Patient-specific surgical options for breast cancer-related lymphedema: technical tips

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient’s pathology, the treatment plan should be carefully decided and individualized. At the authors’ institution, the treatment plan is made individually based on each patient’s symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient’s pathophysiology, optimal outcomes can be achieved. Depending on each patient’s pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.

Patient-specific surgical options for breast cancer-related lymphedema: technical tips

In order to provide a physiological solution for patients with breast cancer-related lymphedema (BCRL), the surgeon must understand where and how the pathology of lymphedema occurred. Based on each patient’s pathology, the treatment plan should be carefully decided and individualized. At the authors’ institution, the treatment plan is made individually based on each patient’s symptoms and relative factors. Most early-stage patients first undergo decongestive therapy and then, depending on the efficacy of the treatment, a surgical approach is suggested. If the patient is indicated for surgery, all the points of lymphatic flow obstruction are carefully examined. Thus a BCRL patient can be considered for lymphaticovenous anastomosis (LVA), a lymph node flap, scar resection, or a combination thereof. LVA targets ectatic superficial collecting lymphatics, which are located within the deep fat layer, and preoperative mapping using ultrasonography is critical. If there is contracture on the axilla, axillary scar removal is indicated to relieve the vein pressure and allow better drainage. Furthermore, removing the scars and reconstructing the fat layer will allow a better chance for the lymphatics to regenerate. After complete removal of scar tissue, a regional fat flap or a superficial circumflex iliac artery perforator flap with lymph node transfer is performed. By deciding the surgical planning for BCRL based on each patient’s pathophysiology, optimal outcomes can be achieved. Depending on each patient’s pathophysiology, LVA, scar removal, vascularized lymph node transfer with a sufficient adipocutaneous flap, and simultaneous breast reconstruction should be planned.

MR Lymphangiography

Currently, there has been an increase in the use of surgical modalities to treat lymphedema and MR imaging to examine lymphatic vessels. Furthermore, there have been several advancements in the field of MR imaging, from the traditional heavily T2-weighted images to three-dimensional images. Three-dimensional images include spoiled gradient echo images, and numerous advanced techniques have been implemented. Among the fat suppression techniques, mDixon technique has recently been in the spotlight.

Local Subcutaneous Injection of Erythropoietin Might Improve Fat Graft Survival, Whereas Continuous Infusion Using an Osmotic Pump Device Was Harmful by Provoking an Overwhelming Foreign Body Reaction in a Nude Mouse Model

BACKGROUND: Since the survival of grafted fat requires successful revascularization, we hypothesized that local delivery of erythropoietin (EPO), a hemangiogenic and antiapoptotic factor, might enhance the survival of fat grafts in a nude mouse model. METHODS: Our experiment consisted of 2 parts. The first involved direct injection of EPO or saline at the grafting site before fat grafting and for 4 days afterwards. In the second part, EPO or saline was delivered continuously for 1 week via an osmotic pump device, and a group without an implantable pump represented the control group. After 16 weeks, the surviving fat grafts were weighed and subjected to histomorphometry. RESULTS: In the first experiment, fat graft survival was higher in the EPO-injected group, but not statistically significant (69.2% vs. 59.2%; P=0.21). Histomorphometry showed significantly higher levels of microvessel formation and less cystic degeneration in the EPO-injected group. In the second experiment, the survival rate was significantly lower in both pump groups than in the control group (40.7% in the EPO pump group, 7.7% in the saline pump group, and 66.7% in the control group). CONCLUSIONS: Local injection of EPO into the fat graft site appeared to improve graft survival, with increased angiogenesis, suppressed inflammation, and decreased degeneration. However, the insertion of an osmotic pump exerted detrimental effects on graft survival and the histomorphometric profiles of the fat graft compared with the control group due to the overwhelming foreign body reaction.

