Application of a deep learning algorithm for three-dimensional T1-weighted gradient-echo imaging of gadoxetic acid-enhanced MRI in patients at a high risk of hepatocellular carcinoma.

PURPOSE: To evaluate the efficacy of a vendor-specific deep learning reconstruction algorithm (DLRA) in enhancing image quality and focal lesion detection using three-dimensional T1-weighted gradient-echo images in gadoxetic acid-enhanced liver magnetic resonance imaging (MRI) in patients at a high risk of hepatocellular carcinoma. MATERIALS AND METHODS: In this retrospective analysis, 83 high-risk patients with hepatocellular carcinoma underwent gadoxetic acid-enhanced liver MRI using a 3-T scanner. Triple arterial phase, high-resolution portal venous phase, and high-resolution hepatobiliary phase images were reconstructed using conventional reconstruction techniques and DLRA (AIRTM Recon DL; GE Healthcare) for subsequent comparison. Image quality and solid focal lesion detection were assessed by three abdominal radiologists and compared between conventional and DL methods. Focal liver lesion detection was evaluated using figures of merit (FOMs) from a jackknife alternative free-response receiver operating characteristic analysis on a per-lesion basis. RESULTS: DLRA-reconstructed images exhibited significantly improved overall image quality, image contrast, lesion conspicuity, vessel conspicuity, and liver edge sharpness and reduced subjective image noise, ringing artifacts, and motion artifacts compared to conventionally reconstructed images (all P < 0.05). Although there was no significant difference in the FOMs of non-cystic focal liver lesions between the conventional and DL methods, DLRA-reconstructed images showed notably higher pooled sensitivity than conventionally reconstructed images (P < 0.05) in all phases and higher detection rates for viable post-treatment HCCs in the arterial and hepatobiliary phases (all P < 0.05). CONCLUSIONS: Implementing DLRA can enhance the image quality in 3D T1-weighted gradient-echo sequences of gadoxetic acid-enhanced liver MRI examinations, leading to improved detection of viable post-treatment HCCs.

Analysis of Watson for oncology and clinicians' treatment recommendations for patients with breast cancer in Korea: A single center experience.

Background: Various clinical applications have been attempted using artificial intelligence (AI) clinical decision support system (CDSS), and it has become a starting point for personalized cancer treatment. We aimed to identify the degree of agreement between the AI-CDSS, Watson for Oncology (WFO), and the clinician in treatment recommendations for Korean breast cancer patients and to provide guidelines for future improvement. Methods: One hundred and eighty-three breast cancer patients who underwent treatment at the Pusan National University Hospital between January 1, 2016 and May 31, 2017 were enrolled in this study. The concordance between WFO's and clinicians' treatment recommendations were examined according to various factors. Results: WFO gave the same treatment option recommendations as clinicians in 74 (40.4%) of the cases. According to the logistic regression, the difference in recommendation concordance between stage I and stage III was statistically significant (P = 0.004), and there was no difference among other factors. Conclusion: The concordance of treatment recommendations was low overall. However, this is largely attributable to the differences of medical insurance system and healthcare environment between the United States and Korea. In the future, region-specific features should be considered or reflected during the development of AI-CDSS.

Temporary blindness caused by corneal edema after a local anesthetic injection in the eyebrow region: a case report.

Plastic surgery around the eyes is usually performed under local anesthesia, using a mixture of lidocaine and epinephrine. Blindness is a rare but devastating complication after the injection of local anesthesia in this region. Most cases reported to date have been caused by occlusion of the ophthalmic artery or central retinal artery. In this case report, however, we present a highly unusual case of blindness caused by corneal edema after a local anesthetic injection. A patient visited the emergency room with a laceration on the eyebrow, and local anesthesia was injected before suturing. Immediately after the injection, severe corneal edema developed, making it impossible to observe the structures in the anterior chamber in detail or check the light reflex and visual acuity of the naked eye. An antibiotic (moxifloxacin hydrochloride) and high-concentration steroid eyedrops were promptly applied. High-concentration steroids were also administered orally. On day 13 post-injury, the visual acuity of the naked eye improved to 1.0, and no recurrence of corneal lesions was observed. Although the cause of corneal edema after the local injection could not be conclusively identified, we hope that this report will help raise clinicians' awareness of this complication and appropriate treatment methods.

