Revealing the pathogenesis of keloids based on the status: Active vs inactive.

Recently, the pathomechanisms of keloids have been extensively researched using transcriptomic analysis, but most studies did not consider the activity of keloids. We aimed to profile the transcriptomics of keloids according to their clinical activity and location within the keloid lesion, compared with normal and mature scars. Tissue samples were collected (keloid based on its activity (active and inactive), mature scar from keloid patients and normal scar (NS) from non-keloid patients). To reduce possible bias, all keloids assessed in this study had no treatment history and their location was limited to the upper chest or back. Multiomics assessment was performed by using single-cell RNA sequencing and multiplex immunofluorescence. Increased mesenchymal fibroblasts (FBs) was the main feature in keloid patients. Noticeably, the proportion of pro-inflammatory FBs was significantly increased in active keloids compared to inactive ones. To explore the nature of proinflammatory FBs, trajectory analysis was conducted and CCN family associated with mechanical stretch exhibited higher expression in active keloids. For vascular endothelial cells (VECs), the proportion of tip and immature cells increased in keloids compared to NS, especially at the periphery of active keloids. Also, keloid VECs highly expressed genes with characteristics of mesenchymal activation compared to NS, especially those from the active keloid center. Multiomics analysis demonstrated the distinct expression profile of active keloids. Clinically, these findings may provide the future appropriate directions for development of treatment modalities of keloids. Prevention of keloids could be possible by the suppression of mesenchymal activation between FBs and VECs and modulation of proinflammatory FBs may be the key to the control of active keloids.

Association of Neoadjuvant Chemotherapy With Postoperative Outcomes in Immediate Prepectoral Prosthetic Breast Reconstruction.

PURPOSE: Neoadjuvant chemotherapy (NACT) followed by total mastectomy and immediate reconstruction has become an important strategy in the treatment of breast cancer. Although the safety of subpectoral implant-based breast reconstruction with NACT has been extensively evaluated, the safety in prepectoral reconstruction has not been clearly elucidated. We aimed to evaluate the association of NACT with immediate prepectoral breast reconstruction outcomes. METHODS: A retrospective review of patients who underwent total mastectomy and immediate implant-based prepectoral breast reconstruction between May and December 2021 was conducted. Patients were categorized into 2 groups: those receiving NACT and those not receiving it. Postoperative complication rates were compared between the 2 groups. The independent association between NACT and the complication profiles was evaluated. Propensity score matching was also conducted. RESULTS: We analyzed 343 cases, including 85 who received NACT treatment and 258 who did not. Compared with the non-NACT group, the NACT group was younger, had a higher body mass index, and a higher rate of adjuvant radiotherapy. There were no differences in the rates of overall complications or type of complication between the 2 groups. In the multivariable logistic analyses, NACT did not show a significant association with the development of adverse outcomes. Similar results were observed in propensity score matching analyses. CONCLUSIONS: Our results suggest that receiving NACT may not have a significant detrimental effect on the postoperative outcomes of immediate prepectoral prosthetic reconstructions. Conducting prepectoral implant-based reconstruction in the setting of NACT might be safe and provide acceptable outcomes.

Reconstruction of circumferential fingertip defect using free superficial palmar branch of the radial artery flap: Report of two cases.

Wide local excision of noninvasive malignant melanomas has been increasingly performed instead of digit amputation, which often results in extensive fingertip defects. Owing to the unique anatomical characteristics of the fingertips, achieving favorable outcomes in both function and cosmesis is challenging during reconstruction. The free superficial palmar branch of the radial artery (SPBRA) flap is advantageous for finger reconstruction. However, its application in circumferential fingertip defects has rarely been reported. In this report, we describe two cases of circumferential fingertip defect reconstruction using a free SPBRA flap after wide local excision of subungual melanoma. The patients were women aged 74 and 63 years at the time of surgery. They presented with subungual melanoma on the right fourth finger and left thumb, in which both biopsies confirmed malignant melanoma in situ (Tis N0 M0), Breslow thickness of 0 mm (noninvasive). After wide local excision, circumferential defects, sized 2.5 × 6 and 2.7 × 7 cm, were formed on their fingertips. A vertically designed free SPBRA flap measuring 2.7 × 6 and 3 × 6 cm was elevated from the unaffected palm in each patient. After performing microvascular anastomosis, the flap was inserted transversely, wrapping the exposed phalangeal bone in a conical shape. The donor site was primarily closed. All flaps survived, and postoperative complications did not develop. Neither local recurrence nor distant metastasis was detected at the latest follow-up in either patient at 24 or 28 months postoperatively. The patients were satisfied with the natural contour of the reconstructed fingertip and recovered functions. In the evaluation of subjective sensory recovery using four scales (excellent, good, fair, and poor), they responded "fair" and "good," respectively. We suggest that the free SPBRA flap could be a reliable reconstructive method for circumferential fingertip defects.