Safety, efficacy, and onset of a novel botulinum toxin type A (Nabota) for the treatment of glabellar frown lines: a single-arm, prospective, phase 4 clinical study

BACKGROUND: Safety, efficacy, and time to onset of effect of botulinum toxin type A is of importance to persons who seek improvement in glabellar frown lines, but this has not been well studied. The aim of this study was to determine the safety, efficacy, and onset of action of a newly developed botulinum toxin type A (Nabota) for the treatment of glabellar frown lines. METHODS: This was a single-arm, open-label, and phase 4 clinical study. Forty-two subjects with glabellar lines were treated with five times of intramuscular injection of 0.1 mL (4 U/0.1 mL) for a total of 20 U of Nabota. Efficacy and safety were assessed at 2, 3, 4, 5, and 14 days. Efficacy was assessed by the investigator and it was defined as a 1-point change on a 4-point scale. RESULTS: Improvement in glabellar frown lines at maximum frown was observed in 85.4% of subjects 2 days after administration. Improvement in glabellar lines at rest was observed in 51.2% of subjects 2 days after administration, and the proportion of subjects showing improvement increased with time. No severe adverse events were recorded. CONCLUSION: Onset of action was observed in the majority of subjects by 2 days after administration of Nabota. In addition, Nabota was found to be safe and effective for the treatment of glabellar frown lines.

Use of a helical composite free flap for alar defect reconstruction with a supermicrosurgical technique

The highly contoured nature of the nose and the abundant free margin makes it especially difficult to reconstruct. In this report, we describe the use of a new helical rim free flap technique for the reconstruction of full-thickness nasal alar defects via supermicrosurgery. Briefly, after a wide excision with a margin of 0.7 cm, an alar defect with a size of 1×1×0.5cm was obtained, which included the full thickness of the skin, mucosa, and lower lateral cartilage. Vessel dissection was performed in a straightforward manner, starting from the incision margin for flap harvest, without any further dissection for reach the greater trunk of the superficial temporal artery. The flap was inset in order to match the contour of the contralateral ala. We closed the donor site via rotation and advancement. No donor site morbidity was observed, despite the presence of a small scar that could easily be covered with hair. The alar contour was satisfactory, and the patient was satisfied with the results. The supermicrosurgical technique did not require further dissection to identify the vessels for anastomosis, leading to better cosmetic outcomes and a reduced operating time.

Thin elevation: A technique for achieving thin perforator flaps

Elevating thin flaps has long been a goal of reconstructive surgeons. Thin flaps have numerous advantages in reconstruction. In this study, we present a surgical method for elevating a thin flap and demonstrate the safety of the procedure. A retrospective review was performed of the electronic medical records of patients who underwent thin flap elevation for lower extremity reconstruction from April 2016 to September 2016 at the Department of Plastic Surgery of Asan Medical Center. All flaps included in this study were elevated above the superficial fascia. A total of 15 superficial circumflex iliac artery free flaps and 13 anterolateral thigh free flaps were enrolled in the study. The total complication rate was 17.56% (n=5), with total loss of the flap in one patient (3.57%) and partial necrosis of the flap in four patients (14.28%). No wound dehiscence or graft loss at the donor wound took place. Elevation above the superficial fascia is not inferior in terms of flap necrosis risk and is superior for reducing donor site morbidity. In addition to its safety, it yields good aesthetic results.

Topical EMLA Cream as a Pretreatment for Facial Lacerations

BACKGROUND: Topical anesthetics, such as eutectic mixture of local anesthetics (EMLA) cream, can be applied to reduce pain before minor procedure. This trial evaluated EMLA as pretreatment for facial lacerations and compared pain, discomfort and overall satisfaction. METHODS: This trial included consecutive emergency department patients > or =16 years of age who presented with simple facial lacerations. At triage, lacerations were allotted to either the routine processing group or EMLA pretreatment group according to date of admission. Initially, the emergency department doctors inspected each laceration, which were dressed with saline-soaked gauze. In the pretreatment group, EMLA cream was applied during wound inspection. The plastic surgeon then completed primary closure following the local injection of an anesthetic. After the procedure, all patients were given a questionnaire assessing pain using the 10-point visual analog scale (VAS) ("no pain" to "worst pain"). All questionnaires were collected by the emergency department nurse before discharge. RESULTS: Fifty patients were included in the routine processing group, and fifty patients were included in the EMLA pretreatment group. Median age was 39.9 years, 66% were male, and the average laceration was 2.67 cm in length. The EMLA pretreatment group reported lower pain scores in comparison with the routine processing group (2.4 vs. 4.5 on VAS, P<0.05), and lower discomfort scores during the procedure (2.0 vs. 3.3, P=0.60). Overall satisfaction was significantly higher in the EMLA pretreatment group (7.8 vs. 6.1, P<0.05). CONCLUSIONS: Pretreating facial lacerations with EMLA topical cream aids patients by reducing pain and further enhancing overall satisfaction during laceration treatment.