Volumetric change of the latissimus dorsi muscle after postoperative chemotherapy and radiotherapy in immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap: final results from serial studies.

BACKGROUND: Breast reconstruction using an extended latissimus dorsi (eLD) flap can supplement more volume than reconstruction using various local flaps after partial mastectomy, and it is a valuable surgical method since the reconstruction area is not limited. However, when performing reconstruction, the surgeon should consider latissimus dorsi (LD) volume reduction due to postoperative chemotherapy (POCTx) and postoperative radiotherapy (PORTx). To evaluate the effect of POCTx and PORTx on LD volume reduction, the effects of each therapy-both separately and jointly-need to be demonstrated. The present study quantified LD volume reduction in patients who underwent POCTx and PORTx after receiving breast-conserving surgery (BCS) with an eLD flap. METHODS: This study included 48 patients who received immediate breast reconstruction using an eLD flap from January 2013 to March 2017, had chest computed tomography (CT) 7-10 days after surgery and 10-14 months after radiotherapy completion, and were observed for more than 3 years postoperatively. One surgeon performed the breast reconstruction procedures, and measurements of breast volume were obtained from axial CT views, using a picture archiving and communication system. A P-value <0.05 was the threshold for statistical significance. RESULTS: The average volume reduction of LD at 10-14 months after completing POCTx and PORTx was 64.5% (range, 42.8%-81.4%) in comparison to the volume measured 7-10 days after surgery. This change was statistically significant (P<0.05). CONCLUSIONS: Based on the findings of this study, when harvesting an eLD flap, surgeons should anticipate an average LD volume reduction of 64.5% if chemotherapy and radiotherapy are scheduled after BCS with an eLD flap.

Usefulness of using additional ultrasonic dissection device in breast cancer surgery: a retrospective cohort study.

BACKGROUND: In breast cancer surgery, electrocautery (EC) is commonly used with the basic method of knot tying, and there are few reports of using other devices such as ultrasonic dissection device (UDD). This study was designed to compare the case of using EC with the basic method of knot tying and the case of using UDD in breast cancer surgery. METHODS: From April 2019 to March 2020, 376 patients who underwent breast cancer surgery at Pusan National University Hospital were enrolled. We compared operation time, complications, and blood loss volume between surgery with and without UDD. RESULTS: We included 306 patients for the final analysis, 142 in the control group and 164 in the trial group. The operation time [minutes (min)] was significantly reduced in the trial group compared to the control group (111.2 vs. 95.5 min, P<0.001). In subgroup analysis, the operation time in the trial group was significantly reduced. There was no significant difference in intraoperative blood loss (P=0.999) and complications [seroma (P=0.965), hematoma (P=0.999), cellulitis (P=0.999)]. CONCLUSIONS: Our study showed that the use of a UDD for surgeons to select instruments for breast cancer surgery may be a good option for both patients and surgeons.

Comparison of breast volume change between oncoplastic breast-conserving surgery with radiation therapy and a simultaneous contralateral balancing procedure through the inverted-T scar technique.

