AESIS-1, a Rheumatoid Arthritis Therapeutic Peptide, Accelerates Wound Healing by Promoting Fibroblast Migration in a CXCR2-Dependent Manner.

In patients with autoimmune disorders such as rheumatoid arthritis (RA), delayed wound healing is often observed. Timely and effective wound healing is a crucial determinant of a patient's quality of life, and novel materials for skin wound repair, such as bioactive peptides, are continuously being studied and developed. One such bioactive peptide, AESIS-1, has been studied for its well-established anti-rheumatoid arthritis properties. In this study, we attempted to use the anti-RA material AESIS-1 as a therapeutic wound-healing agent based on disease-modifying antirheumatic drugs (DMARDs), which can help restore prompt wound healing. The efficacy of AESIS-1 in wound healing was assessed using a full-thickness excision model in diabetic mice; this is a well-established model for studying chronic wound repair. Initial observations revealed that mice treated with AESIS-1 exhibited significantly advanced wound repair compared with the control group. In vitro studies revealed that AESIS-1 increased the migration activity of human dermal fibroblasts (HDFs) without affecting proliferative activity. Moreover, increased HDF cell migration is mediated by upregulating chemokine receptor expression, such as that of CXC chemokine receptor 2 (CXCR2). The upregulation of CXCR2 through AESIS-1 treatment enhanced the chemotactic reactivity to CXCR2 ligands, including CXC motif ligand 8 (CXCL8). AESIS-1 directly activates the ERK and p38 mitogen-activated protein kinase (MAPK) signaling cascades, which regulate the migration and expression of CXCR2 in fibroblasts. Our results suggest that the AESIS-1 peptide is a strong wound-healing substance that increases the movement of fibroblasts and the expression of CXCR2 by turning on the ERK and p38 MAPK signaling cascades.

Association of Fat Graft with Breast Cancer Recurrence in Implant-Based Reconstruction: Does the Timing Matter?

PURPOSE: In two-stage prosthetic breast reconstruction, autologous fat graft (AFG) is often conducted simultaneously with the second-stage operation, which is usually performed shortly after mastectomy. There is a paucity of studies evaluating whether conducting AFG early, with a relatively short interval from the primary operation, is oncologically safe. This study aimed to evaluate potential associations of AFG with breast cancer prognosis, focusing on its timing. METHODS: Patients with invasive breast cancer who underwent immediate two-stage prosthetic reconstruction following mastectomy between 2011 and 2016 were identified. They were categorized into two groups by whether AFG was performed during the second-stage operation. Cumulative incidence of oncologic events was compared between the two groups, after stratifying patients by the time interval between mastectomy and the second-stage operation (≤ 12 months vs. > 12 months). RESULTS: Of 267 cases that met the selection criteria, 203 underwent the second-stage operation within 12 months of mastectomy. AFG was performed for 112 cases and was not performed in 91 cases. The two groups showed similar baseline characteristics including tumor stage and adjuvant treatments. Compared with the control, AFG was associated with lower locoregional recurrence-free survival and disease-free survival, and this difference remained significant after adjusting for other variables including tumor stage. In the 64 cases undergoing the operation after 12 months following mastectomy, oncologic outcomes did not differ between the two groups. CONCLUSION: Our results suggest that AFG timing in relation to mastectomy may be associated with risks for breast cancer recurrence.

Predictors for Implant Rupture in Two-Stage Tissue Expander-Based Breast Reconstruction: A Retrospective Cohort Study.

BACKGROUND: Two-stage tissue expander/implant-based method has been used predominantly for breast reconstruction. Implant rupture is one of the bothersome complications, inducing additional morbidity including reoperation. The present study aimed to identify the independent factors associated with development of implant rupture. PATIENTS AND METHODS: Patients who underwent immediate two-stage prosthetic breast reconstruction between 2010 and 2016 were reviewed. Inserted implants were followed up using magnetic resonance imaging every 2 years and/or ultrasound/computed tomography scans every 6 or 12 months that were conducted for cancer surveillance. Associations of perioperative and intraoperative variables with the development of implant rupture were evaluated. RESULTS: In total, 797 cases (744 patients) were analyzed. During a median follow-up of 43 months after second-stage operation, implant rupture was identified in 22 cases. The 5-year cumulative incidence was 3.1%. Multivariable analyses showed that the interval between the first- and second-stage operations was inversely associated with the risk of implant rupture. Maximal discrimination was observed at the interval of 6.5 months. Cases with an interval ≤ 6 months were associated with higher risks for implant rupture than those with ≥ 7 months, after adjusting for other variables. Type of implant was associated with the development of implant rupture, showing that using two kinds of fourth-generation implant (Allergan Biocell textured round and Allergan smooth round implants) was associated with a significantly increased risk of implant rupture compared with that of Mentor MemoryShape implants (fifth-generation implant). CONCLUSION: Several operation-related variables appear to be associated with implant rupture in two-stage prosthetic reconstruction.

