Natural adhesion between the levator aponeurosis and the subcutaneous layer in the upper lid is e... more Natural adhesion between the levator aponeurosis and the subcutaneous layer in the upper lid is essential for an aesthetically pleasing double eyelid. The study aims to emphasize the outer fascia of orbicularis oculi muscle (OFOOM) as a fixation point on the double eyelid surgery. The authors examined the detailed anatomy of the anterior lamella microscopically during 28 cases of primary double eyelid surgery. Three cadaveric dissections were performed adjunctively to compare the dynamic status in the upper lids. Subdermal tissue components and tissue changes in the upper lids were observed in 64 eyelids from secondary revisional cases who had performed an incisional technique previously. The authors also compared the locations of threads in the anterior lamella in 36 eyelids on which a nonincisional surgery technique had previously been used. At the preferred crease zone in the upper lid, a definite anatomic structure, OFOOM was found between the skin and the orbicularis oculi muscle (OOM). The supratarsal creases created by the incisional technique showed that all of the anterior lamella components were fused tightly together by scar tissue. Examination of the 36 supratarsal creases created by the nonincisional technique showed that threads did not exist in the dermal layer, but were mainly within the OFOOM in 20 eyelids and mainly within the OOM layer in 16 eyelids. To produce satisfactory results during double eyelid surgery, the authors recommend direct suture fixation of the levator aponeurosis to the OFOOM, and not to the dermis or OOM.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2015
Fifteen rabbits were used to assess the effect of Lipo-PGE1 on neovascularization. Merocel(®) and... more Fifteen rabbits were used to assess the effect of Lipo-PGE1 on neovascularization. Merocel(®) and Alloderm(®) of the same size were implanted separately under the back skin to act as matrices for vessel growth. Lipo-PGE1 was injected intravenously for 2 weeks in an experimental group of eight rabbits, and they were compared with a control group of seven untreated animals. Blood flow was measured using the (99m)TcO4(-) clearance technique. The mean blood clearance halftime (T1/2) and washout radioactivity were measured. Newly formed vessels were counted by CD31. The mean clearance halftime was 4005 ± 2161.3 and 13840 ± 4644.6 s in the experimental and control group, respectively, in the 1 × 2 × 1.5-cm-sized implants (p = 0.0125), and 1560 ± 1174.7 and 3405 ± 807.03 s, respectively, in the 2 × 2 × 1.5-cm-sized implants (p = 0.0413). Histological examinations revealed that the mean numbers of newly formed vessels in the experimental and control groups were 11 ± 1.58 and 7.8 ± 1.71, respectively, in the 1 × 2 × 1.5-cm-sized implants (p = 0.0501), and 20.19 ± 12.47 and 12.33 ± 3.25, respectively, in the 2 × 2 × 1.5-cm-sized implants (p = 0.02679). Lipo-PGE1 was found to be effective in promoting angiogenesis in a rabbit matrix model.
Carpal tunnel release is one of the most frequently performed hand operations. However, persisten... more Carpal tunnel release is one of the most frequently performed hand operations. However, persistent, recurrent, or completely new symptoms following carpal tunnel release remain a difficult problem. A retrospective review of the surgical findings and outcomes of 50 consecutive patients who had undergone 55 revision carpal tunnel operations was performed. The initial carpal tunnel release was an endoscopic technique in 34 hands and an open technique in 21 hands. Thirty-four hands continued to have persistent symptoms, 18 hands had recurrent symptoms, and three hands had completely new symptoms. Reexploration revealed incomplete release in 32 patients. Circumferential fibrosis around the median nerve was found in all patients. Forty-six percent of patients with recurrent symptoms had slight palmar subluxation of the median nerve. External neurolysis was performed in 41, epineurectomy was performed in 15, synovial or hypothenar fat flap coverage was performed in eight, and radial forearm adipofascial flap coverage was performed in three hands. Symptomatic improvement following revision surgery after open carpal tunnel release was slightly better (90 percent) compared with after endoscopic carpal tunnel release (76 percent), but complete relief of symptoms following revision surgery was similar after open (57 percent) or endoscopic (56 percent) techniques. Ten patients (20 percent) showed no improvement and five patients required a third operation. A small number of patients (1) continue to have persistent symptoms after carpal tunnel release because of incorrect diagnosis or incomplete release of the transverse carpal ligament; (2) develop recurrent symptoms caused by circumferential fibrosis; or (3) develop completely new symptoms, which usually implies iatrogenic injury to branches of the median nerve. Therapeutic, IV.
Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that ... more Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that induces adhesion. Although incision method provides a significant supratarsal fold, it has the disadvantage of causing a visible depression or scarring when eyes are closed in downward gaze. The authors elevated multiple comblike mini-flaps from upper eyelid pretarsal levator tissues under loupe magnification. Flap bases were anchored on the tarsus using 7-0 nylon sutures, and distal flap portions were pulled out to the skin through a separate incision line and then interposed between edges of orbicularis muscle using absorbable microsutures to achieve a complete myocutaneous layer-by-layer repair. Five hundred twenty-two double eyelidplasties were performed by the senior surgeon (Y.C.) using the described miniflap method. Patients were followed for 6 to 38 months (mean, 26 months). Seven palpebral fold failures were encountered, especially on the medial side, and 12 cases of fold asymmetry occurred because of inappropriate anchoring of miniflaps; all 12 were revised secondarily. No granuloma formation or scar hypertrophy occurred on upper lids. Although mild erythematous skin changes inevitably occurred during the early postoperative period, patients were satisfied with the palpebral folds, which showed no scars during downward gaze at 2 years postoperatively. The authors introduce a modified double eyelidplasty involving the interposition of multiple comblike mini-flaps derived from the pretarsal levator tissue of the upper eyelid. The procedure not only allows clean repair of the upper eyelid without disrupting tissue layer continuity but also enables double eyelidplasty with minimal scar formation.
A severe burn scar contracture of the groin in a 25-year-old woman was successfully reconstructed... more A severe burn scar contracture of the groin in a 25-year-old woman was successfully reconstructed with microdissection and thinning of a pedicled deep inferior epigastric perforator (DIEP) flap. This perforator flap is a relatively thin cutaneous flap, but may still require secondary defatting procedures, especially when used for coverage of mobile anatomic areas such as the groin and axilla. A deep inferior epigastric perforator flap was radically thinned by excising the subcutaneous fatty layer very carefully under loupe magnification, to preserve the subdermal vascular plexus. One year after surgery, the patient can abduct and rotate the hip freely without limitation.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2009
In distal fingertip amputations where microanastomosis may not be possible, composite grafting mi... more In distal fingertip amputations where microanastomosis may not be possible, composite grafting might offer the possibility of maintaining digital length and function using the patient's own tissue. Many trials such as ice-cooling, pharmacologic enhancement and hyperbaric oxygenation have been reported to improve the survival rate of the composite graft. Twenty-four cases of unreplantable fingertip amputation were classified as types I to III according to the level of injury. We performed the composite grafting followed by immediate ice-cooling for 2 weeks and intravenous lipo-prostaglandin E(1) (lipo-PGE(1)) injection for 8.8 days each on average. Twenty-two fingertips in 24 patients survived completely with acceptable appearance and sensibility over the 8 month follow-up period. Confirming that therapeutic angiogenesis using ice-cooling and lipo-PGE(1) can increase the survival rate of the composite graft in unreplantable fingertip amputation, we describe the procedures and postoperative care in detail.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010
Alloderm as a biomechanical scaffold in situations such as skin grafting has been previously demo... more Alloderm as a biomechanical scaffold in situations such as skin grafting has been previously demonstrated. In this paper we describe its utility in a broad range of post-traumatic and congenital hand defects. During the recent three years, 11 patients (7 male, 4 female) ranging in age from 8 to 84 years underwent hand resurfacing using acellular dermis graft. There were 10 traumatic and 1 congenital hand deformities (constriction ring syndrome). The acellular dermis was used as both a dermal filler and as a spacer construct. There was no obvious loss of the acellular dermis or infection. Stable resurfacing was achieved in all patients with reasonable functional and cosmetic outcomes.
As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue r... more As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue regeneration through infiltration of cells and neovascularisation. However, they show not only rather lower take rates compared to autologous skin grafts alone, but they also require more time for sufficient vascular ingrowth to overlay the skin graft. To accelerate this overlaying, we applied vacuum-assisted closure negative-pressure settings over the artificial dermis: Terudermis(®) and Pelnac(®) grafts. Fourteen patients with complex tissue defects were treated, including bone exposure in two cases, tendon exposure in seven cases and soft tissue defects in five cases. Nine cases had combined wound infections. The time interval between the first artificial dermis graft and the second split-thickness skin graft over it was 7·64 days on average. Dermal substitutes took place completely in all cases and there were no graft failures.
