The cover of an ear thermometer probe as a split-thickness skin graft mold in external auditory canal reconstruction

Maintaining the patency of the external auditory canal (EAC) during reconstruction is important because of its physiological role in hearing and immunological protective functions. The curved shape of the EAC presents a challenge when performing a skin graft. One of the key points for a successful skin graft is to ensure compression on the wound bed, and many novel methods, including prefabricated ear molds, have been reported for this purpose. In this study, we present a case of a skin graft performed to reconstruct a skin defect following excision of actinic keratosis in the EAC, using the cover of an ear thermometer probe as a mold for the graft to match the curvature of the EAC. This is an economical and practical method for secure compression dressing of a skin graft in the EAC.

Unilateral autoinflation of a saline-filled breast implant initially diagnosed as capsular contracture: a case report and review of the literature

Spontaneous inflation of saline breast implants is a rare phenomenon. In this case report, we share our experience treating a patient who complained of asymmetric breasts from what appeared to be a straightforward case of capsular contracture. Spontaneous autoinflation of the right breast implant was subsequently found to be the cause of breast asymmetry and hardness. The presentation, diagnostic challenge, management, and mechanism of this rare phenomenon are presented here.

A Novel Hypothesis and Characterization to Isolate Microvascular Endothelial Cells Simultaneously with AdiposeDerived Stem Cells from the Human Adipose-Derived Stromal Vascular Fraction

BACKGROUND@#Angiogenesis and vasculogenesis are essential processes for successful tissue regeneration in tissue engineering and regenerative medicine. The adipose-derived stromal vascular fraction (SVF) is not only a source of adipose stem cells (ASC) but also a suitable source of microvascular endothelial cells because it is a rich capillary network. So, we propose a new hypothesis for isolating adipose-derived human microvascular endothelial cells (HMVEC-A) from the SVF and developed a dual isolation system that isolates two cell types from one tissue.METHOD: To isolate HMVEC-A, we analyzed the supernatant discarded when ASC is isolated from the adipose-derived SVF. Based on this analysis, we assumed that the SVF adherent to the bottom of the culture plate was divided into two fractions: the stromal fraction as the ASC-rich fraction, and the vascular fraction (VF) as the endothelial cells-rich fraction floating in the culture supernatant. VF isolation was optimized and the efficiency was compared, and the endothelial cells characteristics of HMVEC-A were confirmed by flow cytometric analysis, immunocytochemistry (ICC), a DiI-acetylated low-density lipoprotein (DiI-Ac-LDL) uptake, and in vitro tube formation assay. @*RESULTS@#Consistent with the hypothesis, we found a large population of HMVEC-A in the VF and isolated these HMVEC-A by our isolation method. Additionally, this method had higher yields and shorter doubling times than other endothelial cells isolation methods and showed typical morphological and phenotypic characteristics of endothelial cells. @*CONCLUSION@#Cells obtained by the method according to our hypothesis can be applied as a useful source for studies such as tissue-to-tissue networks, angiogenesis and tissue regeneration, patient-specific cell therapy, and organoid chips.

A Novel Hypothesis and Characterization to Isolate Microvascular Endothelial Cells Simultaneously with AdiposeDerived Stem Cells from the Human Adipose-Derived Stromal Vascular Fraction