Adjuvant Chemotherapy in Two-Stage Tissue Expander/Implant Breast Reconstruction: Does it Affect Final Outcomes?

BACKGROUND: In immediate two-stage implant-based breast reconstruction, adjuvant chemotherapy, when indicated, is usually conducted between the stages, which might influence the outcomes of the second-stage operation. OBJECTIVE: The purpose of this study was to evaluate the potential influence of adjuvant chemotherapy on the final outcomes of two-stage implant-based reconstructions. METHODS: Patients who underwent immediate tissue expander/implant breast reconstruction between 2010 and 2016, with completion of both stages, were reviewed. Cases were categorized into two groups-adjuvant chemotherapy and no adjuvant chemotherapy. The rates of adverse outcomes were compared between the groups. RESULTS: A total of 602 cases in 568 patients were analyzed, with a mean follow-up period of 58.5 months, including 236 patients receiving adjuvant chemotherapy and 366 patients not receiving adjuvant chemotherapy. The two groups had similar baseline characteristics, except for a significantly higher rate of adjuvant radiotherapy in the former group. The adjuvant chemotherapy group showed significantly higher rates of overall complications (odds ratio [OR] 2.127, 95% confidence interval [CI] 1.231-3.676), including infections (OR 4.239, 95% CI 1.059-16.970), severe capsular contractures (OR 2.107, 95% CI 1.067-4.159), and reconstruction failures (OR 12.754, 95% CI 1.587-102.481) compared with the control group, after adjusting for other variables, including adjuvant radiotherapy. In the analysis regarding the influence of chemotherapy regimens, the use of sequential anthracycline/cyclophosphamide and taxane, and concurrent 5-fluorouracil, doxorubicin and cyclophosphamide, were associated with increased risks for adverse outcomes compared with the no chemotherapy group, while the use of other regimens, including anthracycline/cyclophosphamide alone, was not. CONCLUSIONS: Adjuvant chemotherapy might influence the final outcomes of two-stage implant-based reconstruction.

Does chemotherapy or radiotherapy affect the postoperative complication in breast cancer patients who underwent immediate breast reconstruction with tissue expander?

BACKGROUND: Immediate breast reconstruction with tissue expander in breast cancer patients who were expected to receive adjuvant therapy, such as chemotherapy or radiotherapy, has been a topic of debate. Postoperative complications from tissue expander procedures can delay the timing of adjuvant treatment and subsequently increase the probability of recurrence. The purpose of this study was to identify the impact of chemotherapy and radiotherapy on postoperative complications in patients who underwent immediate reconstruction (IR) using tissue expander. METHODS: We conducted a retrospective study of 1081 breast cancer patients who underwent mastectomy and IR using tissue expander insertion between 2012 and 2017 in Samsung Medical Center. The patients were divided into two groups based on complications (complication group vs. no complication group). Complication group was regarded to have surgical removal or conservative treatment based on clinical findings such as infection, capsular contracture, seroma, hematoma, rupture, malposition, tissue viability, or cosmetic problem. The complication group had 59 patients (5.5%) and the no complication group had 1022 patients (94.5%). RESULTS: In univariate analysis, adjuvant radiotherapy and adjuvant chemotherapy were significantly associated with postoperative complications. In multivariate analysis, however, only higher pathologic N stage was significantly associated with postoperative complications (p < 0.001). Chemotherapy (p = 0.775) or radiotherapy (p = 0.825) were not risk factors for postoperative complications. CONCLUSIONS: IR with tissue expander after mastectomy may be a treatment option even when the patients are expected to receive adjuvant chemotherapy or radiotherapy. These results will aid patients who are concerned about the complications of IR caused by chemotherapy or radiotherapy determine whether or not to have IR. TRIAL REGISTRATION: Patients were selected and registered retrospectively, and medical records were evaluated.

