Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations.

Hepatic artery thrombosis (HAT) after liver transplantation is associated with a marked increase in morbidity, leading to graft and patient loss. We evaluated the outcomes of adult living donor liver transplantation patients with HAT under an aggressive surgical intervention. A total of 1355 recipients underwent adult living donor liver transplantation at the Seoul National University Hospital. Surgical redo reconstruction for HAT was performed in all cases except in those with graft hepatic artery injury and late detection of HAT. Postoperative HAT developed in 33 cases (2.4%) at a median time of 3.5 days. Thirty patients (90.9%) underwent redo-arterial reconstruction. The survival rates in patients with HAT were similar to the rates in those without HAT (72.7% vs. 83.8%, p = 0.115). Although graft survival rates were lower in patients with HAT (84.8%) than in those without HAT (98.0%) ( p < 0.001), the graft survival rate was comparable (92.0% vs. 98.0%, p = 0.124) in the 25 patients with successful revascularization. Biliary complication rates were higher in patients with HAT (54.5%) than in those without HAT (32.0%) ( p = 0.008). In conclusion, the successful redo reconstruction under careful selection criteria saved the graft without retransplantation in 96.0% of the cases. Surgical revascularization should be preferentially considered for the management of HAT in adult living donor liver transplantation.

Chondrogenesis of Adipose-Derived Stem Cells on Irradiated Cartilage.

BACKGROUND: Irradiated allogeneic costal cartilage is an alternative option of cartilage graft in patients with insufficient autologous cartilage. However, complications can occur during long-term follow-up. This study investigated whether Tutoplast-processed cartilage, one of the irradiated allogeneic costal cartilages, acts as a scaffold for adipose-derived stem cells and chondrogenesis. METHODS: In vitro setting, human adipose-derived stem cells seeded onto Tutoplast-processed cartilage were cultured in chondrogenic medium and observed using a scanning electron microscope. Next, 3 types of irradiated cartilage-including Tutoplast-processed cartilage, undifferentiated stem cells on Tutoplast-processed cartilage (undifferentiated group), and chondrogenic differentiated stem cells on Tutoplast-processed cartilage (chondrogenic group)-were implanted subcutaneously into nude mice. Gross, histologic, and gene expression analyses of Tutoplast-processed cartilages were performed at postoperative weeks 2 and 4. RESULTS: Human adipose-derived stem cells subjected to in vitro three-dimensional culture differentiated into chondrocytes and expressed cartilage-specificgenes. Adipose-derived stem cells seeded onto Tutoplast-processed cartilage were differentiated into chondrocytes in chondrogenic medium. In the chondrogenic group, the chondrogenic-differentiated cells attached to the surface of the Tutoplast-processed cartilage were maintained during the follow-up and were distinct from the existing Tutoplast-processed cartilage. Moreover, the chondrogenic group had higher expression of cartilage-specific genes compared with the undifferentiated group. CONCLUSIONS: Adipose-derived stem cells seeded onto Tutoplast-processed cartilage underwent chondrogenic differentiation, generating new cartilage, which was maintained after implantation without critical complications. The findings are clinically valuable in terms of overcoming the limitations of irradiated allogeneic costal cartilage, and broaden the surgical options for treatments requiring cartilage.

Local recurrence and metastasis in patients with malignant melanomas after surgery: A single-center analysis of 202 patients in South Korea.

Malignant melanoma (MM) is a lethal skin cancer in Western countries. Although the incidence is low in Asians compared to that in Caucasians, it is increasing. However, literature regarding risk factors for prognosis of MM patients who have undergone surgical excision in Asian is limited. This study aimed to investigate the predictive factors for local recurrence and metastasis in MM patients who underwent surgical treatment at a single tertiary-level hospital in Korea. Patients who underwent surgery for MM at our institution between January 1998 and December 2014 were analyzed. We retrospectively investigated risk factors for local recurrence and metastasis after surgery. In cases with distant metastasis, tumor thickness (adjusted Hazard Ratio (HR), 6.139; 95% confidence interval (CI), 2.152 to 17.509; P = 0.001) and increased mitotic number [(0-1/mm2 vs 2-6/mm2: adjusted HR, 4.483; 95% CI, 1.233 to 16.303; P = 0.023); (0-1/mm2 vs > 6/mm2: adjusted HR, 10.316; 95% CI, 2.871 to 37.063; P < 0.001)] were associated with risk in multivariate analysis. Regarding local recurrence, tumor thickness (T4 [≥4mm] vs T1) was found to be a significant risk factor (adjusted HR, 8.461; 95% CI, 2.514 to 28.474; P = 0.001). Our data revealed tumor thickness and increased mitotic count were significant risk factors for local recurrence and distant metastasis in Korean patients with MM after surgery.

