Scar Assessment After Breast Reconstruction: Risk Factors for Hypertrophy and Hyperpigmentation in Asian Patients.

BACKGROUND: Breast scars after breast reconstruction can be hypertrophic and/or hyperpigmented, especially in Asian patients, whose skin is thicker and has increased melanin. Few studies have focused on breast scars after breast reconstruction, and the risk factors for an abnormal breast scar remain unknown. METHODS: We examined 257 Asian patients who underwent an immediate 2-stage unilateral implant-based breast reconstruction. Vascularity, hypertrophy, and hyperpigmentation of the patients' breast scars were assessed at 1 year postoperatively. Risk factors for an abnormal scar were analyzed statistically. Analyzed patient factors included age, body mass index, incision site (frontal or lateral), breast size (the weight of the resected specimen), skin necrosis at the initial operation (expander placement), and adjuvant therapy. RESULTS: At 1 year postoperatively, 161 patients (63%) showed normal vascularity, 77 patients (30%) showed mild vascularity, 18 patients (7%) showed moderate vascularity, and 1 patient (0.4%) showed severe vascularity. No patient factors were correlated with vascularity. Thirty-two patients (12%) showed hypertrophy, and the rate of hypertrophy was significantly higher in the patients with a lateral incision (n = 59) compared with those with a frontal incision (n = 198) (28.8% vs 7.6%, P < 0.01). Even in the frontal incision group, a lateral part of the frontal scar was likely to be hypertrophic. Forty-six patients (18%) showed hyperpigmentation, and the rate of hyperpigmentation was significantly higher in the patients with skin necrosis (n = 47) at the initial operation than those without skin necrosis (n = 210) (57.4% vs 9.0%, P < 0.01). Large breast was also a risk factor for hyperpigmentation due to its higher frequency of skin necrosis. CONCLUSIONS: In Asian patients who undergo breast reconstruction, the use of a lateral incision is a risk factor for hypertrophy, and skin necrosis at the initial operation is a risk factor for hyperpigmentation at the breast scar.

Risk Factors for Skin Flap Necrosis in Breast Cancer Patients Treated with Mastectomy Followed by Immediate Breast Reconstruction.

BACKGROUND: Skin-sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) are the standard techniques for achieving a cosmetic outcome, but necrosis of a cutaneous flap including the nipple-areolar complex (NAC) is a serious complication. To analyze the risk factors for skin flap necrosis, we retrospectively evaluated a clinical database of breast cancer patients treated with mastectomy followed by immediate breast reconstruction. METHODS: Four hundred and twelve cases were consecutively recorded between 2006 and 2016. Body weight (BW), body mass index (BMI), distance from NAC to referent tumor, distance from overlying skin to the tumor and weight of breast resection (WBR) as measured in the operating theater were included in the statistical analysis. RESULTS: NSM, SSM and total mastectomy were performed in 123 (30%), 96 (23%) and 193 cases (47%), respectively. A tissue expander was used in 379 cases (92%), a silicone implant in 8 (2%) and autologous breast reconstruction in 25 (6%). Skin flap necrosis was found in 7% of all cases and NAC necrosis in 13% of NSM cases. In a univariate analysis, BW, NSM and WBR were risk factors for skin flap necrosis, and BW, BMI and WBR were risk factors for NAC necrosis. In a multivariate analysis, NSM and WBR remained significant risk factors for skin flap necrosis, and WBR was a significant risk factor for NAC necrosis. CONCLUSIONS: WBR is an important risk factor for skin flap necrosis. Especially, NAC necrosis should be considered for patients with large-volume breasts who undergo NSM and immediate breast reconstruction.

[A Case of Consciousness Disturbance Due to Hyperammonemia Associated with Urinary Tract Infections].

We describe the case of a patient with hyperammonemia owing to urinary tract infections. The patient, a 66-year-old-woman, was previously diagnosed with bilateral hydronephrosis. She was admitted to the emergency room with macrohematuria and bilateral lumbar pain, which persisted for 2 days. She was hospitalized with the diagnosis of pyelonephritis. Despite antibiotic treatment, she developed sudden disturbance in consciousness on the 2nd day of illness. To improve the hyperammonemia and metabolic acidosis, we initiated continuous hemodiafiltration (CHDF) and urinary drainage by bilateral nephrostomy, after which her consciousness improved, and she was discharged on day 19. For patients with urinary tract infections and who are unaware of disturbance in consciousness, it is important to consider that obstructive urinary tract infections can cause hyperammonemia.

A Simple and Reliable Submental Intubation Technique for Maxillofacial Fractures.