Changes in Korean National Healthcare Insurance Policy and Breast Cancer Surgery Trend in Korea.

BACKGROUND: Since April 2015, the Korean National Health Insurance (NHI) has reimbursed breast cancer patients, approximately 50% of the cost of the breast reconstruction (BR) procedure. We aimed to investigate NHI reimbursement policy influence on the rate of immediate BR (IBR) following total mastectomy (TM). METHODS: We retrospectively analyzed breast cancer data between April 2011 and June 2016. We divided patients who underwent IBR following TM for primary breast cancer into "uninsured" and "insured" groups using their NHI statuses at the time of surgery. Univariate analyses determined the insurance influence on the decision to undergo IBR. RESULTS: Of 2,897 breast cancer patients, fewer uninsured patients (n = 625) underwent IBR compared with those insured (n = 325) (30.0% vs. 39.8%, P < 0.001). Uninsured patients were younger than those insured (median age [range], 43 [38-48] vs. 45 [40-50] years; P < 0.001). Pathologic breast cancer stage did not differ between the groups (P = 0.383). More insured patients underwent neoadjuvant chemotherapy (P = 0.011), adjuvant radiotherapy (P < 0.001), and IBR with tissue expander insertion (P = 0.005) compared with those uninsured. CONCLUSION: IBR rate in patients undergoing TM increased after NHI reimbursement.

Comparative Proteomic Analysis of the Mesenchymal Stem Cells Secretome from Adipose, Bone Marrow, Placenta and Wharton's Jelly.

Mesenchymal stem cells (MSCs) have the potential to be a viable therapy against various diseases due to their paracrine effects, such as secretion of immunomodulatory, trophic and protective factors. These cells are known to be distributed within various organs and tissues. Although they possess the same characteristics, MSCs from different sources are believed to have different secretion potentials and patterns, which may influence their therapeutic effects in disease environments. We characterized the protein secretome of adipose (AD), bone marrow (BM), placenta (PL), and Wharton's jelly (WJ)-derived human MSCs by using conditioned media and analyzing the secretome by mass spectrometry and follow-up bioinformatics. Each MSC secretome profile had distinct characteristics depending on the source. However, the functional analyses of the secretome from different sources showed that they share similar characteristics, such as cell migration and negative regulation of programmed cell death, even though differences in the composition of the secretome exist. This study shows that the secretome of fetal-derived MSCs, such as PL and WJ, had a more diverse composition than that of AD and BM-derived MSCs, and it was assumed that their therapeutic potential was greater because of these properties.

Complications After Immediate 2-Stage Tissue Expander/Implant Breast Reconstruction: A Deeper Look at the Second Stage.

BACKGROUND: Complications after 2-stage tissue expander/implant breast reconstruction have been studied as outcomes of a single procedure. We separately evaluated complications after the second stage and assessed factors associated with the outcomes of the second stage of breast reconstruction. METHODS: Patients who underwent immediate 2-stage breast reconstruction between February 2010 and April 2017 were retrospectively reviewed. Patient demographics, surgical factors of the first stage of breast reconstruction, and complications and number of revision surgeries after the second stage were recorded. Factors associated with postoperative complications were analyzed, and a risk-scoring system was devised. RESULTS: We analyzed 619 patients who underwent 653 immediate 2-stage breast reconstructions. Multivariate analysis showed that complications were associated independently with smoking history, radiotherapy, and a final inflation volume of 450 mL or greater. Each factor contributed 1 point in the creation of a risk-scoring system. The overall complication rate was increased as the risk score increased (1.2%, 4.7%, and 16.0% for 0, 1, and 2 risk scores, respectively, P < 0.001). Revision operation rate was also significantly different across the 3 groups (0.2%, 1.6%, and 12.0% for 0, 1, and 2 risk scores, respectively, P < 0.001). The area under the receiver operating characteristic curve was 0.732 and 0.731 for the logistic regression model and risk-scoring system, respectively (P = 0.975). CONCLUSIONS: In the second stage of immediate 2-stage tissue expander/implant breast reconstruction, the rate of complication and revision surgery can be predicted by a novel risk-scoring system. Greater attention and preventive measures for complications are needed for high-risk patients.