BACKGROUND@#Angiogenesis and vasculogenesis are essential processes for successful tissue regeneration in tissue engineering and regenerative medicine. The adipose-derived stromal vascular fraction (SVF) is not only a source of adipose stem cells (ASC) but also a suitable source of microvascular endothelial cells because it is a rich capillary network. So, we propose a new hypothesis for isolating adipose-derived human microvascular endothelial cells (HMVEC-A) from the SVF and developed a dual isolation system that isolates two cell types from one tissue.METHOD: To isolate HMVEC-A, we analyzed the supernatant discarded when ASC is isolated from the adipose-derived SVF. Based on this analysis, we assumed that the SVF adherent to the bottom of the culture plate was divided into two fractions: the stromal fraction as the ASC-rich fraction, and the vascular fraction (VF) as the endothelial cells-rich fraction floating in the culture supernatant. VF isolation was optimized and the efficiency was compared, and the endothelial cells characteristics of HMVEC-A were confirmed by flow cytometric analysis, immunocytochemistry (ICC), a DiI-acetylated low-density lipoprotein (DiI-Ac-LDL) uptake, and in vitro tube formation assay. @*RESULTS@#Consistent with the hypothesis, we found a large population of HMVEC-A in the VF and isolated these HMVEC-A by our isolation method. Additionally, this method had higher yields and shorter doubling times than other endothelial cells isolation methods and showed typical morphological and phenotypic characteristics of endothelial cells. @*CONCLUSION@#Cells obtained by the method according to our hypothesis can be applied as a useful source for studies such as tissue-to-tissue networks, angiogenesis and tissue regeneration, patient-specific cell therapy, and organoid chips.

Dual-pedicled conjoined abdominal flap for breast reconstruction in a patient with previous radiation therapy

Delayed breast reconstruction is challenging because it requires a large volume and symmetry, and the dual-pedicled deep inferior epigastric perforator (DIEP) flap is used with microvascular augmentation. However, candidate recipient vessels in patients who have undergone radiation therapy may be damaged, with uncertain patency. This report suggests a novel method, the dual-pedicled conjoined abdominal flap, in which a free DIEP flap is combined with a pedicled transverse rectus abdominis muscle (TRAM) flap. A 57-year-old female patient who had undergone modified radical mastectomy and radiotherapy 25 years previously was referred for breast reconstruction. A whole abdominal flap was needed, but supercharged anastomosis was very risky due to calcification and scarring of the internal mammary vessel. Therefore, the thoracodorsal vessels were anastomosed with a free left DIEP flap, which was combined with a right-pedicled TRAM flap. The reconstructed volume was sufficient, and the blood flow was intact. The patient presented a symmetric contour without any complications after 4 months. The dual-pedicled conjoined abdominal flap is reliable for delayed breast reconstruction that requires a large volume and skin replacement, especially in patients with radiation-injured recipient vessels. Even if microscopic anastomosis failure occurs, secondary rescue is made possible by the pedicled TRAM flap.

Umbilical trocar port site keloid management using a transposition flap after laparoscopic surgery

Background@#Keloids can occur anywhere in the human body. They are difficult to remove and can cause distress in patients. Although many options are available to treat keloids, no single method is considered the optimal treatment of choice. The authors encountered cases where an umbilical keloid developed at the trocar site after laparoscopic surgery and managed the keloid using a transposition flap. @*Methods@#A total of 10 umbilical keloid patients treated from 2013 to 2020 were included in this study. All patients developed a keloid due to the placement of a laparoscopic trocar incision port, and their major complaints varied from an asymptomatic nodule to pruritus or pain. All excisions were performed under local anesthesia, and transposition flaps were planned afterward. The surrounding tissue was rearranged so that the shape of the umbilicus was deformed to the minimum extent possible. The keloid scars were examined both preoperatively and 6 months postoperatively using the Patient and Observer Scar Assessment Scale (POSAS). @*Results@#All surgical wounds healed well without complications. The average time interval from laparoscopic surgery to keloid scar revision was 4.3 years. The mean postoperative follow-up period was 10.9 months, and no patient underwent reoperation. Four patients were treated with triamcinolone after surgery due to mild hypertrophy or pruritus. The POSAS observer scale showed significantly decreasing scores over time in all patients (P=0.002). @*Conclusions@#Cosmetically unfavorable keloids that form in the umbilicus following laparoscopic surgery can be improved with a simple procedure using excision and transposition flaps.