Natural adhesion between the levator aponeurosis and the subcutaneous layer in the upper lid is e... more Natural adhesion between the levator aponeurosis and the subcutaneous layer in the upper lid is essential for an aesthetically pleasing double eyelid. The study aims to emphasize the outer fascia of orbicularis oculi muscle (OFOOM) as a fixation point on the double eyelid surgery. The authors examined the detailed anatomy of the anterior lamella microscopically during 28 cases of primary double eyelid surgery. Three cadaveric dissections were performed adjunctively to compare the dynamic status in the upper lids. Subdermal tissue components and tissue changes in the upper lids were observed in 64 eyelids from secondary revisional cases who had performed an incisional technique previously. The authors also compared the locations of threads in the anterior lamella in 36 eyelids on which a nonincisional surgery technique had previously been used. At the preferred crease zone in the upper lid, a definite anatomic structure, OFOOM was found between the skin and the orbicularis oculi muscle (OOM). The supratarsal creases created by the incisional technique showed that all of the anterior lamella components were fused tightly together by scar tissue. Examination of the 36 supratarsal creases created by the nonincisional technique showed that threads did not exist in the dermal layer, but were mainly within the OFOOM in 20 eyelids and mainly within the OOM layer in 16 eyelids. To produce satisfactory results during double eyelid surgery, the authors recommend direct suture fixation of the levator aponeurosis to the OFOOM, and not to the dermis or OOM.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2015
Fifteen rabbits were used to assess the effect of Lipo-PGE1 on neovascularization. Merocel(®) and... more Fifteen rabbits were used to assess the effect of Lipo-PGE1 on neovascularization. Merocel(®) and Alloderm(®) of the same size were implanted separately under the back skin to act as matrices for vessel growth. Lipo-PGE1 was injected intravenously for 2 weeks in an experimental group of eight rabbits, and they were compared with a control group of seven untreated animals. Blood flow was measured using the (99m)TcO4(-) clearance technique. The mean blood clearance halftime (T1/2) and washout radioactivity were measured. Newly formed vessels were counted by CD31. The mean clearance halftime was 4005 ± 2161.3 and 13840 ± 4644.6 s in the experimental and control group, respectively, in the 1 × 2 × 1.5-cm-sized implants (p = 0.0125), and 1560 ± 1174.7 and 3405 ± 807.03 s, respectively, in the 2 × 2 × 1.5-cm-sized implants (p = 0.0413). Histological examinations revealed that the mean numbers of newly formed vessels in the experimental and control groups were 11 ± 1.58 and 7.8 ± 1.71, respectively, in the 1 × 2 × 1.5-cm-sized implants (p = 0.0501), and 20.19 ± 12.47 and 12.33 ± 3.25, respectively, in the 2 × 2 × 1.5-cm-sized implants (p = 0.02679). Lipo-PGE1 was found to be effective in promoting angiogenesis in a rabbit matrix model.
Carpal tunnel release is one of the most frequently performed hand operations. However, persisten... more Carpal tunnel release is one of the most frequently performed hand operations. However, persistent, recurrent, or completely new symptoms following carpal tunnel release remain a difficult problem. A retrospective review of the surgical findings and outcomes of 50 consecutive patients who had undergone 55 revision carpal tunnel operations was performed. The initial carpal tunnel release was an endoscopic technique in 34 hands and an open technique in 21 hands. Thirty-four hands continued to have persistent symptoms, 18 hands had recurrent symptoms, and three hands had completely new symptoms. Reexploration revealed incomplete release in 32 patients. Circumferential fibrosis around the median nerve was found in all patients. Forty-six percent of patients with recurrent symptoms had slight palmar subluxation of the median nerve. External neurolysis was performed in 41, epineurectomy was performed in 15, synovial or hypothenar fat flap coverage was performed in eight, and radial forearm adipofascial flap coverage was performed in three hands. Symptomatic improvement following revision surgery after open carpal tunnel release was slightly better (90 percent) compared with after endoscopic carpal tunnel release (76 percent), but complete relief of symptoms following revision surgery was similar after open (57 percent) or endoscopic (56 percent) techniques. Ten patients (20 percent) showed no improvement and five patients required a third operation. A small number of patients (1) continue to have persistent symptoms after carpal tunnel release because of incorrect diagnosis or incomplete release of the transverse carpal ligament; (2) develop recurrent symptoms caused by circumferential fibrosis; or (3) develop completely new symptoms, which usually implies iatrogenic injury to branches of the median nerve. Therapeutic, IV.
Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that ... more Most double eyelid operations focus on using a levator insertion into the upper eyelid skin that induces adhesion. Although incision method provides a significant supratarsal fold, it has the disadvantage of causing a visible depression or scarring when eyes are closed in downward gaze. The authors elevated multiple comblike mini-flaps from upper eyelid pretarsal levator tissues under loupe magnification. Flap bases were anchored on the tarsus using 7-0 nylon sutures, and distal flap portions were pulled out to the skin through a separate incision line and then interposed between edges of orbicularis muscle using absorbable microsutures to achieve a complete myocutaneous layer-by-layer repair. Five hundred twenty-two double eyelidplasties were performed by the senior surgeon (Y.C.) using the described miniflap method. Patients were followed for 6 to 38 months (mean, 26 months). Seven palpebral fold failures were encountered, especially on the medial side, and 12 cases of fold asymmetry occurred because of inappropriate anchoring of miniflaps; all 12 were revised secondarily. No granuloma formation or scar hypertrophy occurred on upper lids. Although mild erythematous skin changes inevitably occurred during the early postoperative period, patients were satisfied with the palpebral folds, which showed no scars during downward gaze at 2 years postoperatively. The authors introduce a modified double eyelidplasty involving the interposition of multiple comblike mini-flaps derived from the pretarsal levator tissue of the upper eyelid. The procedure not only allows clean repair of the upper eyelid without disrupting tissue layer continuity but also enables double eyelidplasty with minimal scar formation.
A severe burn scar contracture of the groin in a 25-year-old woman was successfully reconstructed... more A severe burn scar contracture of the groin in a 25-year-old woman was successfully reconstructed with microdissection and thinning of a pedicled deep inferior epigastric perforator (DIEP) flap. This perforator flap is a relatively thin cutaneous flap, but may still require secondary defatting procedures, especially when used for coverage of mobile anatomic areas such as the groin and axilla. A deep inferior epigastric perforator flap was radically thinned by excising the subcutaneous fatty layer very carefully under loupe magnification, to preserve the subdermal vascular plexus. One year after surgery, the patient can abduct and rotate the hip freely without limitation.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2009
In distal fingertip amputations where microanastomosis may not be possible, composite grafting mi... more In distal fingertip amputations where microanastomosis may not be possible, composite grafting might offer the possibility of maintaining digital length and function using the patient's own tissue. Many trials such as ice-cooling, pharmacologic enhancement and hyperbaric oxygenation have been reported to improve the survival rate of the composite graft. Twenty-four cases of unreplantable fingertip amputation were classified as types I to III according to the level of injury. We performed the composite grafting followed by immediate ice-cooling for 2 weeks and intravenous lipo-prostaglandin E(1) (lipo-PGE(1)) injection for 8.8 days each on average. Twenty-two fingertips in 24 patients survived completely with acceptable appearance and sensibility over the 8 month follow-up period. Confirming that therapeutic angiogenesis using ice-cooling and lipo-PGE(1) can increase the survival rate of the composite graft in unreplantable fingertip amputation, we describe the procedures and postoperative care in detail.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010
Alloderm as a biomechanical scaffold in situations such as skin grafting has been previously demo... more Alloderm as a biomechanical scaffold in situations such as skin grafting has been previously demonstrated. In this paper we describe its utility in a broad range of post-traumatic and congenital hand defects. During the recent three years, 11 patients (7 male, 4 female) ranging in age from 8 to 84 years underwent hand resurfacing using acellular dermis graft. There were 10 traumatic and 1 congenital hand deformities (constriction ring syndrome). The acellular dermis was used as both a dermal filler and as a spacer construct. There was no obvious loss of the acellular dermis or infection. Stable resurfacing was achieved in all patients with reasonable functional and cosmetic outcomes.
As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue r... more As a dermal scaffold, artificial dermal substitutes allow the body to accomplish its own tissue regeneration through infiltration of cells and neovascularisation. However, they show not only rather lower take rates compared to autologous skin grafts alone, but they also require more time for sufficient vascular ingrowth to overlay the skin graft. To accelerate this overlaying, we applied vacuum-assisted closure negative-pressure settings over the artificial dermis: Terudermis(®) and Pelnac(®) grafts. Fourteen patients with complex tissue defects were treated, including bone exposure in two cases, tendon exposure in seven cases and soft tissue defects in five cases. Nine cases had combined wound infections. The time interval between the first artificial dermis graft and the second split-thickness skin graft over it was 7·64 days on average. Dermal substitutes took place completely in all cases and there were no graft failures.
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