Microsurgical reconstruction using thoracoacromial vessels as recipients for complicated chest wall defects.

BACKGROUND: Free tissue transfer is often required for the reconstruction of complex and deep anterior chest wall wounds, for which the identification of suitable recipient vessels is crucial. Although the internal mammary arteries (IMAs) are a representative option, identifying secondary options when these vessels are compromised remains a challenge. This report evaluated the efficacy of using the thoracoacromial vessels (TAVs) as recipients for chest wall reconstruction by reviewing our experience. METHODS: We conducted a retrospective review of patients undergoing free-flap-based chest wall reconstruction using TAVs as recipient vessels from February 2020 to March 2023. Patient demographics and surgery-related characteristics data were collected. The primary outcome of interest was the occurrence of flap perfusion-related complications. RESULTS: In total, 12 cases utilized TAVs as recipients, primarily for defects following sternotomy, where bilateral IMA was unavailable due to prior surgery. The TAVs with reliable perfusion were consistently identified beneath the pectoralis major muscle. The anterolateral thigh flap was predominantly employed, with musculocutaneous or chimeric flaps introduced for bony defects. The mean pedicle length of the harvested flap was 7.2 cm (range, 3-13), and in cases with a vascular gap, the pedicle was extended using an arteriovenous interposition graft. This resulted in a mean pedicle length needed to reach recipient vessels of 9.9 cm (range, 6.5-19). All flaps survived, with only one experiencing partial necrosis. CONCLUSIONS: The TAV could be considered as an attractive alternative recipient vessel in microsurgical reconstruction of complicated chest wall defects when the use of IMA is not feasible.

Clinical effectiveness of postoperative prostaglandin E1 administration in reducing flap necrosis following microsurgical reconstruction.

BACKGROUND: Extensive experimental evidence has suggested the potential efficacy of prostaglandin E1 (PGE1) in enhancing flap survival, leading to its widespread empirical use following free flap operation. However, the translation of these experimental findings into clinical benefits remains uncertain. This study aimed to assess the clinical effectiveness of postoperative PGE1 administration on the outcomes of microsurgical reconstruction. METHODS: A retrospective review was conducted for patients who underwent free flap-based reconstruction between September 2020 and November 2022, dividing into two cohorts. For all consecutive cases conducted during the formal half, PGE1 was administered for postoperative 7 days (PGE1 cohort), and for those during the latter, PGE1 was not given (non-PGE1 cohort). The profiles of perfusion-related complications (PRC) were compared between the two cohorts. Further analyses after propensity-score matching were performed. RESULTS: In total, 274 cases were analyzed, consisting of 142 in PGE1 and 132 in non-PGE1 cohort. Baseline characteristics were similar between the two cohorts, except for higher rates of comorbidities and chronic wound-related defects in the PGE1 cohort. Overall PRC developed in 37 cases (13.5%), including 6 (2.1%) total loss and 38 (10.2%) partial necrosis. Compared to the control, the PGE1 cohort exhibited significantly lower rates of overall PRC and partial flap necrosis. This difference remained significant on multivariable analyses. The rate of total flap loss did not differ between the cohorts. Consistent associations were observed in the propensity-score matching analysis. CONCLUSION: Postoperative administration of PGE1 appears to be associated with reduced risks for the development of partial flap necrosis.

High-frequency ultrasound-assisted perforator mapping enhances efficiency in microsurgical reconstruction using thin ALT and SCIP flaps.