BACKGROUND: Reduction mammoplasty or mastopexy is performed as an additional balancing procedure in patients with large or ptotic breasts who undergo breast-conserving surgery (BCS). Radiation therapy on breasts that have undergone surgery may result in changes in the volume. This study presents a comparative analysis of patients who received post-BCS balancing procedures to determine whether volume changes were larger in breasts that received radiation therapy than on the contralateral side. METHODS: Thirty-six participants were selected among patients who received BCS using the inverted-T scar technique between September 2012 and July 2017, were followed up for 2 or more years, and had pre-radiation therapy computed tomography images and post-radiation therapy images taken between 12 and 18 months after completion. The average age of the participants was 53.5 years, their average body mass index was 26.62 kg/m2. RESULTS: The pre- and post-radiation therapy volumes of the breasts receiving BCS were 666.08±147.48 mL and 649.33±130.35 mL, respectively. In the contralateral breasts, the volume before radiation therapy was 637.69±145.72 mL, which decreased to 628.14±166.41 mL after therapy. The volume ratio of the affected to the contralateral breasts was 1.05±0.10 before radiation therapy and 1.06±0.12 after radiation therapy. CONCLUSIONS: The ratio of the volume between the two breasts immediately after surgery and at roughly 18 months postoperatively was not significantly different (P=0.98). For these reasons, we recommend a simultaneous single-stage balancing procedure as a reasonable option for patients who require radiation therapy after BCS without concerns regarding volume change.

Recurrent late seroma after immediate breast reconstruction with latissimus dorsi musculocutaneous flap.

The latissimus dorsi musculocutaneous flap (LDMCF) is widely used for breast reconstruction. However, it has the disadvantage of frequent seroma formation at the donor site, and late seroma has also been reported. The authors report histological findings after the surgical treatment of a late, repeatedly recurrent seroma at 10 years after breast reconstruction with LDMCF. In 2008, a 66-year-old female patient underwent immediate breast reconstruction with LDMCF. In 2015, a late seroma was found at the donor site. After aspiration and drainage, the seroma recurred again in 2018. Total surgical excision of the seroma was performed and bloody-appearing fluid was identified in the capsule. The excised tissue was biopsied. Histological examination revealed no evidence of blood in the fluid, and multinucleated giant cells with amorphous eosinophilic proteinaceous material were identified. The cyst was suggestive of chronic granulomatous inflammation. There was no recurrence at 8 months postoperatively. The patient described herein underwent surgical treatment of late seroma that recurred after immediate breast reconstruction with LDMCF, and histological findings were identified. These results may be helpful for other future studies regarding late seroma after breast reconstruction with LDMCF.

Image-guided navigation surgery for bilateral choanal atresia with a Tessier number 3 facial cleft in an adult.

The coexistence of craniofacial cleft and bilateral choanal atresia has only been reported in three cases in the literature, and only one of those cases involved a Tessier number 3 facial cleft. It is also rare for bilateral choanal atresia to be found in adulthood, with 10 previous cases reported in the literature. This report presents the case of a 19-year-old woman with a Tessier number 3 facial cleft who was diagnosed with bilateral choanal atresia in adulthood. At first, the diagnosis of bilateral choanal atresia was missed and septoplasty was performed. After septoplasty, the patient's symptoms did not improve, and an endoscopic examination revealed previously unnoticed bilateral choanal atresia. Computed tomography showed left membranous atresia and right bony atresia. The patient underwent an operation for opening and widening of the left choana with an image-guided navigation system (IGNS), which enabled accurate localization of the lesion while ensuring patient safety. Postoperatively, the patient became able to engage in nasal breathing and reported that it was easier for her to breathe, and there were no signs of restenosis at a 26-month follow-up. The patient was successfully treated with an IGNS.

Adequacy of sentinel lymph node biopsy in malignant melanoma of the trunk and extremities: Clinical observations regarding prognosis.

BACKGROUND: METHODS for identifying local lymph node metastasis in malignant melanoma include sentinel lymph node biopsy (SLNB) and lymph node dissection (LND). In particular, SLNB has been widely used in recent years. This study aimed to retrospectively confirm the adequacy of the current indication criteria for SLNB by applying those criteria to a mixed group of patients who previously received SLNB and LND. METHODS: This study included 77 patients with malignant melanoma of the extremities and trunk who were monitored for >24 months. The patients were classified according to whether the current indication criteria for SLNB were applicable. The sentinel lymph nodes were evaluated for each group. Patients for whom the indication criteria for SLNB and LND were applicable were analyzed according to whether SLNB or LND was performed. Finally, the outpatient records of these patients were reviewed to evaluate recurrence, metastasis, and prognosis. RESULTS: Of the 77 patients, SLNB was indicated according to the current criteria in 60 cases. Among the 60 patients for whom SLNB was indicated, 35 survived the follow-up period disease-free, 21 died during the follow-up period, and four experienced metastasis. The 17 patients for whom SLNB was not indicated had no recurrence or metastasis. CONCLUSIONS: Patients for whom SLNB was not indicated had no recurrence or metastasis. In cases where SLNB is indicated, the possibility of metastasis and recurrence may be high even if SLNB is negative or LND is performed, so more aggressive treatment and careful follow-up are crucial.