Use of cryopreserved cadaveric arterial allograft as a vascular conduit for peripheral arterial graft infection

Major peripheral arterial graft infection is a potentially devastating complication of vascular surgery, associated with significant mortality and high amputation rates. Autologous saphenous veins are considered optimal arterial conduits for lower extremity revascularization in infected fields, but they are often unavailable or unsuitable in these patients. This study describes two patients with major peripheral graft infection, but without available autologous veins, who underwent graft excision and cryopreserved cadaveric arterial allograft reconstruction. Although long-term graft durability is unclear because of gradual deterioration and degeneration, these findings suggest that cadaveric allografts may be good options for patients with major peripheral graft infection.

Diabetic foot ulcer

The clinical significance of diabetes is increasing with a growing aged population and changes in lifestyle. Among all complications of diabetes mellitus, diabetic ulcers are the most severe and expensive. The lifetime incidence of diabetic foot ulceration is as high as 25%. Ulcers frequently become infected and are associated with the risk of limb amputation and increased mortality and healthcare costs. A specialized multidisciplinary team approach is needed to care for patients with ulceration. Comorbidities such as poor limb circulation and the loss of protective sensation due to diabetic vasculopathy and neuropathy should be treated concurrently to promote wound healing. In cases of ischemia, transluminal angioplasty or bypass surgery may enhance circulation, allowing ulcer healing or reconstructive surgery. With an integrated team approach, the major focus of ulcer treatment has changed from amputation to limb salvage. Appropriate follow-up, including the minimization of risk factors and education on foot care in daily living, is essential to prevent re-ulceration.

Pedicled Perforator Flaps for Reconstruction of Bilateral Knee Defects: A Case Report

Reconstruction of soft tissue defects of the knee has always been a challenging task for plastic surgeons. Various reconstructive choices are available depending on the location, size, and depth of the defect relative to the knee joint. Defects on the knee joint have several characteristic features. The use of a free flap is preferred for reconstructions involving obliteration of large-cavity defects, but recipient pedicle isolation can be difficult because of the extent of the injury zone. Furthermore, the true defect during knee joint flexion is larger than during knee joint extension, and a durable flap is necessary for joint movement. We report for the first time on the use of pedicled perforator flaps for reconstruction of bilateral knee defects in a 76-year-old woman. The operative procedure required skeletonizing the perforators of an antero-lateral thigh flap and antero-medial thigh flap and rotating the flap in the defect. The patient returned to normal daily activity and had a full range of motion two months after the accident. The shorter operating time with decreased donor site morbidity and its durability make this flap a valuable alternative for soft tissue reconstruction of the knee.

Effect of Recombinant Human Epidermal Growth Factor Impregnated Chitosan Film on Hemostasis and Healing of Blood Vessels

BACKGROUND: Bleeding can be a problem in wound debridement. In search for an effective hemostatic agent, we experimented with a chitosan film combined with the recombinant human epidermal growth factor (rh-EGF), hypothesizing that it would achieve effective hemostasis and simultaneously enhance arterial healing. METHODS: Forty-eight Sprague-Dawley rats were used, and 96 puncture wounds were made. The wounds were divided into the following four groups: treated with sterile gauze, treated with gelatin sponge, treated with chitosan, and treated with chitosan combined with rh-EGF. Immediate hemostasis was evaluated, and arterial healing was observed histologically. RESULTS: Groups B, C, and D showed a significant rate of immediate hemostasis as compared to group A (P<0.05), but there were no significant differences among groups B, C, and D. Histologically, only group D showed good continuity of the vessel wall after 1 week. It was the only group to show smooth muscle cell nuclei of the vessel wall. CONCLUSIONS: We observed that chitosan has an effective hemostatic potential and the mix of rh-EGF and chitosan does not interfere with chitosan's hemostatic capabilities. We also identified enhanced healing of vessel walls when rh-EGF was added to chitosan. Further research based on these positive findings is needed to evaluate the potential use of this combination on difficult wounds like chronic diabetic ulcerations.