The rate of hepatic artery complications is higher in pediatric liver transplant recipients with metabolic liver diseases than with biliary atresia.

BACKGROUND: Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA. BASIC PROCEDURES: Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed. MAIN FINDINGS: Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3 months; P < 0.001), and had lower Child-Pugh (7.1 vs. 8.4; P = 0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P = 0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P = 0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P = 0.014). PRINCIPAL CONCLUSION: Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications. TYPE OF SUBMISSION: Original article, Case control study, Retrospective. EVIDENCE LEVEL: III.

Long-term Fate of Denervated Skeletal Muscle After Microvascular Flap Transfer.

BACKGROUND: Muscle flap is a valuable option in soft tissue reconstruction. Denervated skeletal muscle is known to undergo degeneration. However, information regarding histological and genetic changes in muscle free flap without reinnervation over long-term follow-up remains unclear. METHODS: We collected flap muscles obtained during secondary exploration surgery after more than 15 years of previous muscle free flap without reinnervation. Compared with normal muscle and fat, histomorphometric and gene expression analysis of flap muscle were performed. RESULTS: During the study period, we collected 5 samples of previous muscle free flap. The mean ± SD postoperative duration after free flap was 18.6 ± 4.0 years. All flap muscles were replaced with adipose tissue based on gross and histological findings. In flap muscle, the expression of gene related to muscle-specific MYH2 gene was downregulated, whereas the expression of genes related to adipose, fibroadipogenic progenitor, and blood vessel was upregulated compared with that of normal muscle. Vascular density and pattern were also similar to those in normal fat. CONCLUSIONS: We demonstrated that muscle free flap without reinnervation eventually converts into adipose tissue regardless of spontaneous reinnervation during muscle regeneration. The long-term findings of the present study will be valuable for muscle flap selection and prognosis.

The Fate of the Adipose-Derived Stromal Cells during Angiogenesis and Adipogenesis after Cell-Assisted Lipotransfer.

BACKGROUND: Cell-assisted lipotransfer is a process in which fat grafting is supplemented with autologous adipose-derived stromal cells. Since the efficacy of the technique was demonstrated, studies have focused on the mechanism by which cell-assisted lipotransfer enhances the rate of graft survival. However, the microenvironmental changes in donor and recipient tissue associated with cell-assisted lipotransfer remain unclear. METHODS: The authors introduced an animal model of cell-assisted lipotransfer using two different transgenic reporter mice. Donor fat from green fluorescent protein-expressing C57BL/6J mice and donor adipose-derived stromal cells from DsRed-expressing C57BL/6J mice were co-transplanted into recipient C57BL/6J mice. During adipose remodeling after cell-assisted lipotransfer, the fate of each donor adipocyte and donor adipose-derived stromal cell was traced using immunofluorescent staining with the whole-mount method. RESULTS: Adipose-derived stromal cell supplementation altered inflammation and promoted angiogenesis and subsequent revascularization in recipient tissue. Tracing at postoperative week 4 revealed that surviving donor adipose-derived stromal cells participated in angiogenesis by differentiating into endothelial cells. Moreover, newly differentiated fat from donor adipose-derived stromal cells and recipient tissue integrated with surviving donor fat, leading to improved retention of the graft. Adipose-derived stromal cell supplementation resulted in a quantitative difference in angiogenesis and adipogenesis during adipose remodeling according to the concentration of adipose-derived stromal cells. CONCLUSIONS: The authors characterized the dynamic changes occurring in donor adipose-derived stromal cells and fat and recipient tissue by tracing these cellular components following cell-assisted lipotransfer. The authors' findings highlight the therapeutic value of cell-assisted lipotransfer in tissue transplantation.