A Study on the Effective Ratio of Fat to Stromal Vascular Fraction for Cell-Assisted Lipotransfer.

BACKGROUND: Fat grafting, used for soft tissue augmentation during aesthetic or reconstructive plastic surgery, has disadvantages of low efficiency and unpredictable resorption rate. As an alternative, cell-assisted lipotransfer (CAL) is widely used because of its simplicity and low fat resorption rate. However, relevant studies on optimal CAL parameters are still lacking. Here, we aimed to identify the most effective ratio of fat to stromal vascular fraction (SVF) for CAL. METHODS: We designed two experimental paradigms. The first involved four groups of mice, each group injected with varying ratios of fat and SVF purified from different amounts of fat from a fixed amount of harvested fat. The second experiment involved four groups of mice, each injected with varying amounts of SVF mixed with a fixed amount of fat tissue. The amount of surviving fat in both experiments was compared 8 weeks after fat transplantation. RESULTS: In the first experiment, the group injected with only fat, without consuming any of the harvested fat for SVF purification, showed the greatest mean volume and weight. In the second experiment, groups with 1:1 or more ratio of fat to SVF showed greater volume and weight than the group without SVF. Notably, a ratio of 1:1 did not give significantly different results than higher ratios. CONCLUSIONS: Thus, when a limited amount of fat tissue is available, using all of it for grafting is the most effective. However, if an adequate amount is available, using a fat-to-SVF ratio of 1:1 is the most efficient. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

A novel technique for placing titanium mesh with porous polyethylene via the endoscopic transnasal approach into the orbit for medial orbital wall fractures.

BACKGROUND: The endoscopic transnasal approach is widely used for reconstructing the medial orbital wall by filling it with a silicone sheet or Merocel, but this technique has the disadvantage of retaining the packing for a long time. To overcome this drawback, a method of positioning an absorbable plate in the orbit has been introduced, but there is a risk of defect recurrence after the plate is absorbed. Here, the authors report the results of a novel surgical technique of placing a nonabsorbable titanium mesh with porous polyethylene into the orbit through the endoscopic transnasal approach. METHODS: Fourteen patients underwent surgery using the endoscopic transnasal approach. Preoperative computed tomography (CT) was used to calculate the size of the bone defect due to the fracture, and the titanium mesh was designed to be shorter than the anteroposterior length of the defect and longer than its height. The titanium mesh was inserted into the orbit under an endoscopic view. The authors then confirmed that the titanium mesh supported the orbital contents by pressing the eyeball and finished the operation. Immediately after surgery, CT results were evaluated. RESULTS: Postoperative CT scans confirmed that the titanium mesh was well-inserted and in the correct position. All patients were discharged without any complications. CONCLUSIONS: We obtained satisfactory results by inserting a titanium mesh with porous polyethylene into the orbit via the transnasal approach endoscopically.

Merkel cell carcinoma: A series of seven cases.

