Three-Dimensional Photography for Evaluating the Effectiveness of Botulinum Toxin Injection for Masseter Hypertrophy.

BACKGROUND: Masseter hypertrophy is a common condition that causes a undesirable square face, and often treated with botulinum toxin type A (BoNTA). Subjective assessments of BoNTA effectiveness vary from physician to patient, necessitating an objective approach for evaluation. This study introduces three-dimensional photography (3DP) for the first time in clinical assessment to evaluate BoNTA treatment for masseter hypertrophy. METHODS: Ten patients received 36U of BoNTA at three injection points on each side masseter muscle. 3DP scanner using Artec Eva® was taken at the first, third, and sixth postoperative months for objective evaluation. Patient's self-perceived prominence, patients self-rated satisfaction, and physicians provided 5-grade scores were the subjective indicators. RESULTS: A significant decrease in left masseter volume at the sixth month (P = 0.002, P = 0.004 at rest and clenching, respectively) was observed. Patient's self-perceived prominence decreased at the first (P = 0.021) and third (P = 0.039) months. Physicians' scores significantly decreased at all postoperative months. No significant changes were noted in the right masseter volume and patients self-rated satisfaction. Patient self-rated satisfaction did not consistently correlate with objective measures, except for left masseter with clenching at the sixth month. CONCLUSION: Three-dimensional photography accurately quantifies facial changes post-BoNTA treatment. Despite objective improvements, patient satisfaction may not align consistently. Reliable assessment tools are crucial in cosmetic surgery to manage expectations and prevent disputes. 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 .

Validation of Fespixon in Postoperative Scar Cosmesis Using Quantitative Digital Photography Analysis.

BACKGROUND: Unsightly scarring after surgery remains a dilemma. One of the challenges is the lack of objective scar assessment tools. OBJECTIVES: This study aimed to evaluate the efficacy of a novel medicine, Fespixon, for prevention and/or alleviation of post-skin incision scarring. A second aim was to demonstrate the practicality of our digital image analysis system to see if this could serve as a sensitive tool to assess scar improvement. METHODS: A prospective, placebo-controlled trial involving patients with postoperative transverse scars was conducted. Each patient received a topical formulation of Fespixon on the left part of the scar and placebo cream on the right. In addition to recording the subjective modified Vancouver Scar Scale and visual analog scale scores, we utilized digital photography for monthly scar analysis, with CIELAB and hue serving as the colorimetric information, and with contrast, correlation, homogeneity, and entropy providing texture information. RESULTS: Forty-six participants (mean age, 52 years) were enrolled in the trial. All the parameters of subjective assessment showed superior results for the Fespixon-treated side, with significant differences in pigmentation, vascularity, pliability, height, itchiness, and patient satisfaction (P = .043, .013, .026, .002, .039, .012, respectively). The trends in color and texture showed increased relative difference ratios, with significant differences in most of the eigenvalues towards the Fespixon-treated side, including CIELAB-L* (P = .000), hue-R,G,B (red, blue, green) values (P = .034, .001, .011), contrast (P = .000), homogeneity (P = .000), correlation (P = .011), and entropy (P = .000). CONCLUSIONS: We validated the efficacy of Fespixon for postoperative scar healing based not only on subjective assessments but also on objective quantitative analyses. The results also indicated that our digital photography quantitative analysis system is an ideal tool for quantification of scar appearance.

Is 3-Dimensional Scanning Really Helpful in Implant-Based Breast Reconstruction?: A Prospective Study.

