Basic Strategies of Augmentation Mammoplasty in Patients with Tendencies of Pectus Excavatum and Carinatum.

BACKGROUND: In this era of growing popularity of cosmetic surgeries, more women of various chest wall shapes are likely to receive augmentation mammoplasty. Pectus excavatum (PE) and pectus carinatum (PC) are the two most common chest wall deformities, and many asymptomatic patients visit the clinic. In this study, we presented various strategies for successfully performing breast augmentation in PE and PC patients without long-term complications such as symmastia. METHODS: From January of 2019 to December of 2021, a total of 132 patients with tendencies of PE and PC received augmentation mammoplasty in our institute. We retrospectively reviewed data on demographics, surgical procedure, outcomes, and complications. RESULTS: Among the 132 cases, 71.21% were done via inframammary approach, and 28.79% via transaxillary approach. The mean implant volume was 337.25 ± 51.46 ml, and the mean follow-up period was 16.48 ± 6.74 months. The Likert scale of outcome satisfaction scored 9.13 ± 0.48. No symmastia occurred. CONCLUSION: We presented our basic strategies of breast surgery in patients with various chest wall anomalies. Augmentation mammoplasty can benefit PE and PC patients physically as well as psychologically, to carry out healthy positive lives. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Periareolar Augmentation Mastopexy: Finding the Aesthetic Level of Breast Lifting.

Background: Ptosis and volume atrophy of the breasts are common symptoms for various ages of women and may induce a considerable amount of stress in daily life. Periareolar augmentation mastopexy is an effective procedure for such conditions, and planning the new nipple position is very important. Aim: To provide a simple, straightforward planning and walkthrough of this operation in a journey to find the ideal level of breast lifting for natural upper fullness. Materials and methods: From January 2019 to December 2021, a total of 193 patients with volume deflation and ptosis of the breast received periareolar augmentation mastopexy in our institute. We retrospectively reviewed data on demographics, surgical procedures, outcomes, and complications. Results: All operations were done with periareolar incisions, and the mean follow-up period was 29.48 ± 9.11 months. The Likert scale of outcome satisfaction scored 9.02 ± 0.61. Complications were minimal, and no symmastia or bottoming out occurred. Conclusion: We present our basic strategies of periareolar augmentation mastopexy with a slight modification of the design. We believe that lifting the nipple to 3-4 cm above the inframammary fold (IMF) (making the top of the areola about 5-6 cm above the IMF) yields satisfactory aesthetic results.

Double Triangle Suture Technique for Inverted Nipple Correction While Preserving the Lactiferous Ducts.

Background: Inverted nipple is a relatively common symptom to encounter, and numerous surgical techniques have been developed for correction. Aim: The aim of this study is to provide a simple and effective procedure with long-term results. Materials and Methods: A total of 209 nipples of 108 patients received inverted nipple correction via double triangle suture technique. Results: Of the 108 patients, 7 patients had unilateral inverted nipple and 101 patients had bilateral. Of the 209 nipples operated, 28 were grade 1, 117 were grade 2, and 64 were grade 3. The mean follow-up period was 13.16 ± 6.77 months. There were minimal complications. Conclusion: Double triangle suture technique is a safe and reliable inverted nipple correction method. It requires two small incisions, few sutures, and minimal operation time. We especially recommend this procedure for young women with potential breastfeeding in the future and who concern for minimal scars.

A prospective comparative study of radiotherapy effect upon scar quality.

