Orbital wall restoring surgery with resorbable mesh plate

BACKGROUND: Orbital resorbable mesh plates are adequate to use for isolated floor and medial wall fractures with an intact bony buttress, but are not recommended to use for large orbital wall fractures that need load bearing support. The author previously reported an orbital wall restoring surgery that restored the orbital floor to its prior position through the transnasal approach and maintained temporary extraorbital support with a balloon in the maxillary sinus. Extraorbital support could reduce the load applied on the orbital implants in orbital wall restoring surgery and the use of resorbable implants was considered appropriate for the author’s orbital wall restoring technique. METHODS: A retrospective review was conducted of 31 patients with pure unilateral orbital floor fractures between May 2014 and May 2018. The patients underwent transnasal restoration of the orbital floor through insertion of a resorbable mesh plate and maintenance of temporary balloon support. The surgical results were evaluated by the Hertel scale and a comparison of preoperative and postoperative orbital volume ratio (OVR) values. RESULTS: The OVR decreased significantly, by an average of 6.01% (p < 0.05) and the preoperative and postoperative Hertel scale measurements decreased by an average of 0.34 mm with statistical significance (p < 0.05). No complications such as buckling or sagging of the implant occurred among the 31 patients. CONCLUSION: The use of resorbable mesh plate in orbital floor restoration surgery is an effective and safe technique that can reduce implant deformation or complications deriving from the residual permanent implant.

Nipple-Areola Complex Necrosis after Nipple-Sparing Mastectomy with Immediate Autologous Breast Reconstruction

BACKGROUND: Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution. METHODS: We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis. RESULTS: Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery. CONCLUSIONS: NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

Stabilizing Morbidity and Predicting the Aesthetic Results of Radial Forearm Free Flap Donor Sites

BACKGROUND: The radial forearm flap is a versatile, widely used flap. However, the possibility of donor site complications has led to concern over its use. Some surgeons prefer using other flaps whose donor sites can be closed primarily with less morbidity, including avoiding unpleasant scarring. However, in our experience, donor site stability of the radial forearm flap can be reliably achieved by using well-implemented specific procedures. Here, we present a collection of donor site cases of the radial forearm flap and investigate factors that affect the aesthetic results as the basis for a reference for selecting a radial forearm flap. METHODS: In this retrospective study, we reviewed 171 cases in which a radial forearm flap was used for free tissue transfer after resecting head and neck cancer. We focused on donor site morbidity rates. Each operation involved a detailed procedure designed to minimize donor site morbidity. Moreover, statistical investigations were conducted for 22 cases to determine factors affecting the scar appearance. RESULTS: Only one case developed total skin graft necrosis as a major complication. Scar-related aesthetic results were acceptable, and the body-mass index, body weight, diabetes, and cardiac problems were significant factors related to the appearance of scars. CONCLUSIONS: Performing the radial forearm flap using a well-implemented detailed technique helps achieve acceptable donor site morbidity results. The aesthetic results were more promising for patients without excess body weight, diabetes, or cardiac problems. Therefore, anxiety about donor site morbidity should not be a reason to avoid selecting the radial forearm flap in suitable patients.

Medial Wall Orbital Reconstruction using Unsintered Hydroxyapatite Particles/Poly L-Lactide Composite Implants

BACKGROUND: Poly-L-lactide materials combined with hydroxyapatite (u-HA /PLLA) have been developed to overcome the drawbacks of absorbable materials, such as radiolucency and comparably less implant strength. This study was designed to evaluate the usefulness of u-HA/PLLA material in the repair of orbital medial wall defects. METHODS: This study included 10 patients with pure medial wall blow-out fractures. The plain radiographs were taken preoperatively, immediately after, and 2 months after surgery. The computed tomography scans were performed preoperatively and 2 months after surgery. Patients were evaluated for ease of manipulation, implant immobility, rigidity and complications with radiologic studies. RESULTS: None of the patients had postoperative complications, such as infection or enophthalmos. The u-HA/PLLA implants had adequate rigidity, durability, and stable position on follow-up radiographic studies. On average, implants were thawed 3.4 times and required 14 minutes of handling time. CONCLUSION: The u-HA/PLLA implants are safe and reliable for reconstruction of orbital medial wall in terms of rigidity, immobility, radiopacity, and cost-effectiveness. These thin yet rigid implants can be useful where wide periosteal dissection is difficult due to defect location or size. Since the u-HA/PLLA material is difficult to manipulate, these implants are not suitable for use in complex 3-dimensional defects.