Immediate Nipple Reconstruction During Implant-Based Breast Reconstruction.

BACKGROUND: Nipple reconstruction is usually performed as a separate procedure, several months after the primary breast reconstruction. This study compared the outcomes of immediate and delayed nipple reconstructions during implant-based breast reconstructions. METHODS: A retrospective review was conducted of patients who underwent nipple reconstruction, after implant-based breast reconstruction, between September 2014 and August 2015. The nipple was simultaneously reconstructed following tissue expander removal and implant placement. The reconstructed nipple was evaluated immediately after surgery and 1 year later using objective measurements of nipple dimension and position, and a subjective assessment. RESULTS: Sixty-one patients were included in the study, undergoing either immediate (n = 37) or delayed (n = 24) nipple reconstructions. Patients undergoing immediate nipple reconstructions had a significantly lower chance of radiotherapy (p = 0.018) and demonstrated a shorter period of tissue expansion (p = 0.011) than those undergoing delayed reconstructions. In the objective evaluations, nipple projections and symmetries between the groups were similar at the 1-year postoperative assessment. In the subjective reviews, esthetic breast mound outcomes were higher among those undergoing immediate reconstructions than among those undergoing delayed reconstructions; similar nipple symmetry and shape outcomes were obtained for both groups. CONCLUSION: In cases of implant-based breast reconstruction, immediate nipple reconstruction concurrent with breast reconstruction provides satisfactory esthetic results compared with conventional delayed nipple reconstruction, in properly selected patients. 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 .

Direct thrombectomy as a salvage technique in free flap breast reconstruction.

BACKGROUND: Breast reconstruction with microvascular free tissue transfer has become a widely used method. Despite a high rate of success, a compromised flap necessitating re-exploration can occur. Here, we introduce direct thrombectomy as a flap salvage technique, and compared the results with conventional thrombectomy. METHODS: A total of 488 patients who underwent breast reconstruction using a free transverse rectus abdominis myocutaneous flap between March 2009 and February 2014 were retrospectively analyzed. Flap salvage was conducted by either conventional thrombectomy using a Fogarty catheter, or direct thrombectomy via either a side branch or additional incisions at the stump of the main pedicle at the distal end of the thrombus. RESULTS: Flap compromise necessitating re-exploration due to extensive pedicle thrombosis was identified in 30 patients (6.1%). Direct thrombectomy was used in 9 patients, and conventional thrombectomy in 21 patients. Direct thrombectomy had a significantly higher success rate of flap salvage than conventional thrombectomy (88.9% vs. 47.6%; P = .049). CONCLUSIONS: In the event of vascular thrombosis after free flap breast reconstruction, direct thrombectomy at the proximal pedicle stump beside the anastomosis opening appears to be an effective and reliable option that minimizes vessel trauma related to conventional catheter use. © 2016 Wiley Periodicals, Inc. Microsurgery 37:402-405, 2017.

A Novel Nipple Reconstruction Technique for Maintaining Nipple Projection: The Boomerang Flap.

Nipple-areolar complex (NAC) reconstruction is the final step in the long journey of breast reconstruction for mastectomy patients. Successful NAC reconstruction depends on the use of appropriate surgical techniques that are simple and reliable. To date, numerous techniques have been used for nipple reconstruction, including contralateral nipple sharing and various local flaps. Recently, it has been common to utilize local flaps. However, the most common nipple reconstruction problem encountered with local flaps is the loss of nipple projection; there can be approximately 50% projection loss in reconstructed nipples over long-term follow-up. Several factors might contribute to nipple projection loss, and we tried to overcome these factors by performing nipple reconstructions using a boomerang flap technique, which is a modified C-V flap that utilizes the previous mastectomy scar to maintain long-term nipple projection.

Oncologic Safety of Immediate Breast Reconstruction for Invasive Breast Cancer Patients: A Matched Case Control Study.