Remote migration of breast filler to the inguinal area: a case report

Polyacrylamide hydrogel (PAAG) is an injectable material for breast augmentation that was developed in the 1980s. It was widely used until the 2000s, but subsequently lost its popularity due to high complication rates. In this case report, we share our experience of a patient complaining of hard and asymmetric breasts who had received PAAG injections 7 years ago. Surprisingly, we found that the filler in the left breast had migrated to the left inguinal area. Although breast fillers have lost ground in recent years, we think that long-term complications of fillers, as observed in this case, will still arise in the future. Therefore, young plastic surgeons who do not have direct experience with this material should be aware of its possible complications.

One-stage nipple and breast reconstruction using a deep inferior epigastric perforator flap after a skin-sparing mastectomy

Background@#Nipple reconstruction is usually performed as a delayed procedure in patients with breast cancer who undergo skin-sparing mastectomy and breast reconstruction surgery using a deep inferior epigastric perforator (DIEP) flap. The authors designed this study to evaluate the utility of breast reconstruction based on a DIEP flap and immediate nipple reconstruction. @*Methods@#A retrospective review was conducted of all patients who underwent breast reconstruction performed by a single plastic surgeon from October 2016 to June 2018. Through a questionnaire and chart review, we compared surgical results and complications in cases of single-stage nipple reconstruction after skin-sparing mastectomy (n=17) with patients who underwent delayed nipple reconstruction after skin-sparing mastectomy, modified radical mastectomy, or simple mastectomy (n=7). @*Results@#In a subjective analysis using clinical photos, the immediate nipple reconstruction group had higher scores than their counterparts in an evaluation of the nipple-areolar complex (NAC) (NAC placement, 3.34 vs. 3.04; nipple projection, 3.05 vs. 3.03; nipple size, 3.30 vs. 3.29). No significant differences between the groups were found in terms of complications. @*Conclusions@#Simultaneous nipple reconstruction is a reliable surgical method with economic advantages. No differences were found in terms of outcomes and complications in comparison to delayed reconstruction. Therefore, surgeons can consider simultaneous nipple reconstruction without particular concerns about asymmetry or necrosis.

Minimal scarring from giant intramuscular lipoma excision with the harmonic scalpel

Lipoma is the most frequent benign mesenchymal tumor. Giant intramuscular lipomas, defined by a measurement greater than 10 cm in any dimension, reside deep to the fascia and originate within the muscle layer. Traditionally, the length of the incision required for excision is equal to or greater than the diameter of the giant intramuscular lipoma. However, because of injury to the surrounding tissues from excessive traction and thermal injury from the energy delivered by the device, long and noticeable scars with a hypertrophic tendency develop, resulting in patient dissatisfaction. Although some esthetically-favorable methods have been reported, including liposuction and liposuction-assisted excision, these methods did not sufficiently excise lipomas, and led to a higher recurrence rate. In contrast, the ultrasonic harmonic scalpel can excise large and deep-seated lipomas with minimal scarring. The ultrasonic harmonic scalpel requires a shorter incision, and it provides a sufficient view of the surgical field, thereby avoiding unnecessary traction applied to the skin and reducing surrounding tissue injury trauma, which results in hypertrophic scars.

Scar dermal transposition flap for depressed scars: A valuable technique for depressed scar management

BACKGROUND: Various methods have been reported for the improvement of widened or depressed scars. However, scars can be complex at presentation. If a widened but flat portion is combined with a tethered or a depressed area, a scar revision method that can effectively resolve all issues is needed. The authors utilized a dermal portion of the widened scar as a re-adhesion barrier and filled tissue after the release of the tethering or depression. METHODS: From July 2014 to December 2017, a total of eight patients presented with combined scars with both widened and depressed areas and underwent scar revisions with scar dermal transposition flaps. The scar flap of the widened scar was de-epithelialized, leaving the dermo-cutaneous pedicle near the depressed area. Without any additional skin incision on the depressed site, the tethering was released by making a skin incision at the scar flap. The de-epithelialized scar dermal flap was transpositioned under the depressed area of the scar. RESULTS: The surgical wounds of all eight patients healed without any complications. The mean follow-up period was 5.25 months. The filling effect of the scar flap persisted without the conspicuous relapse of a depression or tethering. The patients were satisfied with the final results and the fact that no additional incision was needed for the tethered and depressed scar. CONCLUSIONS: If the depressed site is near a widened scar, a scar dermal transposition flap may be a versatile option for improving the depression without an additional skin incision.