Internal Fixation Method Using EZ-Tcon for Transconjunctival Fat Repositioning: Clinical Outcomes and Efficacy.

BACKGROUND: Transconjunctival fat repositioning is the gold standard for the correction of tear trough deformity. For fixation of fat pedicle, the internal fixation (IF) and externalized percutaneous suture (EPS) techniques are used, which have their own advantages and disadvantages. The present study aimed to introduce a new IF technique using a devised needle (EZ-Tcon) and to compare its outcomes with those of the conventional EPS technique. METHODS: Patients with primary tear trough deformity who underwent transconjunctival fat repositioning were reviewed and categorized into two cohorts according to the fixation technique: cohort 1 consisted of patients treated using the conventional EPS technique and cohort 2 consisted of those in whom the new IF technique using EZ-Tcon was adopted. Post-operative complications and aesthetic outcomes were assessed using a four-scale grading system. RESULTS: A total of 545 patients, 211 from cohort 1 and 344 from cohort 2 were evaluated with a median follow-up of 70 days. Compared to cohort 1, cohort 2 showed significantly lower rates of long-standing conspicuous scars on lower eyelid, re-operation and overall complications. In the analysis of aesthetic outcomes, 88.9 percent of cohort 2 showed grade 0 (no deformity) or I (mild deformity) post-operatively. The rate of excellent outcomes (improvements of ≥ two grades) was significantly higher in cohort 2 than in cohort 1 (p-value < 0.001). CONCLUSION: Our technique using EZ-Tcon could possess advantages of the conventional IF and EPS techniques, showing lower complication rates and aesthetically satisfactory outcomes, and could be a safe and reliable method of transconjunctival fat repositioning. 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 .

A Comparison of Immune Responses Exerted Following Syngeneic, Allogeneic, and Xenogeneic Transplantation of Mesenchymal Stem Cells into the Mouse Brain.

Due to their multifactorial aspects, mesenchymal stem cells (MSCs) have been widely established as an attractive and potential candidate for the treatment of a multitude of diseases. A substantial number of studies advocate that MSCs are poorly immunogenic. In several studies, however, immune responses were observed following injections of xenogeneic donor MSCs. In this study, the aim was to examine differences in immune responses exerted based on transplantations of xenogeneic, syngeneic, and allogeneic MSCs in the wild-type mouse brain. Xenogeneic, allogeneic, and syngeneic MSCs were intracerebrally injected into C57BL/6 mice. Mice were sacrificed one week following transplantation. Based on immunohistochemical (IHC) analysis, leukocytes and neutrophils were expressed at the injection sites in the following order (highest to lowest) xenogeneic, allogeneic, and syngeneic. In contrast, microglia and macrophages were expressed in the following order (highest to lowest): syngeneic, allogeneic, and xenogeneic. Residual human MSCs in the mouse brain were barely detected after seven days. Although the discrepancy between leukocytes versus macrophages/microglia infiltration should be resolved, our results overall argue against the previous notions that MSCs are poorly immunogenic and that modulation of immune responses is a prerequisite for preclinical and clinical studies in MSC therapy of central nervous system diseases.

Effects of Antihypertensive Drugs on Outcomes of Breast Reconstruction.

BACKGROUND: Angiotensin receptor blocker (ARB), a commonly used antihypertensive drug, is reported to affect wound healing and flap survival in animal models. However, this has not been elucidated in a clinical series. This study aimed to investigate the impact that perioperative use of ARB has on outcomes after breast reconstruction. METHODS: Patients who underwent immediate breast reconstruction using a tissue expander or a deep inferior epigastric perforator (DIEP) flap were reviewed. The patients were categorized according to the types of antihypertensive medications as follows: the ARB group consisted of hypertensive patients treated with ARB alone or a combination of ARB and other drugs; the non-ARB group included those receiving drugs other than ARB; and the control group did not receive any medication. The effects of antihypertensive drugs on the development of complications were evaluated. RESULTS: The study analyzed 1390 cases including 999 cases of tissue-expander insertion and 391 cases of DIEP flap reconstruction. With regard to tissue-expander reconstruction, the rates of seroma, reoperation, reconstruction failure, and overall complications were significantly higher in the ARB group than in the other two groups. Compared with no medication, ARB use was an independent risk factor for these complications. With regard to DIEP flap reconstruction, the ARB group showed a significantly higher rate of fat necrosis and significantly greater odds for the development of overall perfusion-related complications and fat necrosis than the control group after adjustment for other variables. CONCLUSIONS: Perioperative administration of ARB might be associated with adverse outcomes after breast reconstruction.