PURPOSE: The purpose of this study was to compare locoregional recurrence-free survival (LRFS) and disease-free survival (DFS) between patients undergoing mastectomy and immediate breast reconstruction (IBR) and those undergoing mastectomy alone. METHODS: A retrospective review of patients who underwent mastectomy and immediate breast reconstruction for resectable invasive breast cancer between 2002 and 2010 at a single center was conducted. These cases were matched to patients who underwent mastectomy alone in the same time period, performed by 1:2 matching. Matching control variables included age, tumor size, axillary lymph node metastasis, and estrogen receptor status. Overall, 189 patients were identified in the IBR group, and 362 patients were matched to this group. RESULTS: In the IBR group, 75 patients (39.7%) underwent conventional total mastectomy, 78 (41.3%) underwent skin-sparing mastectomy (SSM), and 36 (19.0%) underwent nipple-sparing mastectomy (NSM). The IBR group was significantly younger than the control group (41.9 and 45.1 years, respectively) (p=0.032), in spite of matching between three age groups. The DFS rates were similar between the IBR group and mastectomy alone group, at 92.0% and 89.9%, respectively, at 5-year follow-up (log-rank test, p=0.496). The 5-year LRFS was 96.2% in the IBR group and 96.4% in the mastectomy alone group (log-rank test, p=0.704), similar to data from previous reports. Subgroup analyses for SSM or NSM patients showed no differences in LRFS and DFS between the two groups. Additionally, in stage III patients, IBR did not cause an increase in recurrence. CONCLUSION: IBR after mastectomy, including both SSM and NSM, had no negative impact on recurrence or patient survival, even in patients with advanced disease.

Surgical Treatment and Prognosis of Angiosarcoma of the Scalp: A Retrospective Analysis of 14 Patients in a Single Institution.

OBJECTIVE: We describe specific surgical methods for angiosarcoma regarding extent of resection and reconstructive options and assess their effect on patients' prognosis. PATIENTS AND METHODS: We retrospectively examined 14 patients undergoing treatment for angiosarcoma of the scalp at our institute between January 2000 and June 2015. Surgical treatment comprised wide excision of the tumor and reconstruction using a free flap with skin graft. Kaplan-Meier survival analysis was used to assess the survival parameters. Univariate and multivariate analyses were performed to evaluate the association between risk factors and outcome parameters. RESULTS: Mean patient age at diagnosis was 69 years, and the mean follow-up period was 17 months. The overall 5- and 2-year survival rates were 15% and 75%, respectively, whereas the 5- and 2-year disease-free survival rates were 7.7% and 38.7%, respectively. The mean survival duration was 32 months. Metastatic tumor dissemination to the lung or brain was closely associated with the major cause of death. Only a deep excision margin was significantly related to the recurrence rate. CONCLUSIONS: Cases of angiosarcoma had a poor prognosis despite the aggressive treatments. Sufficient resection margins are essential for controlling local recurrence. The effect of multidisciplinary approaches needs to be explored.

Wide Local Excision for Dermatofibrosarcoma Protuberans: A Single-Center Series of 90 Patients.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP), a rare low-grade sarcoma of fibroblast origin, tends to extend in a finger-like fashion beyond macroscopic tumor margins. Therefore, incomplete removal and subsequent recurrence are common. This study aimed to determine the efficacy of wide local excision (WLE) for controlling local recurrence of DFSP. METHODS: The medical records of 90 DFSP patients who received WLE at our hospital between June 1992 and January 2015 were retrospectively reviewed. WLE was conducted including a 3 cm (range, 1 to 5 cm) safety margin according to tumor size, location, and recurrence status. Clinical and tumor characteristics and surgical methods were evaluated for risk factor analysis and local recurrence-free survival. RESULTS: DFSP occurred most often in patients in their 30s (30%) and on the trunk (51.1%). Five patients (5.5%) experienced local recurrence during the 43.4-month follow-up period. Recurrence was found at a mean of 10.8 months after WLE. Although no factors were significantly associated with recurrence, recurrences were more frequent in head and neck. Recurrence-free survival was 87% in 6 years and 77% in 7 years. CONCLUSIONS: WLE with adequate lateral and deep margins can effectively control local recurrence rate and is a simple and effective method to treat DFSP.

Use of a Y-Shaped Plate for Intermaxillary Fixation.