INTRODUCTION: The effect of radiation on uncomplicated postoperative scars is unclear. This study aimed to analyze irradiated and non-irradiated scars in patients with unilateral breast cancer, who underwent oncoplastic breast reduction surgery and radiation therapy (RT), to identify how postoperative scar changes with radiation. METHODS: Twenty breast scars in 10 patients were analyzed after unilateral breast-conserving surgery, oncoplastic breast reduction, and RT. Scars were assessed using the Vancouver scar scale (VSS) by two independent blinded observers and three-dimensional scar analysis camera. Paired t-test between irradiated and non-irradiated scars in each patient and correlation of scar score differences with potential contributing factors were analyzed. RESULTS: The VSS was significantly lower for the irradiated scar than that for the non-irradiated contralateral scar (1.40 vs. 4.05, p = 0.001), although time interval from the last radiation to scar assessment had a negative correlation with paired differences of VSS (Spearman's correlation coefficient: -0.637, p = 0.048). Compared with the non-irradiated scar, the irradiated scar showed a significantly high level of hemoglobin (1.04 vs. 1.26, p = 0.017) and melanin (0.55 vs. 0.63, p = 0.03). CONCLUSIONS: Postoperative scars with radiation showed better results in objective and subjective assessments than scars without radiation. These findings suggest that radiation has a positive effect on general scar maturation.

Simultaneous Augmentation Mammoplasty and Vacuum-Assisted Breast Biopsy for Enhanced Cosmesis and Efficacy.

BACKGROUND: In this era of expanding life expectancy and popularity of aesthetic breast surgeries, more women are likely to live more years with their augmented breasts. Thus, consistent attention to general breast health is crucial, and preoperative ultrasound is helpful to locate suspicious lesions. In this study, we present a combinative procedure of augmentation mammoplasty and vacuum-assisted breast biopsy (VABB). METHODS: From January of 2018 to December of 2019, a total of 102 patients received simultaneous augmentation mammoplasty and VABB in our institute. Only patients of primary augmentation mammoplasty who received VABB on unilateral breasts were included. We sought to investigate the results of each breast and safety of adding VABB before performing augmentation within the same incision. RESULTS: Among 204 breasts and implants, 28.43% were done via endoscopic transaxillary approach and 71.57% via inframammary approach. The mean implant volume was 329.34 ± 44.79 ml, and the mean follow-up period was 14.23 ± 4.64 months. All of the complication rates exhibited no statistically significant differences between the two groups. CONCLUSION: Simultaneous augmentation mammoplasty and VABB prevented unnecessary scars and pain, and the complication rates did not statistically differ from those of augmentation only group. This co-operation is a safe and simple method potentially beneficial to many women interested in breast surgery. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Multiplane Facelift Following Facial Bone Contouring for Enhanced Mobilization and Rejuvenation.

INTRODUCTION: The aging process is inevitable in life, and the social demand for rejuvenation increases by year. The face acquires both soft tissue and skeletal changes through aging, and correcting only one side has limits in natural rejuvenation. Thus, the authors combined multiplane facelift with whole-facial bone contouring for maximal results. METHODS: From March 2017 to February 2019, a total of 22 patients received multiplane facelift following facial bone contouring in our institute. The authors retrospectively reviewed information on demographics, surgical procedure, complications, and satisfaction. Under general anesthesia, the patient received reduction malarplasty, genioplasty, and mandible anglectomy via intraoral incisions, and multiplane facelift through retrotragal and postauricular incisions. RESULTS: All patients were females with the mean age of 42.86 ±â€Š9.55. The mean operation time was 296.39 ±â€Š31.87 minutes and the mean follow-up period was 12.59 ±â€Š6.77 months. Few complications included hematoma and unfavorable scars. More than 95% of the patients were very satisfactory with the result. CONCLUSION: In this study, the authors present our novel procedure of combining whole-facial bone contouring and multiplane facelift. This technique can reestablish the facial skeletal foundation and effectively lift soft tissues in various vectors with longevity and safety.

Demographic Factors of Nasal Bone Fractures and Social Reflection.