In 1986, Altemir first reported the use of submental intubation to avoid tracheotomy in patients with panfacial and midfacial fractures for whom intermaxillary fixation is necessary, but orotracheal and nasotracheal intubations are not recommended. This novel technique allowed intraoperative access to perform dental occlusion and reconstruction of the nasal pyramid in patients with skull base fractures. Herein, we describe a refined technique based on Altemir's original procedure. Seven male patients with panfacial fractures underwent submental intubation using our refined technique. The technique was developed after encountering a technical error with Altemir's original procedure. In this new technique, we employed a 2-0 silk suture guide to allow the passage of both the endotracheal and cuff-inflation tubes through the same tunnel created from the oral cavity to the submental area. The success rate of the refined technique was 100%, and there were no intraoperative or postoperative complications. There was 20 seconds of ventilation outage time in total. Endotracheal and cuff-inflation tubes were easily and quickly passed through the same submental tunnel. Our refined technique is simple, easy, safe, fast, inexpensive, and does not require specific materials. Submental scars were smaller and relatively inconspicuous in this study, compared to those reportedly associated with other modified techniques.

Comparison of Nasal Septum and Ear Cartilage as a Graft for Lower Eyelid Reconstruction.

In lower eyelid reconstruction, several types of grafts from the nasal septum, ear cartilage, buccal mucosa, and hard palate mucosa have been used for an inner layer of the lower eyelid, but there have been no studies comparing these grafts. The authors retrospectively reviewed our cases of lower eyelid reconstruction, and compared chondromucosal grafts from the nasal septum (N = 8) and ear cartilage grafts (N = 10) for an inner layer of the lower eyelid. The authors observed no significant difference in operative time, blood loss, or length of hospital stay between the "nasal septum" and "ear cartilage" groups. The final results were aesthetically and functionally satisfactory in both groups. In the nasal septum group, 1 patient suffered from perforation of the nasal septum and another patient suffered from nasal bleeding postoperatively. There were no donor site complications in the ear cartilage group. These findings indicate that both a chondromucosal graft from the nasal septum and an ear cartilage graft are good grafts for an inner layer of the lower eyelid. Regarding the donor site, however, an ear cartilage graft has the advantage of a lower complication rate.

Effectiveness of the proximal medial branch in DIEP flaps for breast reconstruction using Hartrampf zone IV.

BACKGROUND: When performing breast reconstruction using a deep inferior epigastric artery (DIEA) perforator (DIEP) flap, including Hartrampf zone IV, the bipedicled DIEP flap has been argued to be necessary to ensure stable perfusion. However, a proximal medial branch (PMB), which is the most proximal perforator of DIEA, may make it possible to obtain adequate perfusion in a unilateral DIEP flap. This study aimed to clarify the detailed anatomical characteristics of PMB and its potential clinical applications in breast reconstruction. METHODS: This retrospective study was conducted on breast reconstruction using the DIEP flap between May 2020 and July 2023. Data on PMB anatomy were collected from preoperative contrast-enhanced computed tomography angiography, and contralateral perfusion of the flap was estimated using intraoperative indocyanine green angiography. RESULTS: PMB was present in approximately 85% of the cases, arising near the lateral border of the rectus abdominis, branching caudomedially in more than half of the cases, and perforating 2.3 cm laterally and 8.8 cm caudally, on average, from the umbilicus. The average perfusion area of zones II and IV significantly expanded to 96.5% and 74.2%, respectively, when PMB was included in the DIEP flap, and 9 of 22 cases showed contrast extending to the entire zone IV. CONCLUSIONS: The use of the DIEP flap with PMB is a good option for substantial-volume breast reconstruction. When utilizing PMB, it is important to consider its specific anatomy, location of the main perforator, and pedicle length.

Carbon dioxide emissions through land use change, fire, and oxidative peat decomposition in Borneo.

Borneo has accumulated an abundance of woody carbon in its forests and peat. However, agricultural land conversion accompanied by plantation development, dead wood burning, and peat drying from drainage are major challenges to climate change mitigation. This study aimed to develop a method of estimating carbon dioxide (CO2) emissions from land use change, forest and peat fires, and oxidative peat decomposition, and CO2 uptake from biomass growth across Borneo using remote sensing data from 2001 to 2016. Although CO2 uptake by biomass growth in vast forests has shown a significant increasing trend, an annual net release of 461.10 ± 436.51 (average ± 1 standard deviation) Tg CO2 year-1 was observed. The estimated emissions were predominantly characterized by land use changes from 2001 to 2003, with the highest emissions in 2001. Land use change was evaluated from annual land use maps with an accuracy of 92.0 ± 1.0% (average ± 1 standard deviation). Forest and peat fires contributed higher emissions in 2002, 2006, 2009, 2014, and 2015 compared to other years and were strongly correlated with the Southern Oscillation Indexes. These results suggest that more CO2 may have been released into the atmosphere than previously thought.

