Animation Deformity: Evaluating the Role of Morphotopologic Features in Suggesting Preventive Surgical Procedures.

BACKGROUND: Animation deformity is an undesirable complication after subpectoral implant reconstruction and is defined as skin distortion during activation of the pectoralis major muscle. However, detailed anatomical features of deformities have yet to be clarified. This study aimed to elucidate how (morphology) and where (topology) animation deformity occurs in reconstructed breasts, and to assess causes and prevention of animation deformity. METHODS: This study included 100 consecutive patients with breast cancer, who underwent unilateral subpectoral implant reconstruction. Animation deformity was evaluated, and the patients were grouped according to both morphologic and topologic features. Univariate and multivariate analyses were performed to identify independent factors associated with deformities. RESULTS: The patients were divided into three groups based on skin distortions with or without implant movement: group I, 60 patients with upper-medial dimpling; group II, 41 patients with upper-lateral folding; and group III, 52 patients with mid-lower lines. Overall, 86 patients (86 percent) showed one or more types of deformity. Among the patients with animation deformity, 24 (28 percent) had implant movement. The authors' study identified axillary dissection as an independent factor for the upper-lateral folding group (OR, 0.30), implant volume for the mid-lower lines group (OR, 1.01), and age for implant movement (OR, 1.06). CONCLUSIONS: Animation deformity was commonly observed in the cohort of patients who underwent subpectoral implant reconstruction and exhibited three morphotopologic patterns of deformity. The current study demonstrated that the morphotopologic grouping of animation deformity may assist in suggesting possible causes and preventive surgical procedures for these deformities. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The Growth Factors of Subcutaneous Benign Lipoma: Consideration from Anatomical Position of Occurrence.

Subcutaneous lipomas are the most common benign soft-tissue tumors. Theoretically, adipocyte sites could be the primary foci; however, lipomas are likely located in the occipital, neck, shoulder, torso, and thigh areas. To date, no study has reported the anatomical relationship between these subcutaneous structures and lipomas. Therefore, we aimed to investigate the anatomical locations of lipomas and considered their growth factors. In addition, we discussed the mechanism of fat amplification to improve the success of fat grafting. Methods: In the present study, lipomas measuring more than 5 cm in diameter from patients hospitalized between 2017 and 2021 were retrospectively examined using preoperative computed tomography and magnetic resonance imaging as well as clinical records with intraoperative pictures. Results: In total, 22 lipomas of 22 patients were examined. All lesions (100%) were accompanied by neurovascular perforators. Nineteen lesions (86%) were located deep in the superficial fascia, where it was clearly defined. Moreover, all lesions were located at the mobile adipofascial layer adjacent to an anchored fixed or less mobile structure. Conclusions: Lipoma growth might require neurovascular perforators that supply both blood flow and continuous stretching stimuli. The mobile adipofascial layer with bones adjacent to a fixed or less mobile area might also be necessary to grow lipomas. If these findings can be used as clues to elucidate the mechanism of fat amplification in the future, it may lead to an improvement in the survival rate of fat grafts.

Analysis of collateral lymphatic circulation in patients with lower limb lymphedema using magnetic resonance lymphangiography.