Maxillomandibular fractures usually require intermaxillary fixation as a means to immobilize and stabilize the fracture and to re-establish proper occlusion. Arch bars or intermaxillary fixation screws cannot be used for edentulous patients or for patients who have poor dental health. Here, we present a case of repeated intermaxillary fixation failure in a patient weak alveolar rigidity secondary to multiple dental implants. Because single-point fixation screws were not strong enough to maintain proper occlusion, we have used Y-shaped plates to provide more rigid anchoring points for the intermaxillary wires. We suggest that this method should be considered for patients in whom conventional fixation methods are inappropriate or have failed.

The superficial inferior epigastric artery flap and its relevant vascular anatomy in korean women.

BACKGROUND: Lower abdominal soft tissue transfer is the standard procedure for breast reconstruction. However, abdominal wall weakness and herniation commonly occur postoperatively at the donor site. To reduce the morbidities of the donor site, the superficial inferior epigastric artery (SIEA) flap was introduced, but inconsistent anatomy of the SIEA has reduced its utility. In the present study, the anatomy of the superficial inferior epigastric vessels in Korean women was determined with regards to breast reconstructive surgery. METHODS: The vascular anatomies of the SIEA and superficial inferior epigastric vein (SIEV) were evaluated on 32 breast cancer patients receiving free transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy. The existence, pulsation, location, external diameter, and depth of the SIEA and SIEV were measured at the lower abdominal incision level. RESULTS: SIEA and SIEV were present in 48/64 (75.00%) and 63/64 (98.44%) hemi-abdomens, respectively. Pulsation of the SIEA was found in 44/48 (91.67%) cases. The mean locations of SIEA and SIEV were +5.79 (±12.87) mm, and -8.14 (±15.24) mm from the midpoint between the anterior superior iliac spine and symphysis pubis, respectively. The mean external diameters of SIEA and SIEV were 1.20 (±0.39) mm and 1.37 (±0.33) mm, and they were found at a mean depth of 9.75 (±2.67) mm and 8.33 (±2.65) mm, respectively. CONCLUSIONS: The SIEA was absent in 25% of Korean women and had a relatively small caliber. Therefore, careful preoperative assessment of the lower abdominal vasculature is required to achieve successful breast reconstruction using SIEA flaps.

Modified seromuscular patch flap for reinforcing an anastomosis site in hypopharyngeal reconstruction using free jejunal transfer: an anatomical and clinical study.

INTRODUCTION: Free jejunal transfer is commonly used as a reliable reconstructive method after total pharyngolaryngectomy. An anastomotic fistula is the most common complication in the early postoperative period, occurring in 5% to 35% of cases. There have been several studies regarding surgical techniques for minimizing fistula formation. Specifically, the vascularized seromuscular patch flap has been used for reinforcing the anastomosis site; however, this flap does not yield a sufficient range of motion because of traction on the vascular pedicle. METHODS: Between 2004 and 2011, 4 patients underwent vascularized seromuscular patch flaps with free jejunal transfer. A short segment of jejunum on a mesenteric pedicle is usually opened longitudinally along the antimesenteric border to make a patch flap; however, we made a longitudinal incision along 1 side of the mesenteric border. To investigate the vascular anatomy of the flap, a lead oxide-gelatin mixture was injected into the arterial system of 4 fresh cadavers. RESULTS: The flap had increased mobility without traction on the vascular pedicle and adequate circulation. In the injection study, it was shown that the modification guaranteed adequate circulation across the antimesenteric border and from the proximal to the distal end of the flap. CONCLUSION: In conclusion, an incision along 1 side of the mesenteric border produces increased mobility of the jejunal seromuscular patch flap. Angiography can demonstrate clear evidence of a reliable circulation.

Outcomes of surgical management of xanthelasma palpebrarum.

