Focused Issue of This Month 한국성형수술의현재와미래 J Korean Med Assoc 2011 June; 54(6): DOI: /jkma pissn: eissn:

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1 Focused Issue of This Month 한국성형수술의현재와미래 DOI: /jkma pissn: eissn: 한국두개안면성형수술의현재와미래 김석화 * 서울대학교의과대학서울대학교병원성형외과 Sukwha Kim, MD* Department of Plastic and Reconstructive Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea *Corresponding author: Sukwha Kim, kimsw@snu.ac.kr Received May 2, 2011 Accepted May 16, 2011 The five major areas of concern in craniofacial surgery are the cleft lip and palate, hemifacial microsomia, craniosynostosis and its accompanying craniofacial syndromes, maxillofacial surgery, and breakthrough research on the each of these. Furlow s double opposing Z-plasty and 2-flap palatoplasty are often used to correct the cleft palate. Hereafter, the most appropriate surgical timing and methods must be determined through a prospective randomized control study. Currently, Millard s rotation advancement flap technique is generally used to correct the cleft lip. The repair of a cleft lip and especially a bilateral cleft lip is supplemented by presurgical orthodontics. Effort toward mastering the simultaneous repair of the nose continues. For hemifacial microsomia, distraction osteogenesis, orthognathic surgery, and fat injection is employed to correct facial asymmetry. Tissue engineering will soon be introduced as a treatment option. Currently, craniosynostosis is treated with methods such as total calvarial vault remodeling, endoscopic suturectomy, and distraction osteogenesis. In the future, a simpler and less invasive surgical technique must be developed. Maxillofacial (orthognathic) surgery generally refers to the bilateral sagittal split ramus osteotomy and LeFort I osteotomy. In the future, minimally invasive surgical techniques using endoscopes or robots will be introduced. Through the development of recombinant DNA technology, genetic research of craniofacial anomalies has identified many relevant genes. In the future, gene therapy will be plausible. Through advancements in tissue engineering, regeneration of tissue to correct congenital craniofacial deformities through autologous stem cells and scaffolds will be conceivable in the near future. Keywords: Craniofacial surgery; Cleft lip; Cleft palate; Hemifacial microsomia; Craniosynostosis; Maxillofacial surgery 서 론 두개안면성형수술은성형외과영역에서가장큰분야중하나이다. 특히두개안면부의선천성기형을치료하 고, 여러가지원인에의한두개안면부의후천성변형을재건하는학문으로써, 성형외과학의근간이되어왔다고해도과언이아닐것이다. 최근들어미세수술의발달과암환자의증가로인한재건성형수술과, 사회적요구에의한미용성형 c Korean Medical Association This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 576 한국두개안면성형수술의현재와미래