OBJECTIVE: Although the development of lymphatic collaterals is expected following lymphedema, little is known about the anatomic details of such compensatory pathways or their association with symptoms. Magnetic resonance lymphangiography (MRL) has been shown to be superior to lymphoscintigraphy and indocyanine green lymphography in visualizing lymphatics. This study aimed to analyze MRL images of lower limbs to elucidate the patterns of lymphatic collateral formation and their association with the clinical stages of lymphedema. METHODS: We enrolled 56 consecutive patients (112 lower limbs) with lymphedema who underwent MRL. Two radiologists performed a consensus reading of MRL images for the presence or absence of collateral lymphatic pathways, and the results were compared with the clinical stages. Furthermore, the frequency of abnormal MRL findings in 43 asymptomatic lower limbs of patients with unilateral lymphedema was analyzed and compared with that in the 69 symptomatic lower limbs of the patients. The imaging findings were also compared with the cause of lymphedema. RESULTS: All three collateral pathways (anterolateral, deep, and posteromedial lymphatics) were visualized at a higher (P < .05) frequency in stage II than in stage 0 lower limbs. The frequency of visualization of the three collaterals was significantly higher in symptomatic (stages I-III) lower limbs than in asymptomatic (stage 0) lower limbs. Most (76.8%) of the symptomatic limbs exhibited at least one of these collaterals, and the frequency was significantly higher than in the asymptomatic limbs (P < .001). Most (81.4%) of the asymptomatic (stage 0) lower limbs had at least one abnormal finding in terms of lymphatic circulation, although this proportion was significantly lower compared with the symptomatic limbs (98.6%). The collaterals tended to appear less frequently in primary lymphedema than in secondary lymphedema, reaching statistical significance in the posteromedial lymphatics. CONCLUSIONS: These results suggested that the two superficial lymphatic groups and the deep lymphatic system act as major collaterals of the lower limbs in patients with lymphedema. Furthermore, MRL of most patients with unilateral lymphedema demonstrated abnormal findings, including collateral formation, not only in the affected lower limb but also in the asymptomatic lower limb. In primary lymphedema, the collaterals may appear less frequently than in secondary lymphedema. Collaterals should be taken into consideration in planning the site of lymphaticovenous anastomosis and assessing disease progression. MRL can visualize preclinical alterations in lymphatic flow and compensatory pathways; therefore, we expect that it will be useful for the early diagnosis of lymphedema.

Breast implant-associated anaplastic large-cell lymphoma: first case detected in a Japanese breast cancer patient.

This paper details the first breast implant-associated anaplastic large-cell lymphoma (BIA-ALCL) case detected in Japan. The patient, a 67-year-old Japanese woman, was diagnosed with left unilateral breast cancer 17 years ago. Induration and redness presented in the left breast, which had undergone immediate breast reconstructive surgery using a tissue expander, later replaced by a silicone breast implant (SBI). Breast ultrasound showed fluid collection around the SBI. Surgery was performed to remove the left breast implant and the fragmented capsule surrounding the implant. Postoperative pathological findings did not indicate malignancy. Nine months later, a contralateral axillary lymphadenopathy was observed, and an excisional biopsy of the axillary lymph node was performed. The patient was diagnosed with BIA-ALCL and successfully underwent adjuvant CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) chemotherapy.

Pediatric-Specific Midfacial Fracture Patterns and Management: Pediatric Versus Adult Patients.

PURPOSE: The purpose of this study was to compare the midfacial fracture patterns and management approaches between pediatric and adult patients. METHODS: We retrospectively analyzed 164 pediatric patients (<16 years old) and 564 nongeriatric adult patients (16 to 65 years old) with midfacial fractures at a single institution between 2011 and 2016. The location of the fractures, along with the etiology and management of the midfacial fractures, were compared. RESULTS: Significantly greater proportions of pediatric versus adult patients had sports-related injuries (P < 0.001) and sustained nasal fractures (P < 0.001). On the other hand, significantly greater proportions of adult versus pediatric patients were injured in falls, traffic accidents, or assaults (P = 0.004, P < 0.001, and P = 0.002) and sustained maxillary or zygomatic fractures (P = 0.039 and P < 0.001). Bivariate logistic regression analyses revealed that the risks of nasal, maxillary, and zygomatic fractures were significantly related to age status after adjusting for etiology (P < 0.001, P = 0.045, and P < 0.001). In contrast, the risks of hospitalization and surgical treatment were significantly associated with etiology, but not with age status (P = 0.290 and P = 0.847). CONCLUSION: These data suggest that the age-related structure and composition of the facial skeleton affect the pediatric-specific fracture patterns independent of the etiology. The comparisons in this study may serve as a guide for the management of pediatric midfacial fractures.

Restoration of Bilateral Cranial Defects by Hybridization of Microvascular Free Flaps and Artificial Bones.

Although treatment methods for cranial reconstruction have significantly improved over the past decades, patients having potentially negative influences, such as a history of infection, epidural dead space, or inadequate scalp, remain at high risk of postoperative failure from implant infection and exposure necessitating removal. A 41-year-old male patient sustained severe craniofacial injuries in a traffic accident. Cranioplasty with titanium mesh implants failed due to implant infection, leading to implant removal and debridement. Following repeated local infections and a craniectomy, the patient developed large bilateral complex cranial defects. We then performed a multistage operation, consisting of vascularized free-flap transfers to cover the intracranial dead spaces, and bony reconstruction using hydroxyapatite implants, which achieved full restoration of the defects. We believe that this is the better operative plan for treatment of cranial defects in patients with high-risk factors.

