Evaluation of Supratrochlear, Supraorbital and Angular Artery Course Variations and Depth by Doppler Ultrasound.

BACKGROUND: Supratrochlear (STA), supraorbital (SOA), and dorsal nasal artery (DNA) branches from the ophthalmic artery and angular artery (AA) from the facial artery are the primary suppliers of blood to the upper face. Filler injection without precise knowledge of its vascular topography poses a risk of severe complications. METHODS: Seventy-four hemifaces from 37 subjects with a median age of 25.0 (21.0, 35.0) years and a median body mass index of 21.2 (20.0, 25.4) kg/m2 underwent high-frequency ultrasound tests between March 2022 and April 2022. The bilateral location, depth, peak systolic velocity (PSV), and inner diameter (ID) of the four periorbital arteries (STA, SOA, DNA, AA) were measured. RESULTS: The average ID ranges from 0.6~1.0 mm, and the average PSV ranges from 9.2~24.9 cm/s. All arteries detected passed through the superficial subcutaneous fascia. Most subjects' STAs traveled within 1.0 to 2.0 cm from the midline (left 96.8%, right 93.8%), while SOAs were mainly concentrated within 2.0 to 4.0 cm (left 83.9%, right 81.3%). STAs were more superficial and had a larger internal ID and PSV than SOAs (p<0.001). Except for the ID of the right SOA2 being significantly larger than that of the left SOA2 (p<0.05), no dominant side was found. The depth of STAs and SOAs was moderately correlated with BMI (p<0.05), except for STA1 on the left side. The course of AAs presented a high variability. CONCLUSION: These findings emphasize that the periorbital arteries carry with it a likelihood of ocular complication risks during injection. Targeting the supraperiosteal layer in the STA area and the supramuscular layer in the SOA area of the inferior forehead during injection seems reasonable, and an area within 1.0~2.0 cm from the midline should be avoided. Additionally, the high variability of AAs will enhance the understanding of the anatomy of the facial artery terminals. 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 .

Latissimus dorsi muscle flap transfer through endoscopic approach combined with the implant after tissue expansion for breast reconstruction of mastectomy patients.

BACKGROUND: Implant-based breast reconstruction is easy to be performed but has flaws that an unnatural appearance might be presented when no sufficient coverage existing. While autologous tissue reconstruction also has disadvantages like donor site scar and skin patch effect. There is a demand for a new method to obtain natural and aesthetic appearance while surmounting drawbacks of conventional breast reconstruction surgery. METHODS: A retrospective review of thirty-one patients undergoing tissue expander (TE)/implant two-stage breast reconstruction with latissimus dorsi muscle flap (LDMF) transfer through endoscopic approach in Peking University Third Hospital from April 2016 to August 2020 was performed. The LDMF harvest time, drain time, and complications were reviewed. The 3D volume was obtained to assess the volume symmetry of bilateral breasts. The BREAST-Q reconstruction module was used to evaluate the satisfaction. RESULTS: The mean endoscopic LDMF harvest time was 90.4 min. In the mean follow-up of 11.2 months, there were no severe capsular contracture happened. The reconstructed side achieved good volume symmetry to the contralateral side (P = 0.256). Based on the evaluation of the BREAST-Q scores, the outcome of Satisfaction with Breasts was excellent or good in 87.1% of the cases. CONCLUSIONS: The novel type of two-stage breast reconstruction protocol, which includes tissue expansion followed by implant insertion with endoscopy-assisted LDMF transfer, could effectively reduce visible scars, avoid the patch effect, while require short time for LDMF harvest and present low incidence of complications. It is a promising method for breast reconstruction because it achieves good outcomes in the mastectomy patients.

Unilateral Tissue Expander/Implant Two-Stage Breast Reconstruction with the Assistance of Three-Dimensional Surface Imaging.