Superficial Circumflex Iliac Artery Perforator Free Flap for Reconstruction of Small or Medium Sized Defect on Lower Extremities

PURPOSE: For reconstruction of lower extremity defects, various flaps can be used and the appropriate flap must be selected and applied according to the size of the defect. In particular, in cases where the defect size is small to moderate, thinner or smaller volume flaps are useful. The authors performed reconstruction of small to moderate defects on the lower extremities using superficial circumflex iliac artery perforator free flaps and are reporting the results. MATERIALS AND METHODS: Fifteen patients underwent reconstruction of defects on lower extremity areas using superficial circumflex iliac artery perforator free flaps from July 2011 to July 2012 at this hospital. The flaps were elevated from above the deep fat layer, and, in all cases, the vessel diameter of the flaps was less than 1mm, with the exception of superficial vein that accompanied it. RESULTS: The mean follow up period was 4.46 months, and, despite a partial loss in the flap in two cases, there were no total losses. All donor sites were closed with primary closure, and there was no occurrence of complications, such as hematomas, seromas, or lymphorrheas. The patients were highly satisfied with the donor site scar since it could be masked by underwear. CONCLUSION: Compared to other flaps, superficial circumflex iliac artery perforator free flaps are thinner in thickness and smaller in volume, which results in a more natural contour of the recipient site after the operation. In addition, since the flap can be elevated from supra-deep fat layer, the operation time can be shortened, and lymphorrhea can be prevented, which in turn lessens donor-site morbidity.

Techniques in Lower Extremity Reconstruction with Supermicrosurgery

PURPOSE: The concept and development of perforator free flaps have led to significant advances in microsurgery. Ongoing developments in perforator free flap surgery are aimed at reducing complications and improving surgical outcomes. The aim of this study was to evaluate the effectiveness and application of supermicrosurgery in free flap surgery. MATERIALS AND METHODS: A total of 267 patients with soft tissue defects of the lower extremity due to various etiologies from January, 2007 to January, 2013. The patients received either an anterolateral thigh free flap (n=83), a superficial circumflex iliac artery free flap (n=152), an upper medial thigh free flap (n=19), or a superior gluteal artery perforator free flap (n=13). Microanastomosis was performed using a perforator-to-perforator technique, either end-to-end or end-to-side. RESULTS: The mean postoperative follow up period was eight months (range: one to 16 months) and flap loss occurred in 11 cases out of 267. All cases of flap loss occurred within two weeks of surgery due to either arterial insufficiency (n=5) or venous congestion (n=6). CONCLUSION: Supermicrosurgery enables the selection of the most efficient perforator for microanastomosis at the defect site. It also reduces the time required for dissection of recipient vessels, and reduces the possibility of injury to major vessels. Microsurgery using a vessel of less than 1 mm has been reported to increase the risk of flap failure; however, using the most advanced surgical tools and developing experience in the technique can produce success rates similar to those found in the literature.

Direct Percutaneous Alcohol Sclerotherapy for Venous Malformations of Head and Neck Region without Fluoroscopic Guidance: Technical Consideration and Outcome / 신경중재치료의학

PURPOSE: Alcohol is not used directly to the vascular lesion without mixing with the contrast agent because alcohol itself cannot be seen on the fluoroscopy. Since we have used alcohol for the venous malformations in the head and neck area, we realized that alcohol can be safely and effectively used without using fluoroscopy. We present the method of direct sclerotherapy using absolute alcohol without using fluoroscopy. MATERIALS AND METHODS: After obtaining and carefully analyzing direct puncture venogram, we used this technique in 22 patients who underwent alcohol sclerotherapy. Because fluoroscopy was not used during alcohol injection, the angiotable can be placed outside of C-arm so that alcohol was comfortably injected without any obstacle around the patients. Venogram can also be obtained between the injections to detect whether there is any dangerous venous outflow drainage such as the superior ophthalmic vein to the cavernous sinus. To control the venous outflow, local compression to the draining vein was applied. The result and complication such as skin necrosis, infection, and nerve injury were evaluated during mean follow-up period of 13 months (range, 1-63 months). RESULTS: The frequency of sclerotherapy was one in 16 and 2-5 in 6 patients. The volume of alcohol used per treatment session ranged from 2 to 18 mL (mean, 8.5 mL). There was the minimum change in 1 (4.5%), moderately decreased lesion in 12 (54.5%), and markedly decreased lesion in 9 (41%) patients. The patients did not reveal any complications during 12.9 months follow-up period. CONCLUSION: Direct puncture alcohol sclerotherapy without using fluoroscopy can be a safe and effective technique for treating venous malformation of the head and neck areas. In addition, the procedure can be performed in the comfortable position because biplane fluoroscopy would not be necessary.