BACKGROUND: Merkel cell carcinoma (MCC) is a rare neuroendocrine malignancy affecting the skin, for which timely diagnosis and aggressive treatment are essential. MCC has most often been reported in Caucasians, and case reports in Asians are rare. This study presents our experiences with the surgical treatment and radiotherapy of MCC in Asian patients. METHODS: We retrospectively reviewed the records of seven MCC patients between 2000 and 2018 from a single institution, and analyzed patient characteristics, tumor characteristics, surgical treatment, sentinel lymph node evaluation, reconstruction, adjuvant radiation therapy, and prognosis. RESULTS: Eight MCC lesions occurred in seven patients, most commonly in the head and neck region. All patients underwent surgical excision with reconstruction. The final surgical margin was 1.0 cm in most cases, and reconstruction was most commonly performed with a splitthickness skin graft. Five patients received adjuvant radiotherapy, and two patients received sentinel lymph node biopsy. During the follow-up period, three patients remained well, two died from other causes, one experienced recurrence, and one was lost to follow-up. CONCLUSIONS: We treated seven Asian MCC patients and our series confirmed that MCC is a very dangerous cancer in Asians as well. Based on our experiences, thorough surgical excision of MCC with histopathological clearance should be considered, with sentinel lymph node evaluation if necessary, followed by appropriate reconstruction and careful postoperative observation. Adjuvant radiation therapy is also recommended for all Asian MCC patients. The results of this case series may provide guidance for the treatment of Asian MCC patients in the future.

Acellular Dermal Matrix Mistaken as Recurrence of Malignancy Following Surgery on Positron Emission Tomography/Computed Tomography: A Case Report.

OBJECTIVES: To report a rare clinical presentation of an acellular dermal matrix (ADM) used during lateral temporal bone resection mimicking recurrence of cancer of external auditory canal (EAC) on positron emission tomography/computed tomography (PET/CT) 9 months after surgery. METHODS: Case report and literature review. RESULTS: A 71-year-old woman underwent lateral temporal bone resection 9 months earlier for management of squamous cell carcinoma of the EAC. She exhibited recurrence of the tumor on 18F-FDG PET/CT with an intense uptake value (SUVmax 12.8) at the operated site. Exploration was conducted as the location of the lesion was unfavorable to perform biopsy. However, histopathologic evaluation revealed that the lesion was the ADM implanted during surgery. CONCLUSIONS: Care should be taken when using an ADM during malignant tumor surgery if the site of surgery is not conducive for fine needle aspiration or biopsy.

Volumetric change of the latissimus dorsi muscle after immediate breast reconstruction with an extended latissimus dorsi musculocutaneous flap.

BACKGROUND: In immediate breast reconstruction using an extended latissimus dorsi musculocutaneous (eLDMC) flap, the volume of the flap decreases, which causes a secondary deformity of the breast shape. Since little research has investigated this decrease in muscle volume, the authors conducted an objective study to characterize the decrease in muscle volume after breast reconstruction using an eLDMC flap. METHODS: Research was conducted from October 2011 to November 2016. The subjects included 23 patients who underwent mastectomy due to breast cancer, received immediate reconstruction using an eLDMC flap without any adjuvant chemotherapy or radiotherapy, and received a computed tomography (CT) scan from days 7 to 10 after surgery and 6 to 8 months postoperatively. In 10 patients, an additional CT scan was conducted 18 months postoperatively. Axial CT scans were utilized to measure the volumetric change of the latissimus dorsi muscle during the follow-up period. RESULTS: In the 23 patients, an average decrease of 54.5% was observed in the latissimus dorsi muscle volume between the images obtained immediately postoperatively and the scans obtained 6 to 8 months after surgery. Ten patients showed an average additional decrease of 11.9% from 6-8 months to 18 months after surgery. CONCLUSIONS: We studied changes in the volume of the latissimus dorsi muscle after surgery using an eLDMC flap performed after a mastectomy without adjuvant chemotherapy or radiotherapy. In this study, we found that immediate breast reconstruction using a latissimus dorsi muscle flap led to a decrease in muscle volume of up to 50%.

Effects of ginsenoside Rg3 on apoptosis in A375.S2 melanoma cells.

