A Novel Method for Lower Blepharoplasty: Repositioning of the Orbital Septum Using Inverted T-Shaped Plication.

BACKGROUND: Numerous techniques have been used for lower blepharoplasty. The techniques can be classified into four principles: excision of excess fat, septal reset, orbital fat repositioning, and reinforcement of the attenuated orbital septum. OBJECTIVES: We modified the conventional approach of septal reinforcement to utilize an inverted T-shaped plication with preservation of the orbital fat, repositioning the septum below the arcus marginalis to refine tear-trough deformity. METHODS: From April 2010 to September 2015, 93 individuals underwent bilateral lower blepharoplasty. Retrospective chart reviews were performed, and the results and complications during the follow-up period were recorded and photographed. RESULTS: The patients comprised 76 women and 17 men. Thirteen, 33, and 47 patients exhibited mild, moderate, and severe fat herniation, respectively, accompanied by tear-trough deformity. A total of 70 and 23 patients underwent lower blepharoplasty via subciliary and transconjunctival approaches, respectively. We performed inverted T-shaped plication of the orbital septum in mild and moderate cases and X-shaped plication in severe cases, and in moderate and severe cases, we performed septal repositioning simultaneously. The mean follow-up period was 25 months. When immediate mild lid retraction or lid malposition was observed, it recovered without specific treatment within 1 to 2 weeks. No permanent lid malposition or ectropion was observed in any of the patients. CONCLUSIONS: Septal plication with inverted T-shape or X-shape can minimize the downward forces that affect postoperative eyelid malposition and ectropion. Further, these procedures provide sufficiently strong reinforcement of the orbital septum to restore infraorbital fat herniation.

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.

Chondrocutaneous Preauricular Free Flap for Reconstruction of Nasal Defects Aided by Interposition Vascular Graft.

INTRODUCTION: Reconstruction of a nose deformity with a full-thickness defect is not an easy procedure because the nose is highly noticeable, being located at the center of the face, and plays an important role in breathing. Esthetics and functionality are equally important. Local flap reconstruction is an option but it has limitations for reconstruction of large defects because of the following the scar and the deformity at the recipient site. Chondrocutaneous preauricular free flaps can be used to provide grafts with satisfactory esthetics. Since the chondrocutaneous preauricular free flap has a short pedicle for anastomosis with the facial artery and vein, in some patients there is a need for extra vessel grafts. The authors have had several successful results using chondrocutaneous free flaps aided by interposition vascular grafts with the descending branch of the lateral circumflex femoral artery and the accompanying vein. PATIENTS AND METHODS: A total of 6 patients with full thickness defects of the nose participated in chondrocutaneous preauricular free flap operations from 2011 to 2015. Operations were performed under general anesthesia. After dissection around the tissue and scar removal, the flap was designed to be a few centimeters size wide to include cartilage from the helical loop and preauricular skin. After finding the superficial temporal vein by dissection, the incision was extended to the proximal part of the flap and dissection was done below the superficial temporal vessels. To elongate the pedicle of the flap, the descending branch of the lateral circumflex femoral artery, used as a pedicle for the anterolateral femoral flap, and the accompanying vein were harvested together. The harvested descending branch of the lateral circumflex femoral artery and the accompanying vein were placed on the subcutaneous tunnel. End-to-end anastomosis between the pedicle of the flap and the vessel graft as well as between the vessel graft and the facial vessels was done. During flap inset, even though remnant parts were trimmed, sufficient tissue should be left cautiously, and the donor site was closed primarily. RESULTS: All 6 operations were successful. Despite the different etiologies in each patient, the nose defects were not different and the operations were not different either. The operative time varied from 3.5 to 6 hours. No major complications were reported. After the operation, necrosis and donor site complications did not occur, and scarring and deformity of the donor site were minimal. The patients were mostly satisfied with the results. CONCLUSION: Use of the chondrocutaneous preauricular free flap is not only effective for large defects of the nose, but also makes a good donor if the 3-floor structure and subunit structures of the nose are taken into consideration. Since the pedicle of the flap was short, the authors recruited the descending branch of the lateral circumflex femoral artery and the accompanying vein as a vessel graft. A year after surgery, all of the patients were satisfied with the results.

The Classification and Prognosis of Periocular Complications Related to Blindness following Cosmetic Filler Injection.