BACKGROUND: In China, traditional preoperative planning of unilateral breast reconstruction mainly depends on anthropometric measurement and visual assessment. Thus, the lack of objective assessment of breast volume and shape would likely result in suboptimal reconstruction outcomes. Three-dimensional surface imaging (3D-SI), which could provide objective measurement data of the breast, may be a promising solution to this problem. METHODS: A retrospective review of patients undergoing tissue expander (TE)/implant breast reconstruction without any mammoplasty surgery on the contralateral sides in our hospital from August 2013 to May 2018 was performed. All the patients underwent unilateral mastectomy with immediate or delayed insertion of TE, followed by an exchange of a silicone gel implant without contralateral procedures. 3D images were obtained at the time of preoperation, the routine expansion visit, and post-exchange of implant. The breast volume measured by 3D-SI served as a guide to conduct the surgery management, such as in deciding the total volume of expansion and guiding the final implant size selection. 3D-SI also provided objective data to evaluate the final outcomes of the reconstruction. RESULTS: Fifty-one patients were included in this study, in which eighteen patients underwent immediate TE insertion and thirty-three patients underwent delayed TE insertion. The ptosis degree of contralateral breasts was assessed as follows: forty-four were normal, and seven showed mild ptosis. The average expansion degree was controlled at 161.6% ± 14.1% compared to the contralateral breasts. The volume of implants exchanged had a strong linear correlation with the 3D volume of the contralateral breasts at the end of expansion (P < 0.01). The mean time of follow-up was 9.1 ± 6.6 months. There was only one patient who experienced TE leakage with secondary infection and received TE exchange. For the immediate reconstruction group, the overall breast symmetry improved at the completion of implant exchange (P < 0.01), with an average asymmetry of 5.3% ± 4.0% compared with 10.6% ± 6.1% initially. For the delayed reconstruction group, the reconstructed side achieved good volume symmetry to the contralateral side (P > 0.05). There was no significant difference in breast basal width between bilateral breasts post-reconstruction (P > 0.05). CONCLUSION: 3D-SI serves as a valuable adjunct by providing accurate 3D volume of breasts within TE/implant breast reconstruction in Chinese patients without obvious breast ptosis, which could facilitate surgeons to achieve good reconstructive outcomes. 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.

Application of magnetic resonance imaging with intraoperative color Doppler ultrasound in the treatment of patients with polyacrylamide hydrogel injected for breast augmentation: a retrospective study of 204 cases for 12 years.

Purpose: Polyacrylamide hydrogel (PAHG), which had been used widely for breast augmentation, has been banned for more than 15 years. Patients who had been injected PAHG for breast augmentation need evacuation surgery to remove as much as possible. To provide a series of diagnosis and treatment process MRI and intraoperative color Doppler ultrasound are combined for maximal removal of PAHG. Methods: The patients who received evacuation surgery in Peking University Third Hospital from 2010 to 2022 after PAHG injection for breast augmentation were included in this research. MR scanning was performed preoperatively and postoperatively in some of these patients and color Doppler ultrasound was applied to help evacuate PAHG intraoperatively. The mean clearance rate of PAHG was calculated according to the MRI outcomes. Results: Two hundred and 4 patients had received evacuation surgery after PAHG injection for breast augmentation with an average age of 42.8 years and an average body mass index of 21.2 kg/m2. The average PAHG retention time was 13.5 years. Among them, 52 patients underwent pre- and postoperative MRI scanning. The mean three-dimensional (3D) volume of PAHG was 684.8 mL (range, 350.0-1,123.9 mL), and the average residual 3D volume of PAHG was 53.7 mL (range, 12.4-98.3 mL). The mean clearance rate was 92.1%. Conclusion: MRI and intraoperative color Doppler ultrasound can provide effective and precise location information of PAHG for evacuation surgery, which is a reliable method to ensure the maximal removal of PAHG.

Application of epinephrine mixed with local anaesthetics in injection sclerotherapy of early-stage arteriovenous malformation.

PURPOSE: To explore the effect of epinephrine mixed with local anaesthetic injection on blood flow control in early stage arteriovenous malformation (AVM) and explore suitable cases. METHODS: Twenty-five patients with early stage (Schobinger clinical stage I/II) AVM were selected between September 2019 and March 2022. Local anaesthetics containing epinephrine were injected around the nourishing artery and into lesions under the guidance of ultrasound, and the blood flow distribution grade in the lesions as well as the changes in diameter, peak systolic velocity (PSV), and resistance index (RI) of the nourishing arteries and vessels in the lesions were observed to determine the type of AVM suitable for epinephrine injection. After blood flow was controlled, sclerosant agents were injected into the lesions for sclerotherapy. RESULTS: After local injection of the epinephrine mixture, the blood flow distribution in the lesion decreased by one to three grades; the diameter and PSV also decreased, while RI increased. There were statistically significant differences before and after the injection (P < 0.05). The efficacy of the injection was 80% (20/25), especially in patients with lesion vessels, a nourishing artery lumen diameter <2 mm, and a PSV <40 cm/s in the lesion. Patients with Schobinger clinical stage I AWM showed good results. CONCLUSIONS: Local anaesthetics containing epinephrine play a positive role in reducing the distribution and velocity of blood flow in patients with AVM lesions and may be used as an experimental method for the treatment of AVM, which is beneficial for sclerotherapy in patients with early AVM.