Abdominoplasty of cloacal exstrophy: application of reconstructive methods to recurrent and primary cases.

BACKGROUND: Surgical repair of cloacal exstrophy is still challenging. At birth, patients undergo bladder closure, colostomy, and osteotomy of the pubic bone (if necessary, when the interpubic range is wide and cannot be brought together with the hands). This abdominal defect is closed primarily by urologists or pediatric surgeons, if possible, but the patient may experience a relapse of bladder exstrophy and an abdominal defect. Abdominal reconstruction was performed for a series of recurrent and primary (preventive) cases. METHODS: Abdominal wall reconstruction was performed using the rectus abdominis and external oblique muscle fascia flaps, and reinforcement of the bilateral rectus abdominis muscles in 2 cases of cloacal exstrophy patients. One was a recurrent case treated at 7 months old, and the other was done primarily at 2 days after birth. RESULTS: The closure of the abdominal wall was successful and no relapse of bladder exstrophy or abdominal defect has occurred. These patients are now undergoing rehabilitation. CONCLUSION: Cloacal exstrophy usually has many serious complications. The abdominal-wall defect is often large and accompanied by a wide detachment of the pubic bone. Even if the simple closure of abdominal wall is possible at birth, it is usually insufficient. Abdominal-wall repair must be done thoroughly, soon after birth, and plastic surgery techniques should be used.

Estimation of carbon dioxide emissions from the megafires of Australia in 2019-2020.

Catastrophic fires occurred in Australia between 2019 and 2020. These fires burned vast areas and caused extensive damage to the environment and wildlife. In this study, we estimated the carbon dioxide (CO2) emissions from these fires using a bottom-up method involving the improved burnt area approach and up-to-date remote sensing datasets to create monthly time series distribution maps for Australia from January 2019 to February 2020. The highest monthly CO2 emissions in Australia since 2001 were recorded in December 2019. The estimated annual CO2 emissions from March 2019 to February 2020 in Australia were 806 ± 69.7 Tg CO2 year-1, equivalent to 1.5 times its total greenhouse gas emissions (CO2 equivalent) in 2017. New South Wales (NSW) emitted 181 ± 10.2 Tg CO2 month-1 in December 2019 alone, representing 64% of the average annual emissions of Australia from 2001-2018. The negative correlation observed between CO2 emissions and precipitation for 2001-2020 was 0.51 for Australia. Lower than average precipitation and fires in high biomass density areas caused significant CO2 emissions. This study helps to better assess the performance of climate models as a case study of one of the major events caused by climate.

Alteration of arterial blood flow after free muscle transfer.

To investigate blood flow alterations and their determinants after free flap transfer, we focused on a vascularized latissimus dorsi muscle segment for reconstruction of the paralyzed face as an ideal model, since the vascular pedicle and type of flap are identical among patients. Seventeen patients were studied using color Doppler ultrasonography at 6 time points from before the operation to >1 month postoperatively. The influences of preoperative facial arterial flow volume, volume of muscle, and duration of ischemia on postoperative pedicle arterial flow were analyzed. Arterial flow volume decreased dramatically after revascularization and remained constantly low in comparison with preoperative blood flow volume. The shape of the blood velocity waveform reflecting downstream vascular impedance changed, but recovered to the baseline state within 6 days. Preoperative flow volume and transferred muscle weight correlate with postoperative flow volume for 6 days postoperatively. The duration of ischemia was not influential.

Expanded narrow subcutaneous-pedicled island forehead flap for reconstruction of the forehead.

To reconstruct the subsequent defects after resection of a unilateral large forehead lesion, we devised a revised method, "expanded narrow subcutaneous-pedicled island forehead flap." After unilateral forehead skin was expanded by a tissue expander, the flap was designed on the upper half of the expanded forehead skin nourished by the subcutaneous adipomuscular pedicle, including the supratrochlear or supraorbital artery. The elevated flap was then transposed or rotated 180 degrees toward the defect. The donor site was closed with upward advancement of the lower half of the expanded skin. Four patients were treated with this method. The flaps survived completely without serious complications, and acceptable results were obtained in all patients. This method has the advantage of increased freedom of flap design and transfer, providing an effective use of unaffected skin, less scars left on the forehead, and less formation of the dog-ear compared with the conventional procedure.

Free pectoral skin flap in the rat based on the long thoracic vessels: a new flap model for experimental study and microsurgical training.

