Sequential breast and nipple-areolar complex reconstruction after soft tissue necrosis following augmentation mastopexy: a case report

Breast augmentation mastopexy is a common procedure in cosmetic plastic surgery. Augmentation mastopexy has proven to be a relatively safe operation, but surgeons should be aware of and able to cope with disastrous complications such as soft tissue necrosis and nipple loss. The most important consideration in breast reconstruction is the recovery of breast shape and symmetry, as well as the maintenance of the shape of the nipple-areolar complex without any complications. We experienced a case of sequential breast and nipple-areolar complex reconstruction, in which the purse-string suture technique was used to repair medium-sized circular defects accompanied by nipple loss in the central area of both breasts and to preserve the shape of both breast mounds. Modified CV flaps were performed for left nipple reconstruction, and the Elsahy method and the purse-string suture technique were used to reconstruct the right nipple. Tattooing was performed on both breasts for areolar reconstruction. Through sequential reconstruction, the patient achieved satisfactory aesthetic results. In medium-sized, round defects on the central breast accompanied by nipple loss, the pursestring technique is a simple and effective reconstructive option that enables maintenance of the breast mound shape without requiring additional incision or distortion of surrounding structures.

Upper eyelid reconstruction using a combination of a nasal septal chondromucosal graft and a Fricke flap: a case report

Sebaceous carcinoma is a malignant neoplasm that usually arises in the sebaceous glands of the eyelids. Its pathogenesis is unknown; however, irradiation history, immunosuppression, and use of diuretics are known risk factors. The mainstay of treatment for sebaceous carcinoma of the eyelid is wide surgical resection with a safety margin of 5 to 6 mm, which often results in full-thickness defects. The reconstruction of a full-thickness defect of the eyelid should be approached using a three-lamella method: a mucosal component replacing the conjunctiva, a cartilage component for the tarsal plate, and a flap or skin graft for the skin of the eyelid. In this case, a fullthickness defect of the upper eyelid was reconstructed after tumor removal using a combination of a nasal septum chondromucosal composite graft and a forehead transposition flap, also known as a “Fricke flap.” The flap was designed to include a line of the eyebrow on the lower margin of the flap to replace the eyelash removed during tumor excision. The wound healed completely, without any early or late complications, and the outcome was satisfactory.

Upper eyelid reconstruction using a combination of a nasal septal chondromucosal graft and a Fricke flap: a case report

Sebaceous carcinoma is a malignant neoplasm that usually arises in the sebaceous glands of the eyelids. Its pathogenesis is unknown; however, irradiation history, immunosuppression, and use of diuretics are known risk factors. The mainstay of treatment for sebaceous carcinoma of the eyelid is wide surgical resection with a safety margin of 5 to 6 mm, which often results in full-thickness defects. The reconstruction of a full-thickness defect of the eyelid should be approached using a three-lamella method: a mucosal component replacing the conjunctiva, a cartilage component for the tarsal plate, and a flap or skin graft for the skin of the eyelid. In this case, a fullthickness defect of the upper eyelid was reconstructed after tumor removal using a combination of a nasal septum chondromucosal composite graft and a forehead transposition flap, also known as a “Fricke flap.” The flap was designed to include a line of the eyebrow on the lower margin of the flap to replace the eyelash removed during tumor excision. The wound healed completely, without any early or late complications, and the outcome was satisfactory.

Analysis on Usefulness of Various Free Flaps for Primary Reconstruction on Fourth Degree Burn

Purpose@#A fourth degree burn is a full-thickness burn of the skin usually accompanied by damage to deep structures and commonly results in extensive damage to surrounding tissues which makes the treatment of the wound difficult. Coverage of these wound using free flap is known to effective but not commonly used. The purpose of our study is to review our experience and suggest early application of free flap surgery. @*Methods@#A retrospective review was performed from 2010 to 2019, on a total of 34 fourth degree burn patients undergone free flap surgery as primary treatment in our hospital. We reviewed the location of the injury, etiology, TBSA (%), Presence of osteomyelitis, flap choice, complications, period of injury to surgery and healing. @*Results@#Using free flap as a primary reconstrcuction, the outcome is satisfactory. The treatment period was shortened, and there was less loss of function due to complications. Also the incidence of osteomyelitis and amputation was significantly low. @*Conclusion@#Applying free flap surgery as soon as possible in fourth degree burns is effective, such as reducing complications such as infection, reducing amputation, shortening treatment period, and preventing severe sequelae.