INTRODUCTION: The nose is the most protruding central part of the face, and nasal bone fractures are the most common of facial bone fractures, leading up to 39%. Despite its high frequency, not many studies handled the etiology of nasal bone fractures, leading to the necessity of a recent demographic study. MATERIALS AND METHODS: A total of 1111 patients diagnosed with nasal bone fracture from 2013 to 2018 at our institute were evaluated. A retrospective review of the various demographic and etiologic characteristics was done. RESULTS: Numerous factors associated with nasal bone fractures were analyzed. Male patients were 3.3 times greater than the number of female patients, and twenties were the most common age range. Violence was the overall most common cause of injury, while slip down was the most common cause for females. Upon monthly distribution, the highest incidence of nasal bone fractures occurred in September, followed by March and December. The authors further divided the patients by time zone of the fractures, and male patients were most commonly injured from midnight to 3 AM, while female patients were 6 PM to 9 PM. CONCLUSION: Our findings represent a recent urban data of various etiologic factors of nasal bone fracture. The concept of school violence has been widely used since 1990s, and our data reflects that violence of the youth is a serious issue of the society. The mechanism of injury differed among sexes and age groups, and such discrepancies will aid physicians to better understand facial bone fracture patients and educate them in the future.

Sequential reconstruction for recurrent head and neck cancer: A 10-year experience.

BACKGROUND: Most patients with head and neck cancer successfully undergo oncologic resection followed by free or local flap reconstruction, depending on the tumor's size and location. Despite effective curative resection and reconstruction, head and neck cancer patients still face a high risk of recurrence and the possibility of a second primary cancer. Moreover, surgeons hesitate to perform sequential reconstruction following curative resection for several reasons. Few large-scale studies on this subject are available. Therefore, we retrospectively evaluated the outcome of sequential head and neck reconstruction to determine the possible risks. METHODS: In total, 467 patients underwent head and neck reconstruction following cancer resection at our center from 2008 to 2017. Of these cases, we retrospectively reviewed the demographic and clinical features of 58 who had sequential head and neck reconstruction following resection of recurrent cancer. RESULTS: Our study included 43 males (74.1%) and 15 females (25.9%). The mean age at the initial operation was 55.4±15.3 years, while the mean age at the most recent operation was 59.0±14.3 years. The interval between the first and second operations was 49.2±62.4 months. Twelve patients (20.7%) underwent surgery on the tongue, and 12 (20.7%) had procedures on the oropharynx. Thirty-four patients (58.6%) received a sequential free flap reconstruction, and 24 patients (41.4%) were treated using locoregional flaps. No cases of flap failure occurred. CONCLUSIONS: Our findings suggest that patients who need additional operations with recurrent head and neck cancer could optimally benefit from sequential curative resections and reconstructions.

The Modified Keystone Flap for Pressure Ulcers: A Modification of the Keystone Flap With Rotation and Advancement.

INTRODUCTION: The reconstruction of extensive soft tissue defects from pressure ulcers is a great challenge. Resurfacing such defects with like tissues and minimizing morbidities are important. Here we present our surgical experience using a novel modified keystone flap for pressure ulcer patients. METHODS: We retrospectively reviewed the data of 13 consecutive cases reconstructed with the modified keystone flaps between March and December, 2017. The mean dimensions of the reconstructed defect were 7.7 × 6.5 cm, while the mean dimensions of the flap were 12.1 × 8.3 cm. RESULTS: Time efficient reconstructions with the modified keystone flap were performed without any following major complications. Minor wound dehiscence occurred in only one case, which soon healed with conservative management. CONCLUSIONS: Considering its simple design, reliable flap survival, minimal donor-site morbidity, optimal flap thickness, and evenly distributed surgical tension, our novel technique of the modified keystone flap is as an excellent surgical option for the reconstruction of pressure ulcers in the gluteal region.

Demographic characteristics of craniosynostosis patients in Asia.

