BACKGROUND: Multiple approaches for nipple reconstruction exist, and none is considered superior to all others. The star flap is one of the most popular methods for nipple reconstruction, but gradual height loss is a major concern. We present a new modification of the star flap that incorporates a de-epithelialized dermal flap, along with the associated surgical results. METHODS: We reviewed the medical records of patients who underwent nipple reconstruction using the modified star flap method. The design was different from the conventional star flap in that the lateral wings were changed into a trapezoidal shape and de-epithelialized dermal flaps were added. The patients were followed up at 2, 4, 6, and 12 months postoperatively, and nipple height was measured. The postoperative nipple height achieved using the modified method was compared with that obtained using the traditional method. RESULTS: From February 2013 to June 2017, 32 patients received surgery using the modified star flap, and 18 patients who underwent nipple reconstruction before 2013 comprised the conventional method group. All patients had undergone breast reconstruction with an abdominal tissue-based flap. The mean follow-up period was 14.4 months in the modified method group and 17.3 months in the conventional method group. The mean maintenance of projection at 12 months postoperatively was 56.28%±18.58% in the modified method group, and 44.23%±14.15% in the conventional method group. This difference was statistically significant (P<0.05). CONCLUSIONS: The modified method using a de-epithelialized dermal flap provides reliable maintenance of projection in patients who have undergone abdominal tissue-based breast reconstruction.
Female ; Follow-Up Studies ; Humans ; Mammaplasty ; Medical Records ; Methods ; Nipples ; Surgical Flaps

BACKGROUND: Intraoperative indocyanine green (ICG) lymphography can effectively detect functioning lymph vessels in edematous limbs. However, it is sometimes difficult to clearly identify their course in later-stage edematous limbs. For this reason, many surgeons rely on experience when they decide where to make the skin incision to locate the lymphatic vessels. The purpose of this study was to elucidate lymphatic vessel flow patterns in healthy upper extremities in a Korean population and to use these findings as a reference for lymphedema treatment. METHODS: ICG fluorescence lymphography was performed by injecting 1 mL of ICG into the second web space of the hand. After 4 hours, fluorescence images of lymphatic vessels were obtained with a near-infrared camera, and the lymphatic vessels were marked. Three landmarks were designated: the radial styloid process, the mid-portion of the cubital fossa, and the lower border of the deltopectoral groove. A straight line connecting the points was drawn, and the distance between the connected lines and the marked lymphatic vessels was measured at 8 points. RESULTS: There were 30 healthy upper extremities (15 right and 15 left). The average course of the main lymph vessels passed 26.0±11.6 mm dorsal to the styloid process, 5.7±40.7 mm medial to the mid-cubital fossa, and 31.3±26.1 mm medial to the three-quarters point of the upper landmark line. CONCLUSIONS: The main functioning lymphatic vessel follows the course of the cephalic vein at the forearm level, crosses the mid-cubital point, and travels medially toward the mid-axilla.
Extremities ; Fluorescence ; Forearm ; Hand ; Indocyanine Green ; Lymphatic Vessels* ; Lymphedema ; Lymphography ; Skin ; Surgeons ; Upper Extremity* ; Veins

Epidemic keratoconjunctivitis (EKC) and acute hemorrhagic conjunctivitis (AHC) are common diseases caused by human adenoviruses (HAdV) and enteroviruses, respectively, in South Korea. However, there are limited studies on the molecular epidemiology of viral conjunctivitis in South Korea. The main objective of this study was to characterize the genotypes of adenoviruses and enteroviruses causing viral conjunctivitis in the southwest region of South Korea. We collected conjunctival swabs from 492 patients with suspected cases of viral conjunctivitis from 6 ophthalmic hospitals in Gwangju Metropolitan City, in South Korea, between 2012 and 2016. Of the 492 samples tested, HAdVs and enteroviruses were detected in 249 samples (50.6%) and 19 samples (3.9%), respectively. The genotype analysis detected HAdV-8 in 183 samples (73.5%), HAdV-37 in 14 samples (5.6%), and HAdV-3, and HAdV-4 in 9 samples (3.6%) each. We detected coxsackievirus A24 (CVA24) and coxsackievirus B1 (CVB1) in 8 samples (42.0%) and 4 samples (21.0%), respectively. We also reported for the first time HAdV-56-infected cases of EKC in South Korea. Furthermore, we found three cases of coinfection with HAdV and enterovirus genotypes in our samples. HAdV-8 and CVA24, the main causes of EKC and AHC, respectively, worldwide, were also found to be the predominant genotypes in our study.
Adenoviridae ; Adenoviruses, Human ; Coinfection ; Conjunctivitis, Acute Hemorrhagic ; Conjunctivitis, Viral* ; Enterovirus ; Genotype ; Gwangju ; Humans ; Keratoconjunctivitis ; Korea* ; Molecular Epidemiology*

