당뇨병 환자에서 혈장 Thrombin-Antithrombin Ⅲ 및 Plasmin-α_2-Plasmin Inhibitor 복합체의 임상적 의의

김경욱,김은숙,정상수,윤수지,박우일,이준희,남수연,안철우,문병수,김경래,차봉수,송영득,임승길,이현철,허갑범 대한당뇨병학회 2002 Diabetes and Metabolism Journal Vol.25 No.5

연구배경:당뇨병 환자에서 혈액응고 및 섬유소용해 체계의 이상경향이 있어 그 결과로 여러 혈관합병증의 발생위험이 높다는 사실은 널리 알려져 있다. 그 기전은 아직 확실히 밝혀지지 않았으나, 고혈당으로 인한 혈장 단백질들의 비효소성 당화작용이나 산화성 스트레스로 인한 유리 라티칼 작용으로 응고항진이나 섬유소용해 활성의 저하를 유발하는 것으로 생각되고 있다. 최근 응고 및 용해인자와 그 억제자의 복합체들의 증가가 이 상태를 비교적 예민하게 반영한다고 알려져 있다. 방법:본 연구에서는 당뇨병 환자 101명과 정상 대조군 20명에서 혈장내 thrombin­antithrombin complex(TAT)와 plasmin­α₂­plasmin inhibitor complex(PIC)를 측정하여 비교하고, 당뇨병 환자에서 미세혈관 합병증과 대혈관합병증의 유무에 따른 차이와, 이미 혈관 질환의 위험인자로 알려져 있는 인자들간의 상관성을 알아보고자 하였다. 결과:1. 환자의 분포를 살펴보면 혈관합병증이 있는 군은 85명, 혈관합병증이 없는 군은 16명이었고, 평균연령은 각각 57.9±14.1세, 49.9±16.6세로 혈관 합병증이 있는 군에서 더 나이가 많았고, 체질량지수는 23.2±3.4㎏/㎡, 24.1±3.4㎏/㎡로 두 군간 유의한 차이는 없었다. 또 두 군간의 혈압 및 HbA1c, 공복혈당 및 인슐린과 C­peptide, 총 콜레스테롤, 중성지방, HDL­콜레스테롤, Lp⒜는 유의한 차이가 없었고, 미세혈관합병증이 있는 군에서 당뇨병의 유병기간이 길었다. 2. TAT 및 PIC의 농도는 정상 대조군에서는 2.8±1.2 ng/mL, 240.4±69.7 ng/mL이었고, 당뇨병 환자군에서는 9.5±22.6 ng/mL, 472.2±258.7 ng/mL이었다. TAT와 PIC 모두 당뇨병 환자군에서 정상 대조군에 비해 유의하게 증가되어 있었고(p<0.001), TAT/PIC ratio는 두 군간 차이가 없었다. 3. 당뇨병 환자의 혈관합병증에 따른 TAT 및 PIC, fibrinogen 농도는 합병증이 없는 군은 각각 4.1±2.4ng/mL, 362.2±272.0ng/mL, 322.7±102.4mg/mL으로 PIC와 fibrinogen의 증가를 보였으나, 연령을 보정한 후에는 통계학적 유의성은 없었다. 또 대혈관 합병증군에서는 각각 6.0±4.9 ng/mL, 507.4±321.6 ng/mL, 427.1±194.7 mg/dL이었으며 미세·대혈관 합병증군에서는 10.4±6.4 ng/mL, 484.8±269.7 ng/mL, 388.4±132.4 mg/dL으로 TAT의 증가를 보였으나 역시 연령을 보정한 후에는 통계학적 유의성은 없었다. 4. 미세혈관합병증군에서 HbA1c(>8%)가 높은 군의 PIC 농도가 유의하게 높았고(p=0.049), 대혈관합병증군에서 HbA1c(>8%)가 높은 군의 총 콜레스테롤 농도가 유의하게 높았다(p=0.042). 5. 총 당뇨병 환자군에서 PIC는 fibrinogen과 HbA1c와 양의 상관관계를, BMI와 음의 상관관계를 보였으며(r=0.47, 0.31,-0.25), 혈관 합병증이 없는 당뇨병 환자군에서만 TAT는 HbA1c와 양의 상관관계를 보였다(r=0.67). 결론:이상의 결과에서 혈장 TAT 및 PIC 농도는 당뇨병 환자에서 정상 대조군에 비해 의미있게 증가되어 있었고, 당뇨병 환자군에서는 연령의 증가와 유병기간이 혈액응고항진 및 용해의 장애에 큰 역할을 함을 알 수 있었으며, 총 당뇨병 환자군에 PIC와 HbA1c와 양의 상관관계를, BMI와 음의 상관관계를 보였으며 혈관 합병증이 없는 당뇨병 환자군에서만 TAT는 HbA1c와 양의 상관관계를 보였다. 따라서 당뇨병 환자에서 혈액응고 및 용해의 장애가 동반되어 있다고 볼 수 있으며, 혈장 TAT 및 PIC는 혈관합병증으로의 진행을 예측하는 지표로서 유용하리라 생각된다. 또 혈당조절정도와 상관성이 있으므로 혈당조절후에 추적검사를 시행하여 합병증의 예방이 가능한지 추후 연구가 필요하리라 생각된다. Background : Abnormality of coagulation and fibrinolystic system is known as a predisposing factor of vascular complication in diabetes. Although the pathogenesis is not well known, non-enzymatic glycation reaction and the increase in production of free radicals due to an increased oxidative stress may be linked to the hypercoagulibility and hypofibrinolytic activity. As indices of abnormality in coagulation and firinolysis in peripheral blood, plasma thrombin-antithrombin Ⅲ complex (TAT) and plasmin-α_2-plasmin inhibitor complex (PIC) were measured. The purpose of this study was to clarify whether hypercoagulability exists in diabetic patients with or without vascular complication. Methods : In our study, we measured plasma thrombin-antithrombin Ⅲ compelx (TAT) and plasmin-α_2-plasmin inhibit or complex (PIC) in 101 diabetic subjects