PURPOSE: Craniosynostosis (CRS) is a congenital condition resulting premature fusion of one or more cranial sutures. CRS is classified according to the involved sutures into sagittal, metopic, unicoronal, unilambdoid, bicoronal, and multiple-suture CRS, with sagittal suture fusion known to be the most common type. Although multiple studies have presented demographic characteristics of CRS patients, to date, there is no study representing an Asian population. We sought to compare the demographic characteristics of Asian patients to those of Western patients, considering previous reports. MATERIALS AND METHODS: A total of 266 CRS patients treated in a single institution from 1996 to 2016 were retrospectively reviewed. Data from the patients was collected regardless of whether they underwent operation. Patients' age at the time of presentation, sex, and maternal and paternal age at birth were reviewed. Patients were routinely investigated for abnormal genes (FGFR2 and FGFR3). The Bayley Scales of Infant Development, Second Edition (BSID-II), was used to assess the patients' cognitive and psychomotor development. One-way analysis of variance or the Kruskal-Wallis test was used to compare continuous variables. A p value of <0.05 was considered statistically significant. RESULTS: Our study included 157 males (59.02%) and 109 females (40.98%), with an age ranging from 0.1 to 10.5 years. The mean age at the time of diagnosis was 2.01 ± 2.57 years, and the mean age at operation was 2.16 ± 2.61 years. Of the patients, 27 (10.15%) were bicoronal, 28 patients (10.53%) were metopic, 48 patients (18.04%) were unicoronal, 50 patients (18.80%) were unilamboid, and 67 patients (25.19%) were sagittal. Patients with multiple-suture CRS totaled 46 (17.29%). Investigation of abnormal genes revealed six patients (2.20%), including two patients with abnormal FGFR2 and four patients with abnormal FGFR3. Maternal and paternal ages at the patients' birth were 32.18 ± 4.56 years and 34.71 ± 4.72 years, respectively. The mean BSID-II scores were 84.96 ± 22.77 for the Mental Development Index and 84.19 ± 25.62 for the Psychomotor Development Index. To examine the trend of diagnosis of CRS type, we also evaluated the number of new patients diagnosed with nonsyndromic CRS per year at our institution. New diagnoses of CRS generally increased from the year 2009, although variations continued. CONCLUSION: The mean age of our patients is relatively high compared to previous, Western studies. Through this research, we recognized that cultural discrepancies regarding the expectations of Asian parents may lead to prolonged diagnosis of CRS patients, and yet even relatively older CRS infants can successfully be treated with surgical intervention. The prevalence of CRS types and BSID-II development scores varied compared to those in previous Western studies. Further investigations at the genetic level are required to compare the different populations. To diagnose CRS in an effective and timely manner, a physician must be aware of the general characteristics and understand the variations between Western and Eastern populations.

The effect of light-emitting diode (590/830 nm)-based low-level laser therapy on posttraumatic edema of facial bone fracture patients.

PURPOSE: Posttraumatic edema in facial bone fracture patients may interfere with the operation field and delay the schedule. Thus, swiftly reducing the edema alleviates patient discomfort and advances the operation date. Ice packing and compression bandages are often used for such a purpose, but such methods are often inconvenient for the face. In this study, we aim to analyze the effect of light-emitting diode (LED) (590/830 nm)-based low-level laser therapy (LLLT) in posttraumatic edema in facial bone fracture patients. MATERIALS AND METHODS: We conducted a prospective cohort study of 40 patients who were admitted to a single institution for facial bone fracture. The patients were divided into two groups of 20 each, treated either with LLLT or with sham treatment light. We used an LLLT device that consists of planar LED-based arrays with double wavelengths 590 nm and 830 nm. The patients were treated with either true or sham light from posttraumatic day 1-5, twice a day. After each treatment, the volume of a patient's face was measured with a 3-dimensional camera. We analyzed and compared the changes in facial edema. The Wilcoxon rank sum test was conducted for statistical comparison of the two groups, and significance was set to the level of p < 0.05. RESULTS: The sex ratio and mean age of the two groups were of little difference. The fracture sites included the nasal bone, orbital wall, zygomaticomaxillary bone, mandible, and frontal sinus. Mechanisms of injury included fall, assault, traffic accident, sports, and gunshot. The total operation rate of both groups was equal to 85%. Our analysis showed a 16.5% reduction of edema in the LLLT group and 7.3% in the sham light group. The edema reduction was statistically significantly greater in the LLLT group than in the sham light group (p < 0.047). CONCLUSION: LED-based LLLT is recently receiving attention worldwide for its cost-effectiveness and large coverage area compared to traditional laser therapy. Recent studies support its effectiveness in various areas such as wound healing, skin rejuvenation, and pain alleviation. In this study, we treated facial bone fracture patients with LED-based LLLT, and showed its effectiveness in reducing posttraumatic edema.