The purpose of this study was to investigate the vascular anatomy of the pectoral region of the rat to develop a free pectoral skin flap model. In Experiment 1 (n = 6), we performed anatomic dissection and angiographic study of the pectoral region. In Experiment 2 (n = 20), we performed microsurgical free transfer of a pectoral skin flap to the cervical or groin region. Half of the flaps were transferred with flow-though arterial anastomoses. All flaps survived except for 2 cases of autocannibalization. We conclude that the free pectoral skin flap model in the rat is simple and reliable, and can be used as an alternative experimental and training model to the superficial epigastric flap.

Versatility of a posterior-wall-first anastomotic technique using a short-thread double-needle microsuture for atherosclerotic arterial anastomosis.

To perform safe anastomosis for atherosclerotic arteries, we employed a posterior-wall-first anastomotic technique with a short-thread double-needle microsuture. Between October 2005 and September 2007, we performed 17 free flap transfers to the head and neck regions with this technique. Fifteen of 17 patients had one or more risk factors for atherosclerosis. In all patients except one, the superior thyroid artery was employed as a recipient artery and end-to-end anastomosis was performed close to its origin with the external carotid artery. Postoperatively, no anastomotic thrombosis occurred in any patients. The greatest advantage of the double-needle microsuture is that each stitch can be placed from the inner side of the arterial wall to the outer side. This "inner-to-outer" stitch secures full-thickness bite and minimizes intimal damage. Safe and reliable anastomosis could be carried out in an unfavorable setting because the double-needle suture offers a high degree of freedom in suture placement.

Influence of Weight Loss on Volumetric Change in Contralateral Breast During 2-Stage Breast Reconstruction.

Objective: During 2-stage breast reconstruction in patients with unilateral breast cancer, we sometimes experience cases in which the contralateral breast volume changes greatly. However, few studies have examined volumetric changes in the contralateral breast during 2-stage breast reconstruction. Methods: Changes in contralateral breast volume between the first and second operations were examined in patients who underwent 2-stage unilateral breast reconstruction between February 2013 and August 2016 (123 patients aged 49.1 ± 8.6 years). Influences of age, postoperative treatment, and body weight on volumetric changes in the contralateral breast were statistically analyzed. Results: A positive correlation was observed between changes in body weight and contralateral breast volume (correlation coefficient = 0.218, P = .015). Weight loss was particularly important: all patients who lost more than 3 kg showed decreased contralateral breast volume (P = .010). Age and postoperative treatment had no significant effect on the change in contralateral breast volume. Conclusion: Change in body weight, and massive weight loss in particular, is an important factor for volumetric changes in the contralateral breast during 2-stage unilateral breast reconstruction.

Impairment of the brachial plexus after harvest of the latissimus dorsi muscle for reanimation of a paralysed face.

The one-stage neurovascular pedicled latissimus dorsi muscle transfer with a long thoracodorsal nerve for dynamic reanimation of long-standing facial paralysis offers several advantages over other options. However, extensive dissection of the thoracodorsal nerve risks injury to the brachial plexus. We reviewed 264 consecutive cases to assess the extent of the risk of impairment of the brachial plexus and to elicit factors that could possibly induce complications. Six patients had impairment of brachial plexus, but both sensory and motor disturbance disappeared about 11 months postoperatively. All symptoms had completely vanished by 18.5 months. The complications were thought to have resulted from positioning and excessive retraction in four cases. Direct invasion of the brachial cord may not be the main cause. Proper knowledge of the anatomy and optimum attention minimise the risk of severe complications associated with harvesting of the latissimus dorsi muscle.

Risk Factors for Complications in Expander-Based Breast Reconstruction: Multivariate Analysis in Asian Patients.

BACKGROUND: There have been many studies examining risk factors for complications in expander-based breast reconstruction after mastectomy, and some patient factors have been identified as risk factors. However, most of the previous studies were based on Caucasian patients. METHODS: Asian patients who had a tissue expander placed for immediate breast reconstruction between January 2006 and December 2015 (363 patients and 371 expanders) were analyzed retrospectively. Univariate and multivariate analyses were performed to elucidate risk factors for complications. RESULTS: The rate of skin necrosis was significantly higher in nipple-sparing mastectomy than in other types of mastectomies (12 patients among 107 patients, P = 0.001). The weight of the resected specimen was significantly higher in the group with complications than in the group without complications (444 g compared with 363 g, P = 0.027). Other factors (age, body mass index, smoking, expander type, preoperative chemotherapy, axillary dissection) had no significant effect on complications. Multivariate analysis with a logistic regression showed that a large breast (over 500 g) was the only significant risk factor for complications, with an odds ratio of 3.20 and a 95% confidence interval of 1.33-7.54 (P = 0.010). CONCLUSION: In this series of Asian patients, breast size, rather than body mass index, is the most important predictor for complications in expander-based breast reconstruction.