and 20 controls. Comparing TAT and PIC levels in diabetic microvascular complication group, diabetic macrovascular complication group and controls, we examined correlation between risk factors associated with diabetic vascular complication. Results : 1. The group with diabetic vascular complication was older than group without complication. There was no significant difference in BMI, blood pressure, HbA_ic, blood sugar level, insulin, C-peptide, serum creatinine, total cholesterol, triglyceride, HDL-cholesterol, Lp (a) between two groups. The group with diabetic microvascular complication had longer duration of diabetes. 2. Concentration of TAT and PIC were 2.8±1.2 ng/ mL, 240.4±69.7 ng/ mL in controls and 9.5±22.6 ng/ mL, 472.2±258.7 ng/ mL in diabetic patients, respectively. TAT and PIC were significantly higher in diabetic patients than in control (p<0.001). But TAT/PIC ratio was no significant difference between two groups. 3. In diabetic patients, concentration of TAT and PIC and fibrinogen were respectively 4.1±2.4 ng/ mL, 362.2±272.0 ng/ mL, 322.7±102.4 mg/ dL in group without vascular complication and 5.3±4.1 ng/ mL, 529.5±258.7 ng/ mL, 374.9±106.2 mg/ dL in group with microvascular complication, which group had increase in PIC and Fibrinogen but no significance after correction of age. Concentration of TAT and PIC and Fibrinogen were 60.±4.9 ng/ mL, 507.4±321.6 ng/ mL, 427.1±194.7 mg/ dL in macrovascular complication, and 10.4±6.7 mg/ mL, 484.8±269.7 ng/ mL, 388.4±132.4 mg/ dL in combined vascular complication which group showed increase of TAT but also had no significant increase after correction of age. 4. In diabetic microvascular complication patients, group of high HbA_1c (>8%) (p=0.049) had significant high PIC concentration. In diabetic macrovascular complication patients, group of high HbA_1c (>8%) (p=0.042) had significant high total cholesterol concentration. 5. In all diabetic patients, PIC was positively correlated with fibrinogen and HbA_1c and negatively correlated BMI (r=0.47, 0.31, -0.25). Only in daibetic patients without angiopathy, TAT was positively correlated with HbA_1c (r=0.67). Conclusion : In this study, plasma TAT and PIC concentration significantly increased in diabetic patients compared with controls, and PIC was increased in group with microvascular complication, TAT were increased in group with combined micro macrovascular complication. However, there was no significance relationship existed when correctinf for age. PIC was correlated with HbA_1c. TAT was correlated with HbA_1c only in the group without angiopathy. Abnormality of coagulation and fibrinolysis were combined in diabetes, plasma TAT and PIC can be used as an index of vascular complication. Also we found the correlation with the degree of the blood glucose control. Therefore we need follow up study for the possibility of prevention of vascular complication after controlling the blood glucose to age-matched patients (J Kor Diaabetes Asso 25:354~363, 2001).