BACKGROUND: Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration. METHODS: The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries. RESULTS: All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur. CONCLUSIONS: Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.
Diplopia ; Follow-Up Studies ; Humans ; Medical Records ; Nausea ; Operative Time ; Orbit* ; Orbital Fractures* ; Prognosis ; Reflex, Oculocardiac ; Vomiting

BACKGROUND: Among the various signs and symptoms of orbital fractures, certain clinical findings warrant immediate surgical exploration, including gaze restriction, computed tomographic (CT) evidence of entrapment, and prolonged oculocardiac reflex. Despite proper surgical reconstruction, prolonged complications such as diplopia and gaze restriction can occur. This article evaluated the prognostic factors associated with prolonged complications of orbital fractures with muscle incarceration. METHODS: The medical records of 37 patients (37 orbits) with an orbital fracture with muscle incarceration from January 2001 to January 2015 were reviewed. The presence of Incarcerated muscle was confirmed via CT, as well as by intraoperative findings. Various factors potentially contributing to complications lasting for over 1 year after the injury were categorized and analyzed, including age, cause of injury, injury-to-operation time, operative time, fracture type, nausea, vomiting and other concomitant symptoms and injuries. RESULTS: All patients who presented with extraocular muscle limitations, positive CT findings, and/or a positive forced duction test underwent surgery. Of the 37 patients, 9 (24%) exhibited lasting complications, such as diplopia and gaze restriction. The mean follow-up period was 18.4 months (range, 1–108 months), while that of patients who experienced prolonged complications was 30.1 months (range, 13–36 months). Two factors were significantly associated with prolonged complications: injury-to-operation time and nausea/vomiting. Loss of vision, worsening of motility, and implant complication did not occur. CONCLUSIONS: Patients who present with gaze limitations, with or without other signs of a blow-out fracture, require a thorough evaluation and emergent surgery. A better prognosis is expected with a shorter injury-to-operation time and lack of nausea and vomiting at the initial presentation.
Diplopia ; Follow-Up Studies ; Humans ; Medical Records ; Nausea ; Operative Time ; Orbit* ; Orbital Fractures* ; Prognosis ; Reflex, Oculocardiac ; Vomiting

PURPOSE: Up to 90% of pancreatic cancer patients suffer from neuropathic pain. In a palliative care setting, pain control in pancreatic cancer patient is one of the major goals. Ketamine is a N-methyl-D-aspartate (NMDA) receptor antagonist, effective in neuropathic pain. Additionally, there have been studies about the opioid sparing effect of ketamine. This study was held in the palliative care unit among pancreatic cancer patients to determine the factors related to ketamine use and the opioid sparing effect. METHODS: The medical records of pancreatic cancer patients admitted to St. Mary's hospital palliative care unit between January, 2013 and December, 2014 were reviewed. Patients were divided into 2 categories according to ketamine use. Also, opioid use before and after ketamine use was compared in the ketamine group. RESULTS: Compared to the non-ketamine use group, patients in the ketamine group required a higher dose of opioid. The total opioid dose, daily opioid dose, number of daily rescue medications, and daily average rescue dose were statistically significantly higher in the ketamine group. The opioid requirement was increased after ketamine administration. CONCLUSION: In this retrospective study, ketamine was frequently considered in patients with severe pain, requiring higher amount of opioid. Studies about palliative use of ketamine in a larger number of patients with diverse types of cancer pain are required in the future.
Hospices* ; Humans ; Ketamine* ; Medical Records ; Morphine ; N-Methylaspartate ; Neuralgia ; Palliative Care ; Pancreatic Neoplasms* ; Retrospective Studies