Comparative Study of Nipple-Areola Complex Position and Patient Satisfaction After Unilateral Mastectomy and Immediate Expander-Implant Reconstruction Nipple-Sparing Mastectomy Versus Skin-Sparing Mastectomy.

BACKGROUND: Major surgical concerns associated with nipple-sparing mastectomy (NSM) are partial or total nipple-areola complex (NAC) loss, decreased sensation, and nipple malposition. Patient satisfaction and NAC outcomes including malposition in patients who have undergone unilateral expander-implant reconstruction after NSM as compared with skin-sparing mastectomy (SSM) remain unclear. Therefore, the aim of this study was to assess patient satisfaction and NAC outcomes of breast cancer patients who underwent spared or reconstructed NAC after unilateral NSM as compared with unilateral SSM. METHODS: Patients who underwent immediate expander-implant breast reconstruction following unilateral NSM or SSM were included. Medical records of patients from April 2010 to February 2014 were retrospectively reviewed. Reconstruction-related complications such as infection, seroma, haematoma, delayed wound healing, and reconstruction failure were recorded. NAC outcome analysis was performed using preoperative and postoperative digital photographs for each patient. Patient satisfaction with the reconstructed breast and NAC was assessed using a study-specific questionnaire. RESULTS: Delayed wound healing occurred in 18 of 55 NSM patients and 15 of 85 SSM patients (p = 0.040). Final reconstruction failure occurred in 0 NSM patients and 6 SSM patients (p = 0.043). The mean photography analysis score of total aesthetic outcome was 13.12 ± 2.39 in the NSM group and 14.06 ± 2.75 in the SSM group (p = 0.052). The mean questionnaire score of NAC position was 2.88 ± 0.85 in the NSM group and 3.80 ± 0.84 in the SSM group (p = 0.001). The mean questionnaire score of NAC sensitivity was 2.12 ± 0.58 in the NSM group and 1.84 ± 0.46 in the SSM group (p = 0.003). Satisfaction with the reconstructed breast was similar (p = 0.913) after NSM and SSM. CONCLUSIONS: We observed no significant difference in breast reconstruction satisfaction between the NSM and SSM groups. Although overall satisfaction with breast reconstruction is high, patients in the NSM group often report dissatisfaction with nipple position. With a favourable score for NAC position, skin-sparing mastectomy followed by NAC reconstruction can be considered as a balanced alternative to NSM for properly selected patients with breast cancer. 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 .

Clinical Application of Three-Dimensionally Printed Biomaterial Polycaprolactone (PCL) in Augmentation Rhinoplasty.

BACKGROUND: This clinical study aimed to investigate the safety and surgical outcome of three-dimensionally (3D) fabricated polycaprolactone (PCL) mesh in rhinoplasty. In particular, this study explored how a 3D-printed PCL mesh performs as a bioabsorbable scaffold after a long period following implantation. METHODS: A retrospective review of 101 patients who received primary or secondary rhinoplasty with a PCL mesh was performed. Patient demographics and surgery-related outcomes were examined. Clinical efficacy and safety were evaluated using the Global Aesthetic Improvement Scale at postoperative 18 months. From two revisional cases, a biopsy specimen of implanted PCL was acquired and histopathological analysis was performed. RESULTS: Of all the patients, 98.0% showed no postoperative infection-related foreign body reaction or distinct abnormal reaction, and the implants were observed to maintain long-term efficacy until 18-month follow-up. In patients who received spreader grafts, significant differences between preoperative and postoperative Cottle sign scores were found. Histopathological analysis showed features of adjacent tissue infiltration into pores of the PCL mesh and regeneration of neo-cartilaginous tissue and collagen around the mesh 20 months after implantation. CONCLUSION: This study demonstrates that a novel biodegradable PCL mesh with a 3D structure is a safe and effective material for corrective rhinoplasty because it is easy to use and capable of maintaining its volume in the long term without foreign body response. This biocompatible material will have a wide range of applications as the most suitable alternative to nonabsorbable materials in rhinoplasty and reconstruction surgeries, such as fashioning spreader grafts and septal extension grafts. 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 .