관해된 정신분열병과 양극성장애 환자의 언어성 기억 및 학습 기능 비교

우종민,정성심,정인원,김이영,이동수,홍경수 大韓神經精神醫學會 2001 신경정신의학 Vol.40 No.4

연구목적 : 본 연구는 관해 상태에 있는 정신분열병과 양극성장애 환자의 언어성 기억 및 학습 기능을 평가하고 이를 정상대조군과 비교하여 기억 요소의 질환별 특성을 분석하고자 실시하였다. 방 법 : 관해상태의 정신분열병 환자 30명과 양극성장애 환자 28명 및 정상대조군 72명을 대상으로 성, 연령, 교육연한, 발병연령, 잔여증상, 추체외로증상, 단순주의력 수준을 통제한 후 한글언어청각학습검사를 실시하여, 초과용량 즉각기억, 기억의 등록, 유지, 인출, 재인, 학습전략, 간섭효과를 분석하였다. 결 과 : 한글언어청각학습검사 결과를 세 집단간 비교한 결과, 정신분열병은 전행성 간섭효과를 제외한 모든 항목에서 대조군보다 유의하게 저하된 기억 수행을 보였으며, 양극성장애에 비해서도 대부분의 회상 시도에서 유의한 저하를 보였다. 특징적으로 학습 전략 활용 능력이 저조하였다. 양극성장애는 대조군에비해 즉각기억, 재인,학습전략에서 유의한 차이를 보이지 않았으나, 반복에 따른 회상과 학습은 대조군에 비해 유의하게 저하되었다. 정신분열병에 비해서는 전반적으로 비슷하거나 우월했지만, 간접자극 제시에 의한 회상 저하는 세 집단 중 가장 크게 나타났다. 환자군에서 검사성적에 대한 임상적 특성의 설명력을 분석한 결과, 정신분열병에서는 BPRS의 무력증 소척도, 유병기간, 입원횟수 등이 유의한 설명력을 갖는 것으로 나타났고, 양극성장애에서는 우울삽화 횟수가 유의한 설명력을 갖는 것으로 나타났다. 결 론 : 관해상태의 양극성장애와 정신분열병 모두에서 대조군과 구별되는 언어성 기억 및 학습 기능 저하가 관찰되었다. 이러한 기억 및 학습 기능의 결함은 이들 두 장애의 고유한 질병 특성 표지자일 가능성이 높으며, 향후 이들 질환의 병태생리를 이해하고 치료적 접근 방법을 모색하는 데에 단초가 될 수 있을 것이다. Objectives : This study was to investigate the verbal memory and learning ability in remitted schizophrenic patients and euthymic bipolar patients in order to explore trait-dependent cognitive deficits of each disorder. Methods : Verbal memory was assessed with KAVLT(the Korean version of Rey Auditory Verbal Learning Test) in outpatients with remitted schizophrenia(N=30), euthmic bipolar disorder(N=28), and normal control(N=72), KAVLT is made for assessment of immediate supraspan memory, registration, retention, retrieval, recognition, learning strategy, and interference effect. Several confounding factors including age, sex, educational level, attention span, residual psychopathology, and extrapyramidal symptoms were controlled among 3 groups. Patient groups were matched according to the age of onset, duration of illness, and frequency of hospitalization. Results : 1) The performance of bipolar group generally fall between the performance of schizophrenia and normal controls, while being most impaired in retroactive interference. Schizophrenic group showed significant impairment on most variables of KAVLT in comparison with the groups of bipolar disorder and normal control. 2) Within group analysis revealed that residual negative symptoms, duration of illness, and number of admission were highly correlated with the impairment of verbal memory and learning in schizophrenics. Number of depressive episodes and age were negatively correlated with verbal memory and learning among bipolar disorder patients. Conclusions : Both remitted schizophrenia and euthymic bipolar patients showed distinctive impairment in verbal memory and learning compared with controls. These results suggest that apecific impairment of verbal memory and learning in remitted state can be trait-dependent marker in both diseases. These deficits can give clues to the understanding of the pathophysiology and searching for more appropriate therapeutic interventions of mental disorders to improve cognitive deficits in remitted patients.