Patient Satisfaction with Implant Based Breast Reconstruction Associated with Implant Volume and Mastectomy Specimen Weight Ratio.

PURPOSE: Breast volume assessment is one of the most important steps during implant-based breast reconstruction because it is critical in selecting implant size. According to previous studies, there is a close relationship between the mastectomy specimen weight and resected breast volume. The aim of this study was to evaluate long-term patient satisfaction with implant-based breast reconstruction guided by the ratio of implant volume to mastectomy specimen weight. In doing so, we describe the ideal ratio for patient satisfaction. METHODS: A total of 84 patients who underwent implant-based breast reconstruction for breast cancer were included in this study. The patients were grouped by the ratio of implant size to mastectomy specimen weight (group 1, <65%; group 2, 65%-75%; and group 3, >75%). Outcome analysis was performed using a questionnaire of patient satisfaction and the desired implant size. RESULTS: Patient satisfaction scores concerning the postoperative body image, size, and position of the reconstructed breast were significantly higher in group 2. The average ratio of the ideal implant volume to mastectomy specimen weight for each group was 71.9% (range, 54.5%-96.7%), with the differences across the three groups being not significant (p=0.244). CONCLUSION: Since there is an increase in breast reconstruction, selecting the appropriate breast implant is undoubtedly important. Our novel technique using the ratio of implant volume to mastectomy specimen weight provides physicians a firm guide to intraoperative selection of the proper implant in reconstructive breast surgery.

Variance of the pectoralis major in relation to the inframammary fold and the pectoralis minor and its application to breast surgery.

Understanding the anatomy of the muscles and other structures of the chest is of great importance in breast surgery. We have conducted the first analysis of the overall variations and relationships among the pectoralis major (PM), inframammary fold (IMF), and pectoralis minor (Pm). We studied 30 patients and 10 cadavers, leading to a total of 50 breasts. Preoperatively, the breast width was measured, and the costal origin of the lowest IMF point was marked. Intraoperatively, we recorded the costal origins of the PM and IMF, PM width, the distance between the PM and IMF, and the relationship and distance between the PM and Pm. Among the patients, PMs originated from the sixth rib in 80% and above the IMF in 66.67%. The mean distances between the PM and IMF were 10.5 mm in the patients and 16 mm in the cadavers. The mean PM/breast width ratio was 0.82 in the patients and 0.85 in the cadavers. The PM and Pm mostly crossed on the fourth or fifth rib, and the average angles between the two muscles were 23.5° and 21.4° in the patients and cadavers, respectively. This study is the first to analyze the anatomical variations of the PM, IMF, and Pm simultaneously. We also examined the differences between Western and Asian populations. Understanding the anatomy is undoubtedly crucial for breast surgery, and here we provide a firm guide to the variations to be expected during operations, which can lead to successful outcomes. Clin. Anat. 30:357-361, 2017. © 2017 Wiley Periodicals, Inc.

Surgical Management of Gynecomastia: Subcutaneous Mastectomy and Liposuction.

BACKGROUND: The treatment of gynecomastia depends on multiple factors, and the best modality is controversial. In this study, we aimed to determine the best management approach by comparing outcomes of two groups of patients with gynecomastia who received subcutaneous mastectomy combined with liposuction and liposuction only. METHODS: We conducted a retrospective analysis of 64 patients who underwent surgery for gynecomastia. We divided the patients into two groups: group A, patients who underwent liposuction only; and group B, patients who underwent liposuction and subcutaneous mastectomy. The serial photographs of all patients were clinically evaluated with respect to size, shape, scarring, and overall outcome by three plastic surgeons, and patient satisfaction was surveyed with regard to palpable lumps, size, shape, scarring, and overall outcome. RESULTS: Of the 64 subjects, 16 received liposuction only, and 48 received the combination procedure. A total of 125 breasts were involved. The doctors' scores for size and overall outcome were significantly better in the combination group, whereas scarring was better in the liposuction-only group. Similarly, patient satisfaction regarding size was significantly higher in the combination group, and satisfaction regarding scarring was significantly higher in the liposuction-only group. The scores for scarring in the combination treatment group were acceptable. CONCLUSION: Our study shows that combination treatment with liposuction and subcutaneous mastectomy results in satisfactory outcomes, including the extent of scarring. We conclude that this combination treatment should be recommended as the standard surgical treatment for gynecomastia and can provide excellent results in cases where glandular tissue needs to be removed. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Facial Flap Repositioning in Posttraumatic Facial Asymmetry.

