The Lazy S Design: A Novel Skin Closure Design in Skin-Sparing Mastectomy for Implant-Based Breast Reconstruction

Preservation of the breast skin envelope during immediate implant-based breast reconstruction is important for producing symmetrical and natural-looking breasts. We propose the lazy S design for the closure of round-shaped wounds with the hope of improving the aesthetic outcomes and reducing the tension on the wound by preserving the skin. Additionally, the direction of tension is dispersed due to the shape of this design. Patients undergoing implant reconstruction after skin-sparing mastectomy may benefit from the lazy S design.

Reconstruction of the Foot Using a Superficial Inferior Epigastric Artery Free Flap

When foot reconstruction is performed in the pretibial area, the ankle, or the dorsum of the foot, the need for a reliable flap remains a challenge. We found that the superficial inferior epigastric artery (SIEA) free flap can be used as an alternative tool for this purpose, as it helps to solve the problems associated with other flaps. We describe 2 cases in which we reconstructed the foot using an SIEA free flap, which was pliable enough to fit the contours of the area. Postoperatively, the flaps were intact and showed excellent aesthetic results. Thus, the SIEA free flap can be an alternative tool for patients with a low body mass index who undergo reconstructive surgery involving the pretibial area, ankle, knee, or dorsum of the foot, all of which require a soft and flexible flap.

Comparison of the Amount of Drainage in 3 Acellular Dermal Matrices in Implant-Based Breast Reconstruction: A Retrospective Study

BACKGROUND: Acellular dermal matrix (ADM)-assisted breast reconstruction has gained popularity because it has several advantages. Some studies have reported that the use of ADM was strongly associated with postoperative complications, especially seroma formation. We performed direct-to-implant breast reconstruction using 3 types of human allograft products (CGDerm®, AlloDerm®, and MegaDerm®). The purpose of this study was to obtain information useful for the selection of an ADM product by comparing the amount of collected serum and the maintenance period of the drain. METHODS: Seventy-three patients with breast cancer who underwent ADM-assisted implant breast reconstruction between March 2011 and January 2016 were included in this study. The patients were divided into 3 groups based on the type of ADM that was used. The demographic characteristics collected were: age, body mass index (BMI), breast reconstruction location, smoking history, axillary dissection, comorbidities (such as hypertension and diabetes mellitus [DM]), breast implant size, breast implant type, amount of ADM, the total amount of serum that was collected in the drain, and the maintenance period of the drain. RESULTS: We obtained significant results after adjusting for variables including age, BMI, DM, axillary dissection, ADM amount, and breast implant size. Compared to AlloDerm, MegaDerm showed a significantly smaller amount of total drained serum and a significantly shorter drain maintenance period. CONCLUSIONS: The use of MegaDerm led to smaller amounts of drained serum and a shorter drain maintenance period than when AlloDerm was used. In contrast, no significant differences were found between CGDerm and AlloDerm, or between CGDerm and MegaDerm.

Early Management of Scars Using a 532-nm Nd:YAG Laser

BACKGROUND: Laser therapy is generally postponed until scar maturation. We speculated that the use of laser therapy at the beginning of the wound healing process might minimize discomfort and problems at an early stage. METHODS: From January 2013 to May 2014, we conducted a study of 50 patients who underwent primary closure or scar revision procedures due to facial scarring. Within 1 to 2 weeks after the removal of all stitches, we performed laser treatments with a 532-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser. To assess the improvement of the scars, we evaluated the scars using the Vancouver Scar Scale (VSS) and conducted a photo analysis using a computer graphics program. RESULTS: The mean score on the VSS decreased from 5.99 to 1.49 after the laser treatment. The score for each evaluation item decreased, meaning that the scars improved. The differences showed statistical significance. In the photo analysis that was conducted using Adobe Photoshop, the mean brightness of the pixels located within the scar territory increased from 61.54% to 69.42% after laser treatment, and the mean chroma decreased from 50.65% to 43.12%. These changes were statistically significant. CONCLUSIONS: We used a 532-nm Nd:YAG laser at an early stage of scar formation and confirmed improvements in the redness, hyperpigmentation, and hypertrophy of the scars shortly after treatment.

