Sanghoon Park

Palatal fractures have previously been classified according to the anatomic location of the fracture line, which is helpful for understanding the types of palatal fracture, but which is insufficient for helping the surgeon to decide which fracture to open and how to do so. The purpose of this study was to aid in the establishment of a precise treatment plan by determining the surgical approach and the types of stabilization that should be used for different types of palatal fracture. In a retrospective review of 136 consecutive Le Fort maxillary fractures over 6 years, 18 patients (13.2 percent) with palatal fractures were analyzed. The principle of open reduction and internal fixation was applied to all the patients. In six patients (33 percent), exploration and fixation was done in the palatal surface. Eight patients (44 percent) needed an extended period of immobilization (4 to 6 weeks). No major complications were observed during the follow-up period. An algorithm was devised to help establish a proper treatment plan, and palatal fractures were classified into four types: closed reduction, anterior treatment, anterior and palatal treatment, and combined. The key elements considered in deciding the treatment principle and the classification of a palatal fracture were the possibility of closed reduction, surgical exposure, site of rigid fixation, and stability of fractured segments after rigid fixation. The outcome of reconstruction and the postoperative course differed depending on the type of palatal fracture. This classification scheme provided an easy and simple way to establish a treatment plan and was helpful in learning the treatment principles of palatal fracture.

In reconstructions around the knee, the use of a free flap is indicated in a limited number of cases, but it plays a critical role in cases of extensive defects or unavailability of local flaps. The selection of the recipient vessel is an essential and challenging step for a successful free tissue transfer. Popliteal vessels and other small vessels around the knee have been reported to be used as recipient vessels, but the choice of recipient vessels around the knee has not been established. In this study, after a thorough investigation of the vascular anatomy at the knee region, the superior medial genicular vessels and the descending genicular vessels were considered to be the proper recipient vessels, and a clinical application was tried. From July of 1997 to July of 1999, a total of seven cases of soft-tissue defects around the knee—four cases in the posterior region and three cases in the anterior region—were reconstructed with free flaps, using the superior medial genicular vessels and the descending genicular vessels, respectively. All flaps survived completely, with no flap loss. The advantages of these vessels are their proximity to the knee and their reliability, versatility, simplicity, and size match. The outstanding characteristic of this combination of vessels is their versatility, because the combination can cover all defects around the knee. The clinical application and the versatility of the combination of the superior medial genicular vessels and the descending genicular vessels as the recipient vessels was confirmed for the reconstruction of posterior and anterior knee defects. (Plast. Reconstr. Surg. 107: 1177, 2001.)

The superior gluteal vessel has been reported as a recipient in free-tissue transfer for the coverage of complex soft-tissue defects in the lumbosacral region, where a suitable recipient vessel is difficult to find. The characteristics of proximity, vessel caliber, and constancy make the superior gluteal vessel preferable to previously reported recipient vessels. However, there are technical difficulties in microsurgery (e.g., short pedicle length and deep location) and muscle injury (transection of the muscle) associated with use of the superior gluteal vessel. The purpose of this article is to present a modification of an approach to the gluteal vessel to alleviate technical difficulties and minimize muscle injury. From August of 1997 to January of 1999, six patients received microvascular transfer of the latissimus dorsi muscle or myocutaneous flap to the sacral (4) and ischial (2) regions. The causes of defects were tumor (1), trauma (1), and pressure sores (4). A musclesplitting approach was used on the superior gluteal vessel and was later applied to the inferior gluteal vessel. The gluteus maximus muscle was split as needed in the direction of its fibers, and the perforators were dissected down to the superior or inferior gluteal artery and vein deep into the muscle. The follow-up period ranged from 6 to 22 months, and all of the flaps survived with complete recovery of the lesion. The major drawbacks of using the superior and inferior gluteal vessels can be overcome with the muscle-splitting approach, which provides increased accessibility and additional length to the vascular pedicle while causing minimal injury to the muscle itself. It also proves to be an easy, safe, and reliable method of dissection. When free-tissue transfer to sacral, gluteal, and ischial regions is indicated, the muscle-splitting approach to the superior and inferior gluteal vessels is a recommended option in the selection of a recipient vessel. (Plast. Reconstr. Surg. 106: 81, 2000.)

For the injury of the lower leg associated with both bone and soft-tissue defect, the combined free flap and the Ilizarov distraction method were described as a useful treatment modality. During the procedure of distraction, however, revisions were frequently needed to change the pin position or to change the flap configuration. In case of flap ischemia, distraction should be delayed or abandoned. Then, a vascularized bone transfer might be necessary. To avoid these complications and achieve safe distraction, the configuration of the flap with its vascular pedicle should be carefully planned in terms of the future bony lengthening procedures and the concomitant softtissue changes of the lower leg. According to the response of local tissue to the distraction process, the lower limb can be divided into four compartments (active mobile, passive mobile, receptive, and restrictive). The configuration of the transferred free flap with its vascular pedicle can be classified into five types. To minimize the undue forces to the vascular pedicle and reduce the possibility of vascular compromise, the transferred free flap should have the configuration that its vascular pedicle lies in the territory of the mobile compartment. In performing free-tissue transfer combined with the Ilizarov method in the lower extremity, the configuration of the flap with its vascular pedicle should be carefully planned, and the characteristics of lower leg tissue should be kept in mind during the distraction. (Plast. Reconstr. Surg. 105: 1680, 2000.)