BACKGROUND: Breast reconstruction is an integral part of breast cancer treatment, and implant-based breast reconstruction is the most commonly used method worldwide. However, there is still no technique that allows surgeons to predict the volume of the required implant. Although computed tomography and magnetic resonance imaging provide adequate representations of the breast, these procedures are time-consuming, expensive, and expose patients to radiation. Therefore, there is a need for safer, noninvasive alternatives for preoperative breast volume measurements. PATIENTS AND METHODS: This study is a prospective review of 12 patients with early-stage breast cancer who underwent nipple-sparing mastectomy and immediate breast reconstruction with implants. Preoperatively, the Artec Eva 3D scanner was used to acquire volumetric measurements of the breasts. Intraoperatively, the volume of the mastectomy specimen was measured using the water displacement method. Correlations among the preoperative breast, mastectomy specimen, and estimated and final implant volumes were analyzed through Pearson correlation coefficient. A correction prediction factor of 85% was applied where necessary. Patient and physician satisfaction were evaluated 3 months postoperatively. RESULTS: Our study found a statistically significant correlation between the preoperative breast volumes measured by the Artec Eva 3D scanner and intraoperative mastectomy specimen volumes (r = 0.6578). There was no correlation between the preoperative breast volumes and final implant volumes, mastectomy specimen volumes and final implant volumes, and estimated implant volumes and final implant volumes. CONCLUSIONS: Although the Artec Eva 3D scanner can offer relatively accurate measurement of breast volumes, multiple studies still need to be done to determine how these data can be applied to the mastectomy procedure and breast implant selection. It may be more applicable for preoperative planning in breast augmentation surgery. Future surgeons should also take into account that variabilities in natural breast size, tumor size, cancer stage, and in patient and physician preferences all influence the outcome of breast reconstruction surgery.

Modified Simultaneous Double Eyelid Blepharoplasty and Ptosis Correction With a Single-Knot, Continuous, Nonincisional Technique.

BACKGROUND: "Double eyelid" blepharoplasty is one of the most common cosmetic operations among Asian populations. Some patients might present with concomitant mild to moderate blepharoptosis, even though they choose initially to undergo blepharoplasty for cosmetic reasons. OBJECTIVE: Using nonincisional double eyelid surgery without ptosis correction tends to produce unsatisfactory results. We introduce our modified suture method for the simultaneous correction of blepharoptosis during double eyelid blepharoplasty. MATERIALS AND METHODS: We carried out a retrospective review on 13 patients who underwent simultaneous nonincisional ptosis correction and double eyelid surgery, using a single-knot continuous technique, from January 2017 to December 2019. A superior tarsal (Müller's) muscle tagging suture was utilized to achieve an accurate tucking during surgery and create a double upper lid fold simultaneously. RESULTS: The mean patient age was 31.8 years (range=23-54), and 9 patients (69%) were female. The mean marginal reflex distance 1 increased from 2.46±0.36 mm preoperatively to 4.07±0.61 mm postoperatively with a statistically significant difference. Most patients showed favorable results with an average of 10.8 months of follow-up and minimal complications. CONCLUSIONS: This simultaneous double eyelid blepharoplasty technique using a single-knot, continuous, nonincisional technique is relatively easy and effective, with minimal downtime and few postoperative complications, and avoids scarring for patients with mild to moderate blepharoptosis.

Adipose-derived stem cell induced-tissue repair or wound healing is mediated by the concomitant upregulation of miR-21 and miR-29b expression and activation of the AKT signaling pathway.