A Case of Mycobacterium kansasii Cutaneous Infection in a Heart Transplant Recipient / 대한내과학회지

Mycobacterium kansasii is a slow-growing, nontuberculous mycobacterium (NTM) that primarily affects lung tissue. Cutaneous infection with M. kansasii has not been reported previously in heart transplant recipients in Korea. We report a case of cutaneous infection caused by M. kansasii in a heart transplant recipient. The patient was treated successfully for 18 months with ciprofloxacin, clarithromycin, ethambutol, and rifampin.

A Case of Mycobacterium kansasii Cutaneous Infection in a Heart Transplant Recipient / 대한내과학회지

Mycobacterium kansasii is a slow-growing, nontuberculous mycobacterium (NTM) that primarily affects lung tissue. Cutaneous infection with M. kansasii has not been reported previously in heart transplant recipients in Korea. We report a case of cutaneous infection caused by M. kansasii in a heart transplant recipient. The patient was treated successfully for 18 months with ciprofloxacin, clarithromycin, ethambutol, and rifampin.

Effect of Recombinant Human Epidermal Growth Factor Against Cutaneous Scar Formation in Murine Full-thickness Wound Healing

A visible cutaneous scar develops from the excess formation of immature collagen in response to an inflammatory reaction. This study examined the role of epidermal growth factor (EGF) in the formation of cutaneous scars. Twenty Crl:CD-1 (ICR) mice were used and 2 full-thickness skin wounds were made on the dorsum of each mouse. One of the wounds was treated with recombinant human EGF by local application and the other was treated with saline for control until complete healing was achieved. The EGF-treated group's wounds healed faster than the control group's. The width of the scar was smaller by 30% and the area was smaller by 26% in the EGF-treated group. Inflammatory cell numbers were significantly lower in the EGF-treated group. The expression of transforming growth factor (TGF)-beta1 in the EGF-treated group was increased. It was observed that the amount of collagen in the EGF-treated group was larger than the control group. In the EGF-treated group, the visible external scars were less noticeable than that in the control group. These results suggest that EGF can reduce cutaneous scars by suppressing inflammatory reactions, decreasing expression of TGF-beta1, and mediating the formation of collagen.

Reconstruction of Soft Tissue Defect with Free Flap in Pediatric Patients

PURPOSE: Free flap reconstruction in the pediatric population is difficult. However, microsurgery has had remarkable success rates in children. The aim of study is to present our clinical experience using free flap for reconstruction of soft tissue defects in children and to describe long-term follow-up results. METHODS: Between June 2002 and July 2010, 30 cases of pediatric reconstruction were performed with free flap. The authors analyzed several items, such as the kind of flap, associated complications, and growth problems. RESULTS: Among the 30 cases, 21 cases were due to traffic accidents, 5 to cancer, and 4 to falls and other soft tissue defects. The lower leg and foot were the most common sites of the lesion. In the free flap operations we have done, 20 cases involved an anterolateral thigh perforator free flap, 6 a superficial circumflex iliac perforator free flap, and 4 an upper medial thigh perforator free flap. In early postoperative complications, partial necrosis was seen in 2 cases, infection in 1 case, and the hematoma in 1 case. A satisfactory success rate and functional results were achieved. CONCLUSION: Free flap reconstruction in children allows satisfactory function with no significant effect on growth. Free flaps are regarded as the primary choice for selective pediatric reconstructive cases.

Appropriate Administration of Prophylactic Antibiotics in Clean Operations: A Preliminary Report

Surgical site infection is one of the most common hospital infections and surgical complications. Appropriate administration of prophylactic antibiotics is, therefore, important to reduce surgical site infection rate. The use of prophylactic antibiotics in Korea tends to be too long and clinical confirmation of safe reduction of oral antibiotics use is mandatory. This is a preliminary report on the results of reducing oral antibiotics from 5 to 2 days in clean plastic surgery patients. Patients who underwent clean operation under local anesthesia between June 2008 and December 2008 were included in this study. The patients were divided into two groups, and they received oral antibiotics for 2(group O2) or 5(group O5) days. Complication rates, related expenses, and patients' complaints regarding the medication were compared between the two groups, considering the intravenous antibiotics use. There was no significant systemic or infection-related complication. An overall complication rates were 2.8% in group O2, 4.8% in group O5. All the complications were regional and required no surgical intervention. There were no significant differences between total(p=0.72), intravenous antibiotics administered patients(p=0.08), and intravenous antibiotics non-administered patients(p=1.00). Oral antibiotics could safely be reduced to 2 days in clean plastic surgery excluding intravenous antibiotics.