Preoperative asymmetry is a risk factor for reoperation in involutional blepharoptosis.

BACKGROUND: Patients with involutional blepharoptosis sometimes require reoperation because of functional or esthetic reasons after the primary operation. Few studies have analyzed the risk factors for reoperation in such cases. METHODS: We retrospectively analyzed the cases of 274 patients who underwent levator aponeurosis surgery for bilateral involutional blepharoptosis. We examined the risk factors for reoperation using univariate and multivariate analyses. RESULTS: Reoperation was performed for 89 of the 274 patients (32.5%). There was no significant difference in the rate of reoperation among surgeons. In the univariate analysis, patients with preoperative asymmetry, defined as a difference of >1 mm in the marginal reflex distance between the right and left sides, showed a significantly higher rate of reoperation (42.7%) than those without asymmetry (28.1%) (p = 0.018). Age, sex, and ptosis severity did not affect the rate of reoperation. The multivariate analysis with a logistic regression showed that preoperative asymmetry was a significant risk factor for reoperation, with an odds ratio of 1.90 (p = 0.019). CONCLUSION: In involutional blepharoptosis, patients with preoperative asymmetry should be informed of the higher risk of reoperation, and the balance between the right and left sides should be carefully adjusted intraoperatively.

Toxic Shock Syndrome Caused by Methicillin-Resistant Staphylococcus aureus (MRSA) After Expander-Based Breast Reconstruction.

OBJECTIVE: Toxic shock syndrome is a rare but life-threatening complication after plastic surgery procedures. METHODS: We experienced 2 cases of toxic shock syndrome after expander-based breast reconstruction caused by methicillin-resistant Staphylococcus aureus. RESULTS: The first patient took a severe clinical course due to the delayed diagnosis and treatment, and the second patient recovered rapidly after the early diagnosis and treatment based on our experience of the first case. Fever, rash, and gastrointestinal symptoms (diarrhea and/or vomiting) were characteristic and important for the early diagnosis of toxic shock syndrome. CONCLUSIONS: Considering the increased prevalence of methicillin-resistant Staphylococcus aureus, we should suspect methicillin-resistant Staphylococcus aureus in cases of toxic shock syndrome that occur postoperatively, and the empiric administration of vancomycin should be initiated in such cases.

Predictive Factors for Drainage Volume after Expander-based Breast Reconstruction.

BACKGROUND: Closed suction drains are widely used in breast reconstruction, and the drains are removed based on a volume criterion. However, to the best of our knowledge, there has been no study analyzing predictive factors for drainage volume after breast reconstruction. METHODS: Data of daily drainage in cases with expander-based breast reconstruction between February 2013 and March 2015 (131 patients and 134 expanders) were retrospectively analyzed. Patient factors and operative factors were examined for their influences on total drainage using univariate and multivariate analyses. RESULTS: The total drainage was 557.3 ± 359.7 mL. A strong correlation was observed between total drainage and duration of drains (correlation coefficient, 0.908). Operative factors, such as mastectomy type, expander type, operative time, and blood loss, did not affect the total drainage. Patients with axillary lymph node dissection showed a higher total volume of drainage (P < 0.001). The weight of the resected specimen, body weight, and breast volume calculated preoperatively showed a strong correlation with total drainage (correlation coefficients, 0.454, 0.388, and 0.345, respectively). In multiple regression analysis with preoperative data, age (P = 0.008), body weight (P = 0.018), and scheduled axillary dissection (P < 0.001) were significant predictive factors for total drainage. Among postoperative data, age (P = 0.003), axillary dissection (P = 0.032), and weight of resected specimen (P = 0.013) were significant predictors. CONCLUSIONS: Based on preoperative and/or postoperative information, plastic surgeons can predict the total drainage and duration of drains after expander-based breast reconstruction. Age, breast mass, and axillary lymph node dissection are important factors for this prediction.

Congenital hypertrophy of multiple intrinsic muscles of the foot.

Congenital hypertrophy of a single intrinsic muscle of the foot is rare, and as far as we know, only six cases have been reported. We describe a case of congenital anomaly that showed hypertrophy of multiple intrinsic muscles of the foot; the affected muscles were all the intrinsic muscles of the foot except the extensor digitorum brevis or extensor hallucis. Other tissues such as adipose tissue, nervous tissue, or osseous tissue showed no abnormalities. To reduce the volume of the foot we removed parts of the enlarged muscles.