BACKGROUND: Adipose-derived stem cells (ADSCs), a subpopulation of mesenchymal stem cells, are characterized by their potential to differentiate into multiple cell lineages. Due to their abundance and relative ease of procurement, ADSCs are widely used for tissue repair and regeneration. However, the molecular mechanisms of the therapeutic effect of ADSCs remain unknown. METHODS: MicroRNAs have emerged as important signaling molecules in skin wound healing, and their roles in ADSC-based therapies must be addressed. Here, we investigated the potential of ADSCs in improving cutaneous wound healing in vitro and in vivo. RESULTS: We simulated the microenvironment of the wound site by coculturing human dermal fibroblasts (HDFs) with ADSCs. We found that cocultured HDFs expressed significantly higher levels of miR-29b and miR-21 and had higher proliferation and migration rates than ADSCs cultured without HDFs. Moreover, increased expression of Collagen Type I Alpha 1 Chain (COL1A1), Collagen Type III Alpha 1 Chain (COL3A1), alpha-smooth muscle actin (α-SMA), vascular endothelial growth factor (VEGF), and Phosphoinositide 3-kinase (PI3K), p-Akt and decreased expression of Phosphatase and tensin homolog (PTEN) and matrix metalloproteinase (MMP)-1 was detected, suggesting extracellular remodeling and fibroblast activation and proliferation. We validated the in vitro results by using a rodent skin excisional wound model and implanted ADSC sheets in the wound. Compared with the controls, wounds implanted with ADSC sheets had significantly higher rates of wound-closure; increased expression of α-SMA, VEGF, PI3k, PTEN, COL1A1, and COL3A1; decreased expression of PTEN and MMP1; and upregulated levels of miR-29b and miR-21 in the skin. CONCLUSION: In summary, we evidenced that ADSCs facilitate the increase in miR-29b and miR-21 levels and promote the activation and proliferation of dermal fibroblasts and extracellular matrix (ECM) remodeling, with the associated release of VEGF. Thus, the ADSC-mediated increase in microRNAs is essential in tissue repair and has a therapeutic potential in cutaneous wound healing.

Is sequential free flap safe in oral cancer reconstruction in the same patient? An outcome and complication analysis.

BACKGROUND: Sequential free flap reconstruction in patient with head and neck cancer can provide reliable and effective wound coverage. Only a few studies have reported on the outcome and complications analysis but without consensus on the recipient vessels and flap chosen. Herein, we presented the outcome and analysed the risk factors for complications in sequential free flap reconstruction. PATIENTS AND METHODS: Patients who had sequential free tissue transfers due to cancer recurrence, second primary cancer, or secondary correction of the soft tissue contractures and volume deficits were all included. Variables extracted included demographics, comorbidities, free flap characteristics, infection, dehiscence and flap necrosis rates. RESULTS: In total, 40 patients with 92 free flaps were analyzed; 42 initial and 50 sequential free flaps. The most common recipient vessels for sequential flap were contralateral superficial thyroid vessels (68%). The most common flap for both initial and sequential free flap was anterolateral thigh flap (64.3 and 62%). The success rate of sequential free flap was 92.0 compared to 92.9% for initial free flap, which showed no significant difference. Female was independently associated with delayed wound healing with an odds ratio of 90.91 (95% confidence interval 0.001-0.17, P = 0.001), as well as diabetes with an odds ratio of 31.14 (95% confidence interval 2.60-373.19, P = 0.007). Sequential free flap was not a risk factor for any complication. CONCLUSIONS: Sequential free flap is a reliable method for head and neck surgery without more complication rate comparing to initial free flap reconstruction. More attentions should be paid on patients with preferential risk for certain complications.

Efficacy and Safety of Botulinum Toxin A in Axillary Bromhidrosis and Associated Histological Changes in Sweat Glands: A Prospective Randomized Double-Blind Side-by-Side Comparison Clinical Study.

BACKGROUND: The efficacy of botulinum toxin A (BTX-A) therapy in axillary hyperhidrosis has been documented; however, there are a few studies reporting the efficacy of BTX-A in treating axillary bromhidrosis. The histological changes occurring in sweat glands after BTX-A treatment are also unknown. OBJECTIVE: The authors report on the efficacy and safety of BTX-A in the treatment of axillary bromhidrosis and on the histological changes in sweat glands after BTX-A treatment. MATERIALS AND METHODS: Nineteen patients were included in this study. The patients were administered BTX-A injection in one axilla and sterile normal saline as placebo in the other axilla. The degree of malodor was evaluated subjectively by the patients before and 3 months after treatment. Sweat secretion was quantified by the gravimetric method. All patients underwent standard apocrinectomy in both axillary regions. RESULTS: The mean degree of malodor and mean sweat production in the BTX-A-treated axilla were significantly lower than those in the control axilla (2.42 vs 8.00; p < .0001 and 13.33 vs 33.75 mg/min; p = .0028, respectively) at 3 months after therapy. The histological studies showed apocrine sweat glands with atrophic changes and hypoplasia in treated axilla. CONCLUSION: BTX-A injection is an easy, fast, noninvasive method of treating axillary bromhidrosis.