BACKGROUND: With the growing demand for the use of thin perforator flaps, obtaining knowledge on the superficial anatomy of perforators is imperative for stable flap elevation. Conventional modalities for perforator mapping fall short in providing such information. High-frequency ultrasound (HFUS), known for visualizing the superficially located anatomic structures, may potentially fill this void. This study aimed to evaluate the effectiveness of HFUS in the outcome of anterolateral thigh (ALT) and superficial circumflex iliac artery perforator (SCIP) flap-based reconstructions. METHODS: Consecutive patients who underwent free ALT or SCIP flap-based reconstruction from January 2021 to November 2022 were retrospectively reviewed. Perforator mapping was conducted using a handheld Doppler during the first year, while HFUS was used in the latter part. The two techniques were compared in terms of flap harvesting time and perfusion-related complication rates while considering the flap elevation plane. RESULTS: In total, 123 cases were analyzed, including 82 ALT flaps (41 in each group) and 41 SCIP flaps (16 in the Doppler and 25 in the HFUS group). The time required for flap elevation exhibited a tendency to decrease in the HFUS group, with a significant difference observed in cases involving thin flap elevation (super-thin ALT flaps and pure-skin-perforator SCIP flaps). Compared with the Doppler group, the HFUS group demonstrated significantly lower rates of PRCs, particularly partial flap necrosis. This difference remained significant in multivariable analyses. CONCLUSION: Our results suggest that HFUS might be an appealing modality for perforator mapping in cases requiring thin ALT and SCIP flap.

Latissimus dorsi myocutaneous free flap for post-sacrectomy reconstruction: Outcomes compared with gluteal muscle flap.

BACKGROUND: Excision of sacral tumor results in extensive defects and vital organ exposure, requiring soft tissue reconstruction for dead space obliteration. Diverse reconstruction options, mainly regional flaps, have been utilized but are limited by high postoperative morbidity. A reliable reconstructive method with low morbidity and facilitated recovery has yet been sought for. In this study, we aimed to evaluate the use of free latissimus dorsi (LD) flap for post-sacrectomy defect reconstruction by comparing its outcomes with local gluteus maximus (GM) flap. METHODS: A retrospective review was conducted of all patients with sacral malignancy who underwent partial or total sacrectomy and immediate reconstruction with LD or GM flap between 2013 and 2022. Nineteen patients were analyzed, including 10 GM flaps and nine LD flaps. Postoperative outcomes were compared between the two groups. RESULTS: The average size of LD flaps was 173.8 cm2 . Seven patients developed complication in the GM group and two patients in the LD group. Complication rate at sacrectomy site was lower in the LD group (p = .003) showing complication-free sacrectomy site and two donor site seromas. The LD group resulted in shorter hospital stay (p = .033) and earlier ambulation than the GM group (p = .001). Mean follow-up period was 63 months for GM group and 17 months for LD group. Three patients in the GM group underwent re-operation, while no delayed complication was observed in the LD group. CONCLUSION: Free LD flaps may provide reliable outcomes with early recovery and may be considered an effective option for sacrectomy defect reconstruction.

Efficacy of the enhanced recovery after surgery protocol on reducing surgical disparities related to overweight/obesity in deep inferior epigastric perforator flap breast reconstruction.

BACKGROUND: When choosing a method of deep inferior epigastric perforator (DIEP) flap for breast reconstruction, concerns regarding the potentially detrimental effects of obesity on postoperative recovery remain. Enhanced recovery after surgery (ERAS) is known to facilitate rapid postoperative recovery. This study aimed to examine the effect of the ERAS protocol on the disparity between normal/underweight and overweight/obese patients after DIEP flap breast reconstruction. METHODS: A retrospective review of consecutive patients who underwent DIEP flap breast reconstruction between January 2015 and November 2022 was conducted. The patients were categorized into two groups: pre-ERAS and post-ERAS. In each group, associations between overweight/obese patients (BMI ≥25 kg/m2 ) and postoperative course were evaluated. RESULTS: In total, 217 patients in the pre-ERAS group (including 71 overweight/obese) and 165 in the post-ERAS group (including 58 overweight/obese) were analyzed. The post-ERAS group had shorter length of stay (LOS) (8.0 versus 7.0 days, p-value <.001) and lower postoperative pain scores (5.0 versus 3.0 at postoperative day (POD) 1, p-value <.001) than the pre-ERAS group. The complication profiles did not differ according to ERAS adoption. In the pre-ERAS group, overweight/obese patients showed a significantly longer LOS (8.0 versus 9.0 days, p-value = .017) and a higher postoperative pain score (3.0 versus 4.0 at POD 2, p-value = .018) than normal/underweight patients; however, these differences disappeared in the post-ERAS group, showing similar LOS, pain scores, and analgesic consumption. CONCLUSIONS: Implementation of the ERAS protocol in DIEP free-flap breast reconstruction may reduce overweight/obesity-related disparities in postoperative recovery.

