A Comparison of Aesthetic Outcomes of Umbilicoplasty in Breast Reconstruction with Abdominal Flap: Inverted-U Versus Vertical Oval Incision.

BACKGROUND: The umbilicus is a key aesthetic unit of the abdominal wall. It contributes to the natural curvature of the abdomen and is now considered as one of the most important factors in the overall results and patient satisfaction. In this study, we present an inverted-U incisional technique for umbilicoplasty. This study aims to describe the senior author's approach to umbilicoplasty and compare the aesthetic outcomes of the inverted-U method with those of the vertical oval incisional technique. METHODS: In this retrospective cohort study, we analyzed a total of 109 patients including 51 who underwent umbilicoplasty with the inverted-U incisional technique and 58 who had surgery with the vertical oval incisional method. With the description of our operative technique, the aesthetic outcomes of both techniques were compared by two independent surgeons using a 5-point Likert scale in terms of shape, size, depth, natural appearance and periumbilical scarring. Also, the total scores of the five items were calculated to give a final score for each patient (range, from 5 to 25 points). RESULTS: On all measured parameters, the inverted-U incisional technique produced favorable outcomes compared with the vertical oval incisional technique. Also, the inverted-U incisional technique was given significantly higher total scores than was the vertical oval incisional technique (inverted-U 14.73 ± 2.47 vs. vertical oval 11.26 ± 3.02, p = 0.002). CONCLUSIONS: In this study, an inverted-U incisional technique produced significantly favorable outcomes in terms of shape, size, depth, natural appearance and overall score compared to a vertical oval incision (p < 0.05). We believe that this technique enables surgeons to achieve a better shape, natural retrusive appearance and superior hood. LEVEL OF EVIDENCE III: In this study, an inverted-U incisional technique produced significantly favorable outcomes in terms of shape, size, depth, natural appearance and overall score compared to a vertical oval incision (p < 0.05). We believe that this technique enables surgeons to achieve a better shape, natural retrusive appearance and superior hood.

Reliability of the Patient and Observer Scar Assessment Scale in Evaluating Linear Scars after Thyroidectomy.

OBJECTIVE: To compare the reliability of the Patient and Observer Scar Assessment Scale (POSAS) with the Vancouver Scar Scale (VSS) in evaluating thyroidectomy scars. METHODS: At 6 months after the operation, 112 patients who underwent thyroid surgery via collar neck incision were evaluated by two blinded plastic surgeons and two senior residents using the VSS and the observer component of the POSAS. In addition, the observer-reported VAS score and patient-reported Likert score were evaluated. Internal consistency, interobserver reliability, and correlations between the patient- and observer-reported outcomes were examined. RESULTS: The observer component of POSAS scores demonstrated higher internal consistency and interobserver reliability than the VSS. However, the correlations between the observer-reported VAS score and the patient-reported Likert score (0.450) and between the total sum of patient and observer component scores (0.551) were low to moderate. CONCLUSIONS: The POSAS is more consistent over repeated measurements; accordingly, it may be considered a more objective and reliable scar assessment tool than the VSS. However, a clinician's perspective may not exactly match the patient's perception of the same scar.

Ten-year experience of robotic latissimus muscle flap reconstructive surgery at a single institution.

BACKGROUND: Robotic reconstructive surgery has been performed since 2012 at our institution. The purpose of this study was to report our 10-year experience with robot-assisted reconstructive surgery and compare the clinical outcomes of different robotic models. METHODS: Medical records of 41 patients who had chest or breast reconstruction during October 2012 ∼ May 2021 were reviewed retrospectively. Different robotic models were evaluated and compared in terms of surgical technique, demographic variables, postoperative complication, and operative parameters. esthetic assessments were performed by four plastic surgeons to evaluate symmetry, scar formation, and general esthetic features based on patients' photographs. RESULTS: Overall, out of 41 robot-assisted reconstructive surgeries, 13 were performed with the Da Vinci Si model, 18 with the Da Vinci Xi model, and 10 with the Da Vinci Sp model. The docking time, robot operation time, and hospitalization time were shorter for surgeries, which used the Da Vinci Sp model than other models. All other complications and operative parameters showed no significant difference. Improved esthetic outcome was achieved for all patient groups. Group Sp had the most favorable score, followed by Group Xi and Group Si, although there were no statistical implications. CONCLUSIONS: Ever since the introduction of the Da Vinci model in 2012, we have successfully implemented the robot-assisted reconstructive surgery. Surgical technique improved over the last 10 years. With the introduction of the Sp model, we are now at the stage of further developing the surgical technique and establishing the robotic reconstructive surgery.