Perfect facial and body symmetry is an important aesthetic concept which is very difficult, if not impossible, to achieve. Yet, facial asymmetries are commonly encountered by plastic and reconstructive surgeons. Here, we present a case of posttraumatic facial asymmetry successfully treated with a unique concept of facial flap repositioning. A 25-year-old male patient visited our department with severe posttraumatic facial asymmetry. There was deviated nasal bone and implant to the right, and the actual facial appearance asymmetry was much more severe compared to the computed tomography, generally shifted to the right. After corrective rhinoplasty, we approached through intraoral incision, and much adhesion from previous surgeries was noted. We meticulously elevated the facial flap of both sides, mainly involving the cheeks. The elevated facial flap was shifted to the left, and after finding the appropriate location, we sutured the middle portion of the flap to the periosteum of anterior nasal spine for fixation. We successfully freed the deviated facial tissues and repositioned it to improve symmetry in a single stage operation. We conclude that facial flap repositioning is an effective technique for patients with multiple operation history, and such method can successfully apply to other body parts with decreased tissue laxity.

Acute Respiratory Distress Syndrome after the Use of Gadolinium Contrast Media.

Acute respiratory distress syndrome (ARDS) is a medical emergency that threatens life. To this day, ARDS is very rarely reported by iodine contrast media, and there is no reported case of ARDS induced by gadolinium contrast media. Here, we present a case with ARDS after the use of gadobutrol (Gadovist) as a magnetic resonance imaging (MRI) contrast medium. A 26 years old female without any medical history, including allergic diseases and without current use of drugs, visited the emergency room for abdominal pain. Her abdominopelvic computed tomography with iodine contrast media showed a right ovarian cyst and possible infective colitis. Eighty-three hours later, she underwent pelvis MRI after injection of 7.5 mL (0.1 mL/kg body weight) of gadobutrol (Gadovist) to evaluate the ovarian cyst. She soon presented respiratory difficulty, edema of the lips, nausea, and vomiting, and we could hear wheezing upon auscultation. She was treated with dexamethasone, epinephrine, and norepinephrine. Her chest X-ray showed bilateral central bat-wing consolidative appearance. Managed with mechanical ventilation, she was extubated 3 days later and discharged without complications.

Factors associated with diabetic retinopathy and nephropathy screening in Korea: the Third and Fourth Korea National Health and Nutrition Examination Survey (KNHANES III and IV).

This cross-sectional study was done to identify and determine the socio-demographic and health-related factors associated with diabetic retinopathy and nephropathy screening in Korea. Participants included 2,660 adults, aged 40 or older, with diabetes. Of the 2,660 adults, 998 (37%) and 1,226 (46.1%) had received a diabetic retinopathy and a nephropathy screening within one year, respectively. Regarding retinopathy, subjects older than 65, living in urban areas, with high educational levels, and with self-reported "unhealthy" status were likely to receive annual screening. Subjects living in urban areas, with higher educational levels, with self-reported "fair" or "unhealthy" status, and with 1 to 2 co-morbidities were likely to receive annual nephropathy screening. The Korea Composite Stock Price Index (KOSPI) continued to rise until 2007 when it started to decline over the subsequent years, following the same curve as the diabetic retinopathy and nephropathy screening rates during that time. Together with the financial matter, lack of patient education proved to be a hindrance to diabetes-related screening. The relatively low screening rates in Korea compared to the Western countries are likely to be due to the difference in the health system, economic situations and national demographics.