Deep-Plane Lipoabdominoplasty in East Asians.

BACKGROUND: The objective of this study was to develop a new surgical technique by combining traditional abdominoplasty with liposuction. This combination of operations permits simpler and more accurate management of various abdominal deformities. In lipoabdominoplasty, the combination of techniques is of paramount concern. Herein, we introduce a new combination of liposuction and abdominoplasty using deep-plane flap sliding to maximize the benefits of both techniques. METHODS: Deep-plane lipoabdominoplasty was performed in 143 patients between January 2007 and May 2014. We applied extensive liposuction on the entire abdomen followed by a sliding flap through the deep plane after repairing the diastasis recti. The abdominal wound closure was completed with repair of Scarpa's fascia. RESULTS: The average amount of liposuction aspirate was 1,400 mL (700-3,100 mL), and the size of the average excised skin ellipse was 21.78×12.81 cm (from 15×10 to 25×15 cm). There were no major complications such as deep-vein thrombosis or pulmonary embolism. We encountered 22 cases of minor complications: one wound infection, one case of skin necrosis, two cases of undercorrection, nine hypertrophic scars, and nine seromas. These complications were solved by conservative management or simple revision. CONCLUSIONS: The use of deep-plane lipoabdominoplasty can correct abdominal deformities more effectively and with fewer complications than traditional abdominoplasty.

Nipple Reduction With the Chullo-Hat Technique.

BACKGROUND: Although various techniques of nipple reduction have been described in the literature, many are difficult to design or have unreliable outcomes. For men, as well as women who do not plan to breastfeed, it is not necessary to apply a complicated technique that protects the lactiferous ducts. OBJECTIVES: The authors introduce a simple technique for nipple reduction that has achieved consistent, reproducible results. METHODS: The desired nipple length is marked, and a chullo-hat excision pattern is drawn. After infiltration of a local anesthetic solution around the nipple, excision of the excess nipple tissue is performed, comprising 2 triangular flaps. The remaining 2 pillars are approximated with 5-0 Nylon simple interrupted sutures. However, the wound is not completely closed in the central area of the nipple, which promotes the drainage of discharge. RESULTS: Fifty-three women (106 nipples) underwent this surgery between December 2009 and December 2013. The follow-up period ranged from 6 months to 2 years (mean, 10 months). No major complications occurred, and the scars were very inconspicuous. The postoperative appearance of nipples was consistently similar in size and shape. CONCLUSIONS: This simple technique was safe and effective in nipples of different sizes. The results were reliable and consistent with expectations. Although this study included only women, the authors believe that outcomes would be successful in men as well. LEVEL OF EVIDENCE: 4 Therapeutic.

Transaxillary endoscopic breast augmentation with shaped gel implants.

BACKGROUND: At its inception, transaxillary breast augmentation was a blind technique associated with complications and unpredictable outcomes. The transaxillary approach now involves electrocautery dissection with direct endoscopic visualization and yields excellent aesthetic outcomes with a concealed scar. Shaped implant devices can be combined with transaxillary augmentation for natural-appearing results that can be individualized to the patient. OBJECTIVES: The authors sought to improve the results of transaxillary endoscopic breast augmentation by placing shaped gel implants in patients with an indistinct or absent inframammary fold (IMF), who wished to avoid a breast scar. METHODS: One hundred sixteen Asian women underwent transaxillary endoscopic breast augmentation with electrocautery dissection and were evaluated in a prospective study. A partial retropectoral plane pocket was created in 4 sequential dissection steps with direct endoscopic visualization and careful control of bleeding. Shaped cohesive gel implants were placed to produce smooth, natural-appearing breast mounds and well-defined IMFs. RESULTS: Patients were monitored for 6 to 24 months after surgery (mean, 10 months; median, 12 months). There were no instances of pneumothorax, instrument-related skin burns, or severe implant deformation due to rotation or displacement of the implants postoperatively. Three of 116 patients (2.6%) experienced Baker 3 unilateral capsular contracture. One patient developed a unilateral hematoma at 3 weeks after surgery. CONCLUSIONS: Endoscopic breast surgery is associated with shortened recovery times, a reduced need for drainage, and excellent outcomes, including a well-defined and symmetric IMF. This approach, combined with shaped gel implants, can yield natural-appearing results of transaxillary breast augmentation. LEVEL OF EVIDENCE: 4 Therapeutic.

Modified superficial circumflex iliac artery perforator flap and supermicrosurgery technique for lower extremity reconstruction: a new approach for moderate-sized defects.