Prevalence and molecular characteristics of DNA mismatch repair protein-deficient sebaceous neoplasms and keratoacanthomas in a Japanese hospital-based population.

BACKGROUND: Muir-Torre syndrome (MTS) is currently considered as a clinical variant of Lynch syndrome (LS). The clinical significance of the screening of patients with MTS-associated cutaneous tumors for the identification of LS has not yet been established. In addition, the prevalence and molecular characteristics of mismatch repair (MMR) protein deficiency in such tumors has scarcely been investigated in the Japanese population. METHODS: Immunohistochemistry (IHC) for MMR proteins (MLH1, MSH2, MSH6 and PMS2) was performed in formalin-fixed paraffin-embedded sections prepared from 16 sebaceous neoplasms (SNs) resected from 13 patients and 32 keratoacanthomas (KAs) resected from 31 patients at our institution between January 2005 and March 2014. Tumors showing MMR protein loss were further subjected to genetic analysis for detecting the presence of germline and/or somatic alterations of the MMR genes to identify the precise molecular mechanisms underlying the protein loss. RESULTS: Among the 16 SNs resected from 13 patients, eight SNs resected from five patients (38.5%) showed loss of expression of MMR proteins (MLH1/PMS2 loss, one patient; MSH2/MSH6 loss, four patients). Genetic analyses showed a pathogenic germline MSH2 mutation in one patient, somatic hypermethylation of the MLH1 promoter region in one patient, and somatic alterations of MSH2 without detectable germline mutations of MSH2 in three patients. None of the KAs examined in the study showed any loss of MMR protein expression. CONCLUSIONS: The efficacy of routine screening of cutaneous neoplasms known to be associated with MTS by IHC for MMR proteins to identify LS may be fairly limited. MMR protein loss as determined by IHC in SNs is not always diagnostic of LS, and appears, in most cases, to be a result of somatic inactivation of the MMR genes.

Vascular consideration in repair of total scalp avulsion.

Successful total scalp replantation was performed in our case. Based on the angiosome concept and anatomical study, the avulsed scalp survived with unilateral anastomosis of the superficial temporal artery and superficial temporal vein, largely due to the presence of rich arterial and venous arcades in the scalp. The patient currently has no problems with activities of daily living, although total hypoaesthesia and dysfunction of the left frontal muscle of the forehead are present. In addition, the combined findings of hair growth pattern indicated the vascular territories of the scalp skin.

Platelet-derived Factor Concentrates with Hyaluronic Acid Scaffolds for Treatment of Deep Burn Wounds.

A deep burn wound is a critical condition that generally necessitates vascularized tissue coverage. We performed the injection of platelet-derived factor concentrates combined with non-cross-linked hyaluronic acid scaffolds for 2 patients with critical burn wounds with bone and tendon exposure and achieved successful healing. Hyaluronic acid was considered to have served as a controlled-release carrier of platelet-derived factors, being clinically effective for the treatment of deep burn wounds.

Composite grafting for distal digital amputation with respect to injury type and amputation level.

PURPOSE: This study evaluated the composite graft survival rate in distal digital amputations with respect to injury type and amputation level. METHODS: Twenty-seven patients with complete fingertip amputations (32 digits) distal to the distal interphalangeal joint who were treated by composite grafting from January 2010 to February 2012 were enrolled. Injury type was classified as clean-cut, blunt-cut, or crush-avulsion. Amputation level was classified according to Ishikawa's classification: subzones I-IV. Graft survival was categorised as complete, partial, or no survival. RESULTS: The graft was more likely to exhibit complete survival in clean-cut injuries (50%) than in blunt-cut (10%) or crush-avulsion injuries (12.5%). However, when complete and partial survival were combined, there was no significant difference among injury types (clean-cut = 83.3%, blunt-cut = 70.0%; crush-avulsion = 68.8%). Composite grafting in sub-zone I provided good results (complete survival = 50%; partial survival = 50.0%; no survival = 0%). When complete and partial survival were combined, there was no significant difference with respect to amputation level except sub-zone I (II = 70.6%; III = 66.7%; IV = 60%). In sub-zone II, clean-cut injuries exhibited better graft survival than blunt-cut or crush-avulsion injuries. In sub-zones III and IV, no complete graft survival was observed. CONCLUSION: In conclusion, all types of injuries in sub-zone I and clean-cut injuries in sub-zone II are candidates for composite grafting. Blunt-cut and crush-avulsion injuries in sub-zone II are marginal candidates for composite grafting. Any type of injury in sub-zone III or IV is contraindicated for composite grafting and should be treated by microanastomosis.