Comparison of the Amount of Drainage in 3 Acellular Dermal Matrices in Implant-Based Breast Reconstruction: A Retrospective Study

BACKGROUND: Acellular dermal matrix (ADM)-assisted breast reconstruction has gained popularity because it has several advantages. Some studies have reported that the use of ADM was strongly associated with postoperative complications, especially seroma formation. We performed direct-to-implant breast reconstruction using 3 types of human allograft products (CGDerm®, AlloDerm®, and MegaDerm®). The purpose of this study was to obtain information useful for the selection of an ADM product by comparing the amount of collected serum and the maintenance period of the drain. METHODS: Seventy-three patients with breast cancer who underwent ADM-assisted implant breast reconstruction between March 2011 and January 2016 were included in this study. The patients were divided into 3 groups based on the type of ADM that was used. The demographic characteristics collected were: age, body mass index (BMI), breast reconstruction location, smoking history, axillary dissection, comorbidities (such as hypertension and diabetes mellitus [DM]), breast implant size, breast implant type, amount of ADM, the total amount of serum that was collected in the drain, and the maintenance period of the drain. RESULTS: We obtained significant results after adjusting for variables including age, BMI, DM, axillary dissection, ADM amount, and breast implant size. Compared to AlloDerm, MegaDerm showed a significantly smaller amount of total drained serum and a significantly shorter drain maintenance period. CONCLUSIONS: The use of MegaDerm led to smaller amounts of drained serum and a shorter drain maintenance period than when AlloDerm was used. In contrast, no significant differences were found between CGDerm and AlloDerm, or between CGDerm and MegaDerm.

Early Management of Scars Using a 532-nm Nd:YAG Laser

BACKGROUND: Laser therapy is generally postponed until scar maturation. We speculated that the use of laser therapy at the beginning of the wound healing process might minimize discomfort and problems at an early stage. METHODS: From January 2013 to May 2014, we conducted a study of 50 patients who underwent primary closure or scar revision procedures due to facial scarring. Within 1 to 2 weeks after the removal of all stitches, we performed laser treatments with a 532-nm neodymium-doped yttrium aluminium garnet (Nd:YAG) laser. To assess the improvement of the scars, we evaluated the scars using the Vancouver Scar Scale (VSS) and conducted a photo analysis using a computer graphics program. RESULTS: The mean score on the VSS decreased from 5.99 to 1.49 after the laser treatment. The score for each evaluation item decreased, meaning that the scars improved. The differences showed statistical significance. In the photo analysis that was conducted using Adobe Photoshop, the mean brightness of the pixels located within the scar territory increased from 61.54% to 69.42% after laser treatment, and the mean chroma decreased from 50.65% to 43.12%. These changes were statistically significant. CONCLUSIONS: We used a 532-nm Nd:YAG laser at an early stage of scar formation and confirmed improvements in the redness, hyperpigmentation, and hypertrophy of the scars shortly after treatment.

Deep-Plane Lipoabdominoplasty in East Asians

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Deep-Plane Lipoabdominoplasty in East Asians

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Immediate Implant Reconstruction after Eliminating Polyacrylamide Hydrogel (Amazingel) in Complicated Breasts

Many injection materials have been used in cosmetic surgery for soft-tissue contour correction or breast augmentation. In China, Amazingel injection mammaplasty had been used widely because the procedure was non-invasive and easy to perform. But, numerous complications have been reported after injection of Amazingel composed of polyacrylamide gel such as breast pain, hardening, deformity, lump, gel migration, etc. In this article, we report a case of a 37-year-old Chinese female who complained of breast discomfort and deformity after Amazingel injection. We safely eliminated Amazingel and reconstructed the breasts with silicone implants. We could achieve aesthetically tolerable results.