The superficial circumflex iliac artery perforator (SCIP) flap is an evolved form of groin flap. It overcomes the inherent disadvantages of the groin flap by preserving the deep fascia but still requires challenging skills because of short pedicles and small caliber of vessels. The use of SCIP flap was evaluated for lower extremity use.From June of 2009 to August of 2011, a total of 79 cases were performed (age range, 4-80 years) on the lower extremity using supermicrosurgical approach. All flaps were harvested above the deep fat and the pedicles were taken above or just below the deep fascia to reconstruct the defects throughout the lower extremity.Supermicrosurgery technique was used in 71 cases. A total of 75 cases were performed successfully; 1 case underwent revision but failed and 2 cases were lost within 2 days of surgery. Average size of the flap was 75.5 cm, thickness 7 mm, average length of pedicle was 5 cm, and the average caliber of artery was 0.7 mm. Donor sites were all closed primarily but complications were noted with 1 dehiscence and prolong drainage of lymphatics. Flaps provided good functional coverage and appearance. The average follow-up was 12 months.With the modification of elevating the flap on the superficial fascia, we can harvest a thin flap without additional debulking and avoid complications such as lymphorrhea. Furthermore, with the perforator to perforator or perforator to small distal vessel approach, we can apply this flap on all regions of the lower extremity overcoming the difficulties with short pedicle and small vessel caliber. In our hands, the modified SCIP flap is the flap of choice for small to moderate size defects in the lower extremity.

Selection of the recipient veins for additional anastomosis of the superficial inferior epigastric vein in breast reconstruction with free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps.

There have been many methods to use the superficial inferior epigastric vein (SIEV) for improvement of flap circulation during breast reconstruction with free abdominal flap. If the SIEV is used for the purpose of adding another draining route, selection of ideal recipient vein is a crucial step. We reviewed our experiences of using the SIEV as additional vein in free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator breast reconstruction to find out the ideal recipient vein for SIEV. Between April 2006 and July 2010, 153 cases of breast reconstruction were performed using free transverse rectus abdominis musculocutaneous or deep inferior epigastric artery perforator flaps. Additional SIEV anastomosis was performed in 45 cases with risk factors. First choice of the recipient vein was the lateral thoracic vein if the SIEV was placed laterally after the inset of the flap. If the lateral thoracic vein was ablated with lymph node dissection, the branch of the thoracoacromial vein was selected. If the SIEV was placed medially, the perforator of the internal mammary vein was used. No vascular compromise was observed in cases with additional SIEV anastomosis with those recipient veins, whereas 9 cases of flap-related complications were observed in the remaining 108 cases without additional SIEV anastomosis. The incidences of the venous congestion were significantly different between the 2 groups. Combination of the lateral thoracic vein, branch of the thoracoacromial vein, and the perforator of the internal mammary vein provided an excellent choice of the recipient vein for the SIEV with reliability and availability.

Use of the upper medial thigh perforator flap (gracilis perforator flap) for lower extremity reconstruction.

BACKGROUND: The upper medial thigh perforator flap is a free-style skin flap elevated suprafascially from the upper medial thigh in a transverse manner based on any reliable perforator. METHODS: A total of 40 cases were performed in 40 patients with lower extremity soft-tissue defects from various causes. The anatomy of the flap, the elevation technique, and the results after reconstruction were evaluated. RESULTS: All flaps were raised suprafascially in a free-style flap approach. The average size of the flaps was 71.6 cm2 (vertical width, 6.4 cm; transverse length, 10.9 cm). An average number of 1.3 reliable pulsating pedicles was noted entering the flap, and 90 percent originated from the medial circumflex femoral artery. The perforators were one-third musculocutaneous and two-thirds septocutaneous type. The average length of the pedicle was 6 cm, and the average diameter of the artery was 0.8 mm. The flaps were thinned according to the needs of the patient. The donor sites were closed primarily. Thirty-nine flaps survived, and no recurrence of the original abnormality was seen during the follow-up period. CONCLUSIONS: Despite the short pedicle length, small diameter of the vessel, and inconsistent perforator position, the surgeon can use the upper medial thigh perforator flap to overcome the disadvantages by understanding the free-style free flap approach. The flap can obtain reasonable size, well-hidden scar, preservation of muscle function, good pliability, and superficial nerves and vein included for additional quality. This flap, in the hands of experienced surgeons, can be reliable for reconstructing the lower extremity.