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

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

The keystone flap is a fascia-based island flap with two conjoined V-Y flaps. Here, we report a case of successful treatment of a trochanter pressure sore patient with the traditional keystone flap. A 50-year-old male patient visited our department with a 3×5 cm pressure sore (grade III) to the left of the greater trochanter that was covered with eschar. Debridement was done and the defect size increased to 5×8 cm in an elliptical shape. Doppler ultrasound was then used to locate the inferior gluteal artery perforator near the wound. The keystone flap was designed to the medial side. The perforator based keystone island flap covered the defect without resistance. The site remained clean, and no dehiscence, infection, hematoma, or seroma developed. In general, greater trochanter pressure sores are covered with a perforator based propeller flap or fascia lata flap. However, these flaps have the risk of pedicle kinking and require a large operation site. For the first time, we successfully applied the keystone flap to treat a greater trochanter pressure sore patient. Our design was also favorable with the relaxation skin tension lines. We conclude that the keystone flap including a perforator is a reliable option to reconstruct trochanteric pressure sores.
Arteries ; Debridement ; Fascia Lata ; Femur* ; Hematoma ; Humans ; Male ; Middle Aged ; Pressure Ulcer* ; Relaxation ; Seroma ; Skin ; Ultrasonography ; Wounds and Injuries

Reconstruction of the lower extremities is difficult due to a lack of skin laxity and muscular tissues. Here, we present a case of lower extremity reconstruction via the anterior tibial artery perforator based segmental muscle island flap. Our patient was a 75-year-old male with a chronic ulcerative wound on the right lower leg from an old car accident. A 5.0×0.5 cm size ulcerative wound with tibial bone exposure was noted. We planned to reconstruct the lower extremity defect with a free flap, but the vessel status was severely compromised intraoperatively. Thus, we found the anterior tibial artery perforator using Doppler ultrasound, elevated the tibialis anterior muscle segment flap, and transposed it to cover the defect successfully. The flap presented with a nice contour and the skin graft covering the flap survived completely. There were no complications of the surgical site at three months follow-up and no gait morbidity. This is a meaningful case applying the concept of segmental muscle flap based on a perforator that had advantages including proper bulkiness, vascularization, and preservation of function, which were well applied, leading to great success.
Aged ; Follow-Up Studies ; Free Tissue Flaps ; Gait ; Humans ; Leg ; Lower Extremity* ; Male ; Perforator Flap ; Skin ; Tibial Arteries ; Transplants ; Ulcer ; Ultrasonography ; Wounds and Injuries

The Nuss procedure has good cosmetic effects, but it could be cause of bleeding and organ injury during dissection of the anterior mediastinum. We have made an effort to overcome the defects of the traditional method through the anterior mediastinum, thus we developed a transilluminated introducer that made it safer and simpler to operate within a 1 cm incision only. A total of 67 patients underwent the Nuss procedure using the transilluminated introducer. Thirty-six patients underwent the procedure with the transilluminated introducer only (age<14 years). Thirty-one patients had an additional thoracoscopy (age> or =14 years). There were no major complications, such as massive bleeding or organ injury in the thoracic cavity during or after the Nuss procedure. Our findings demonstrated that the anterior mediastium could be dissected simply and safely by the use of a transilluminated introducer during the Nuss procedure without fatal major complications, such as bleeding and organ injury.
Cosmetics ; Funnel Chest ; Hemorrhage ; Humans ; Mediastinum ; Thoracic Cavity ; Thoracic Wall ; Thoracoscopy

