Management of Congenital Melanocytic Nevus on Face Using Multiple Re-expansion Method: Aesthetic and Psychosocial Results.

BACKGROUND: Congenital giant melanocytic nevus on the face is a challenging condition, especially in the pediatric population. It can produce significant cosmetic deformity with negative psychosocial effects in pediatric patients even after treatment. The objective of this study was to report aesthetic and psychosocial results in the management of congenital melanocytic nevus on the face using multiple reexpansion. METHODS: Data of 6 patients with congenital melanocytic nevus on the face who underwent excision and multiple reexpansion at our center from September 2004 to August 2017, were retrospectively reviewed. To evaluate aesthetic outcomes, preoperative and final photographs of each patient were reviewed by 3 other plastic surgeons and 4 laypersons. For comparison, 6 other patients who were treated with conventional surgery during the same period were reviewed. After final reconstruction surgery, the authors surveyed patients' satisfaction via telephone. RESULTS: Six patients were followed up for an average of 87.66 months (range, 55-123 months). The mean number of tissue expander insertions was 3.33 and the mean number of total expanders inserted was 4.83. Complication associated with expander exposure occurred in 1 patient during the fifth expansion. The average score of aesthetic outcome in the multiple reexpansion group was superior to that of the conventional group (2.60 versus 2.10, P = 0.03). During the telephone survey, patients did not rate their appearance as positive, although they were comparatively satisfied with the surgical procedure. CONCLUSION: Considering the low rate of malignancy involving congenital melanocytic nevus in childhood, multiple reexpansion is an attractive option to obtain better results compared with other reconstructive methods.

Phenotypic association of presence of a somatic GNAQ mutation with port-wine stain distribution in capillary malformation.

BACKGROUND: A somatic mutation of GNAQ (c.548G>A, p.Arg183Gln) plays a key role in capillary malformation development. The present study aimed to evaluate clinical manifestations of port-win stain (PWS) associated with this genetic mutation. METHODS: Skin tissue was obtained from 70 patients with capillary malformation who had been treated with excision for lesions. Droplet digital polymerase chain reaction was used to quantify the abundance of cells with the GNAQ mutation. RESULTS: The GNAQ mutation was found in 50 patients. Patients with lesions involving upper facial region, which included forehead, eyebrow, and upper eyelid, showed a significantly higher rate of positive GNAQ mutation than those not involving it. Cases with facial PWS involving all three facial regions (upper, middle, and lower) showed significantly higher positive rate of GNAQ mutation compared to those involving one or two. CONCLUSIONS: Presence of the somatic mutation GNAQ p.Arg183Gln might be associated with clinical manifestations of PWS.

Negative-Pressure Wound Therapy for Managing Complicated Wounds at Extracorporeal Membrane Oxygenation Sites.

OBJECTIVE: To evaluate the effectiveness of negative-pressure wound therapy (NPWT) for management of wound complications at extracorporeal membrane oxygenation (ECMO) removal sites. METHODS: The authors retrospectively reviewed patients who underwent NPWT at ECMO removal sites followed by the development of wound complications including skin necrosis, lymphorrhea, and femoral vessel exposure. A nonadhesive bacteria-binding mesh was used as a wound contact layer of NPWT application. Patient characteristics and clinical outcomes were evaluated. RESULTS: Nine patients underwent NPWT for complicated wounds at ECMO sites. The mean age of patients was 49.2 years (range, 14-64 years). All patients exhibited wound complications with lymphorrhea and skin necrosis. Seven of nine patients had wound cultures that were positive for microorganisms, but culture conversion to negative was achieved after NPWT application for a mean period of 21.2 days (range, 12-30 days). Lymphorrhea was successfully managed, and formation of fresh granulation tissue was observed in all patients. Wound healing either by primary closure, skin graft, or secondary healing was achieved without recurrence of wound complications. There were no cases of femoral vessel injury or aneurysm during NPWT application. CONCLUSIONS: Negative-pressure wound therapy appears to be a safe and effective treatment option in the management of complicated wounds at ECMO sites.

Vertical Spacing of Perforators in Deep Inferior Epigastric Perforator Flap Breast Reconstruction Can Affect the Outcomes.

BACKGROUND: The present study aimed to evaluate the influence of vertical location and spacing of perforators within flaps on the outcomes of deep inferior epigastric perforator (DIEP) flap breast reconstruction. METHODS: Patients who underwent unilateral breast reconstruction with unipedicle DIEP flaps were identified. They were categorized into cohorts based on the entry of perforators in the middle third (cohort 1), upper third (cohort 2), and multiple third parts (cohort 3) of the flaps. Perfusion-related complications including fat necrosis diagnosed with ultrasound and donor-site morbidity were compared between the cohorts. RESULTS: A total of 287 patients were analyzed, including 51 in cohort 1, 75 in cohort 2, and 161 in cohort 3. The cohorts were well matched, except for a greater number of perforators and more frequent harvest of both medial and lateral row perforators in cohort 3. Rates of overall perfusion-related complications and fat necrosis differed significantly between cohorts, with the highest rates in cohort 2. Fat necrosis occurred predominantly in the caudal portion of the flap in cohort 2, whereas it was relatively evenly distributed in the cephalic and caudal portions in cohorts 1 and 3. Rates of donor-site complications were similar across the cohorts. Multivariate analyses demonstrated that vertical spacing of perforators had an independent influence on developing perfusion-related complications and fat necrosis, showing that cohort 2 had significantly higher odds compared with cohorts 1 and 3, respectively. CONCLUSION: Vertical spacing of perforators might affect the risk of perfusion-related complications in DIEP flap breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Refinements in Elevation of the Reconstructed Auricle: The "Zigzag Incision".

OBJECTIVE: Auricular elevation with superficial temporal fascia and skin graft is widely used in microtia reconstruction using costal cartilage. However, in some patients, there has been occurrence of contraction of skin graft, which led to insufficient projection of the elevated auricle and diminished auriculocephalic angle with unfavorable long-term results. In this article, the authors introduce their multiple triangular flaps with zigzag incision to maintain stable projection and natural retroauricular sulcus appearance in auricular reconstruction patients. METHODS: The authors have designed zigzag incision along the lateral margin of the ear framework to prepare triangular flaps targeting the root of the helix or inferior half of the auricle. Depending on the extent of remnant skin coverage, the number of triangular flaps is varied. The posterior raw surface of the ear framework was covered with triangular flaps and full-thickness skin graft. RESULTS: Zigzag incision was conducted in 22 microtia patients who underwent auricular elevation using superficial temporal fascia and skin graft. Mean follow-up period was 2 years and there were no reports of occurrence of surgery-related complications, specifically skin necrosis, infection, or hematoma. The auricular projections were well maintained and auriculocephalic angle of the constructed auricles was similar to the healthy ears. CONCLUSIONS: The author's method comprises comparatively easy techniques and leads to good projection of the auricular angle. A zigzag incision using the triangular flaps could be an attractive surgical option for preventing shrinkage of grafted site and in achieving sufficient projection in autologous reconstructed auricle.

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 .