Comparison of the Complications in Vertical Rectus Abdominis Musculocutaneous Flap with Non-Reconstructed Cases after Pelvic Exenteration

BACKGROUND: Perineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage. METHODS: We retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction. RESULTS: Flap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%). CONCLUSIONS: Despite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.

Comparison of Mechanical Stability between Fibular Free Flap Reconstruction versus Locking Mandibular Reconstruction Plate Fixation

BACKGROUND: The fibular free flap has been used as the standard methods of segmental mandibular reconstruction. The objective of mandibular reconstruction not only includes restored continuity of the mandible but also the recovery of optimal function. This paper emphasizes the advantage of the fibular free flap reconstruction over that of locking mandibular reconstruction plate fixation. METHODS: The hospital charts of all patients (n=20) who had a mandibular reconstruction between 1994 and 2013 were retrospectively reviewed. Eight patients had plate-only fixation of the mandible, and the remaining 12 had vascularized fibular free flap reconstruction. Complications and outcomes were reviewed and compared between the 2 groups via statistical analysis. RESULTS: Overall complication rates were significantly lower in the fibular flap group (8.3%) than in the plate fixation group (87.5%; p =0.001). Most (7/8) patients in the plate fixation group had experienced plate-related late complications, including plate fracture or exposure. In the fibular flap group, no complications were observed, except for a single case of donor-site wound dehiscence (1/12). CONCLUSION: The fibular free flap provides a more stable support and additional soft tissue support for the plate, thereby minimizing the risk of plate-related complications. Fibular free flap is the most reliable option for mandibular reconstruction, and we believe that the flap should be performed primarily whenever possible.

Comparison of Mechanical Stability between Fibular Free Flap Reconstruction versus Locking Mandibular Reconstruction Plate Fixation

BACKGROUND: The fibular free flap has been used as the standard methods of segmental mandibular reconstruction. The objective of mandibular reconstruction not only includes restored continuity of the mandible but also the recovery of optimal function. This paper emphasizes the advantage of the fibular free flap reconstruction over that of locking mandibular reconstruction plate fixation. METHODS: The hospital charts of all patients (n=20) who had a mandibular reconstruction between 1994 and 2013 were retrospectively reviewed. Eight patients had plate-only fixation of the mandible, and the remaining 12 had vascularized fibular free flap reconstruction. Complications and outcomes were reviewed and compared between the 2 groups via statistical analysis. RESULTS: Overall complication rates were significantly lower in the fibular flap group (8.3%) than in the plate fixation group (87.5%; p =0.001). Most (7/8) patients in the plate fixation group had experienced plate-related late complications, including plate fracture or exposure. In the fibular flap group, no complications were observed, except for a single case of donor-site wound dehiscence (1/12). CONCLUSION: The fibular free flap provides a more stable support and additional soft tissue support for the plate, thereby minimizing the risk of plate-related complications. Fibular free flap is the most reliable option for mandibular reconstruction, and we believe that the flap should be performed primarily whenever possible.

Treatment of Vasculopathy in Diabetic Foot by Percutaneous Transluminal Angioplasty

PURPOSE: In treating diabetic foot ulcers, satisfactory vascularity is an essential prerequisite. To improve vascularity, a bypass graft has long been carried out. Recently, however, percutaneous transluminal angioplasty(PTA) has also been tried since the PTA is less invasive than the bypass graft. However, publication demonstrating the improvement of vascularity after the PTA are lacking. Therefore, this study was designed to show usefulness of the PTA in treating vasculopathy of diabetic foot. MATERIALS: and Methods This study included 30 feet of 24 ischemic diabetic foot patients. Inclusion criteria were diabetes(duration>5years) and a significant lower extremity ischemia, as determined by a transcutaneous oxygen pressure(TcpO2)<30mmHg. The PTA was carried out in 61 arteries. PTA procedure was considered successful, when residual stenosis was less than 30%. The procedure was considered failed when residual stenosis was more than 50%. Residual stenosis between 30% and 50% was considered acceptable. For evaluation of PTA effect, foot TcpO2 and infrared thermography were measured before and 7th day after PTA. RESULTS: Immediately after PTA performed in 61 arteries, 58 and 3 arteries were evaluated as being successful and acceptable, respectively. Before PTA, average foot TcpO2 was 12.6+/-8.8mmHg and its value was increased to 44.2+/-23.9 on 7th day after PTA(p<0.01). Average skin temperature was 31.8+/-1.2degrees C before PTA and it was increased to 33.5+/-1.1degrees C on 7th day after PTA (p<0.01). CONCLUSION: PTA procedure increases tissue oxygenation of ischemic diabetic feet which do not have wound healing potential due to low tissue oxygenation, to the level of possible wound healing. In addition, PTA increases skin temperature of ischemic diabetic feet which can imply an improvement of peripheral circulation.