2 특 집 수술의빈도가증가하고술기가많이발달하였으나, 두개안면성형수술은여전히성형외과영역의한축을담당하는중요한분야임에틀림이없다. 이논문의목적은두개안면성형수술의현재의상황과미래의발전방향에대해논의하고자한다. 구순구개열 1. 구개열 20세기초반의구개열 (cleft palate) 수술의목적은구개의길이를연장하여언어발달을원활하게하는것이었으나, 최근에는적절한언어발달뿐아니라상악을비롯한안면골의성장장해를피하는것이중요한논쟁거리가되었다. 이논쟁거리는주로언제수술을하고어떤수술방법을선택하는가에초점을맞췄다. 언어발달이 1세이전에시작되므로일찍구개열수술을할수록언어발달이좋아진다고한다. 반대로 5세까지도안면골의횡적성장 (transverse facial growth) 이완성되지않기때문에, 늦게수술하는것이성장에유리하다고한다. 이런이유로수술시기가병원마다조금씩다르다. 2세전, 18 개월전, 9-12개월, 혹은연구개는 3-6개월, 경구개는 개월에수술하는 2단계방법까지다양한결과가보고되고있다. 최근에는 12개월이전에수술하는것이가장인정받고있다 [1,2]. 수술방법으로현재까지가장널리이용되는연구개열의수술술기로는 Furlow 이중대립구개열수술 (Furlow double opposing Z-plasty) 이고, 경구개열의수술술기로는 von Langenbeck, Veau-Wardill-Kilner 구개성형술, 2피판구개성형술 (2 flap palatoplasty) 등의점막골막피판 (mucoperiosteal flap) 이주로사용되고있다 [1-3]. 미래에는전향적무작위배정대조군연구 (prospective randomized control study) 를통해서, 가장적절한수술시기와수술방법이조사되어야하고, 성장이완료되는성인까지의추적관찰연구도병행되어야겠다. 2. 구순열 Millard의회전전진피판술 (rotation advancement flap) 은디자인이쉽고, 수술중수정이가능하고, 내측입술분절의길이와외측입술분절의길이의차이를조정하기쉽고, 봉합선이인중기둥 (philtral column) 과콧구멍바닥 (nostril floor) 에놓이게되어수술흉터가눈에잘띄지않는장점으로인해, 현재구순열 (cleft lip) 수술의표준이되고있다. 최근에는여러술자들에의해 Millard의회전전진피판술을변형시킨여러가지방법이소개되고있으나, 대부분은큰차이가없는방법들이다. 표정을지을때도입술모양이일그러지지않는구순열수술법에대한연구가진행될것으로보인다 [4,5]. 반안면왜소증 반안면왜소증 (hemifacial microsomia) 혹은두개안면왜소증 (craniofacial microsomia) 은제 1, 2 새궁 (branchial arches) 으로부터유래하는구조물의기형이생긴질환으로, 상악과하악의저형성, 소이증, 무이증, 청력소실등의귀변형등이대표적증상이다. 반안면왜소증은임상양상이매우다양한것이특징인데, 다양한임상양상을잘표현하고분류하기위해서 OMENS 분류법을사용하고있다. OMENS 분류법이란눈 (orbit), 하악 (mandible), 귀 (ear), 신경 (nerve), 연부조직 (soft tissue) 을기준으로임상양상을기술하는것으로, 임상양상의심한정도도함께기술할수있는것이장점이다 [6,7]. 반안면왜소증의심한정도는쥐젖 (skin tag) 이있고경미한안면비대칭부터, 소이증을동반하고하악의심한저형성으로호흡곤란이있는경우까지매우다양한편이다. 치료의목표는호흡곤란을예방, 치료하고, 정상식이를가능케하며청력을보존하고안면부비대칭을교정하고, 적절한치아의교합을유지하는것인데, 이치료들은안면부의적절한성장과발달을위해나이에따라다르고각시기마다특징적인치료가필요하다. 그러므로성형외과, 소아과, 치과, 이비인후과, 신경외과, 유전학과, 정신과, 안과, 언어치료과, 영양과등이협진하는체계적인치료가꼭필요하다. 과거에는주로비대칭인하악의교정을위해서단순히연골이식술혹은골이식술을하였으나, 현재는골신연술 (dis- 대한의사협회지 577

3 Kim SH traction osteogenesis), 악교정수술 (maxillofacial surgery), 지방이식술 (fat injection) 을이용하여하악과안면부의비대칭을효과적으로교정하고있다. 미래에는줄기세포를이용하거나조직공학 (tissue engineering) 을이용하여, 병변으로인해덜발달한부위를재건해주는치료가도입될것으로보인다. 두개골조기유합증 두개골조기유합증 (craniosynostosis) 은두개골봉합선이조기에닫히는질환으로, 뇌와두개골의성장을방해하여, 뇌압이증가하여뇌혈류량이줄고, 실명, 경련등여러가지신경학적합병증을초래할수있다. 두개골조기유합증의수술적방법이약 100여년전에소개된후현재까지계속해서진화하고있다. 초기에는봉합선절골술 (suturectomy) 과두개골대상절제술 (strip craniectomy) 을하였으나, 절골술을한자리에재골화 (reossification) 가생기고, 매우어린영아에서는효과가있으나두개골조기유합증이진행된나이많은어린이에게는효과가별로없었다. 이를해결하기위해 년대에두개관개조술 (extensive calvarial remodeling) 이소개되었고, 기능적인면뿐아니라, 미용적으로도우수한결과를얻을수있었다. 그러나이런수술은긴수술시간과입원기간, 수혈이필요할정도의많은출혈등의합병증이생기게되었다. 이로인해최근에는내시경봉합선절골술 (endoscopic suturectomy) 을시도하고있다. 또한조기에유합된봉합선을절골한후, 두개골신연술 (distraction osteogenesis) 로치료하고있다. 미래에내시경봉합선절골술과두개골신연술의대규모수술후결과와장기간의추적관찰후의결과가조사되어야할것이다 [8-11]. 악교정수술 하악지 (ramus) 를시상분할 (sagittal splitting) 하는하악지시상분할법이하악의악교정수술의주를이루고있고이것은골접합면이넓어서악간고정 (intermaxillary fixation) 기간이짧은것이큰장점이다 [12,13]. LeFort I 상악골절골술 (LeFort I maxillary osteotomy) 뿐아니라 LeFort III 상악골절골술, 전두안면골단일블록전진절골술 (frontofacial monobloc advancement osteotomy) 등이선천성두개악안면기형에필요에따라서다양하게사용되어수술의결과가크게향상되고있다 [12,13]. 