follows : intimal dissection in 143 lesions(21.3%) including acute closure in 9 lesions(1.3%), emergency bypass surgery in 6 patients(1.2%), myocardial infarction in 9 patients(1.7%), rupture of coronary artery in 2 patients, air embolism in 1 patient, and death in 1 patient(0.19%). 3) The causes of the procedural failure(n=57 patients) included guidewire passage failure in 27, balloon passage failure in 4, catheter engagement failure in 1, acute closure in 7, coronary artery rupture in 2, and suboptimal result in 16 patients. 4) Clinical follow-up was obtained in 455 patients for a mean follow-up duration of 13.2months and clinical restenosis rate was 31%(141/455). The repeat coronary angiogram was performed in 168 patients(209 lesions) for a mean follow up duration 5.4month and demonstrated 48%(100/209) angiographically restenosis rate. The clinical restenosis rate was significantly lower in subgroups with <10% of residual stenosis(18.9%, p<0.05), left circumflex coronary artery(18.5%, p<0.05). 5) The restenosis following angioplasty(n=100 lesions) was treated with repeated PTCA in 57, Stent(Palmaz-Schatz) in 6, DCA in 3, elective CABG in 9, and medication in 25. 6) During the clinical follow-up, there were nonfatal myocardial infarction in 4 patients. CONCLUSION: 1) The coronary angioplasty is an effective treatment for revascularization that has a high success rate, low incidence of complications and excellent long-term survival. 2) The restenosis rate was affected by residual stenosis which suggests that the implication of minimal residual stenosis is the most important determining factor to reduce the restenosis rate after angioplasty.
Angioplasty* ; Catheters ; Constriction, Pathologic ; Coronary Artery Disease ; Coronary Vessels ; Embolism, Air ; Emergencies ; Exercise Test ; Follow-Up Studies ; Humans ; Incidence ; Myocardial Infarction ; Phenobarbital ; Radionuclide Imaging ; Recurrence ; Rupture ; Thallium

No abstract available.
Humans

BACKGROUND: The purpose of this study was to evaluate the clinical feasibility of bedside intravenous ergonovine test with echocardiography as a noninvasive diagnostic method for coronary vasospasm. METHODS: Bedside ergonovine test was performed in 50 patients with chest pain one day after coronary angiography with spasm provocation test ; 30 patients showed positive results of provocation test while in 20 patients there was no evidence of coronary vasospasm. A bolus of ergonovine maleate(0.025 or 0.05mg) was injected at 5 min intervals up to total cumulative dosage of 0.35mg, and 12-leads ECG and 2D-echo were recorded every 3 min after each injection. Left ventricular wall motion was analyzed with a commercially available 'QUAD' system. The positive criteria of bedside ergonovine test included reversible ST segment elevation or depression, T wave changes in ECG(ECG criteria) and reversible regional wall motion abnormalities(RWMA) in Echo(Echo criteria). RESULTS: The overall sensitivity and specificity of ECG criteria were 73%(22/30) and 100% respectively ; The sensitivity of Echo criteria increased up to 90%(27/30) without the change of the specificity. Among 22 patients with reversible ECG changes only 73%(16/22) showed typical ST segment elevation while ST depression was recorded in 2 patients(9%) and minor T wave peaking or flattening without ST segment displacement in 4 patients(18%). Concomitant fixed coronary lesion does increase the sensitivity of the test compared to pure coronary vasospasm with ECG criteria(100% vs 60%, p<0.05). Mean dose of ergonovine with positive result was 173+/-95 microgram(mcg) and the amount of ergonovine for positive result was significantly larger in patients with low disease activity(Chest pain <5 times/week) than those with high disease activity(213+/-83 vs 123+/-86mcg, p<0.01). There was no procedure related mortality or fatal arrhythmias. CONCLUSIONS: Ergonovine echocardiography is a highly sensitive and specific test for coronary vasospasm and is safe in selected patients in whom the exercise test is negative and severe fixed coronary artery disease has been excluded. Presence of concomitant fixed coronary artery disease and the degree of clinical activity of coronary vasospasm may influence the results of this test.
Arrhythmias, Cardiac ; Chest Pain ; Coronary Angiography ; Coronary Artery Disease ; Coronary Vasospasm* ; Depression ; Echocardiography* ; Electrocardiography ; Ergonovine* ; Exercise Test ; Humans ; Mortality ; Sensitivity and Specificity ; Spasm

BACKGROUND: Recent development of transesophageal echocardiography(TEE) makes it possible to record pulmonary venous flow velocities(PVFV) accurately. To observe the differences of PVFV between normal controls and patients with severe mitral stenosis and to clarify the effects of percutaneous mitral valvuloplasty(PMV) on PVFV, TEE was performed in 12 normal controls and 11 patients with severe mitral stenosis. METHODS: PVFV was recorded from left upper pulmonary vein in longitudinal view of midesophageal position with a 5 MHz probe. Peak velocity and velocity-time integral(VTI) of systole and diastole were calculated with a digitizer. TEE was performed before and one day after PMV. Hemodynamic data(left atrial pressure, transmitral diastolic pressure gradient and cardiac output) were analyzed to demonstrate the possible correlation with PVFV. RESULTS: 1) 75%(9/12) of normal controls showed 4 distinct phases of PVFV with 2 systolic forward peaks, I diastolic forward and I end-diastolic backward peak. Peak systolic velocity was 52.6+/-.9cm/sec and peak diastolic forward velocity was 36.0+/-10.3cm/sec : Systolic VTI was greater than diastolic VTI, too(11.1+/-3.6cm vs 5.2+/-.6cm). 2) In patients with tight mitral stenosis(mean mitral area : 0.9cm2), most(10/11, 91%) showed one peak of systolic forward flow : Peak systolic velocity(27.8+/-15.8cm/sec) and systolic velocity-time integral(3.4+/-1.8cm)were significantly smaller than those of normal controls, while there was no statistical difference in peak diastolic forward velocity and velocity-time integral(34.5+/-12.7cm/sec, 4.3+/-1.7cm) compared to normal controls. There were no significant differences according to the rhythm. After successful PMV(mean mitral valve area : 1.9cm2) peak systolic and diastolic velocities increased up to 46.9+/-13.8cm/sec, 41.4+/-7.5cm/sec respectively, and systolic increase was statistically significant. The systolic increase of peak pulmonary venous velocity and velocity-time integral was more prominent in normal sinus group compared to patients with atrial fibrillation. 3) In patients with mitral stenosis, there was no correlation between peak diastolic forward velocity of pulmonary vein and peak transmitral early diastolic velocity(r=-0.19, p=0.40) : There was a weak negative correlation between mean left atrial pressure and peak systolic velocity of pulmonary vein(r=-0.46, p=0.03) in the pooled data of pre- and postvalvuloplasty(N=22). Also there noticed a negative correlation between diastolic transmitral pressure gradient and peak diastolic velocity of pulmonary vein(r=-0.49, p=0.02, N=22). CONCLUSION: Pulmonary venous velocities of patients with tight mitral stenosis showed decreased peak systolic velocity and VTI due to increased left atrial pressure and decreased compliance. which normalized immediately after successful PMV. In patients with mitral stenosis there seems to be somewhat different relationships between hemodynamic indices and pulmonary venous flow velocities, and further study with more patients with variable mitral valve area would be necessary to clarify the exact correlation.
Atrial Fibrillation ; Atrial Pressure ; Blood Pressure ; Compliance ; Diastole ; Echocardiography, Transesophageal ; Hemodynamics ; Humans ; Mitral Valve ; Mitral Valve Stenosis* ; Pulmonary Veins ; Systole