Aging-related changes in the mid-face skin elasticity in East Asian women

BACKGROUND: Age-related changes in facial skin is a major concern in women. This study aimed to objectively evaluate normal skin elasticity and age-related differences in the faces of East Asian women. There are no standard values for data related to normal skin on East Asian women. METHODS: We studied 129 healthy East Asian women without a history of cosmetic procedures or surgeries. Skin elasticity was assessed at the cheek and lower eyelid points, which were assessed on both the right and left sides of the face. RESULTS: The age of the subjects showed significant negative correlations with the R2 and R7 parameters, which represent skin elasticity after deformation. CONCLUSION: We therefore concluded that the primary decrease in skin elasticity in East Asian women occurs in the midface region.

New economical and simple device for intraoperative expansion on small and medium sized soft tissue defects

Intraoperative expansion has been used to cover small to large defects without disadvantages of the conventional tissue expanders. Various materials, for example, expanders and Foley catheters are being used. We introduce a new, convenient and economical device immediately available in the operating room, according to the defect size for intraoperative expansion, with latex gloves or balloons. The retrospective study was done with 20 patients who presented with skin and soft tissue defects. During the operation, expansion was done with latex gloves or balloons inflated with saline through an intravenous line and a three-way stopcock. After the inflation, the glove was removed and skin was covered with expanded tissue. A careful decision was made regarding the inflation volume and placement of the expander according to the defect size. There were no postoperative complications. The skin contracture and tension was minimal with a texture similar to the adjacent tissue. The new intraoperative expansion devices with latex gloves and balloons were cheap and made easily right in the operation room. The reconstruction of small to large sized skin defects can be done successfully, functionally and aesthetically without using expensive commercial materials.

Modified Abbé flap for reconstruction of Cupid’s bow and vermilion tubercle in secondary cleft lip deformity

BACKGROUND: Abbé flap technique is one of the most challenging operations to correct horizontal deficiencies in secondary cleft lip deformity. Since its first introduction, the operative method was dynamically modified from simple variation to complete conceptual change, but conventional Abbé flap has many drawbacks in esthetic and functional aspect. Our purpose was reconstructing the symmetry of Cupid's bow and central vermilion tubercle with minimal sequalae. METHODS: From 2008 to 2016, this technique was applied to 16 secondary cleft lip patients who had total or more than 60% of unilateral deficiency of Cupid's bow and central lip or tubercle pouting deficiency. A quadrangular-shaped flap was transferred from vermilion including skin and white line of central or contralateral lower lip. Pedicle division and insetting were made at 9 (unilateral) or 10 (bilateral) days after transfer. Secondary lip revision was done with open rhinoplasty after wound maturation. RESULTS: Overall satisfaction was high with modified technique. Scar was minimally noticeable on both upper and lower lip especially. Balanced Cupid's bow and symmetric vermilion tubercle were made with relatively small size of flap compared to conventional Abbé flap. An accompanying benefit was reduced ectropion of lower lip, which made balanced upper and lower lip protrusion with more favorable profile. CONCLUSION: A new modified Abbé flap technique showed great satisfaction. It is worth considering in secondary cleft lip patient who has central lip shortage and asymmetry of upper lip vermilion border line. Our technique is one of the substitutes for correction of horizontal and central lip deficiency with asymmetric Cupid's bow.

Bowel Perforation Due to Immobilization after Resurfacing Thumb with Anterolateral Thigh Free Flap in an Elderly Diabetic Woman

Inevitable immobilization after surgery on lower extremities can induce chronic constipation. Elderly diabetic women usually express ambiguous gastrointestinal symptoms and signs. We present here a case of panperitonitis developed from severe fecal impaction in an elderly diabetic woman after hand reconstruction using material harvested from the lower extremities. A 68-year-old diabetic female underwent anterolateral thigh free flap and wound revision twice on the left thumb. Three weeks after surgery, she complained about mild abdominal pain though she had daily defecation. Despite encouraging ambulation, her compliance was low. Resection of the sigmoid colon and colostomy were performed after diagnosis with bowel perforation. However, the patient went into septic shock and died with multiorgan failure after the guardians issued a DNR (do not resuscitate) order. For preventing bowel perforation, increased uptake of dietary fiber and early ambulation postoperatively should be encouraged, after even hand surgeries.

Is Robot-Assisted Surgery Really Scarless Surgery? Immediate Reconstruction with a Jejunal Free Flap for Esophageal Rupture after Robot-Assisted Thyroidectomy

Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.