Thermoplastic nipple splint: A simple method of maintaining nipple projection

Maintaining projection of the reconstructed nipple is important for achieving natural and aesthetically appealing outcomes in breast reconstruction. Although various methods of avoiding mechanical force on the reconstructed nipple have been developed, the existing methods are inconvenient, crude, non-reusable, and difficult to clean or adjust. In the present study, a simple method of creating a nipple splint using a thermoplastic material is described. This splint can be easily manipulated, washed, and reused, and it is comfortable to wear for long-term use without any complications and convenient for the patient to apply.

A New Skin Graft Donor Site Using the Abdominal Dog-Ear Deformity in Mastectomy Flap Necrosis

BACKGROUND: Mastectomy flap necrosis is a common complication after mastectomy and immediate reconstruction with a deep inferior epigastric perforator (DIEP) flap. After abdominal free flap breast reconstruction, the most common secondary procedure is dog-ear correction of both flanks. We introduce a treatment for skin necrosis with a full-thickness skin graft (FTSG) using the abdominal dog-ear deformity. METHODS: In patients with skin necrosis of a mastectomy flap, we debrided all necrotic tissue when the demarcation was complete. We then performed an FTSG using the skin from the dog-ear correction of both flank areas. We fixed the graft with a tie-over dressing, and it was then removed on postoperative day 5. RESULTS: Skin necrosis of the mastectomy flap and dog-ear deformity were treated without any complications. The color and texture of the breasts were satisfactory. CONCLUSIONS: If a patient experiences post-mastectomy skin flap necrosis and has a dog-ear deformity on both sides of the flank after a DIEP flap, a dog-ear skin flap can be a good alternative donor site for reconstruction.

Extension block and direct pinning methods for mallet fracture: A comparative study

BACKGROUND: Mallet fracture can easily occur during sports activities or in daily life; however, the principles and methods of treatment for such fractures remain debated. Among the surgical treatments, various methods of closed reduction have been proposed. We treated patients with the extension block method (EBM) and the direct pinning method (DPM), and then compared the results. We assessed differences in range of motion and measurements of finger movement after surgery. METHODS: A total of 41 patients who underwent surgery from August 2013 to September 2015 were evaluated retrospectively. Among them, 21 patients were treated with the EBM and 20 patients were treated with the DPM. We then compared extensor lag, range of motion, and outcomes according to Crawford’s criteria between before surgery and at 6 to 8 months postoperatively. RESULTS: The postoperative extensor lag improvement was 4.28° and 10.73°, and the postoperative arc of motion was 55.76° and 61.17° in the EBM and DPM groups, respectively. The Crawford assessment showed no statistically significant difference between the groups, although the score in the DPM group was higher than that in the EBM group (3.5 vs. 3.1). CONCLUSIONS: As closed reduction methods for the treatment of mallet fracture, both the EBM and DPM showed good results. However, the DPM proved to be superior to the EBM in that it produced greater improvements in extensor lag and range of motion.