사지 체벽 복합기형 1례

우종진,조석재,박소정,박재복,김용진,조경일,이헌수 啓明大學校 醫科大學 1993 계명의대학술지 Vol.12 No.3

Limb body wall complex(LBWC) has been included in the spectrum of defects seen in early amnion rupture sequence. LBWC is a complicated fetal malformation with essential features of exencephaly or encephaloceles associated with facial clefts, lateral body wall defects with evisceration of organs, and limb defects. Our case is characterized by the absence of craniofacial anomalies and normal development of urogenital system comparing with other repoerted cases. We present a case of LBWC with a brief review of the literatures.

韓國 高等學校 地球科學 敎育課程 變嬅硏究

우수경 이화여자대학교 교육대학원 1991 이화교육논총 Vol.2 No.-

The Earth Science Curriculum was established and promulgated in 1955. It is thirty five years since it was exeuted. Just as the curriculum has been changed by the need of a nation and a society, the Earth Science Curriculum was revised from the first period to the fifth period in 1963, 1973, 1981 and 1988. The aims in this study is to analyze the Earth Science Curriculum from the viewpoints of theoritical backgrounds, unit hours, objectives, contents, and attentiveness of instruction and evaluation. The other is to suggest the desirable future Earth Science Curriculum. The effects of this study are as follow: 1. The unit hours of Earth Science have ranged between 4 unit hours, but are so lacking for learning for learning the contents in Earth Science that we can't reinforce the fundamental scientific education. 2. The Earth Science objectives were diversified so as to manage the needs of future society. As education philosophy was changed from subject contered to experience centered curriculum and then from experience centered to discipline centered curriculum and then from discipline centered to human centered curriculum, the objectives were changed, too. 3. The Earth Science instruction contents were systematized on the basis of ESCP curriculum and contained synthetic contents. Recently, the importance of environmental education is emphasized in "Environment and resources" and so on. 4. Attentiveness of instruction and evaluation were inserted since the second period. curriculum and have emphasized conceptual system and scientific investigation, but the expression is abstract. Conclusively, We must not only maintain the consistency among the education objectiveness, the contents, and the attentiveness of instruction and evaluation, but also allot sufficient unit hours so that the Earth Science education may get effected.

지문과 정신분열증

우숙희,정국동,최송표,조근자,양은진,김수일,박경란,이영호,김원식 충남대학교 의과대학 지역사회의학연구소 1998 충남의대잡지 Vol.25 No.1

Fingerprint patterns of 333 schizophreniacs who met with the diagnostic criterias of International Pilot Study of Schizophrenia except items associated with chronicity in exclusion criteria were studied, and the following results were obtained. 1. The frequency distribution of the fingerprint patterns in the 333 schizophreniacs was ulnar loop, whorl, twinned loop, arch, radial loop in order in both control and schizophrenia groups. 2. Finger ridge counts of both sexes were decreased significantly in schizophrenia group. 3. Dissociation of fingerprint pattern in the schizophrenia group was 51.1%, which was far greater than 6.25% of control group. Number of dissociation was greatest in the thumb, followed by index, middle, ring, and little finger in order. According to the above results, it is considered that both the number of finger ridges and degree of dissociation of fingerprint patterns were closely related with schizophrenia. Analysis of fingerprints and palmprints with the aid of chromosomal analysis would contribute the early diagnosis and prevention of schizophrenia.