Reconstructive Modalities According to Aesthetic Consideration of Subunits of the Cheek after Wide Excision of Skin Cancer

BACKGROUND: Defects of the cheek present a reconstructive challenge because of the visibility of the site, as well as the limited local tissue supply. In addition, the cheek abuts several structures with expressive function, such as the eye, mouth, and surrounding facial musculature. This report describes a system of classifying cheek defects according to tumor size and location and present corresponding reconstruction techniques used to accomplish three-dimensional restoration of all missing components and adequate texture matching. METHODS: From 2008 to 2013, 27 patients with cheek defects resulting from skin cancer excision were treated. According to the size of the defect, location on the cheek, and relationships to adjacent structures and existing skin tension lines, different surgical methods were applied. RESULTS: The procedures used for cheek reconstruction included direct closure, Limberg flap, V-Y advancement flap, slide-swing flap, cheek rotation flap, and full-thickness skin graft. All flaps healed well without major complications, and no cancer recurrence was detected during follow-up. CONCLUSIONS: The anatomic classification of skin cancers and surgical protocols described in this report is simple and appropriate for reconstruction involving the cheek. Wide excision of skin cancer and appropriate, relatively easy-to-perform flaps based on this classification system can successfully produce safe and aesthetically-pleasing surgical outcomes.

Silicone Implant-Based Paranasal Augmentation for Mild Midface Concavity

BACKGROUND: Midface concavity is a relatively common facial feature in East Asian populations. Paranasal augmentation is becoming an increasingly popular procedure for patients with mild concavity and normal occlusion. In this study, we evaluate clinical outcomes following a series of paranasal augmentation. METHODS: A retrospective review was performed for patients with Class I occlusion who had undergone bilateral paranasal augmentation using custom-made silicone implants, between October 2005 and September 2013. Patient charts were reviewed for demographic information, concomitant operations, and postoperative complications. Preoperative and postoperative (1-month) photographs were used to evaluate operative outcome. RESULTS: The review identified a total of 93 patients meeting study criteria. Overall, aesthetic outcomes were satisfactory. Five-millimeter thick silicone implant was used in 81 cases, and the mean augmentation was 4.26 mm for this thickness. Among the 93 patients, 2 patients required immediate implant removal due to discomfort. An additional 3 patients experienced implant migration without any extrusion. Nine patients complained of transient paresthesia, which had resolved by 2 weeks. There were no cases of hematoma or infection. All patients reported improvement in their lateral profile and were pleased at follow-up. Complications that arose postoperatively included 9 cases of numbness in the upper lip and 3 cases of implant migration. All cases yielded satisfactory results without persisting complications. Sensations were fully restored postoperatively after 1 to 2 weeks. CONCLUSION: Paranasal augmentation with custom-made silicone implants is a simple, safe, and inexpensive method that can readily improve the lateral profile of a patient with normal occlusion. When combined with other aesthetic procedures, paranasal augmentation can synergistically improve outcome and lead to greater patient satisfaction.

Benign Lymphoepithelial Lesion of Parotid Gland and Secondary Amyloidosis as Concurrent Manifestations in Sjogren's Syndrome

No abstract available.

Negative Pressure Wound Therapy of Chronically Infected Wounds Using 1% Acetic Acid Irrigation

BACKGROUND: Negative-pressure wound therapy (NPWT) induces angiogenesis and collagen synthesis to promote tissue healing. Although acetic acid soaks normalize alkali wound conditions to raise tissue oxygen saturation and deconstruct the biofilms of chronic wounds, frequent dressing changes are required. METHODS: Combined use of NPWT and acetic acid irrigation was assessed in the treatment of chronic wounds, instilling acetic acid solution (1%) beneath polyurethane membranes twice daily for three weeks under continuous pressure (125 mm Hg). Clinical photographs, pH levels, cultures, and debrided fragments of wounds were obtained pre- and posttreatment. Tissue immunostaining (CD31, Ki-67, and CD45) and reverse transcription-polymerase chain reaction (vascular endothelial growth factor [VEGF], vascular endothelial growth factor receptor [VEGFR]; procollagen; hypoxia-inducible factor 1 alpha [HIF-1-alpha]; matrix metalloproteinase [MMP]-1,-3,-9; and tissue inhibitor of metalloproteinase [TIMP]) were also performed. RESULTS: Wound sizes tended to diminish with the combined therapy, accompanied by drops in wound pH (weakly acidic or neutral) and less evidence of infection. CD31 and Ki-67 immunostaining increased (P<0.05) post-treatment, as did the levels of VEGFR, procollagen, and MMP-1 (P<0.05), whereas the VEGF, HIF-1-alpha, and MMP-9/TIMP levels declined (P<0.05). CONCLUSIONS: By combining acetic acid irrigation with negative-pressure dressings, both the pH and the size of chronic wounds can be reduced and infections be controlled. This approach may enhance angiogenesis and collagen synthesis in wounds, restoring the extracellular matrix.