The Efficacy of Midline Barbed Absorbable Sutures in Progressive Tension Closure of Abdominal Flap Donor Sites

BACKGROUND: The donor site of abdominal flaps for breast reconstruction consists of a wide suprafascial cavity that poses a risk of seroma formation. The authors evaluated the efficacy of continuous progressive tension sutures (PTS) using unidirectional barbed absorbable sutures for decreasing the volume of fluid collection and the risk of seroma at the abdominal donor site. METHODS: Between March 2013 and February 2015, 37 consecutive patients underwent breast reconstruction using a deep inferior epigastric artery perforator flap. Two patients who underwent salvage operations were excluded. Ten patients underwent standard abdominal flap donor site closure without PTS. Seven received donor site closure with interrupted Vicryl PTS between the abdominal flap and abdominal muscle fascia. Eighteen patients underwent closure with continuous PTS using unilateral barbed absorbable sutures. Body mass index, the approximate flap area, the duration of drain maintenance, the total drained volume, and the incidence of seroma were compared across these 3 groups. The operative time and subjective difficulty perceived by the surgeon was compared between the 2 PTS groups. RESULTS: The total drained volume was lower and the duration of drain maintenance was shorter in both PTS groups than in the standard closure group. There were no cases of seroma in the PTS groups, and 2 that resolved with conservative care in the standard closure group. More time was required and the subjective difficulty score was significantly higher for interrupted PTS than for continuous PTS. CONCLUSIONS: Continuous PTS effectively reduced the duration of drain insertion, the total volume of drained fluid, and was swifter and easier to perform than interrupted PTS.

Relapsed Bilateral Gigantomastia Caused by Pseudoangiomatous Stromal Hyperplasia after Reduction Mammoplasty

Gigantomastia is an abnormal proliferation of breasts by excessive mammary tissue. Pseudoangiomatous stromal hyperplasia (PASH) is a rare benign disease due to nonspecialized fibrous mammary stroma. The incidence of gigantomastia caused by bilateral diffuse PASH is extremely rare. The authors experienced a unique case of recurrent PASH-caused gigantomastia after reduction mammoplasty. Recurrent PASH-caused gigantomastia has never been reported in the literature so far. A 33-year-old woman who suffered of gigantomastia underwent bilateral reduction mammoplasty 4 years ago. Recurrence occurred, and she visited our department. Both breasts were dense without palpable mass. Mammography revealed extremely dense breasts with a bilateral complex glandular pattern. Mastectomy with Wise-pattern incision line was performed. Nipple was reconstructed at the same time using the triangular skin flaps. Pathologic examination revealed numerous slit-like stromal clefts lined by endothelial-like spindle cells were present in well demarcated nodules and diffuse hyperplastic stromas. The finding was consistent with PASH. Reconstruction of aesthetic breast was impossible due to thinned remaining skin and subcutaneous fat tissues. Nevertheless, patient was satisfied, for her anxiety about relapse and discomfort was gone.

Feasibility and Aesthetic Results of Small Bilateral V-Y Advancement Flaps in the Extremities and Back

BACKGROUND: Random type small V-Y advancement flap is widely used for facial reconstruction with advantages including good color and texture match. However, the flap is not as widely used in the extremities and back as in the face because of apprehension of the relatively poor vascularity as a risk factor of flap necrosis. We used a small bilateral V-Y advancement flap for the repair of extremity and back defects from various causes. Competent clinical outcomes are described. METHODS: Between 2007 and 2014, 24 patients (48 flaps) with skin defects in the upper or lower extremities and back were enrolled. The site of the defect was on back (n=6), forearm (n=7), upper arm (n=2), lower leg (n=5), thigh (n=3), and axilla (n=1). RESULTS: Among the 48 flaps, 47 survived (no event: 42 flaps, total necrosis: 1 flap, partial necrosis: 5 flaps). All partial necrotized flaps healed in 3–4 weeks with conservative care. However, debridement and skin grafting was required for the total necrosis flap. One total necrosis and two partial necroses occurred on the anterolateral side of the lower leg. Two partial necroses occurred on the paraspinal area. CONCLUSIONS: Contour deformities including central depression and the dog-ear deformity were not observed. Small bilateral V-Y advancement in the extremity and back could be a safe and useful flap, if thick subcutaneous fat and subcutaneous plexus were saved. But areas with thin subcutaneous fat layer, such as the anterolateral lower leg, are poor candidates and carry the increased risk of improper subcutaneous pedicle circulation.