Efficacy of Partial- Versus Full-Sling Acellular Dermal Matrix Use in Implant-Based Breast Reconstruction: A Head-to-Head Comparison.

BACKGROUND: Acellular dermal matrix (ADM), popularly used in tissue expander-based breast reconstruction, is applied either as a partial or full sling, but without any consensus regarding which method of application produces better outcomes. We aimed to compare the outcomes between two patient groups who underwent tissue expander-based breast reconstruction using these techniques. METHODS: A retrospective review was conducted for consecutive patients who underwent immediate two-stage implant-based breast reconstruction using ADM between January 2013 and June 2016. They were categorized into two cohorts: cohort 1 included patients in whom ADM was applied using the partial-sling technique, insetting it obliquely after releasing the pectoralis major muscle from its costal origin, and cohort 2 included those who underwent a full-sling technique, insetting it transversely after releasing the muscle from its costal and lower sternal origin. Postoperative complications and aesthetic outcomes were compared between the two groups. RESULTS: We analysed 329 cases (167 in cohort 1 and 162 in cohort 2) with similar baseline characteristics in both cohorts. Reconstruction failure occurred in 2.4% of overall patients. The rates of each and overall acute complications did not differ significantly between the cohorts. Cohort 2 showed significantly lower rates of tissue expander displacement and malposition following the first-stage operation and rippling following the second-stage operation, differences that retained the influences in multivariate analyses. Higher aesthetic scores were obtained in cohort 2. CONCLUSION: Using the full-sling ADM might reduce unintended migration of prostheses and enable proper tissue expansion, resulting in better overall outcomes without increasing morbidities. 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 .

Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study.

PURPOSE: Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions. METHODS: A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed. RESULTS: A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511). CONCLUSIONS: A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.

Reliable transfer of multiple perforator-based pedicled flaps: Surgical technique and clinical outcomes.

PURPOSE: Although an increase in flap perfusion by incorporating multiple perforators has been demonstrated with free perforator flaps, whether the same efficacy can be achieved with pedicled flaps remains unclear, due to concerns regarding pedicle tension or kinking during flap transposition. The aim of this report was to investigate the reliability of multiple perforator-based pedicled flaps in a series of clinical cases. PATIENTS AND METHODS: Twenty-six patients undergoing soft tissue reconstruction using multiple perforator-based pedicled flaps from 2008 to 2012 were reviewed. The causes of the defects were oncologic (n = 15) or chronic wounds (n = 11). The defect sites were the trunk (n = 19), lower extremities (n = 4), head and neck (n = 2), and upper extremities (n = 1). Diverse flap types were used, including the superior gluteal artery perforator flap, the lateral femoral circumflex artery perforator flap, the medial femoral circumflex artery perforator flap, and the thoracodorsal artery perforator flap. The flaps were transposed in a rotation-and-advancement manner after skeletonizing each perforator and proximally dissecting the pedicle. The donor site was closed primarily. RESULTS: Mean flap size was 125.2 cm2 , and the mean number of perforators used was 2.3 (2-5). The mean angle of pivotal rotation for flap transposition was 132.8°. No rotation-related problems including pedicle kinking or twisting developed, and all flaps survived completely. No significant donor-site morbidity was observed. The mean follow-up period was 38.1 months. CONCLUSIONS: This report suggests that through meticulous dissection of pedicles of sufficient length, the multiple perforator-based pedicled flaps can be successfully transposed while minimizing the risk of pedicle tethering. © 2015 Wiley Periodicals, Inc. Microsurgery 37:105-111, 2017.

Reconstructing facial contour deformities using stereoscopic thoracodorsal artery perforator adipofascial flaps.