BACKGROUND: Conventional correction of malunioned zygoma requires complete regional exposure through a bicoronal flap combined with a lower eyelid incision and an upper buccal sulcus incision. However, there are many potential complications following bicoronal incisions, such as infection, hematoma, alopecia, scarring and nerve injury. We have adopted a zygomaticofrontal suture osteotomy technique using transconjunctival incision with lateral paracanthal extension. We performed a retrospective review of clinical cases underwent correction of malunioned zygoma with the approach to evaluate outcomes following this method. METHODS: Between June 2009 and September 2015, corrective osteotomies were performed in 14 patients with malunioned zygoma by a single surgeon. All 14 patients received both upper gingivobuccal and transconjunctival incisions with lateral paracanthal extension. The mean interval from injury to operation was 16 months (range, 12 months to 4 years), and the mean follow-up was 1 year (range, 4 months to 3 years). RESULTS: Our surgical approach technique allowed excellent access to the infraorbital rim, orbital floor, zygomaticofrontal suture and anterior surface of the maxilla. Of the 14 patients, only 1 patient suffered a complication—oral wound dehiscence. Among the 6 patients who received infraorbital nerve decompression, numbness was gradually relieved in 4 patients. Two patients continued to experience persistent numbness. CONCLUSION: Transconjunctival incision with lateral paracanthal extension combined with upper gingivobuccal sulcus incision offers excellent exposure of the zygoma-orbit complex, and could be a valid alternative to the bicoronal approach for osteotomy of malunioned zygoma.
Alopecia ; Cicatrix ; Conjunctiva ; Decompression ; Eyelids ; Follow-Up Studies ; Hematoma ; Humans ; Hypesthesia ; Maxilla ; Methods ; Orbit ; Osteotomy* ; Retrospective Studies ; Sutures ; Wounds and Injuries ; Zygoma* ; Zygomatic Fractures

BACKGROUND: Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution. METHODS: We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis. RESULTS: Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery. CONCLUSIONS: NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.
Bandages ; Body Mass Index ; Breast Neoplasms ; Breast* ; Debridement ; Female ; Humans ; Mammaplasty* ; Mastectomy* ; Necrosis* ; Nipples ; Risk Factors ; Skin ; Skin Transplantation ; Smoke ; Smoking ; Surgical Flaps ; Tissue Donors

BACKGROUND: The radial forearm flap is a versatile, widely used flap. However, the possibility of donor site complications has led to concern over its use. Some surgeons prefer using other flaps whose donor sites can be closed primarily with less morbidity, including avoiding unpleasant scarring. However, in our experience, donor site stability of the radial forearm flap can be reliably achieved by using well-implemented specific procedures. Here, we present a collection of donor site cases of the radial forearm flap and investigate factors that affect the aesthetic results as the basis for a reference for selecting a radial forearm flap. METHODS: In this retrospective study, we reviewed 171 cases in which a radial forearm flap was used for free tissue transfer after resecting head and neck cancer. We focused on donor site morbidity rates. Each operation involved a detailed procedure designed to minimize donor site morbidity. Moreover, statistical investigations were conducted for 22 cases to determine factors affecting the scar appearance. RESULTS: Only one case developed total skin graft necrosis as a major complication. Scar-related aesthetic results were acceptable, and the body-mass index, body weight, diabetes, and cardiac problems were significant factors related to the appearance of scars. CONCLUSIONS: Performing the radial forearm flap using a well-implemented detailed technique helps achieve acceptable donor site morbidity results. The aesthetic results were more promising for patients without excess body weight, diabetes, or cardiac problems. Therefore, anxiety about donor site morbidity should not be a reason to avoid selecting the radial forearm flap in suitable patients.
Anxiety ; Body Weight ; Cicatrix ; Esthetics ; Forearm* ; Free Tissue Flaps* ; Head and Neck Neoplasms ; Humans ; Necrosis ; Retrospective Studies ; Skin ; Skin Transplantation ; Tissue Donors* ; Transplants

BACKGROUND: Perineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage. METHODS: We retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction. RESULTS: Flap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%). CONCLUSIONS: Despite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.
Cicatrix ; Humans ; Myocutaneous Flap* ; Pelvic Exenteration* ; Peritonitis ; Rectus Abdominis* ; Retrospective Studies ; Surgery, Plastic ; Wound Infection