Effectiveness of a combination therapy using non-ablative fractional laser and intralesional triamcinolone injection for thyroidectomy scar treatment: a prospective, randomized, blinded pilot study.

BACKGROUND: The occurrence of thyroid cancer has increased dramatically, and postoperative scars are placed at easily visible locations. Many patients show stronger desire for scar prevention. So far, numerous approaches have been discussed for the treatment of scars; this study is conducted to verify whether the early application of combined therapy contributes to minimal scar formation. METHODS: Between March 2019 and December 2019, total of 64 patients with thyroidectomy scars of a size greater than 4.5 cm located on the anterior neck were enrolled in this prospective pilot study. Subjective and objective evaluation were carried out using the Patient and Observer Scar Assessment Scale (POSAS) at one, two, and six months after operation. Results were compared between a treatment group and a non-treatment group. RESULTS: In PSAS score, the mean values of pain, itching sensation, pliability, thickness, and relief were significantly higher in the laser and steroid treatment group (p = 0.009, p = 0.000, p = 0.013, p = 0.002, and p = 0.007). The value of color of the scars showed no significant differences (p = 0.504). In OSAS score, parameter of thickness, relief, and surface area score was significantly higher score in the combination group (p = 0.029, 0.035, and 0.020), while vascularity, pigmentation, and pliability were not significantly different between two groups (p = 0.548, p = 0.983, and p = 0.128). CONCLUSION: This study demonstrates that early combination therapy contributes to scar improvement to a meaningful extent based on POSAS. We believe that the combined therapy has a synergy effect on scar management, which improves the patients' quality of life in relation to their postoperative scars.

Current Protocol for Aesthetic Scar Management in Thyroid Surgery.

OBJECTIVES/HYPOTHESIS: We compared the scar quality when different protocols were applied, and eventually aim to find the optimal scar management protocol. STUDY DESIGN: We conducted a prospective, randomized, and blinded comparison of different scar management protocols in a single center. METHODS: We allocated 126 patients who underwent thyroidectomy via collar neck incision randomly into three groups. Patients in group A were treated with tissue adhesive only. Patients in group B were treated by means of subcuticular suturing and early scar management with a non-ablative fractional laser (NAFL) and intralesional triamcinolone injection (ILI). Patients in group C had skin closure with tissue adhesive and early scar management. At 6 months after the operation, the Patient and Observer Scar Assessment Scale (POSAS) and the width of the final scar were compared. RESULTS: Comparing the sum of PSAS, groups B and C showed significant higher satisfaction than did group A (22.81 ± 11.66 in group A, 10.9 ± 5.14 in group B, and 15.19 ± 9.98 in group C). In the sum of OSAS, group B also showed a significant difference than did groups A and C (17.74 ± 6.75 in group A, 10.26 ± 3.60 in group B, and 14.52 ± 6.48 in group C). Also, group B showed a narrower scar width than did groups A and C. CONCLUSIONS: Our finding suggests that subcuticular suturing using barbed suture material and early treatment with a combination therapy using NAFL and ILI showed a favorable aesthetic outcome for both patients and operators. Based on our algorithmic approach for thyroidectomy scar, we anticipate an optimal aesthetic outcome. LEVEL OF EVIDENCE: II Laryngoscope, 131:E2188-E2195, 2021.

Safety and efficacy of transcutaneous bone conduction implant surgery for hearing improvement in microtia patients with bilateral hearing impairment.