An anatomic study of nipple position and areola size in Asian men.

BACKGROUND: In planning gender-reassignment surgery for biological women and treating men with gynecomastia, surgeons must have a thorough understanding of anatomically correct nipple positions and appropriate areola sizes in men. OBJECTIVES: The authors sought to determine whether body height or body mass index (BMI) affects nipple position or areola size in men. METHODS: Anatomic measurements of the nipples and areolae of 50 Japanese men were obtained. A relative coordinate system was defined, where the medial-lateral and superior-inferior positions of the nipple were quantitatively indicated by distance ratios between anatomic landmarks. Nipple positions were evaluated for each patient by referring to this coordinate system, and the positions were compared between groups categorized by body height or BMI. RESULTS: Nipple position was not significantly affected by body height. However, the nipple tended to be located more laterally in participants with higher BMI. The vertical nipple position differed between standing and supine positions. Tall men had larger areolae than short men; however, areola size did not differ with respect to BMI. CONCLUSIONS: Nipple position and areola size vary by body shape. Consideration of the differences is recommended when performing procedures such as female-to-male gender-reassignment surgery or correction of gynecomastia.

Assessment of the RIVET fixation system for cranioplasty using the pull-out technique.

Cranioplasty using custom-made hydroxyapatite (HAP) ceramic implants is a common procedure to repair skull defects. However, commercially available titanium screws are only minimally stabilized due to characteristic brittleness. We developed the RIVET technique which involves fixing a bioabsorbable plate atop a HAP block using bioabsorbable screws extending beyond both layers, and evaluated fixation strength using the pull-out test and microtomography. Three experimental conditions were compared: a non-RIVET group, RIVET group, and dry skull control group. Pull-out strength significantly differed across groups (non-RIVET group, 1.33 ± 1.21 kgf; RIVET group, 4.46 ± 0.84 kgf; and control group, 6.99 ± 1.14 kgf, P < 0.01). Microtomography of the dry skull control group revealed thread grooves fitted to the screws. The non-RIVET and RIVET groups presented fewer thread grooves than the control group, and the screws did not fit perfectly to the HAP block. However, fixation in the RIVET group was more stable, as the rivet was firmly lodged into the implant. In conclusion, by melting and creating the rivet, pull-out strength can be increased and rigid stabilization of HAP can be obtained. This technique uses commercially available absorbable plate and screws, and thus can be used widely in clinical applications involving HAP blocks with different porosities and thicknesses.

Muscular pedicled lateral chest composite flap-a new nonmicrosurgical option for forearm salvage.

SUMMARY: Posttraumatic upper or lower limb salvage is still challenging. Under difficult situations in which only one vessel supplies the hand or foot, free microvascular reconstruction might damage not only the transferred tissue but also the terminal hand or foot. Two cases of incomplete amputation of the unilateral forearm with large radius bone and soft tissue loss were reconstructed using a newly-refined pedicled osteomyocutaneous flap including vascularized rib, lateral part of the latissimus dorsi muscle, and skin as a lateral chest flap. After insetting of the flap, the transferred limb is fixed with a soft bandage, and the flap is divided no less than 4 weeks after the first operation. The flap completely survived, and bone union between the rib and radius was observed. Although our treatment needed a two-stage procedure, safe and secure reconstruction with an appropriate amount of tissue for salvage was accomplished.

A case of microstomia subsequent to toxic epidermal necrolysis surgically treated by simple technique.

SUMMARY: Toxic epidermal necrolysis (TEN) is a rare but severe adverse dermatitis that is an autoimmune reaction to drugs such as nonsteroidal anti-inflammatory drugs. TEN most severely affects the mucous membranes including the mouth and could develop into microstomia; however, microstomia in relation to TEN has rarely been reported in the literature. We describe an adult female patient who developed microstomia due to scar contracture of the bilateral oral commissures subsequent to TEN and was successfully treated by a simple surgical technique consisting solely of transverse incision of the commissure and longitudinal closure.