Usefulness of Free Tissue Transfer for the Reconstruction of Extensive Thigh Defects.

BACKGROUND: Despite the increasing popularity of free tissue transfer, thigh defects have been alienated from their potential indication, owing to the abundance of regional reconstruction options. However, some challenging situations where locoregional modalities may lead to suboptimal outcomes often require free flap. Due to lacking studies regarding microvascular reconstruction of thigh defects, this study aimed to investigate the versatility of free tissue transfer for reconstruction of thigh defects. METHODS: A retrospective review was performed for patients who underwent microvascular reconstruction of thigh defects between 2003 and 2021. Their demographics and operation-related data were summarized and postoperative outcomes were evaluated. RESULTS: Sixty-five patients were analyzed, with a median follow-up period of 15.5 months. Most common situations requiring free tissue transfer were extensive defects, followed by large dead space with exposure of major neurovascular bundle and chronic wounds surrounded by unhealthy regional tissue. Defects were most frequently located in the anterior compartment horizontally and in the distal thigh vertically. The median surface area of the defects was 180.0 cm2. The latissimus dorsi musculocutaneous and thoracodorsal artery perforator flaps were the two most commonly used flaps. Reliable recipient vessels could generally be easily found in the vicinity of defects. Overall complications developed in 12 cases (18.5%), including two of partial flap necrosis. No total flap loss was encountered. CONCLUSION: Free tissue transfer could provide reliable outcomes and facilitate rapid recovery, and could be actively considered for reconstruction of thigh defects in situations unfavorable to the locoregional option.

Safety of Drainless Donor Closure in DIEP Flap-Based Breast Reconstruction: A Prospective Analysis Using Ultrasound.

BACKGROUND: Although drainless donor closure with progressive tension suture (PTS) technique has been attempted to further reduce donor morbidity in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, its clinical safety has not yet been fully elucidated. This study prospectively investigated donor morbidity after DIEP flap elevation and drain-free donor closure. METHODS: A prospective cohort study was performed on 125 patients who underwent DIEP flap-based breast reconstruction and drainless donor closure. Postoperatively, the donor site was evaluated repetitively using ultrasonography. Development of donor complications, including any fluid accumulation and seroma (defined as detection of fluid accumulation after postoperative one month), was prospectively noted, and independent predictors for the adverse events were evaluated. RESULTS: On ultrasound examination conducted within postoperative 2 weeks, 48 patients were detected to have fluid accumulation at the donor site, which were more frequently detected in cases of delayed reconstruction and those with lesser number of PTS conducted. The majority of those events (95.8%) were resolved with one- or two-times ultrasound-guided aspirations. Five patients (4.0%) showed persistent fluid accumulation after postoperative 1 month, which were successfully treated with repetitive aspiration without requiring reoperation. No other abdominal complications developed except for three of delayed wound healing. On multivariable analyses, harvesting larger-sized flap and conducting lesser number of PTS were independent predictors for the development of fluid accumulation. CONCLUSION: The results of this prospective study suggest that drainless donor closure of the DIEP flap with meticulous placement of PTS followed by postoperative ultrasound surveillance appears to be safe and effective.

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.

Selective Application of Blood Glucose Monitoring After Free Flap Surgery: Potential Indications in Real-World Practice.