The Potential of Acellular Dermal Matrix Combined With Neural Stem Cells Induced From Human Adipose-Derived Stem Cells in Nerve Tissue Engineering.

INTRODUCTION: Reconstruction of segmental peripheral nerve gap is still challenging when the autografts are unavailable owing to limited availability of donor site and functional recovery. The creation of artificial conduits composed of biological or synthetic materials is still developing. Acellular dermal matrix (ADM) has been widely studied and its extension and plasticity properties may become suitable nerve conduits under different forms of nerve gaps. Adipose-derived stem cells (ADSCs) have the potential to differentiate into various cell types of different germ layers including neural stem cells (NSCs). The purpose of this experiment is to use ADM as a scaffold combined with NSCs induced by ADSCs to establish neural tissue engineering. METHODS: The ADSCs were isolated from syringe-liposuction adipose tissue harvested from abdominal fat and then cultured in keratinocyte serum free media to trigger into neural stem cells. Stem cells were confirmed by the expression of surface markers nestin and SOX2 in NSCs with Western blot and immunofluorescent staining. Matrix enzyme treatment was used to obtain ADM to remove immunogenic cells while maintaining the integrity of the basement membrane complex and the extracellular matrix structure of the dermis. The NSCs were cocultured with ADM for 3 days, and survival markers Ki67 and neural stem cell markers nestin were detected. RESULTS: These NSCs can form neurospheres and express nestin and SOX2. The NSC can further coculture with ADM, and it will continue to express survivor markers and neural stem cell markers on ADM. CONCLUSIONS: These findings provide evidence that the combination of ADM and NSC has the same potential as neural tissue engineering as other acellular sciatic nerve.

Goal-Directed Fluid Resuscitation Protocol Based on Arterial Waveform Analysis of Major Burn Patients in a Mass Burn Casualty.

BACKGROUND: Adequate fluid titration during the initial resuscitation period of major burn patients is crucial. This study aimed to evaluate the feasibility and efficacy of a goal-directed fluid resuscitation protocol that used hourly urine output plus the arterial waveform analysis FloTrac (Edwards LifeSciences, Irvine, Calif) system for major burns to avoid fluid overload. METHODS: We conducted a retrospective cohort study of 43 major burn patients at the Tri-Service General Hospital after the Formosa Fun Coast Dust Explosion on June 27, 2015. Because of the limited capacity of intensive care units (ICUs), 23 intubated patients were transferred from the burn wards or emergency department to the ICU within 24 hours. Fluid administration was adjusted to achieve a urine output of 30 to 50 mL/h, cardiac index greater than 2.5 L/min/m, and stroke volume variation (SVV) less than 12%. The hourly crystalloid fluid infusion rate was titrated based on SVV and hourly urine output. RESULTS: Of the 23 critically burned patients admitted to the ICU, 13 patients who followed the goal-directed fluid resuscitation protocol within 12 hours postburn were included in the analysis. The mean age (years) was 21.8, and the mean total body surface area (TBSA) burned (%) was 68.0. The mean Revised Baux score was 106.8. All patients sustained inhalation injury. The fluid volumes administered to patients in the first 24 hours and the second 24 hours (mL/kg/% total body surface area) were 3.62 ± 1.23 and 2.89 ± 0.79, respectively. The urine outputs in the first 24 hours and the second 24 hours (mL/kg/h) were 1.13 ± 0.66 and 1.53 ± 0.87, respectively. All patients achieved the established goals within 32 hours postburn. In-hospital mortality rate was 0%. CONCLUSIONS: The SVV-based goal-directed fluid resuscitation protocol leads to less unnecessary fluid administration during the early resuscitation phase. Clinicians can efficaciously manage the dynamic body fluid changes in major burn patients under the guidance of the protocol.