최근에우리나라에서는작은얼굴과어리게보이는얼굴을선호하는사회적경향으로인해미용적목적의악교정수술이많이시행되고있다. 이와더불어구순구개열환자와선천성두개악안면기형환자의악골성장이완료된이후에치아부정교합 (malocclusion) 과미용적목적을위해서악교정수술이보편화되고있는추세이다. 미래에는 2차원평면상의두개안면계측을통한환자의진단및치료의계획을세우는것이아니라 3차원공간에서두개안면계측으로환자를진단및치료를계획하는것이보편화될것이며, 수술법에서는수술후합병증을줄이고, 빠른회복을위한최소침습 (minimal invasive) 개념의내시경이나로봇을이용한악교정수술이도입될것으로예상된다. 또한환자들이매우불편해하는수술후악간고정기간을줄이기위한고정방법이나골치유속도를증진하는방법이연구되어소개될것이고, 수술후부정교합이나재발의원인이되는부정확한하악골과두 (condyle) 의위치를해결하는획기적인방법이소개될것이다. 두개안면기형연구 1. 유전자연구 두개안면기형 (craniofacial anomaly) 의유전자연구는지난 20여년동안유전자재조합기술 (recombinant DNA technology) 의발달로인해폭발적으로발달하였다. 50개이상의두개안면증후군 (craniofacial syndrome) 에서질병과관련된유전자가밝혀졌다. 인간의전체염색체를밝히는연구 (whole genome sequencing project) 가진행됨에따라서, 미래에는두개안면기형과관련된모든유전자가밝혀질것이고, 이를이용한유전자치료가가능할것으로예상된다 [14]. 578 한국두개안면성형수술의현재와미래

4 특 집 2. 조직공학 과거의두개안면기형에대한연구는주로임상적인연구 이었다. 최근에분자생물학이발달하고, 특히줄기세포에 대한연구와관심이증가함에따라줄기세포를이용해조직 (tissue) 결손을재건하려는연구가많이시도되고있다. 선 천성두개안면기형으로인한조직의결손이나, 외상, 암절 제술후의조직결손에서자가 (autologous) 줄기세포와지 지체 (scaffold) 를이용해결손된조직을재생하려는연구는 앞으로계속되어멀지않아임상에서실현될수있을것이다 [15,16]. 3. 안면부이종이식 2005 년 11 월프랑스에서개에물려안면부를손상당한 여성에게최초로안면부이종이식 (facial allotransplantation) 이실시된이후, 현재까지전세계적으로 12 명의환자 에게안면부이종이식이시행되었다. 면역억제제의발달과 미세수술의발달로인해가능하게된것인데국내에서는아 직시도된바가없다. 국내에서도안면부의심한손상으로 고통을받고있는환자를위해조만간시행되어야할것으로 생각된다. 국립장기이식관리센터와협력하여장기적출에 관한규정을개정하고, 의학연구윤리심의위원회와협력하 여안면부이종이식수술이승인되도록추진해야할것이다 [17-19]. 미래에는외상, 암등으로생긴두개안면부의결손 뿐만아니라, 선천성두개안면기형으로이상이생긴조직을 이종이식하여그기능과모양을회복시켜주는날도도래할 것으로생각한다 [20]. 결 론 구순구개열, 반안면왜소증, 두개골조기유합증, 악교정수술 로대표되는두개안면성형수술은과거부터현재까지그랬듯 이미래에도더욱더발전할것이다. 특히두개안면성형수술과 관련된연구, 그중에서도조직공학의발달로인해결손된조 직을완벽히재건할수있는날이머지않아올것으로보인다. 핵심용어 : 두개안면성형수술 ; 구순열 ; 구개열 ; 반안면왜소증 ; 두개골조기유합증 ; 악교정수술 REFERENCES 21. Sadove AM, van Aalst JA, Culp JA. Cleft palate repair: art and issues. Clin Plast Surg 2004;31: Hoffman WY, Mount D. Cleft palate repair. In: Mathes SJ, Hentz VR. Plastic surgery. Philadelphia: Saunders; p Noorchashm N, Dudas JR, Ford M, Gastman B, Deleyiannis FW, Vecchione L, Jiang S, Cooper GM, Haralam MA, Losee JE. Conversion Furlow palatoplasty: salvage of speech after straight-line palatoplasty and incomplete intravelar veloplasty. Ann Plast Surg 2006;56: Demke JC, Tatum SA. Analysis and evolution of rotation principles in unilateral cleft lip repair. J Plast Reconstr Aesthet Surg 2011;64: Kim SW, Oh M, Park JL, Oh AK, Park CG. Functional reconstruction of the philtral ridge and dimple in the repaired cleft lip. J Craniofac Surg 2007;18: Heike CL, Hing AV. Craniofacial microsomia overview. In: Pagon RA, Bird TD, Dolan CR, Stephens K. GeneReviews [Internet]. Seattle: University of Washington [updated 2009 Mar 19; cited 2011 May 17]. Available from: nlm.nih.gov/books/nbk Werler MM, Starr JR, Cloonan YK, Speltz ML. Hemifacial microsomia: from gestation to childhood. J Craniofac Surg 2009;20 Suppl 1: Mehta VA, Bettegowda C, Jallo GI, Ahn