Evaluation of facial artery course variations, diameters, and depth by Doppler ultrasonography.

BACKGROUND: The facial artery (FA) is the main blood vessel supplying blood to the face. It is essential to understand the anatomy of FA around the nasolabial fold (NLF). This study aimed to provide the detailed anatomy and relative positioning of FA to help avoid unexpected complications in plastic surgery. METHODS: FA was observed from the inferior border of the mandible to the end of its terminal branch in 66 hemifaces of 33 patients with Doppler ultrasonography. The evaluation parameters were: (1) location, (2) diameter, (3) FA-skin depth, (4) relationship between the NLF and FA, (5) distance between the FA and significant surgical landmarks, and (6) the running layer. The FA course is classified based on the terminal branch. RESULTS: The most common FA course was Type 1, which had an angular branch as the final branch (59.1%). The most common FA-NLF relationship was that the FA was situated inferior to the NLF (50.0%). The mean FA diameter was 1.56 ± 0.36 mm at the mandibular origin, 1.40 ± 0.37 mm at the cheilion, and 1.32 ± 0.34 mm at the nasal ala. The FA diameter on the right hemiface was thicker than that on the left hemiface (p < 0.05). CONCLUSION: The FA mainly terminates in the angular branch, running in the medial NLF and in dermis and subcutaneous tissue, with a blood supply advantage in the right hemisphere. We suppose that a deep injection into periosteum around the NLF may be safer than an injection into the superficial musculoaponeurotic system (SMAS) layer.

Sirolimus as a promising drug therapy for blue rubber bleb nevus syndrome: Two-case report.

Blue rubber bleb nevus syndrome is a very rare systemic vascular malformation frequently affecting the skin and the gastrointestinal tract. The pathogenesis of the disease is still unclear, and the standard treatment does not exist. This study reports two blue rubber bleb nevus syndrome cases, of which the second patient received the TEK gene mutations detection and got a low-dose sirolimus therapy, compared with the first patient who was not treated with sirolimus. The report shows some positive findings of TEK gene mutations and the efficacy of sirolimus treatment. We postulate that the TEK gene mutations play an important role in the pathogenesis. The mutations of different locations of the TEK gene cause a wide range of activating TIE2 mutations, which could stimulate the mammalian target of rapamycin signaling pathways to mediate angiogenesis, resulting in different clinical phenotypes of cutaneomucosal venous malformations. Sirolimus could effectively block the upstream and downstream factors of mammalian target of rapamycin signaling pathways to achieve the antiangiogenic effect. The initial dose of sirolimus can be 0.05-0.1 mg/kg/d for a trough level of 5-15 µg/L in the treatment of blue rubber bleb nevus syndrome. However, a lower-dose sirolimus is also effective while minimizing the side effects.

Effect of 810 nm Near-Infrared Laser on Revascularization of Ischemic Flaps in Rats.

OBJECTIVE: To investigate the effect of 810 nm near-infrared (NIR) laser on the revascularization of ischemic flaps. BACKGROUND: It has long been proved that photobiomodulation therapy (PBMT) improves the blood supply of flaps. NIR laser improves the treatment of hypodermis-located lesions and of flap survival, but basic research on the use of 810 nm NIR laser for ischemic flap revascularization is still lacking. MATERIALS AND METHODS: We prepared two symmetrical long random-pattern flaps on the backs of 60 rats. Each flap was 6 cm long, 1 cm wide, and 1 cm to the middle line. The flaps were divided into an irradiated flap group and an internal control group. The irradiated flaps underwent postoperative 810 nm laser therapy with the energy density of 11.30 J/cm2 daily. The control flaps were covered by stainless steel to avoid laser irradiation. We observed the viability of the flaps. The flaps underwent Hematoxylin and Eosin (H&E) staining for the observation of histomorphology, immunohistochemical staining of factor VIII for the capillary count, α-smooth muscle actin for the small arterial count, and vascular endothelial growth factor for the integrated optical density (OD) of the positive stained color. RESULTS: The irradiated flaps showed significantly better flap survival than the control flaps. H&E staining showed that the irradiated flaps had clear tissue structure and little inflammatory cell infiltration. The control flaps demonstrated comparatively worse results. Vascular endothelial growth factor staining showed that the difference in integrated OD between the irradiated flaps and the control flaps was not statistically significant. α-smooth muscle actin and factor VIII staining showed significantly greater numbers of arterioles and capillaries in the irradiated flaps than the control flaps after 4 days of irradiation. CONCLUSIONS: PBMT with 810 nm NIR laser could enhance ischemic flap revascularization and increase flap viability.