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

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

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*

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

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: Nitrous oxide inactivates cobalamin which is important in the folate-dependent synthesis of thymidylate. Also, methotrexate has the anti-cancer activity. The aim of this work was to determine the optimal pressure and exposure time of nitrous oxide that maximize the suppression of cancer growth, and the adequate level of methotrexate that maximize the anti-cancer activity of nitrous oxide. METHODS: Acute lymphoblastic leukemic cells and normal lymphocytes were cultured in hyperbaric chamber at 1, 2 and 3 atm of 74% nitrous oxide in 24, 48 and 72 hours at 0, 0.3, 0.5 and 0.7 micrometer of methotrexate, respectively. The results were expressed in the ratio of cell number in hyperbaric chamber to that in the incubator. RESULTS: Compared to control, the growth rates of cancer cells and lymphocytes were 0.767, 0.990 at 1 atm, 0.592, 0.880 at 2 atm and 0.718, 0.864 at 3 atm of nitrous oxide in 24 hours. The survival fraction of cancer cells and lymphocytes were 0.767, 0.894 in 24 hours, 0.800, 0.630 in 48 hours, and 0.571, 0.597 in 72 hours, at 1 atm of nitrous oxide. The growth rates of cancer cells and lymphocytes were 1.012, 0.745 at 0 micrometer, 0.912, 0.696 at 0.3 micrometer, 0.77, 0.647 at 0.5 micrometer and 1.133, 0.506 at 0.7 micrometer of methotrexate. CONCLUSIONS: The pressure increase of nitrous oxide significantly suppressed the growth of lymphocyte but not cancer cells. However, growth of cancer cells and lymphocytes were significantly reduced at high concentration of methotrexate and larger exposure time.
Cell Count ; Incubators ; Leukemia ; Lymphocytes ; Methotrexate* ; Nitrous Oxide* ; Vitamin B 12

BACKGROUND: In patients with mitral stenosis(MS) the predilection of the left atrial appendage(LAA) for thrombus formation has been known, while the characteristics and clinical implications of LAA flow have not been clearly analyzed. This prospective study with transesophageal echocardiography(TEE) was done to compare the LAA flow velocities of normal controls and patients with tight MS, to evaluate the correlation between LAA flow and hemodynamic indices and to observe the effects of successful percutaneous mitral valvuloplasty(PMV) on LAA flow. METHODS: TEE was performed in 12 normal controls and 50 patients with tight MS using a 5.0 MHz biplane transducer(Hewlett Packard SONOS 1000). Left atrial spontaneous echo contrast(SEC) was semiquantified(Grade 0-III) according to the relative extent of swirling echo movement in left atrial cavity : Grade I denotes SEC confined to LAA and swirling movement over the half of left atrial cavity was graded as III. In patients with MS. TEE was performed one day before and after PMV.Hemodynamic data(left atrial pressure, transmitral diastolic pressure gradient, cardiac output and mitral valve area) were obtained just before and after PMV. RESULTS: 1) In normal controls LAA flow recording showed two pairs of LAA ejection(positive) and filling(negative) waves. One pair of LAA ejection(appendage peak positive flow ; APF) and filling flow(appendage peak negative flow ; ANF) occurred 143+/-22msec and 289+/-33msec respectively after the onset of the ECG P wave. In early diastole another small pair of LAA ejection(ACF) and filling(ADF) occurred 550+/-21msec and 671+/-50msec respectively after the onset of ECG QRS wave. Mean absolute velocities of APF and ANF were 54+/-21 and 54+/-22cm/sec respectively, which were significantly higher than those of ACF(16+/-6cm/sec) and ADF(16+/-5cm/sec). 2) In patients with tight MS(mitral valve area of 0.9+/-0.3cm2) mean velocities of APF(20+/-12cm/sec) and ANF(23+/-16cm/sec) were significangly decreased compared with normal controls. There was no significant correlation between hemodynamic indices and absolute velocities of LAA flow. SEC was observed in 62%(31/50) and mean velocities of APF(10+/-8cm/sec) and ANF(12+/-11cm/sec) were significantly lower in patients with SEC than those values(25+/-19, 27+/-21cm/sec) in patients without SEC. There was strong negative correlation between the absolute values of APF and ANF and the grade of SEC(rAPF=-0.75, pAPF=0.00 ; rANF=-0.70, pANF=0.00). 3) After successful PMV(mitral valve area of 2.0+/-0.4cm2), APF increased from 20+/-12cm/sec to 36+/-24cm/sec and statistically significant increase of ANF was also observed(23+/-16cm/sec vs 36+/-22cm/sec, p<0.05). In patients with sinus rhythm, PMV normalized LAA flow(APF=52+/-14cm/sec, ANF=51+/-10cm/sec) while still decreased flow velocities were recorded in patients with atrial fibrillation(APF=15+/-4cm/sec, ANF=16+/-6cm/sec). CONCLUSIONS: Recording of LAA flow with TEE is an indicator of LAA function and risk of thrombus formation and cardiogenic embolism, which may not be obtained with conventional hemodynamic indices. Improvement of LAA flow and normalization of flow velocities in patients with sinus rhythm immediately after successful PMV raises a question of role of PMV in prevention of thromboembolism. Randomized sudies of the long-term effects of PMV in MS will be required before this important question can be answered.
Atrial Appendage* ; Atrial Natriuretic Factor ; Atrial Pressure ; Balloon Valvuloplasty* ; Blood Pressure ; Cardiac Output ; Diastole ; Echocardiography, Transesophageal ; Electrocardiography ; Embolism ; Hemodynamics ; Humans ; Mitral Valve ; Mitral Valve Stenosis* ; Prospective Studies ; Thromboembolism ; Thrombosis