ES. The evolution of surgical management for craniosynostosis. Neurosurg Focus 2010;29:E Do Amaral CM, Di Domizio G, Tiziani V, Galhardi F, Buzzo CL, Rinco T, Kharmandayan P, Bueno MA, Bolzani N, Sabbatini RM, Lopes LD, Lopes PF, Paiva B, Paiva RM, Turchiari LA. Gradual bone distraction in craniosynostosis. Preliminary results in seven cases. Scand J Plast Reconstr Surg Hand Surg 1997;31: Mofid MM, Manson PN, Robertson BC, Tufaro AP, Elias JJ, Vander Kolk CA. Craniofacial distraction osteogenesis: a review of 3278 cases. Plast Reconstr Surg 2001;108: Cho BC, Hwang SK, Uhm Kl. Distraction osteogenesis of the cranial vault for the treatment of craniofacial synostosis. J Craniofac Surg 2004;15: Hausamen JE. The scientific development of maxillofacial surgery in the 20th century and an outlook into the future. J Craniomaxillofac Surg 2001;29: Rotas N, Sykes JM. Esthetic orthognathic surgery. Facial Plast Surg Clin North Am 2002;10: Global strategies to reduce the health care burden of cranio- 대한의사협회지 579

5 Kim SH facial anomalies: report of WHO meetings on international collaborative research on craniofacial anomalies. Cleft Palate Craniofac J 2004;41: Garcia-Godoy F, Murray PE. Status and potential commercial impact of stem cell-based treatments on dental and craniofacial regeneration. Stem Cells Dev 2006;15: Runyan CM, Taylor JA. Clinical applications of stem cells in craniofacial surgery. Facial Plast Surg 2010;26: Devauchelle B, Badet L, Lengele B, Morelon E, Testelin S, Michallet M, D Hauthuille C, Dubernard JM. First human face allograft: early report. Lancet 2006;368: Hui-Chou HG, Nam AJ, Rodriguez ED. Clinical facial composite tissue allotransplantation: a review of the first four global experiences and future implications. Plast Reconstr Surg 2010;125: Plastic surgery smartbrief [Internet]. Arlington Heights: American Society of Plastic Surgeons; 2011 [cited 2011 Jun 7]. Available from: veservlet?issueid=cee279be-c7a5-42be-8e3d-f295 D2D2D3D8&lmid=archives. 20. Washington KM, Zanoun RR, Cadogan KA, Afrooz PN, Losee JE. Composite tissue allotransplantation for the reconstruction of congenital craniofacial defects. Transplant Proc 2009;41: Peer Reviewers Commentary 본논문은현재한국두개안면성형수술의실태를구순구개열, 반안면왜소증, 두개골조기유합증, 악교정수술, 기초연구분야로나누어잘설명하고있다. 뿐만아니라이들각분야에서현재활발히진행되고있는발전방향에대하여도기술하였으며, 향후유전공학, 조직공학, 이종이식의발전과더불어두개안면성형분야에서기대하거나연구중인부분을소개함으로써미래를내다보고준비할수있는시야를제공하고있는점이좋았다. 다만지면에제한을받아서인지일차기형의교정술후에남아있는이차변형, 예를들면, 구순열비변형, 두개골조기유합증의이차변형 등에대한내용이빠져있는점이아쉽다. [ 정리 : 편집위원회 ] 580 한국두개안면성형수술의현재와미래

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100520_1840È£_Ä¡ÀÇ½Åº¸__³»Áö.pdf A gift to our Dental Artists! The New Genaration Flowable Resin 3 People 5 6 7 The 6th Congresss of the International Cleft Palate Foundation in conjunction with 14th National Congress of Korean Cleft