Arteriovenous Fistula Formation Using Microscope Rather than Surgical Telescope

The number of patients with chronic renal failure who require renal replacement therapy is increasing and dialysis is still the mainly used renal replacement therapy. The first choice of surgical technique currently used is side-to-end anastomosis of the radial artery and the cephalic vein. The authors report on a case of an effective arteriovenous shunt operation performed using microscopy. A 53-year-old male with chronic renal failure was referred to plastic and reconstructive surgery department to undergo an arteriovenous shunt operation. Venography was performed before surgery in order to find the appropriate vessel for the arteriovenous shunt operation. The cephalic vein on the wrist showed a diameter of over 4 mm, which was appropriate for an arteriovenous shunt operation. Anastomosis of the vessels was performed under microscopy using Nylon #9-0. Blood flow and vessel diameter were evaluated by venography after surgery and showed well maintained function of the shunt. Complications such as bleeding, edema of the upper arm, and wound dehiscence did not occur. Many factors and certain complications may affect the long-term patency of an arteriovenous shunt; however, exquisite surgical technique is the most important factor in a successful operation. Thus, arteriovenous shunt operation using microscopy is thought to be a good treatment option.

Treatment of Botulinum Toxin Type A in Parotid Fistula after Face Lifting

Botulinum toxin type A has an inhibitory action not only on neuromuscular junctions, but also postganglionic sympathetic and cholinergic autonomic parasympathetic acetylcholine release at the secretary end of the salivary gland. Use of botulinum toxin to treat sialorrhea was first reported in 1997 by Bushara. Parotid duct or gland injuries with parotid fistula are uncommon but troublesome complications of surgical trauma. Here, we report two patients with constant leakage of serous fluid and a swelling cheek after facelift surgery. Each patient underwent an amylase test, starch iodine test, and sialography. After diagnosis of parotid fistula, a total of 50 units botulinum toxin was injected into the parotid gland. Facial bandage, scopolamine, and minimizing temporomandibular joint motion were instructed. Leakage volume decreased gradually, and symptoms subsided within 2 weeks. Neither functional problems nor complications occurred. In conclusion, a parotid fistula after facial surgery can be treated effectively with botulinum toxin; this treatment option should be considered before proceeding with invasive surgical treatment.

Correction of Severely Asymmetric Calf using Latissimus Dorsi Musculocutaneous Free Flap and Customized Silicone Implant

Calves can be easily seen in daily life and are an important part of the body contour. Asymmetric calves can develop from unbalanced distribution and deposition of fat and muscles between the legs. Calf asymmetry may be due to congenital factors, disease (e.g., poliomyelitis, cerebral palsy, or infection), spinal cord injury, or the effects of surgical treatment and may have severe adverse psychological and social implications. Generally, an asymmetric calf is diagnosed when the difference of the longest circumference between both calves is more than 2 cm. Several surgical methods have been introduced for the correction of an asymmetric calf. Implant insertion or fat injection is used to augment a hypotrophic calf. Selective neurectomy, liposuction, muscle resection, radiofrequency, and botulinum toxin injection are used to treat a hypertrophic calf. With the development of microsurgery, the authors planned to use a latissimus dorsi musculocutaneous free flap (LDMC free flap) with silicone implant to add calf volume to obtain natural calf contour. The authors present the first successful case of correction of a severely asymmetric calf using an LDMC free flap and customized silicone implant.

Treatment Algorithm of Complications after Filler Injection: Based on Wound Healing Process

Soft tissue filler injection has been a very common procedure worldwide since filler injection was first introduced for soft tissue augmentation. Currently, filler is used in various medical fields with satisfactory results, but the number of complications is increasing due to the increased use of filler. The complications after filler injection can occur at any time after the procedure, early and delayed, and they range from minor to severe. In this review, based on our experience and previously published other articles, we suggest a treatment algorithm to help wound healing and tissue regeneration and generate good aesthetic results with early treatment in response to the side effects of filler. Familiarity with the treatment of these rare complications is essential for achieving the best possible outcome.