mecA 양성 메티실린 내성 포도구균의 mec 조절유전자에 대한 분자역학적 연구 및 다양성 분석

우희연,이남용,맹성호,한승훈,인경수,김상욱,성승용,김익상,최명식 대한화학요법학회 2000 대한화학요법학회지 Vol.18 No.3

목적 : 병원 감염과 지역 감염의 원인균으로서의 중요성이 증가되고 있는 MRSA와 MRCNS의 메티실린 내성 관련 유전자에 대해 분자역학적인 조사를 시행하고 mec 조절유전자의 다양성을 분석하여 분자유전학적 연구와 감염 관리에 기본적 자료를 제공하고자 연구를 시행하였다. 방법 : 본 연구에서는 국내 동일 대학병원에서 분리된 mecA 양성 MRSA 78균주와 MRCNS 36균주를 대상으로 항균제 감수성 검사와 중합효소연쇄반응을 시행하여 표현형과 유전형의 분포를 알아보고 내성 정도와 유전형의 상관성을 분석하였다. 결론 : 최소억제농도를 측정하여 oxacillin 감수성 양상을 알아본 결과 총 90개의 MRSA 임상검체 중 3균주에서 감수성을 보였고, MRCNS 36균주는 모두 내성을 보였으며, 고도 내성을 보이는 균주일수록 다제내성을 보이고 있었다. 중합효소연쇄반응으로 mecA 유전자 유무를 분석하여 mecA 양성을 보인 MRSA 78균주와 MSCNS 36균주 만을 대상으로 mec 조절유전자에 대한 중합효소연쇄반응을 시행하여 유전형의 분포를 조사하였다. 그 결과 MRSA와 MRCNS 모두에서 mecA-Pr-mecA-mecR1-mecI형, mecA-Pr-mecA-mecR1형과 mecA-Pr-mecA-mecR-1의 5′말단형의 3가지 유전형이 공통적으로 관찰되었는데, 이외에 MRSA에서는 mecA-mecR1형, mecA-mecR1의 5′말단형이, MRCNS에서는 mecA-Pr-mecA형과 mecA형이 추가로 분리되었다. 유전형의 분포를 연도별로 분석한 결과 연도별로 우세한 유전형이 서로 다른 것을 알 수 있었다. 유전형과 내성 정도의 상관성을 분석한 결과, mecA-Pr-mecA-mecR1을 보유한 MRSA의 경우 mecA 억제유전자로 생각되는 mecI 유전자 유무에 관계없이 모두 고도 내성을 나타내어 mecI의 유무는 내성 정도와는 일정한 관련이 없었으나, MRSA와 MRCNS 모두에서 mecI와 동시에 mecR1의 3′말단이 결혼된 유전형이 저도 및 중등도 내성을 보이는 균주에서 유의하게 많이 관찰되어 mecI가 결손된 균주에서는 mecR1의 3′말단부위의 유무가 내성 정도의 결정에 중요한 역할을 할 것으로 생각하였다. 결론 : 국내에서 분리되는 메티실린 내성 포도구균의 유전형의 분포가 국외 분리주와 차이를 보이는 것으로 관찰되었다. 또한 기존의 보고와는 달리 메티실린 내성 정도와 유전형 사이에 유의한 연관성이 있는 것으로 관찰되어 mec조절유전자가 내성 발현 뿐만 아니라 내성 정도의 결정에 중요한 역할을 하는 것으로 관찰되었다. MRSA가 중요한 감염균임에도 불구하고 아직까지 MRSA의 내성기전에 대해 확실하게 규명되지 않아 치료가 더욱 어려워지고 있는 실정이므로 이에 대한 더욱 종합적인 연구와 동시에 발생과 확산을 막기 위한 노력이 필요할 것으로 생각된다. Background : High prevalence of methicillin resistance has been noticed in staphylococci which also have been recognized as important nosocomial and multi-drug resistant pathogens. In this study, we investigated the distribution of mec regulator genes and the presence of the mutation in mecIgene to reveal the resistance mechanism at molecular level. Methods : The isolates included 90 clinical isolates of MRSA, 36 MRCNS of which methicillin resistance were determined by disk diffusion test and isolated in a single hospital during 1996-1999. We performed microdilution MIC test for oxacillin resistance and Kirby-Bauer test for other antibiotics. Genotypes of mecA positive (determined by PCR) isolates (78 MRSA, 36 MRCNS) were investigated by PCR amplification of mec regulator genes such as 3' end and 5' end of mecR1. mecI, and Pr-mecA. Results : In MIC assay, all MRSA strains except 3 strains and all MRCNS strains showed oxacillin resistance. The level of resistance correlated to the multi-drug resistance. Seven genotypes were observed in mecA positive MRSA and MRCNS. Differences of predominant genotypes among years isolated and among species were observed. Deletions of the 3' end of mecR1 and the mecI were more frequently observed in the low- and borderline-level resistant MRSA and MRCNS (P(0.05). So the important role of 3' end of mecRI in determining resistance level was suggested. Conclusion : This study demonstrated that genomic distribution of methicillin-resistant staphylococci isolated in Korea was different from that of strains isolated in other countries. And important role of mec regulator genes for expression of methicillin resistance was suggested.