Common side effects during hyaluronic acid filler injections are typically mild and reversible, but several reports of blindness have received attention. The present study focused on orbital symptoms combined with blindness, aiming to classify affected patients and predict their disease course and prognosis. From September of 2012 to August of 2015, nine patients with vision loss after filler injection were retrospectively reviewed. Ptosis, ophthalmoplegia, and enophthalmos were recorded over a 6-month follow-up, and patients were classified into four types according to periocular symptom manifestation. Two patients were categorized as type I (blindness without ptosis or ophthalmoplegia), two patients as type II (blindness and ptosis without ophthalmoplegia), two patients as type III (blindness and ophthalmoplegia without ptosis), and three patients as type IV (blindness with ptosis and ophthalmoplegia). The present study includes previously unpublished information about orbital symptom manifestations and prognosis combined with blindness caused by retinal artery occlusion after cosmetic filler injection. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Opportunistic Biopsy of Internal Mammary Lymph Nodes During Immediate Breast Reconstruction After Mastectomy for Breast Malignancies.

BACKGROUND: This study was designed to explore the clinicopathological factors associated with internal mammary lymph node (IMN) metastasis in radiologically IMN-negative breast malignancies and to discuss the clinical value of opportunistic biopsy during immediate breast reconstruction using free flaps, where the internal mammary vessels are the recipient. METHODS: We retrospectively reviewed patients who received curative total mastectomy for breast malignancy followed by immediate reconstruction using transverse rectus abdominis myocutaneous (TRAM) free flap. Suspicious lymph nodes encountered during dissection of the third intercostal space for the recipient vessels were biopsied. Clinicopathological variables and the clinical impact associated with IMN metastasis were analyzed. RESULTS: Among 269 patients who underwent immediate reconstruction using a TRAM free flap, suspicious lymph nodes were identified and biopsied in 54 (20.1%) patients, and IMN metastasis was confirmed in 12 (22.2%) of these (4.5% of all reconstructions). Five patients were positive despite negative axillary lymph nodes and 11 underwent therapeutic plan modifications. Multivariate analysis revealed that IMN metastasis was independently associated with medial tumor location, invasive tumor >2 cm, and positive human epidermal growth factor receptor-2 status (P < 0.05). CONCLUSIONS: Aggressive IMN evaluation and biopsy in a subset of patients during immediate breast reconstruction using a TRAM free flap provided an additional opportunity for accurate breast cancer staging and appropriate adjuvant treatment, while minimizing unnecessary complications.

A comparison of axial circumference between superficial circumflex iliac artery perforator flap and other workhorse flaps in dorsal foot reconstruction.

BACKGROUND: Management and reconstruction of dorsal foot defects present various difficulties and challenges. The main purpose of this article is to discuss experiences of using superficial circumflex iliac perforator (SCIP) flap in various defects of the dorsal foot region. METHODS: From August 2012 to February 2015, a total of 13 patients - nine males and four females - received a reconstruction operation for dorsal foot defects using SCIP flaps (the SCIP group). The defects were caused by trauma (n = 9), diabetes (n = 3), and malignancy (n = 1). The mean age was 43.07 years, which ranged between 19-70 years. Additionally, 19 other patients, who underwent reconstruction operation of the foot dorsum using ALT and TDAP flaps during the same study period, were recruited for comparison. The axial circumference of the operated foot and unoperated contralateral foot was measured, and the difference were compared between all patients, as well as between the two groups. RESULTS: All of the flaps survived after the operation, but secondary procedures were performed in two cases due to partial skin necrosis. The mean follow-up period was 13 months. The mean axial circumference discrepancy of the SCIP group (12.08 ± 2.96 mm) was significantly lower compared with ALT (25.21 ± 3.16 mm) and TDAP (29.88 ± 1.55 mm) groups (p < 0.01). CONCLUSIONS: The authors experienced good results with using the SCIP flap in dorsal foot reconstruction. Reconstruction with the SCIP flap can be a good surgical option, with better postoperative symmetry and minimal donor sequelae, compared to conventional workhorse flaps.

Experimental Design for Composite Face Transplantation.

Face allotransplantation represents a novel frontier in complex human facial defect reconstruction. To develop more refined surgical techniques and yield fine results, it is first imperative to make a suitable animal model. The development of a composite facial allograft model in swine is more appealing: the facial anatomy, including facial nerve and vascular anatomy, is similar to that of humans. Two operative teams performed simultaneously, one assigned to harvest the donor and the other to prepare the recipient in efforts to shorten operative time. The flap was harvested with the common carotid artery and external jugular vein, and it was transferred to the recipient. After insetting the maxilla, mandible, muscles, and skins, the anastomosis of the external jugular vein, external carotid artery, and facial nerve were performed. The total mean time of transplantation was 7 hours, and most allografts survived without vascular problems. The authors documented that this model is well qualified to be used as a standard transplantation training model and future research work, in every aspect.