BACKGROUND: For free-flap monitoring, physical examination still serves as the criterion standard. Blood glucose measurement (BGM) has been suggested to be useful in identifying flap perfusion status. Nonetheless, its routine use may not be cost-effective in real-world settings. This study aimed to share the experiences of using BGM for flap monitoring and suggest its potential indications. METHODS: Of cases of free flap reconstruction conducted between March 2017 and May 2021, those using BGM for flap monitoring were reviewed. Blood glucose measurement was selectively conducted for the following specific situations, which included encountering a flap showing a reddish discoloration and/or rapid capillary refilling time in the immediate postoperative period, monitoring discolored flaps after conducting a salvage operation, and conducting bloodletting therapy for salvaging congestive flaps. The clinical course and outcomes were evaluated. RESULTS: Of a total of 203 cases, 35 used BGM for flap monitoring in addition to clinical examination. In 29 cases, BGM was performed to distinguish early hyperemia from true venous insufficiency. All flaps showed BGM greater than 60 mg/dL with a mean value of 115.42, suggesting early hyperemia, and had uneventful postoperative courses. In 3 cases with already discolored flaps after a salvage operation, BGM was conducted 4 times serially every 3 hours and showed a mean value of 81.6 mg/dL with increasing trends. The flaps recovered completely. In the other 3 cases requiring bloodletting therapy, BGM was conducted an average of 11 times at a median interval of 7 hours. The bloodletting therapy was terminated with reference to the value of BGM when it showed greater than 60 mg/dL while the therapy was on hold. All flaps were successfully salvaged except one showing partial necrosis. CONCLUSIONS: Blood glucose measurement may be helpful in assessing flap perfusion and decision making in certain clinical situations and may be useful as an ancillary tool for flap monitoring. Selective application of BGM may contribute to achieving optimal outcomes.

Coverage of radial forearm free flap donor site defect using another free flap.

BACKGROUND: Donor site defects following the radial forearm flap (RFF) harvest have been usually covered with skin grafting, which often lead to suboptimal outcomes and donor morbidities, including delayed healing and scar contractures. The present report aimed to evaluate the outcomes of using another free flap, the domino flap, for coverage of donor site defects following RFFF harvest. METHODS: Five patients (two males and three females) who underwent coverage of donor defects of RFFF using another free flap between 2019 and 2021 were reviewed. Their mean age was 74 years and the mean dimension of the defect of the RFF donor site was 8.7 × 5.6 cm. Four patients used an anterolateral thigh flap and one used a superficial circumflex iliac artery perforator flap. RESULTS: The mean size of the domino flaps were 12.2 × 5.8 cm. Distal stumps of radial vessels adopting retrograde flow were used as recipients in four cases, and proximal ones adopting anterograde in one. The donor site of the domino flaps was primarily closed. All patients recovered well without any postoperative complications. Aesthetically pleasing outcomes with no functional impairment related to scar contractures were observed in the donor site of RFF during the mean follow-up of 15.7 months. CONCLUSIONS: Use of another free flap for coverage of RFFF donor defects may provide rapid wound healing and satisfactory outcomes, and may be considered an alternative option in cases with large-sized defects that are expected to take a long time to achieve complete healing with skin grafting.

Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases.

Choosing reliable recipient vessels is crucial for successful free flap reconstruction of lower extremity defects, especially in patients with ischemic vasculopathy. This report describes our experience with the intraoperative use of indocyanine green angiography (ICGA) for selecting recipient vessels in lower extremity free flap reconstruction cases. Three patients with lower extremity defects and ischemic vasculopathy underwent free flap reconstruction. Intraoperatively, the candidate vessels were evaluated using ICGA. In the first case, a 10 × 6 cm defect on the anterior side of the lower third of the leg caused by minor trauma and associated with peripheral arterial occlusive disease was reconstructed using a super-thin anterolateral thigh flap based on one perforator. In the second case, a 12 × 8 cm defect on the posterior side of the right lower leg caused by a dog bite and associated with severe atherosclerosis throughout all three major vessels in the lower leg was reconstructed using a muscle-sparing latissimus dorsi myocutaneous flap. In the third case, a 13.5 × 5.5 cm defect on the right lateral malleolar region, where the peroneus longus tendon was exposed due to Buerger's disease, was reconstructed using a one perforator-based super-thin anterolateral thigh flap. In all cases, ICGA was used to evaluate the functionality of the candidate recipient vessels. In two cases, the candidate vessels showed acceptable blood flow, and the operations proceeded as planned. In the third case, the planned vessels of posterior tibial vessels were not identified to have sufficient blood flow, and one of their branches showing enhancement in ICGA was selected and used as a recipient vessel. All flaps survived completely. No adverse events occurred during the follow-up period of postoperative 3 months. Our results suggest that ICGA may be a valuable diagnostic tool for evaluating the quality of candidate recipient vessels in cases where their functionality cannot be guaranteed with conventional imaging modalities.