Latissimus dorsi flaps oriented on the lateral intercostal artery perforators: anatomical study and application in autologous breast reconstruction.

Autologous breast reconstruction with the latissimus dorsi (LD) musculocutaneous flap has several problems including scarcity of tissue and postoperative atrophy of muscles. We report a modification of the flap based on a re-evaluation of the intramuscular and perforating vascular anatomy focused on the intercostal vascular system. Our anatomical study confirmed the following technical improvements: splitting of the muscle oriented along the 10(th) posterior intercostal artery; siting the axis of the flap on the centre of the 10(th) lateral intercostal artery perforator to obtain ample subcutaneous fat cranial to the iliac crest; and enclosing the dermoadipofascial flap around the split muscular pedicle. These flaps were used in 12 patients who required reconstruction without implants. The results showed a consistent volume of tissue and shape, and less donor site morbidity. Our modifications can be used to improve the three-dimensional potential of the LD flap in autologous breast reconstruction.

Endoscopic and ultrasonic removal of a lipoma on the forehead with no facial scarring: practicality of patient's early return to work.

We used endoscopy and ultrasonic liposuction to remove lipomas from the forehead to facilitate early return to work. The tumours were approached through a pair of small remote scalp incisions behind the frontal hairline, which continued to subperiosteal dissection, thereby avoiding injury to the supraorbital or supratrochlear neurovascular bundles. The deep surfaces of the lipomas were identified easily through the periosteum by well-illuminated and magnified endoscopic views, and protruded through the periosteal incisions. An ultrasonic cannula was introduced to emulsify and aspirate the lipomas. Parts of the lipomas were extracted by forceps as solid specimens for histopathological evaluation. Preservation of the neurovascular bundles and complete resection of the tumours in the bloodless operative fields were confirmed by direct endoscopic monitoring. Of five patients treated, three returned to their jobs within two postoperative days, with no protective dressings on their faces. There have, to our knowledge, been few reports describing this combination of endoscopy and ultrasonic treatment of forehead lipomas.

Free pectoral skin flap in the rat based on the long thoracic vessels: a new flap model for experimental study and microsurgical training.

The purpose of this study was to investigate the vascular anatomy of the pectoral region of the rat to develop a free pectoral skin flap model. In Experiment 1 (n = 6), we performed anatomic dissection and angiographic study of the pectoral region. In Experiment 2 (n = 20), we performed microsurgical free transfer of a pectoral skin flap to the cervical or groin region. Half of the flaps were transferred with flow-though arterial anastomoses. All flaps survived except for 2 cases of autocannibalization. We conclude that the free pectoral skin flap model in the rat is simple and reliable, and can be used as an alternative experimental and training model to the superficial epigastric flap.

Relationship between microvascular arterial anastomotic type and area of free flap survival: comparison of end-to-end, end-to-side, and retrograde arterial anastomosis.

BACKGROUND: Various types of arterial anastomosis are used in the recipient beds of clinical free flap transfers, but their respective hemodynamic efficiencies have not yet been elucidated. The purpose of this study was to investigate the relationship between the type of arterial anastomosis and the area of free flap survival. The authors transferred free three-territory flaps in rats using three different types of arterial anastomosis (end-to-end, end-to-side, and retrograde) and compared their areas of survival. METHODS: Sixty Wistar rats were divided into three groups (n = 20 in each group). A free three-territory flap was elevated and transferred microsurgically to the left ventral region in each rat. The arterial anastomosis was performed in an antegrade end-to-end fashion in group 1, in an end-to-side fashion in group 2, and in a retrograde end-to-end fashion in group 3. The arterial blood flow to the flap was measured 30 minutes after revascularization. On day 5, the area of flap survival was evaluated and whole-body angiography was performed. RESULTS: The average area of flap survival was 90.8 +/- 12.9 percent in group 1, 91.5 +/- 14.3 percent in group 2, and 53.4 +/- 15.5 percent in group 3. There was a statistically significant difference between group 3 and each of the other two groups. CONCLUSIONS: End-to-side and end-to-end arterial anastomoses resulted in an equivalent blood inflow and area of flap survival. Retrograde arterial anastomosis was far inferior to antegrade arterial anastomosis in terms of the area of flap survival, and only the first vascular territory was safe from necrosis.