Usefullness of Chimeric Flaps Based on the Subscapular Vascular System

PURPOSE: Compound tissue defects remain a challenge to reconstructive surgeons. The objective of this study was to introduce examples of successful reconstruction of compound defects of the head and neck and upper and lower limbs, using chimeric flaps based on the subscapular vascular system. METHODS: We report 19 reconstruction cases using chimeric flaps based on the subscapular vascular system. The scapular flap, scapular fascia, scapular bone, parascapular flap, latissimus dorsi, latissimus dorsi perforator flap, latissimus dorsi myocutaneous perforator flap, serratus anterior, serratus anterior fascia, and rib bone were used as components for chimeric flaps. 12 cases had defects of the upper limb, three in the lower limb, three in the head and neck area, and one case had a defect of the thoracoabdominal wall. RESULTS: Defect sizes ranged from 6x8cm to 20x22 cm. The component used most often for skin coverage was the latissimus dorsi perforator flap; for soft tissue bulk, the latissimus dorsi; for fascia coverage, the serratus anterior fascia flap; and for bone reconstruction, the scapular bone flap respectively. In all cases reconstruction was done successfully without additional operative procedures or flap necrosis. CONCLUSION: Because it is fairly easy to employ vascular pedicles of sufficient length and diameter, enabling the use of diverse types of tissue with various shapes and sizes, the use of chimeric flaps based on the subscapular vascular system allows one-stage reconstruction tailored to the characteristics of the defect area.

Comparison of Doppler and CT Angiography as a Predictor of Healing Diabetic Foot Ulcers

PURPOSE: Adequate tissue oxygenation is considered as an essential factor for wound healing. In the non- diabetic population, an uncompromised macrocirculation generally leads to adequate tissue oxygenation. On the contrary, the macrocirculation in diabetic patients may not correlate with tissue oxygenation because of structural changes in the capillary basement membrane. Nevertheless, many medical professionals in Korea rely on macrocirculation evaluation when predicting wound healing potential of the diabetic ulcers. The purpose of this study is to compare reliability of two common macrocirculation assessment methods, Doppler probing and CT angiography, on tissue oxygenation in diabetic foot patients. METHODS: Doppler and CT angiography scores were given according to the patency of the anterior and posterior tibial arteries. Tissue oxygenation was measured by transcutaneous partial oxygen tension(TcpO2). Doppler and CT angiography scores were statistically analyzed against TcpO2 values. Sixty-eight diabetic foot ulcer patients were included in this study. RESULTS: The test was carried out on Doppler score and TcpO2 variables displayed a p-value of 0.0202, and concluded that the two variables were statistically dependent. The test used to determine for linear trends between Doppler scores and TcpO2 variables displayed a p-value of 0.0149, displaying statistical linear trend between the two variables. On the contrary, the tests between CT angiography scores and TcpO2 variables showed p-values of 0.1242 and 0.6590, that means no correlation between CT angiography and TcpO2 scores. CONCLUSION: Doppler probing is more reliable than CT angiography in predicting tissue oxygenation of diabetic foot ulcers.

A Pilot Clinical Study on the Use of Differentiated Adipocyte Injection for Soft Tissue Augmentation

Several suspension biomaterials are available for soft tissue augmentation. Although these gel type implants have been shown to be relatively safe and convenient, their varying degrees of resorption require repeated percutaneous injections. Previous in vivo and in vitro studies have shown that the injection of cultured human adipocytes can produce a sufficient volume effect with extended in vivo stability. This pilot study was undertaken to evaluate the clinical efficacy of this method. Between November 2007 and January 2008, 5 patients were treated with implants of autologous differentiated adipocytes for wrinkle correction and forehead augmentation. The contour changes of the treatment sites were investigated in accordance with the passage of time, as was the occurrence of complications. The degree of patient satisfaction was also evaluated. The injected bioimplants remained in situ. Two weeks after injection, they began to show evidence of a soft tissue augmentation effect. All patients were satisfied with the overall results of this method, and no complications occurred during the follow-up period. The results obtained indicate that differentiated human adipocytes may be successfully injected as living grafts for long-term implants, and that this method is a well tolerated, effective way of performing soft tissue augmentation.