PURPOSE: Correcting facial contour deformities is a challenge, as it demands thoughtful planning on design, composition of flap, and secondary procedures. The thoracodorsal artery perforator (TDAP) flap has become a workhorse flap for various reconstructions. In this report, we present our experience of reconstructing facial contour deformities using the free TDAP adipofascial flap, focusing on its customized design. PATIENTS AND METHOD: Sixteen patients underwent correction of a facial contour deformity with free TDAP adipofascial flaps from 2002 to 2012. The causes of defects were Romberg disease (n = 7), oncological defects (n = 5), craniofacial microsomia (n = 3), and trauma (n = 1). The flaps were three-dimensionally designed in a contour map fashion to have different thickness according to the defects by adjusting the height of adipose tissue and varying tissue composition. Customized dimension of flaps having reliable perfusion were harvested with minimized sacrifice of overlying skin. RESULTS: Flap size ranged from 6 × 3 cm to 25 × 25 cm. Six flaps were based on two perforators and the other 10 on one. Five flaps were harvested in a chimeric fashion. All flaps survived completely. No donor morbidity developed in any case. Seven patients underwent secondary corrections including fat injection or liposuction. Improved contour and symmetry were achieved in all patients and was confirmed by a photographic evaluation. Mean follow-up period was 37.8months. CONCLUSIONS: Our results suggest that the stereoscopic TDAP adipofascial flaps with diligent secondary approaches may be a reliable alternative for aesthetic reconstruction of facial contour deformities. © 2015 Wiley Periodicals, Inc. Microsurgery 37:300-306, 2017.

Impact of Acellular Dermal Matrix (ADM) Use Under Mastectomy Flap Necrosis on Perioperative Outcomes of Prosthetic Breast Reconstruction.

BACKGROUND: There is conflicting data on the potential necrotic complications of acellular dermal matrix (ADM) use in breast reconstruction, and most studies focus on mastectomy flap necrosis as an outcome measure associated with ADM use. The aim of this study was to examine cases with necrotic complications with and without the use of ADM and to investigate whether ADM affected perioperative outcomes in cases with necrotic complications. METHODS: Patients who experienced mastectomy flap necrosis following mastectomy with tissue expander placement between January 2009 and March 2015 were retrospectively reviewed. The primary outcome was explantation of the expander, and other associated outcomes such as seroma or infection were also recorded. RESULTS: A total of 57 breasts with mastectomy flap necrosis were identified: 32 of which were in the non-ADM group and 25 in the ADM group. The rate of explantation was 28% (7/25) in the ADM group versus 6.3% (2/32) in the non-ADM group, which was significantly different (P = 0.034). The ADM group had a significantly higher rate of "major" infection requiring surgical debridement than the non-ADM group (P = 0.016). Multivariate analysis showed that the use of ADM was trending toward an increasing expander rate with borderline significance (P = 0.05). CONCLUSION: This study demonstrated that ADM use under mastectomy flap necrosis was a potential risk for explantation of the expander and major infection. Surgeons should be cautious with the use of ADM with devascularized mastectomy skin flaps prone to necrosis. 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 .

The Impact of Expander Inflation/Deflation Status During Adjuvant Radiotherapy on the Complications of Immediate Two-Stage Breast Reconstruction.

BACKGROUND: The question of whether expander inflation/deflation status has any bearing on surgical complications in the setting of adjuvant radiation (XRT) has not been addressed. The objective of this study is to investigate whether the inflation/deflation status of the expander at the time of XRT is associated with complications in immediate two-stage expander-implant breast reconstruction. METHODS: A retrospective review of 49 consecutive patients who underwent immediate two-stage expander-implant breast reconstruction and received post-mastectomy XRT was conducted. Full deflation of the expanders was performed in the deflation group (20 patients), while the expanders remained inflated in the inflation group at the time of XRT (29 patients). XRT-related complications of each stage of reconstructions were compared between the two groups, and multivariable regression analysis was performed to identify risk factors for XRT-related complications. RESULTS: Overall XRT-related complications (65.0 vs. 6.9%, p < 0.001) and reconstruction failures (35.0 vs. 6.9%, p = 0.022) of the first-stage reconstructions were significantly higher in the deflation group. The most common cause of reconstruction failure in the deflation group was failure to re-expand due to skin fibrosis and contracture. In multivariable analysis, deflation of expanders was a significant risk factor for overall complications (odds = 94.4, p = 0.001) and reconstruction failures (odds = 9.09, p = 0.022) of the first-stage reconstructions. CONCLUSIONS: Maximal inflation without deflation before XRT can be an option to minimize XRT-related complications and reconstruction failure of the first-stage reconstructions. 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 .