Nasal Anthropometry on Facial Computed Tomography Scans for Rhinoplasty in Koreans

BACKGROUND: Cephalometric analysis is essential for planning treatment in maxillofacial and aesthetic facial surgery. Although photometric analysis of the Korean nose has been attempted in the past, anthropometry of the deeper nasal structures in the same population based on computerized tomography (CT) has not been published. We therefore measured three anthropometric parameters of the nose on CT scans in our clinical series of patients. METHODS: We conducted the current retrospective study of a total of 100 patients (n=100) who underwent a CT-guided radiological measurement at our institution during a period ranging from January of 2008 to August of 2010. In these patients, we took three anthropometric measurements: the nasofrontal angle, the pyramidal angle, and the linear distance between the nasion and the tip of the nasal bone. RESULTS: The mean nasofrontal angle was 131.14degrees in the male patients and 140.70degrees in the female patients. The mean linear distance between the nasion and the tip of the nasal bone was 21.28 mm and 18.02 mm, respectively. The mean nasal pyramidal angle was 112.89degrees and 103.25degrees at the level of the nasal root, 117.49degrees and 115.60degrees at the middle level of the nasal bone, and 127.99degrees and 125.04degrees at the level of the tip of the nasal bone, respectively. CONCLUSIONS: In conclusion, our data will be helpful in the preparation of silicone implants for augmentation and/or corrective rhinoplasty in ethnic Korean people.

Case Reports of Adipose-derived Stem Cell Therapy for Nasal Skin Necrosis after Filler Injection

With the gradual increase of cases using fillers, cases of patients treated by non-medical professionals or inexperienced physicians resulting in complications are also increasing. We herein report 2 patients who experienced acute complications after receiving filler injections and were successfully treated with adipose-derived stem cell (ADSCs) therapy. Case 1 was a 23-year-old female patient who received a filler (Restylane) injection in her forehead, glabella, and nose by a non-medical professional. The day after her injection, inflammation was observed with a 3x3 cm skin necrosis. Case 2 was a 30-year-old woman who received a filler injection of hyaluronic acid gel (Juvederm) on her nasal dorsum and tip at a private clinic. She developed erythema and swelling in the filler-injected area A solution containing ADSCs harvested from each patient's abdominal subcutaneous tissue was injected into the lesion at the subcutaneous and dermis levels. The wounds healed without additional treatment. With continuous follow-up, both patients experienced only fine linear scars 6 months postoperatively. By using adipose-derived stem cells, we successfully treated the acute complications of skin necrosis after the filler injection, resulting in much less scarring, and more satisfactory results were achieved not only in wound healing, but also in esthetics.

Consideration on Application of Modified Monitored Anesthetic Care in Plastic Surgery

PURPOSE: Many patients have fear for surgery owing to the injection of lidocaine and the possible pain in the course of the operation. To resolve such a problem the cases to do plastic surgery with monitored anesthetic care are increasing, in which something like sedatives is injected into vein without endotracheal intubation and under voluntary respiration, but the usage is now under the controversy. METHODS: There were 25 patients who had surgery with local anesthesia, and another 25 patients who had surgery with monitored anesthetic care which belongs to ASA class 1 and 2 from January to April, 2009. Their anesthesia records were collected and surveys were given before and after the surgery and the surgery staff recorded OAA/S during the surgery. The postoperative surveys included the awakening during the surgery, pain, anxiety, and the degree of patient's satisfaction through visual analogue scale to identify the difference between the two methods. RESULTS: The OAA/S results according to time lapse show that it is possible to lead a fast effective sedation and recovery with monitored anesthetic care, and monitored anesthetic care enhances both surgeon's convenience level and patient's satisfaction level, and reduces awakening, pain, and anxiety, compared to local anesthesia. CONCLUSION: The current paper shows about the plastic surgery, particularly the outpatient surgery, when monitored anesthetic care method is applied, it could gain a fast sedation and recovery or an effective sedation of patients. The method also has some affirmative effects in regard with surgeon's convenience and the patients' satisfaction degree and the reduction of their awakening, pain, and anxiety. With careful and adequate watch on the measures about vital signs like electrocardiogram, the degree of oxygen saturation, and blood pressure, it could clinically be very useful.