Intraoperative Assessment of the Relationship Between Nipple Circulation and Incision Site in Nipple-Sparing Mastectomy With Implant Breast Reconstruction Using the SPY Imaging System.

INTRODUCTION: Nipple-sparing mastectomy (NSM) and immediate breast reconstruction with gel implants have grown in popularity because of superior aesthetic outcomes. One risk of this procedure is overexcision of the flap leading to inadequate circulation in the breast envelope. METHODS: We investigated 17 cases of NSM and gel implant breast reconstruction. Patients were divided into an infra-areolar incision group and a supra-areolar incision group. Nipple-areolar complex perfusion was evaluated using the SPY imaging system after NSM and gel implant breast reconstruction. We aimed to discover any relationships between the incision method and nipple-areolar complex (NAC) circulation in NSM and gel implant breast reconstruction. RESULTS: For successful breast surgery, awareness of the blood supply to the breast, especially the NAC, is very important. In our study, with the indocyanine green SPY imaging system, most ingress (arterial inflow) and egress (venous outflow) rates in the infra-areolar incision group were better than those in the supra-areolar incision group (P < 0.005). CONCLUSIONS: We have shown that an infra-areolar incision provides better blood flow following NSM and gel implant breast reconstruction. In our experience, in order to prevent the possible ischemia of NAC, we used the smaller gel implants, which is approximately 10 to 20 mL smaller than the original implant size measured by the sizer, if the egress rate of NAC is lower than 0.2. These findings have implications in the clinical setting as surgeons have a choice to provide a better outcome for patients.

Functional results of free tissue transfer for complex heel-calcaneal defects.

BACKGROUND: Loss of soft tissue in heel-calcaneal region is frequently caused by trauma, infection, or tumors. Limited availability of similar tissue becomes challenging, therefore, the use of free tissue transfer offers a solution. Our aim is to describe long term functional outcome of different free tissue transfers for these defects. PATIENTS AND METHODS: We retrospectively reviewed 24 consecutive cases of the heel-calcaneal defect between January 2009 and December 2014. The free fasciocutaneous perforator (FCP) flaps were performed in 14 cases and free muscle flaps with skin graft in 10 cases. The postoperative complications, range of motion and ability of ambulation or exercise were administered to evaluate functional results. RESULTS: The average follow-up period was 26.5 months. The survival of free flap was 100%. Early complication included venous thrombosis, infection and edge dehiscence was noted in 8 cases. Late complication with insensate ulcers developed in 3 cases (1 cases in FCP flap, 2 cases in muscle flap). All ulcers healed spontaneously without surgical intervention. The postoperative average range of motion of ankle regained 52.79 degree in FCP flap group and 56.4 degree in muscle flap group. The ability of ambulation or exercise returned in 13 cases in FCP group (13/14) and 9 cases in muscle flap group (9/10). No differences of complication rate (P = .403), ROM (P = .363) or functional evaluation (P = .803) could be found between these two groups. CONCLUSIONS: Both FCP flap and muscle flaps provided the similar and excellent functional results in resurfacing of heel-calcaneal defects after long term follow up.

Use of split-thickness plantar skin grafts in the management of leg and foot skin defects.

The basic principle of donor site selection is to take skin from areas that will heal with minimal scarring while balancing the needs of the recipient site. For skin loss from the lower legs and feet, the most common harvest site for split-thickness skin grafts is the anterior or posterior thigh; grafts from the plantar areas have been mostly used to cover the volar aspect of digits and palms. Between September 2015 and September 2017, 42 patients with areas of skin loss on the legs or feet were treated with plantar skin grafts because of their cosmetic benefits and the convenience of the surgical procedure and postoperative wound care. Our technique of harvesting a single layer of split-thickness skin graft (0.014 in. thick) from a non-weight-bearing area of the foot of the injured leg is simple and provided good functional and cosmetic outcomes at both the donor and recipient sites. All patients were very satisfied with the recovery progress and final results. Therefore, in the management of skin defects in the lower legs or feet that comprise less than 1.5% of the total body surface area, our surgical method is a reliable alternative to anterior or posterior thigh skin grafting.