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

N, N-dimethylformamide (DMF) is a solvent which is widely used in the industrial workplace. It causes the liver damages to the chronically exposed workers and is also well known as the harzadous material to generate occupational malignancies. DMF is mainly metabolized into N-hydroxymethyl-N-methylformamide (HMMF) by the microsomal cytochrome p-450. HMMF breaks down to NMF. However, the detailed mechanism of its toxicity are unknown. In this experiment, the metabolism and the toxicity of DMF was investigated using an isolated perfumed liver model. DMF (0, 10, 25mM) were added into recirculating perfusate of the isolated perfused rat liver. Samples were collected at 0, 30, 45, 60, 75, 90 minutes from inferior vena cava. The gas-chromatography was used to analyze the metabolite of DMF, The changes in the oxygen consumption rate by DMF were monitored during perfusion. The enzyme activity (AST, ALT, LDH) in the perfusate were treasured to find out whether DMF causers hepatotoxicity. As perfusion continued, DMF concentration in the perfusate decreased, and NMF 1.16mM was detected. The oxygen consumption rate increased both at 10mM and 25mM DMF concentration. However, when SKF 525A, a known inhibitor of cytochrome p-450, had been pretreated (300uM before DMF addition, the oxygen consumption rate was significantly inhibited, indicating that cytochrome p-450 system is responsible for the conversion to NMF. With DMF addition, the activity of AST, ALT, and LDH significantly increased time dependently and dose dependently. However, the pretreatment of perfused liver with SKF 525A shoved that the release of AST, ALT and LDH was inhibited. In summary, it is found that DMF is metabolized to NMF in liver, and that cytochrome p-450 mono-oxygenase is suggested to play a role in the biotransformation of NMF. The time course of BMF toxicity in relation to NMF formation is compatible with hypothesis that the hepatotoxicity of DMF is mediated via NMF. Further study combined with in vivo experiment through the toxicological approaches is expected.
Animals ; Biotransformation ; Cytochrome P-450 Enzyme System ; Liver* ; Metabolism* ; Oxygen Consumption ; Perfusion ; Rats ; Vena Cava, Inferior

A 66-year-old man presented with exertional dyspnea. He was found to have an unruptured aneurysm of the right sinus of Valsalva causing significant right ventricular outflow obstruction. This aneurysm was diagnosed by transthoracic two-dimensional echocardiography, transthoracic three-dimensional echocardiography, transesophageal echocardiography, contrast echocardiography and 64-slice multidetector cardiac computed tomography. Because unruptured aneurysms of the sinus of Valsalva are rarely symptomatic, they can be difficult to detect. However, the unruptured aneurysm of the right sinus of Valsalva in this case caused significant right ventricular outflow tract obstruction, resulting in exertional dyspnea.
Aged ; Aneurysm* ; Dyspnea ; Echocardiography ; Echocardiography, Three-Dimensional ; Echocardiography, Transesophageal ; Humans ; Sinus of Valsalva* ; Ventricular Outflow Obstruction*

PURPOSE: To investigate the significance of the cortex-hilum (CH) area ratio and longitudinal-transverse (LT) axis ratio and the blood flow pattern for diagnosis of metastatic axillary lymph nodes by ultrasound in breast cancer patients. METHODS: From October 2005 to July 2006, we prospectively evaluated axillary nodes with ultrasound in 205 consecutive patients who had category 4B, 4C or 5 breast lesions according to the Breast Imaging Reporting and Data System-Ultrasound (BI-RADS-Ultrasound(R)). Among the 205, there were 24 patients who had pathologic verification of breast cancer and axillary lymph node status. For a total of 80 axillary nodes we measured the areas of the cortex and hilum of lymph nodes and calculated the area ratio. We also measured the length of the longitudinal and transverse axis of the lymph nodes and calculated the length ratio. We evaluated the blood flow pattern on power Doppler imaging and classified each lymph node into a central or peripheral pattern. Diagnostic performance was analyzed according to positive criteria for lymph node metastasis (CH area ratio >2, LT axis ratio <2, peripheral type on power Doppler imaging). RESULTS: The sensitivity of the CH area ratio was superior to that of the LT axis ratio (94.1% vs. 82.3%, p=0.031) and to that of the blood flow pattern (94.1% vs. 29.4%, p=0.009). For specificity, all three evaluating parameters had high values (89.1-95.6%) and no significant differences were found (p=0.121). The CH area ratio had a better positive predictive value than the LT axis ratio (94.1% vs. 80.0%, p=0.030) and power Doppler imaging (94.1% vs. 66.6%, p=0.028). For the negative predictive value, the CH area ratio was superior to the LT axis ratio (95.6% vs. 86.6%, p=0.035) and the blood flow pattern (95.6% vs. 63.0%, p=0.027). CONCLUSION: We recommend the CH area ratio of an axillary lymph node on ultrasound as a quantitative indicator for the classification of lymph nodes. The CH area ratio can improve diagnostic performance when compared with the LT axis ratio or blood flow pattern.
Axis, Cervical Vertebra ; Breast ; Breast Neoplasms ; Humans ; Lymph Nodes ; Lymphatic Metastasis ; Neoplasm Metastasis ; Prospective Studies ; Sensitivity and Specificity

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