The precise role of radiotherapy for low grade gliomas including the optimal radiation dose and timing of treatment remains unclear. The information given by a retrosepctive analysis may be useful in the design of prospective randomized studies looking at radiation dose and time of surgical and radiotherapeutic treatment. The records of 56 patients (M:F=29:27) with histologically verified cerebral low grade gliomas(47 cases of grade 1 or 2 astrocytomas and 9 oligodendrogliomas) diagnosed between 1979 and 1989 were retrospectively reviewed. The extent of surgical tumor removal was gross total or radical subtotal in 38 patients(68%) and partial or biopsy only in the remaining 18 patients(32%). Postooperative radiation therapy was given to 36 patients(64%) of the total 56 patients with minimum dose of 5000 cGy (range=1250 to 7220 cGy). The 5-and 10-year survival rates for the total 56 patients were 44% and 32% respectively with a median survival of 4.1 years. According to the histologic grade the 5- and 10-year survivals were 52% and 35% for the 24 patients respectively with grade I astrocytomas compared to 20% and 10% for the 23 patients with grade II astrocytomas. Survival of oligodendroglioma patients was greater than those with astrocytoma (65% vs 36% at 5 years), and the difference was also remarkable in the long term period of follow up (54% vs 23% at 10 years). Those who received high-dose radiation therapy (> or =5400 cGy) had significant better survival than those who received low-dose radiation(< 5400 cGy) or surgery alone (p<0.05). The 5-and 10-year survival rates were, respectively 59% and 46% for the 23 patients receiving high-dose radiation, 36% and 24% for the 13 patients receiving low-dose radiation, and 35% and 26% for the 20 patients with surgery alone. Survival rates by the extent of surgical resection were similar at 5 years (46% vs 41%), but long term survival was quite different (p<0.01) between total/subtotal resection and partial esection/biopsy (41% and 12%, resepctively). Previously published studies have identified important prognostic factors in these tumor : age, extent of surgery, grade, performance status, and duration of symptoms. But in our cases statistical analysis revealed that grade I histology (p<0.025) and young age (p<0.001) were the most significant good prognostic variables.
Astrocytoma ; Biopsy ; Brain Neoplasms ; Follow-Up Studies ; Glioma ; Humans ; Oligodendroglioma ; Radiotherapy* ; Retrospective Studies ; Survival Rate

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