Brachial plexus injury after microwave-based treatment for axillary hyperhidrosis and osmidrosis.

Axillary hyperhidrosis combined with osmidrosis is a common problem, especially in Asian communities, that patients find annoying. Even though several surgical techniques have been reported to treat hyperhidrosis/osmidrosis permanently, patients would prefer a non-surgical approach. A microwave-based device was invented during this decade, and it has proven to be a safe and efficient way to treat axillary hyperhidrosis/osmidrosis without major complications. Mild complications reported are vacuum-associated marks, oedema, tenderness and temporary altered skin sensation. We herein report a rare case of brachial plexus injury with sensory and motor dysfunction that occurred after microwave-based treatment. The patient did not fully recover after 6 months of rehabilitation. Our case suggests that a lower initial energy level should be used for thin patients with less fat tissue on the underarm areas, regardless of the patient's sex.

Effect of budesonide and azelastine on histamine signaling regulation in human nasal epithelial cells.

Both glucocorticoids and H1-antihistamines are widely used on patients with airway diseases. However, their direct effects on airway epithelial cells are not fully explored. Therefore, we use the primary culture of human nasal epithelial cells (HNEpC) to delineate in vitro mucosal responses to above two drugs. HNEpC cells were cultured with/without budesonide and azelastine. The growth rate at each group was recorded and measured as population double time (PDT). The histamine1-receptor (H1R), muscarinic1-receptor (M1R) and M3R were measured using immunocytochemistry and western blotting after 7-days treatment. Then, we used histamine and methacholine to stimulate the mucus secretion from HNEpC and observed the MUC5AC expression in culture supernatants. Concentration-dependent treatment-induced inhibition of HNEpC growth rate was observed. Cells incubated with azelastine proliferated significantly slower than that with budesonide and the combined use of those drugs led to significant PDT prolong. The immunocytochemistry showed the H1R, M1R and M3R were obviously located in the cell membrane without apparent difference after treatment. However, western blotting showed that budesonide can significantly up-regulate the H1R, M1R and M3R level while azelastine had opposite effects. Histamine and methacholine stimulated MUC5AC secretion was greater in cells treated with budesonide but was lesser in those treated with azelastine, as compared to controls. Our data suggest that both budesonide and azelastine can significantly inhibit HNEpC proliferation, and therefore, be helpful in against airway remodeling. Long-term use of budesonide might amplify histamine signaling and result in airway hyperreactivity to stimulants by enhancing H1R, M1R and M3R expression while azelastine can oppose this effect. Therefore, combined use of those two drugs in patients with chronic inflammatory airway diseases may be an ideal option.

Breast Reconstruction Using Pedicled Latissimus Dorsi Myocutaneous Flaps in Asian Patients With Small Breasts.