방사선사진에서의 골질과 임상적으로 평가한 골질 분류의 상관관계

김현우,허경회,박관수,김정화,이원진,허민석,이삼선,최순철 대한구강악안면방사선학회 2006 Imaging Science in Dentistry Vol.37 No.1

Purpose : To investigate the validity of digital image processing on panoramic radiographs in estimating bone quality before endosseous dental implant installation by correlating bone quality in radiographic images with clinical bone quality classification. Materials and Methods : An experienced surgeon assessed and classified bone quality for implant sites with tactile sensation at the time of implant placement. Including fractal dimension eighteen morphologic features of trabecular pattern were examined in each anatomical sites on panoramic radiographs. Finally bone quality of 67 implant sites were evaluated in 42 patients. Results : Pearson correlation analysis showed that three morphologic parameters had weak linear negative correlation with clinical bone quality classification showing correlation coefficients of -0.276, -0.280, and -0.289, respectively (p<0.05). And other three morphologic parameters had obvious linear negative correlation with clinical bone quality classification showing correlation coefficients of -0.346, -0.488, and -0.343 respectively (p<0.05). Fractal dimension also had a linear correlation with clinical bone quality classification with correlation coefficients -0.506 significantly (p<0.05). Conclusion : This study suggests that fractal and morphometric analysis using digital panoramic radiographs can be used to evaluate bone quality for implant recipient sites. (Korean J Oral Maxillofac Radiol 2006; 36 : 25-32)

프로와 아마추어 씨름선수들의 경쟁상태 및 특성불안에 관한 연구

이한우,육동원,고의석,김경수 한국스포츠리서치 2004 한국 스포츠 리서치 Vol.15 No.1

The purpose of this study was to investigate differences of competition state anxiety (somatic state anxiety, cognitive state anxiety, and state self-confidence) and competition trait anxiety among three groups(highschool, university, and professional Korean Ssireum Players), and between winners and non-winners to analyze and evaluate the state of competition anxiety felt by players. Further more, This study present some useful guiding principles of effective coaching to improve the performance ability and control the competition anxiety of Ssireum players at fields. A total of 487 Ssireum players(204 highschool players, 206 college players and 77 professional players) participated in the SCAT and the CSAI-2 competition anxiety tests. Data were analyzed with One-way ANOVA and T-test. Results were as followings : College players showed significantly lower competition trait anxiety than highschool and professional players. Winner-group showed significantly lower competition trait anxiety than non-winner group. The three groups showed no statistically meaningful differences in the somatic and the cognitive state anxiety, but professional players showed significantly higher state self-confidence than highschool players. There were no differences in somatic state anxiety between winner group and non-winner group, but winner group showed significantly lower cognitive state anxiety and higher state self-confidence than non-winner group.

배양된 골수 간엽 간세포에서 골형성의 유도 및 그 표식 인자의 발현

석경수,김현우,한수봉 대한정형외과학회 골.연부조직이식학회 2003 대한골.연부 조직이식학회지 Vol.3 No.1

조직확장기 사용의 임상적 고찰

한흥수,김우경,김수신,백세민 大韓成形外科學會 1991 Archives of Plastic Surgery Vol.18 No.1

Recently, soft tissue expansion technique using tissue expanders has become a popular method for reconstruction of soft tissue defect because it provides high quality tissue with similar color, texture and hair bearing characteristics without significant donor site problems. During the period September, 1983 to December, 1988, we used tissue expanders to treat 36 patients with soft tissue defect, 3 scalp, 10 face, 6 neck, 4 trunk, 10 upper extremity, 3 lower extremity and evaluated the operative techniques, results and complications as follows. 1. We achieved favorable results in 31 cases(86.1%), especially in scalp, face and upper extremity, but poor results in lower extremity, especially below knee in location. 2. We experienced major complications in 2 cases(5.6%) such as implant exposure and minor complications in 7 cases(19.4%) such as hematoma, partial necrosis, infection, underlying bony depression etc. 3. Capsular excision is not desirable, but capsular release may permitted to acquire maximal length of the advancing flap. 4. In case of microtia, expanded tissue which was obtained from expanders is defficient for elevation of framework without skin graft. 5. Accurate and meticulous preoperative evaluation is the most important factor in achieving good and results.