BACKGROUND: In microtia patients with bilateral hearing impairment, hearing improvement is crucial for language development and performance. External auditory canal reconstruction (EACR) has been performed to improve hearing, but often result in complications. We performed transcutaneous bone conduction implant (TBCI) surgery in these patients. This study aimed to evaluate the safety and efficacy of TBCI surgery. METHODS: A retrospective review was performed of five patients who underwent auricular reconstruction and TBCI surgery and 12 patients who underwent EACR between March 2007 and August 2018. Hearing improvement was measured based on the air-bone gap values using pure-tone audiometry over a 6-week postoperative period. We reviewed other studies on hearing improvement using EACR and compared the findings with our result. The surgical techniques for TBCI were reviewed through case analyses. RESULTS: Postoperative hearing outcomes showed a significant improvement, with a mean gain of 34.1 dB in the TBCI cohort and 14.1 dB in the EACR cohort. Both gains were statistically significant; however, the TBCI cohort showed much larger gains. Only three of the 12 patients who underwent EACR achieved hearing gains of more than 20 dB, which is consistent with previous studies. All patients who underwent TBCI surgery demonstrated hearing gains of more than 20 dB and experienced no device-related complications. CONCLUSIONS: TBCI is a safe and effective method of promoting hearing gains in microtia patients with bilateral hearing impairment. TBCI surgery provided better hearing outcomes than EACR and could be performed along with various auricular reconstruction techniques using virgin mastoid skin.

A comparative study between sterile freeze-dried and sterile pre-hydrated acellular dermal matrix in tissue expander/implant breast reconstruction.

BACKGROUND: In implant-based breast reconstruction, acellular dermal matrix (ADM) is essential for supporting the inferolateral pole. Recent studies have compared non-sterilized freeze-dried ADM and sterilized pre-hydrated ADM, but have not assessed whether differences were attributable to factors related to sterile processing or packaging. This study was conducted to compare the clinical outcomes of breast reconstruction using two types of sterile-processed ADMs. METHODS: Through a retrospective chart review, we analyzed 77 consecutive patients (85 breasts) who underwent tissue expander/implant breast reconstruction with either freezedried ADM (35 breasts) or pre-hydrated ADM (50 breasts) from March 2016 to February 2018. Demographic variables, postoperative outcomes, and operative parameters were compared between freeze-dried and pre-hydrated ADM. Biopsy specimens were obtained for histologic analysis. RESULTS: We obtained results after adjusting for variables found to be significant in univariate analyses. The total complication rate for freeze-dried and pre-hydrated ADMs was 25.7% and 22.0%, respectively. Skin necrosis was significantly more frequent in the freeze-dried group than in the pre-hydrated group (8.6% vs. 4.0%, P=0.038). All other complications and operative parameters showed no significant differences. In the histologic analysis, collagen density, inflammation, and vascularity were higher in the pre-hydrated ADM group (P=0.042, P=0.006, P=0.005, respectively). CONCLUSIONS: There are limited data comparing the outcomes of tissue expander/implant breast reconstruction using two types of sterile-processed ADMs. In this study, we found that using pre-hydrated ADM resulted in less skin necrosis and better integration into host tissue. Pre-hydrated ADM may therefore be preferable to freeze-dried ADM in terms of convenience and safety.

Effects of vasopressors on circulation in the porcine abdominal island flap model.

BACKGROUND: During reconstructive surgical procedures, systemic vasopressors are frequently used to maintain normal blood pressure. However, questions have arisen regarding the pharmacologic effects of vasopressors on flap circulation. Many plastic surgeons have expressed concern about the possibility of impaired flap circulation caused by the vasoconstrictive effect of the drugs. However, the opposing argument exists that the increase in mean arterial pressure from vasoactive agents may improve flap perfusion. The purpose of this study was to evaluate the effect of commonly used vasopressors on flap circulation. METHODS: The vertical rectus abdominis myocutaneous (VRAM) island flap was raised in five female pigs (38.2∼40.7 kg). Hemodynamic parameters were measured continuously by a carotid arterial catheter. A bi-directional transonic vascular doppler flow probe and Laser Doppler perfusion monitor (LDPM) unit were applied to record the continuous change in pedicle artery flow and microvascular perfusion following intravenous administration of dopamine (3, 5, 10µg/kg/minute), dobutamine (1.25, 2.5, 5µg/kg/minute), and norepinephrine (0.05, 0.1, 0.2µg/kg/minute). RESULTS: Both microvascular perfusion and pedicle flow were generally proportional to the mean arterial pressure, and all three vasopressors improved flap perfusion and pedicle flow without deleterious effects. Norepinephrine showed the highest microvascular perfusion and dobutamine showed the highest pedicle flow rate. The mean blood pressure was the only statistically significant factor to affect both microvascular perfusion and pedicle flow (p < 0.0001). CONCLUSION: Our results strongly suggest that the foremost three vasopressors can be used for flap surgery without deterioration, and that the maintenance of adequate systemic blood pressure is crucial for good flap circulation.