BACKGROUND: The use of implants is still the most common procedure for breast reconstruction because they are easy, less painful than tissue transplants, and do not need a donor site. However, it is challenging to find a suitable implant for patients with small breasts, and some women fear foreign bodies and possible complications or reoperations. Autologous breast reconstruction using the pedicled latissimus dorsi (LD) myocutaneous flap without an implant provides a good option for Asian women with small breasts. MATERIALS AND METHODS: Between June 1992 and December 2015, 31 patients underwent breast reconstruction with 33 LD flaps (29 unilateral and 2 bilateral). The skin paddle of the flap was designed with an oblique or transverse pattern depending on the mastectomy defect and the elasticity of skin. The thoracodorsal nerve was divided during flap harvesting to prevent a "twitching breast" postoperatively. Patients refused to have contralateral breast augmentation except for 2 with bilateral simultaneous augmentation after mastectomy bilaterally. Outcome measures were flap survival, shape and contour, symmetry of breast, complication of flap and donor site, patient satisfaction, and any local tumor recurrence or metastasis. RESULTS: The mean patient age was 46.7 years (range, 27-72), and the mean body mass index was 22.5 kg/m (range, 18.6-30). The mean size of the harvested skin paddle was 11.9 × 5.0 cm (range, 10 × 3 cm to 15 × 9 cm). Mean operative times were 200.8 minutes (range, 112-230 minutes) and 305 minutes (range, 300-310 minutes) for unilateral and bilateral reconstructions, respectively. Pathology reports showed a negative safety margin in all cases. Most cases were of invasive duct carcinoma (58%). All LD flaps survived, and the wounds healed satisfactorily over a mean follow-up of 49.9 months (range, 3-161 months). Donor sites were closed primarily with a hidden linear scar under the dorsal bra strap. Donor site morbidities were mainly seromas (15%), which were treated conservatively in most patients. CONCLUSIONS: The LD flap produced good autologous tissue for reconstruction, and no implants were needed for Asian women with small breasts. The reconstructed breasts showed good shape, contour, and symmetry. The results of donor site were acceptable and no significant functional loss. There were no major complications, and patient satisfaction was high.

Postmastectomy Breast Reconstruction Combined With Contralateral Breast Augmentation for Taiwanese Women With Small Breasts.

BACKGROUND: Although autogenous tissue-based breast reconstruction has been widely used in the past decade, implant-based breast reconstruction is more often used in Taiwan because Asian women are generally slender with small breasts. For patients with very small breasts, it is hard to achieve the goal of reconstructing a similar breast to the contralateral one, even with the smallest size implant available commercially. Therefore, these patients need not only breast reconstruction but also contralateral breast augmentation. Here we report the surgical outcomes and cosmetic results of breast reconstruction using cohesive gel implants combined with simultaneous contralateral breast augmentation. MATERIALS AND METHODS: A retrospective chart review was conducted to identify all patients with AA-sized to B-sized breast cups undergoing expander-implant reconstruction combined with contralateral breast augmentation between 2002 and 2015. Thirty patients were included. For each patient, patient profile (age, body mass index, and initial breast size), type and stage of breast cancer, surgical information (including implant sizes and the type of reconstruction and augmentation), and postoperative subjective pain scales were recorded. Outcomes were analyzed by identifying complications, the need for surgical revision, the presence of local or distant metastases, and patient satisfaction ratings. RESULTS: At a mean 2.3-year follow-up (range, 4 months to 12 years), problems occurred in 7 of the 30 patients, with 9 complications in 8 reconstructed breasts and in 1 augmented breast. Complications were mostly capsule contracture. Aesthetic satisfaction was rated as "excellent" or "good" by most of the patients, and only 1 commented "poor" on both overall and reconstructed results because of postoperative radiotherapy-associated skin necrosis. The total mean subjective pain scale was 1.9/10; a higher mean pain scale of 3.08 was noted in those patients undergoing augmentation with no extra incision. CONCLUSIONS: This is the first report of implant-based breast reconstruction with simultaneous contralateral augmentation in Taiwan, showing its efficacy, safety, and good cosmetic outcomes with relatively low complication and revision rates.

A Biodegradable Hemostatic Gelatin/Polycaprolactone Composite for Surgical Hemostasis.