Methylene Blue Dye-Induced Skin Necrosis in Immediate Breast Reconstruction: Evaluation and Management

BACKGROUND: For early breast cancer patients, skin-sparing mastectomy or nipple-sparing mastectomy with sentinel lymph node biopsy has become the mainstream treatment for immediate breast reconstruction in possible cases. However, a few cases of skin necrosis caused by methylene blue dye (MBD) used for sentinel lymph node localization have been reported. METHODS: Immediate breast reconstruction using a silicone implant was performed on 35 breasts of 34 patients after mastectomy. For sentinel lymph node localization, 1% MBD (3 mL) was injected into the subareolar area. The operation site was inspected in the postoperative evaluation. RESULTS: Six cases of immediate breast reconstruction using implants were complicated by methylene blue dye. One case of local infection was improved by conservative treatment. In two cases, partial necrosis and wound dehiscence of the incision areas were observed; thus, debridement and closure were performed. Of the three cases of wide skin necrosis, two cases underwent removal of the dead tissue and implants, followed by primary closure. In the other case, the breast implant was salvaged using latissimus dorsi musculocutaneous flap reconstruction. CONCLUSIONS: The complications were caused by MBD toxicity, which aggravated blood disturbance and skin tension after implant insertion. When planning immediate breast reconstruction using silicone implants, complications of MBD should be discussed in detail prior to surgery, and appropriate management in the event of complications is required.

Staged Scar Revision of Angulated Facial Scar

Scar revision techniques are chief among the most important skills for facial plastic and reconstructive surgeons. In order to achieve the least amount of scarring following a surgical procedure, it is crucial that the surgeon always consider skin tension. In our hospital, staged scar revision was conducted on patients with angulated facial scars in order to reduce skin tension. We conducted a retrospective chart review of patients undergoing staged scar revision for angulated facial scars at our hospital from July 2002 to September 2010. The follow-up period was at least six months. All pre-and post-operative photographs were analyzed by two independent plastic surgeons. And the patients were asked to rate their overall satisfaction with their scar revision as very satisfied(5), satisfied(4), neutral(3), dissatisfied(2) or completely dissatisfied(1). Staged scar revision was used in 51 patients with angulated facial scars. Overall, a significantly improved scar and above(score > or =4), graded by an independent plastic surgerns, was notes in 47 patients(92.1%). And, 45 patients(88.2%) were satisfied with their scar revisions. In all cases, the postoperative clinical course was uneventful without any complications. In conclusion, staged scar revision is considered a good option for the treatment of angulated facial scar.

Clinical Experiences with Foreign Body Granuloma of the Nose: 7-Year Experience with 18 Patients

PURPOSE: The injection of various materials, including medical fillers and unregulated products, is widespread, potentially causing the development of foreign body granulomas. Should this occur on the nose, the contour deformity and inflammatory signs that result from these granulomas are aesthetically undesirable to patients. The purpose of our study is to share our experiences using different surgical approaches, depending on the affected portion of the nose, to optimize management of this challenging problem and to evaluate patient's satisfaction using our in-house questionnaire along with degree of improvement by two independent plastic surgeons. METHODS: We treated 18 patients who underwent surgical excision of nasal foreign body granulomas via a perilesional approach to the lesion (n=12) or by transcolumellar incision (n=6) at our hospital over a period of seven years from March 2003 to October 2010. Nonparametric statistics were used and are presented as medians (25th-75th). Patient satisfaction was evaluated on a scale of 1 to 5 using an in-house questionnaire. All pre-and post-operative photographs were analyzed by two independent plastic surgeons. Post-operative outcomes were evaluated based on the surgeons' consensus ratings. RESULTS: All patients receiving the transcolumellar approach reported a high level of satisfaction with the results. All but two patients who received the perilesional approach were satisfied with the outcome. No outcomes were rated as no change or worse by the consensus ratings. CONCLUSION: For the upper two-thirds of the nose, perilesional surgical excision can lead to substantial patient satisfaction with modified contour deformity and infection control. The transcolumellar approach resulted in better outcomes and patient satisfaction for the lower one-third of the nose.