Natural course of fat necrosis after deep inferior epigastric perforator flap-based breast reconstruction: Evaluation based on ultrasound examination.

BACKGROUND: Fat necrosis, often developing following deep inferior epigastric perforator (DIEP) flap-based breast reconstruction, is not a negligible complication. This study aimed to conduct a longitudinal assessment of the clinical course of fat necrosis in breast reconstruction with DIEP flap. METHODS: Among patients undergoing immediate DIEP flap-based breast reconstruction between 2009 and 2017, those who developed fat necrosis on ultrasonographic examination and did not undergo surgical intervention for the lesion were reviewed. Changes in lesion size over time were assessed based on regular ultrasound examinations. RESULTS: A total of 37 cases were analyzed, with a mean follow-up of 52.6 months (range, 19-114). Their mean age was 45.8 years, and the mean body mass index was 23.4 kg/m2 . Of these, 21 lesions had disappeared over time. The mean time from detection to the disappearance was 30.4 months. The remaining 16 lesions did not disappear and persisted for a median follow-up of 43.5 months. Compared with the lesions that persisted, those that disappeared were significantly smaller in initial size (p = 0.040) and had a lower inset ratio of the harvested flap (p = 0.006). The optimal cutoff value for the initial size for disappearance was ≤1.97 cm. Among the lesions >1.97 cm in size, 6 (35.3%) of 17 lesions disappeared, whereas in those ≤1.97 cm, 15 (75.0%) of 20 disappeared over time, with a significant difference (p = 0.041). CONCLUSION: The natural course of fat necrosis that develops following the DIEP flap may differ according to its initial size.

Penoscrotal defect reconstruction using loco-regional flaps in treatment of extramammary Paget's disease: Experience and suggestion of a simplified algorithm.

BACKGROUND: Reconstruction of penoscrotal defects resulted from margin-controlled excision of extramammary Paget's disease (EMPD) remains challenging, due to its unpredictably varying extents. The present study aimed to investigate outcomes of reconstruction of penoscrotal defects following radical excision of EMPD and to introduce a simplified algorithm for selecting reconstruction strategies. METHODS: Patients with penoscrotal EMPD who were treated with wide excision and subsequent reconstruction from 2009 to 2020 were reviewed. Their demographics, operation-related characteristics, and postoperative outcomes were evaluated. RESULTS: In total, 46 patients with a mean age of 64.9 years (range, 44-85 years) were analyzed. An average size of defects was 129.6 cm2 (range, 8-900 cm2 ). The most frequently involving anatomical subunit was scrotum, followed by suprapubic area and penile shaft. Twenty-six patients had defects spanning multiple subunits. The most commonly used reconstruction methods for each anatomical subunit were internal pudendal artery perforator (IPAP) flaps and/or scrotal flaps for scrotal defects, superficial external pudendal artery perforator (SEPAP) flaps for suprapubic defects, and skin grafts for penile defects. In all but four cases, successful reconstruction was achieved with combination of those reconstruction options. No major complications developed except for one case of marginal flap necrosis. All patients were satisfied with their aesthetic and functional results. CONCLUSIONS: Diverse penoscrotal defects following excision of EMPD could be solidly reconstructed with combination of several loco-regional options. A simplified algorithm using in combination of IPAP flap, SEPAP flap, scrotal flap, and skin graft may enable efficient and reliable reconstruction of penoscrotal EMPD defects.

Association of Dual Venous Anastomosis with Reduced Risks for Flap Congestion in Microsurgical Lower Extremity Reconstruction: A Multicenter Study.