Massive bleeding is the leading cause of battlefield-related deaths and the second leading cause of deaths in civilian trauma centers. One of the challenges of managing severe wounds is the need to promote hemostasis as quickly as possible, which can be achieved by using hemostatic dressings. In this study, we fabricated 2 kinds of gelatin/polycaprolactone composites with 2 ratios of gelatin/polycaprolactone, 1:1 and 2:1 (GP11 and GP21, respectively). Scanning electron microscopy revealed that the GP11 composite exhibited rougher and more porous structure than the GP21 composite did. Furthermore, both composites showed similar biocompatibility as that of tissue culture polystyrene. Moreover, both GP composites tended to show a gradual decrease in contact angle to zero within 40 minutes. The in vitro blood plasma coagulation assay revealed that the prothrombin time was significantly longer for the GP composites than it was for the Quikclot composite, whereas the activated partial thromboplastin time of the GP11 composite was significantly shorter than that of the gauze. Furthermore, the GP11 had the largest platelet adsorption of all the composites. The in vivo coagulation test showed an obvious shortening of the bleeding time with the Quikclot and GP21 compared with gauze sample. In conclusion, the GP composites showed superior biocompatibility and hemostasis to the gauze and comparable effects with the Qickclot composite. Therefore, the GP composites have the potential for development as biodegradable surgical hemostatic agents.

Pedicled medial sural perforator flap for the reconstruction of knee defects.

Soft tissue defects exposing the patellar tendon or bone are common in patients who have experienced trauma or implant infection. The purpose of this article is to present our experience of six patients who underwent reconstruction of soft tissue defects of the knee using a pedicled medial sural perforator flap. Between November 2013 and November 2015, six patients who presented with a soft tissue defect overlying the knee were admitted to our hospital. After adequate debridement or wide excision of the tumour, these patients underwent pedicled medial sural perforator flap placement to resurface the complex soft tissue defects and to provide a gliding surface for the exposed patellar tendon. The patients' age, comorbidity, aetiology, defect size and location, flap size, perforator numbers and lengths, outcome and follow-up period were reviewed. The six medial sural perforator flaps survived completely, and the wounds healed satisfactorily over a mean follow-up of 21·5 months (range, 6-51 months). Donor sites were closed primarily or covered with a split-thickness skin graft. The medial sural perforator flap is a reliable flap for coverage of defects overlying the knee. The thin and pliable flap, long pedicle length and less donor site mobility benefit patients. Thus, the medial sural perforator flap may be a valuable alternative for defect reconstructions overlying the knee, which produces satisfactory results both functionally and cosmetically.

Enhanced wound-healing performance of a phyto-polysaccharide-enriched dressing - a preclinical small and large animal study.

Alginate is a natural rich anionic polysaccharide (APS), commonly available as calcium alginate (CAPS). It can maintain a physiologically moist microenvironment, which minimises bacterial infection and facilitates wound healing at a wound site. Patients with burn injuries suffer from pain and an inflammatory response. In this study, we evaluated the CAPS dressing and traditional dressing containing carboxymethyl cellulose (CMC) for wound healing and scar tissue formation in a burn model of rat and swine. In our pilot study of a burn rat model to evaluate inflammatory response and wound healing, we found that the monocyte chemoattractant protein (MCP)-1 and transforming growth factor (TGF)-ß were up-regulated in the CAPS treatment group. Next, the burn swine models tested positive for MCP-1 in a Gram-positive bacterial infection, and there was overproduction of TGF-ß during the burn wound healing process. Rats were monitored daily for 1 week for cytokine assay and sacrificed on day 28 post-burn injury. The swine were monitored over 6 weeks. We further examined the pain and related factors and inflammatory cytokine expression in a rodent burns model monitored everyday for 7 days post-burn. Our results revealed that the efficacy of the dressing containing CAPS for wound repair post-burn was better than the CMC dressing with respect to natural wound healing and scar formation. The polysaccharide-enriched dressing exerted an antimicrobial effect on burn wounds, regulated the inflammatory response and stimulated anti-inflammatory cytokine release. However, one pain assessment method showed no significant difference in the reduction in levels of adenosine triphosphate in serum of rats after wound dressing in either the CAPS or CMC group. In conclusion, a polysaccharide-enriched dressing outperformed a traditional dressing in reducing wound size, minimising hypertrophic scar formation, regulating cytokines and maximising antimicrobial effects.