Absence of Linea Alba in Breast Reconstruction with Pedicled TRAM Flap: A Case Report

PURPOSE: The anatomical anomaly of the rectus abdominis muscle and it's fascia is very rare. No case of the absence of the linea alba below the umbilicus has yet been reported. During breast reconstruction with pedicled TRAM flap, we experienced one case of absence of linea alba. METHODS: The patient was a 38-years old female who underwent immediate breast reconstruction with pedicled TRAM flap after Right modified radical mastectomy in June 2010. While the TRAM flap was being elevated, bilateral twitching of the rectus abdominis muscle occurred when electrocautery was applied, and we found the absence of the linea alba below the umbilicus. RESULTS: When the rectus abdominis muscle was exposed, the linea alba below the umbilicus was not observed, and the bilateral rectus abdominis muscle was indistinguishably fused in a gross observation. In addition, bilateral twitching of rectus abdominis muscle was simultaneously observed as one muscle unit when electrocautery was applied. As with both rectus abdominis muscles was bluntly dissected with scissors, the scanty fatty tissues were observed between the both rectus muscles, and the bilateral rectus abdominis muscle was easily separated. The flap was transposed into the corresponding defect to make breast mound. Midline fascia was fixed to the posterior rectus sheath to reconstruct smilar anatomic linea alba. Abdominal defect was reinforced by suturing between remaining anterior rectus sheath. CONCLUSION: As the unexpected anatomical anomaly may affect the operation outcome, surgeons should be careful when they unexpectedly encounter the anatomical anomaly during an operation. Here, we report a rare case of absence of the linea alba seen at the time of pedicled TRAM flap elevation for breast reconstruction.

120 Cases of Facial Foreign Body Granuloma

PURPOSE: As the use of soft tissue fillers becomes more popular, complications such as foreign body granuloma (FBG) are increasing. We report 120 cases of facial FBG and review the available literatures. METHODS: 120 patients of facial FBG in our clinic from Mar. 2003 to Feb. 2008 were complied and analyzed. A retrospective chart review was done and patient satisfaction was evaluated with a questionnaire using 5 score scale. Patients with severe inflammation sign or bizarre deformity underwent surgical excision and those with minimal symptoms or a history of hyaluronic acid injection received injection therapy using hyaluronidase. RESULTS: 100 females and 20 males were observed. The average age was 43.7 years(from 16 to 74). 84 patients received surgical therapy and 36, injection therapy. Deformity of facial contour, foreign body sensation and inflammation sign were the three main chief complaints. 84 patients did not know what the injection materials were. The known materials are as follows: collagen, hyaluronic acid, silicone oil, paraffin. 92 cases were performed by unlicensed practitioners, 29 by physicians. Anatomical site most frequently affected by the foreign body granuloma was the cheek (25.8%), followed by forehead(19.2%), lips (15.8%), nose (9.2%), mentum(8.3%), eyelid and eyebrow (4.3%) and temple(0.8%). In 21 patients(17.5%), FBGs were found on multiple sites. Patients with inflammation sign got the highest satisfaction(3.19+/-0.73)(p=0.001) among 3 chief complaints. And patient satisfaction was statistically higher in surgical therapy group(3.43+/-0.72) than in injection therapy group(2.97+/-0.88)(p=0.003). CONCLUSION: We suggest that it may be beneficial to tailor the type of treatment for FBG relying on wound state and patient's chief complaints. In surgical therapy, resolute approach is necessary to correct facial deformity definitely and to minimize inflammation. Injection therapy could be another option for those with minimal symptoms or a history of hyaluronic acid injection. To prevent foreign body granuloma, not only plastic surgeons but also other physicians should inject soft tissue fillers with great caution and we should warn the public of disastrous consequences associated with illegal medical practice.