BACKGROUND: Flap congestion related with venous thrombosis is a major cause for microsurgical lower extremity reconstruction failure. Conducting dual venous anastomosis has been suggested to reduce risks for the adverse outcomes; however, its efficacy remains controversial. This study evaluated a potential association of dual venous anastomosis with the development of flap congestion in diverse clinical situations. METHODS: This multicenter study included patients who underwent microsurgical lower extremity reconstruction at two institutions. They were divided into two groups based on the number of venous anastomoses-single and dual groups. Their perfusion-related complications (PRCs), including total/partial flap loss, arterial or venous insufficiency, and emergent reoperation, were compared. Independent association of the number of venous anastomoses with the outcomes was evaluated. Further analyses were conducted using propensity score matching. RESULTS: In total, 225 cases were analyzed, of which 92 were included in the single group and the other 133 in the dual group. The two groups had generally similar baseline characteristics. The dual group presented significantly lower rates of PRC, including total/partial flap loss, flap congestion, and emergent reoperation. Multivariable analyses showed that conducting dual venous anastomoses was associated with reduced risks for the development of overall PRC and flap congestion. These associations were more prominent when restricting analyses for cases with chronic wound and trauma (vs. oncologic defects). Similar associations were observed in the propensity score matching analysis. CONCLUSION: Conducting dual venous anastomosis seems associated with reduced risks for flap congestion in microsurgical lower extremity reconstruction, especially for cases with unfavorable conditions.

Association of Preoperative Sarcopenia with Adverse Outcomes of Breast Reconstruction Using Deep Inferior Epigastric Artery Perforator Flap.

BACKGROUND: Sarcopenia, defined as a significant loss of skeletal muscle mass and function, is suggested to be associated with an increased risk of complications after various surgical interventions. However, evidence regarding sarcopenia in microsurgical breast reconstruction has been lacking. The present study was designed to evaluate the association between preoperative sarcopenia and adverse outcomes in deep inferior epigastric perforator (DIEP) flap-based breast reconstruction. METHODS: Patients who underwent breast reconstruction using DIEP flap between 2009 and 2018 were reviewed. Sarcopenia was defined as a skeletal muscle index < 38.5 cm2/m2, calculated by normalizing the cross-sectional area of the skeletal muscle, measured at the level of the third lumbar vertebra based on preoperative computed tomography angiography, to patient height. Postoperative complication rates were compared between patients with sarcopenia and those without it. Independent association of sarcopenia with complication profiles were evaluated. Further analyses were conducted using propensity score matching. RESULTS: In total, 557 patients were analyzed, of which 154 (27.6%) had preoperative sarcopenia. The sarcopenia group had a significantly lower body mass index, a lower elevated flap weight, and greater use of bipedicled flaps compared to the nonsarcopenia group. Complications developed in 128 patients (23.0%) and were more prevalent in the sarcopenia group. Preoperative sarcopenia was associated with a significantly higher rate of complications, including breast hematoma, breast wound problems, abdominal functional weakness, and reoperation in the multivariable analyses. Similar associations were observed in the propensity score matching analysis. CONCLUSIONS: Preoperative sarcopenia appears to be associated with adverse outcomes in DIEP flap-based breast reconstruction.

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.

Usefulness of Interposition Arteriovenous Bundle Grafts in Free Flap Surgery: A Case Series and Systematic Review.

BACKGROUND: The paucity of reliable recipient vessels adjacent to defects poses a great challenge in free flap reconstruction. Although the use of interposition vein grafts to cover the vascular gap is common, its potential association with higher risks of flap compromise is often reported. Interposition arteriovenous bundle grafts have been introduced as an alternative. This study aimed to evaluate the outcomes of free tissue transfer using interposition arteriovenous bundle grafts and to conduct a systematic review of studies that reported the use of the technique. METHODS: Patients who underwent free tissue transfer using the interposition arteriovenous bundle graft technique were assessed for flap perfusion-related complications. A systematic review of literature was performed using pooled analysis to calculate the rate of perfusion-related complications. RESULTS: Overall, 14 cases of free flap reconstruction used the interposition arteriovenous bundle graft technique to cover vascular gaps in diverse regions. The most common donor vessel of this graft was the descending branch of the lateral circumflex femoral vessels (mean length, 6.9 cm). All flaps survived except for 1 case of partial flap loss, showing a flap compromise rate of 7.1%. A systematic review identified 13 studies that represented 78 cases using this technique. In the pooled analysis, including the current series, the overall flap survival rate was 95.7%, reporting 4 of 92 cases of flap compromise. CONCLUSIONS: The interposition arteriovenous bundle graft technique may help overcome the challenges of pedicle shortage or lack of adjacent recipient vessels in free flap reconstruction.