BACKGROUND: Xanthelasma palpebrarum (XP) is a benign disorder manifesting as yellowish cholesterol-laden plaques on the eyelids. This paper presents the outcomes in patients with XP who have undergone surgical excision as the main modality of treatment. METHODS: A retrospective review of patients who received surgery for xanthelasma palpebrarum from March 2007 to March 2011 was conducted. Patients were classified into four grades according to the location and extent of the lesion, with grade I being the mildest and grade IV being the most diffuse. Simple excision was performed in grade I and II lesions, while local flaps and skin grafts were performed in the more advanced grades. RESULTS: Ninety-five cases from March 2007 to March 2011 were included in this study. 66 cases (70%), were treated by simple excision. Twenty-four cases (25%) and 5 cases (5%) were treated by simple excision in combination with or without local flaps and skin grafts. In approximately 1/4 of the patients, orbicularis oris muscle involvement was observed. 4 patients (4.2%) developed scar contracture postoperatively, which required a secondary procedure. Recurrence was reported in 3 patients (3.1%). Otherwise. There were no other reports of major complications or disfigurement. CONCLUSIONS: We found that for lesions involving the deep dermis and/or muscle, surgical excision was the most appropriate therapeutic option.

Magnetic resonance imaging-based volumetric analysis and its relationship to actual breast weight.

BACKGROUND: Preoperative volume assessment is useful in breast reconstruction. Magnetic resonance imaging (MRI) and mammography are commonly available to reconstructive surgeons in the care of a patient with breast cancer. This study aimed to verify the accuracy of breast volume measured by MRI, and to identify any factor affecting the relationship between measured breast volume and actual breast weight to derive a new model for accurate breast volume estimation. METHODS: From January 2012 to January 2013, a retrospective review was performed on a total of 101 breasts from 99 patients who had undergone total mastectomy. The mastectomy specimen weight was obtained for each breast. Mammographic and MRI data were used to estimate the volume and density. A standard statistical analysis was performed. RESULTS: The mean mastectomy specimen weight was 340.8 g (range, 95 to 795 g). The mean MRI-estimated volume was 322.2 mL(3). When divided into three groups by the "difference percentage value", the underestimated group showed a significantly higher fibroglandular volume, higher percent density, and included significantly more Breast Imaging, Reporting and Data System mammographic density grade 4 breasts than the other groups. We derived a new model considering both fibroglandular tissue volume and fat tissue volume for accurate breast volume estimation. CONCLUSIONS: MRI-based breast volume assessment showed a significant correlation with actual breast weight; however, in the case of dense breasts, the reconstructive surgeon should note that the mastectomy specimen weight tends to overestimate the volume. We suggested a new model for accurate breast volume assessment considering fibroglandular and fat tissue volume.

Prevention of capsular contracture with Guardix-SG(®) after silicone implant insertion.

BACKGROUND: Capsular contracture is the most common side effect of breast implant insertion and the problem that breast surgeons seek to avoid the most. Previous animal studies have proved that an antiadhesive barrier solution (AABS) prevents peri-implant capsule formation. In this study, the authors sought to explore the effect that Guardix-SG(®), an AABS that can encapsulate implants in the form of a gel, can have on capsular contracture. METHOD: This study used 12 female New Zealand white rabbits weighing 2.5-3 kg. Implants were inserted into the subpanniculus carnosus plane through an incision in the bilateral midback area. Once the implant was inserted, 3 g of Guardix-SG(®) and normal saline were instilled into the left and right sides, respectively. The rabbits were killed 6 months after the procedure. The intracapsular pressure was measured using tonometry with a 38.2-g circular glass piece, and capsular thickness was measured by dyeing the biopsy specimen with hematoxylin and eosin and Masson's trichrome stain. The myofibroblasts were quantitatively analyzed through monoclonal anti-alpha smooth muscle actin antibody immunohistochemistry staining. RESULTS: The intracapsular pressure in the control group (4.51 ± 0.98 mmHg) was significantly higher (p = 0.002) than in the study group (3.51 ± 0.4 mmHg). The average capsular thickness was significantly greater in the control group (0.33 ± 0.15 mm; p = 0.015). In the analysis, the interrelation between capsular thickness and intracapsular pressure was insignificant in both groups, as was the number of myofibroblasts in both groups (p = 0.582). CONCLUSION: Through this study, the authors were able to demonstrate that capsular contracture can be suppressed in the rabbit model by instilling Guardix-SG(®) after insertion of cohesive gel implants in the subpanniculus carnosus plane. 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 .