Immediate Breast Reconstruction after Skin-Sparing Mastectomy

No abstract available.

Immediate One-Stage Breast Reconstruction Including Nipple-Areolar Complex

As surgical trend for breast cancer changes, the method for breast reconstruction is also changing. Due to improved diagnostic techniques and public awareness, more and more patients with breast cancer are diagnosed at earlier stage and the number of patients who undergo skin sparing mastectomy is also increasing. Skin sparing mastectomy has several advantages for immediate breast reconstruction over modified radical mastectomy. Its preservation of breast skin envelope and inframammary fold made it possible to provide more natural breast mound shape without any evidence of increased local recurrence of malignancy. Furthermore, in case of immediate breast reconstruction after modified radical mastectomy, procedures for nipple-areolar reconstruction was deferred for fear of postoperative deformation and vascular problem of the flap. This interval made patients less satisfied with the result and postoperative adjuvant treatment had to be sometimes postponed. To avoid these limitations, "one-stage" breast reconstruction including nipple-areolar complex was performed after skin sparing mastectomy. From December 1998 to March 2000, a total of 12 patients with breast cancer underwent skin-sparing mastectomies, which were followed by immediate reconstruction using our new technique. After long-term follow-up, no major complication including flap necrosis or asymmetry was found and all patients were satisfied with the results. With careful patient selection and adequate intra-operative flap tailoring, this new technique could offer lots of advantages to both surgeons and patients.

Immediate One-Stage Breast Reconstruction Including Nipple-Areolar Complex

As surgical trend for breast cancer changes, the method for breast reconstruction is also changing. Due to improved diagnostic techniques and public awareness, more and more patients with breast cancer are diagnosed at earlier stage and the number of patients who undergo skin sparing mastectomy is also increasing. Skin sparing mastectomy has several advantages for immediate breast reconstruction over modified radical mastectomy. Its preservation of breast skin envelope and inframammary fold made it possible to provide more natural breast mound shape without any evidence of increased local recurrence of malignancy. Furthermore, in case of immediate breast reconstruction after modified radical mastectomy, procedures for nipple-areolar reconstruction was deferred for fear of postoperative deformation and vascular problem of the flap. This interval made patients less satisfied with the result and postoperative adjuvant treatment had to be sometimes postponed. To avoid these limitations, "one-stage" breast reconstruction including nipple-areolar complex was performed after skin sparing mastectomy. From December 1998 to March 2000, a total of 12 patients with breast cancer underwent skin-sparing mastectomies, which were followed by immediate reconstruction using our new technique. After long-term follow-up, no major complication including flap necrosis or asymmetry was found and all patients were satisfied with the results. With careful patient selection and adequate intra-operative flap tailoring, this new technique could offer lots of advantages to both surgeons and patients.

Repair of Complete Cleft Palate by Modified 2-Flap Palatoplasty

The goal of palatoplasty is focused on two points. One is to close the palatal defect completely and the other is to create velopharyngeal system for normal speech production. After palatoplasty, scaring of palatal bare area is an important factor contributing to maxillofacial growth aberration. Bardach reported that most palatal clefts could be closed without bare bone by using the two-flap palatoplasty. On the basis of clinical experiences of the two-flap palatoplasty, authors made the lateral incision on the noncleft side to decrease the chance of bony exposure. From November 2000 to January 2001, nine children with complete cleft palate underwent two-flap palatoplasty without lateral incision on noncleft side (modified two-flap palatoplasty). Mean age at cleft repair was 11.2 months, and mean follow-up period was 2.9 months. Incision was performed on the medial edges of both side and the alveolar ridge of the cleft side. After elevation, the mucoperiosteal flaps of both sides were rotated downward. The palatal gap was simply closed without tension. Palatal fistula did not occur, and there was no postoperative bleeding. Modified two-flap palatoplasty method can be suggested to reduce the bare bone exposure, scarring and resultant growth disturbance. However, more in-depth study by long term follow-up is needed to evaluate growth pattern and speech evaluation.