Deep Inferior Epigastric Perforator Flap Breast Reconstruction in a Patient with Huge Uterine Leiomyoma

The deep inferior epigastric perforator (DIEP) flap has long been the gold standard for autologous breast reconstruction. Various factors that can disrupt abdominal wall vascular anatomy make dissection of the DIEP flap a technically demanding procedure. The mass effect from a huge uterine leiomyoma has not been previously reported as a factor influencing abdominal wall vascularity. The aim of this report was to describe the case of a patient with a huge uterine leiomyoma who underwent immediate free DIEP flap breast reconstruction without any major complications.

Deep Inferior Epigastric Perforator Flap Breast Reconstruction in a Patient with Huge Uterine Leiomyoma

The deep inferior epigastric perforator (DIEP) flap has long been the gold standard for autologous breast reconstruction. Various factors that can disrupt abdominal wall vascular anatomy make dissection of the DIEP flap a technically demanding procedure. The mass effect from a huge uterine leiomyoma has not been previously reported as a factor influencing abdominal wall vascularity. The aim of this report was to describe the case of a patient with a huge uterine leiomyoma who underwent immediate free DIEP flap breast reconstruction without any major complications.

A New Method of Umbilical Transposition

BACKGROUND: Creating a natural-looking umbilicus during closure of the donor-site in abdominally based free flap breast reconstruction is a factor of satisfaction for both the patient and surgeon. We present a simple method of umbilical transposition that results in an aesthetic, natural-looking umbilicus. METHODS: From March 2011 to November 2014, fifty three consecutive female patients received abdominal flap breast reconstruction. Twenty patients (from March 2011 to February 2013) underwent umbilical transposition through a cross like incision in the abdominal flap, with fascial fixation sutures but no dermal flaps. Thirty three patients (March 2013 to November 2014) received umbilical transposition in the following method. An oval-shaped incision is made at the location of the new umbilicus on the abdominal flap. This oval is deepithelialized, and full-thickness incisions are made at the 2, 6, and 10 o'clock directions to create three triangular dermal flaps. These are pulled down to the abdominal fascia using sutures that pass through the umbilical stalk and the abdominal fascia at the 3, 9, and 12 o'clock directions. This results in an umbilical stalk lined with dermal flaps, creates a natural periumbilical concavity, and anchors the abdominal flap inward to minimize tension. The cranial flap enhances superior hooding. RESULTS: Patient and surgeon satisfaction, surveyed 2 months after surgery with a satisfaction scoring system, were higher in the dermal flap group. CONCLUSIONS: The technique using three dermal flaps in an oval skin incision is simple, relatively easy to learn, and results in an aesthetic, natural-looking umbilicus.

A Case of Cold Urticaria Mistaken as Congestion Status during Breast Reconstruction with Deep Inferior Epigastric Perforator Free Flap Coverage

We present the first reported case of cold urticaria, which was mistaken as congestion status, in a patient undergoing breast reconstruction with deep inferior epigastric perforator (DIEP) flap coverage. A 53-year-old woman underwent an immediate bilateral breast reconstruction with DIEP flap coverage. The harvested DIEP flap was wrapped with wet gauze and kept above an ice pack to minimize ischemic damage before flap in-setting to the mastectomy site. After the transfer of the harvested DIEP flap, she had suddenly developed an erythematous and edematous lesion, specifically on the flap. The room temperature was raised and a single dose of steroid and antihistamine was given intravenously. At the first instance, flap congestion was suspected; however, as the rash gradually spread throughout the body, we could deduce that it was cold urticaria. The erythematous rash and whirl resolved soon after receiving medication. Patients with known cold urticaria undergoing surgical procedures require several precautions (e.g., antihistamine, relatively warm operation room) to lessen the risk of severe reaction. Especially in patients with DIEP free flap, the lack of preoperative treatment could result in a pinkish flap due to urticaria, which could be mistaken by the surgeon as a congested flap.