BACKGROUND: Malignant melanoma is the most aggressive skin cancer, and metastatic malignant melanoma is very difficult to treat. Ginsenoside Rg3 extracted from ginseng has been reported to have anticancer effects in various kinds of cancer. It has also been reported that Rg3 induced apoptosis and inhibited metastasis of melanoma cells derived from rats, but studies on the anti-cancer effects of Rg3 on melanoma cells originating from humans have been rarely reported. In this study, to investigate whether Rg3 has anticancer effects in human melanoma cells, A375.S2 cells were used to determine whether Rg3 induces apoptosis of malignant melanoma cells and which signaling pathway leads to apoptosis. METHODS: In this study, we conducted in vitro experiments. First, we examined the effect of Rg3 on A375.S2 cells to change cell viability, cell morphology, colony formation ability, and cell motility. And then, through the use of flow cytometric assay, Western blot, and immunocytochemistry, we examined that Rg3-treated melanoma cells were killed through apoptosis. Finally, we examined the signaling pathway of apoptosis by measuring cell viability after treatment with apoptotic kinase inhibitor. RESULTS: As a result, cell viability, cell morphology, colony formation ability, and cell motility of A375.S2 cells treated with Rg3 were changed. After this experiment, we demonstrated that Rg3 induces A375.S2 melanoma cell apoptosis. Also, this apoptosis can be related to the MEK signaling pathway. CONCLUSIONS: We have shown that Rg3 can induce apoptosis of A375.S2 human melanoma cells through this study.

Evaluation of the donor site after the median forehead flap.

BACKGROUND: Forehead flaps are useful for facial reconstruction. Studies of these flaps have mostly focused on the results of the reconstruction. However, due to the scarring and changes on the forehead caused by the median forehead flap (MFF), surgeons may be reluctant to perform this flap. Research into the donor site is needed for practical purposes. METHODS: We examined 42 patients who underwent an MFF at Pusan National University Hospital from 1996 to 2016. Based on a retrospective chart review, we examined the occurrence of complications. We also evaluated scars on the forehead using the Vancouver Scar Scale (VSS) and assessed changes in the eyebrow position of 22 patients. RESULTS: No complications occurred in the 42 patients. The mean VSS score of the 22 patients was 2.8±0.79. The ratio of the height of the eyebrow on each side to the distance between the medial canthi increased postoperatively, meaning that both the left and right brows were elevated slightly (P=0.026 and P=0.014). However, the symmetry between the left and right sides did not change (P=0.979). The ratio of the interbrow distance to the distance between the medial canthi decreased slightly, meaning that the interbrow distance narrowed mildly (P<0.001). Moreover, there were no noticeable changes in the brow position as seen in a photo overlay. CONCLUSIONS: There were no notable complications in the forehead. Forehead scarring was acceptable. No change in brow symmetry was observed via photographic measurements and a photo overlay. Therefore, we propose that the MFF is a useful choice for minimizing scarring or deformation of the donor site.

Inframammary Flap Excision Method in Breast Augmentation: Improving Symmetry of NAC and IMF.

BACKGROUND: When we perform a breast augmentation through the inframammary fold (IMF) approach, incision placement at the new IMF is a key element of the planning process. In the majority of the previously published methods, the new IMF was planned based on the nipple-areola complex (NAC) position. However, these methods can lead to asymmetry in the IMF if the NAC is not symmetrical. METHODS: We present the IMF flap excision method for correction of asymmetries of NAC and IMF. The new IMF position was marked based on the ICE technique. We have redesigned the higher side IMF to the same height as the lower side. And then we removed the amount of the skin and soft tissue, which corresponded to the difference between the 2 IMF. We dissected the submuscular breast pocket higher than in the usual cases, making it easier to move the breast tissue downward. RESULTS: This method was performed on 21 patients, with an average follow-up time of 6 months (range, 2-9 months). The average correction amount of asymmetry of the NAC ranged from 3 to 15 mm and was maintained throughout the follow-up period. NAC downward positioning and symmetry of IMF were observed. Almost all patients showed improvement or complete resolution of their nipple asymmetry. CONCLUSION: The IMF flap excision method corrected the asymmetries in the NAC and IMF without additional scars. This method should be strongly considered in patients undergoing a primary breast augmentation procedure with mild NAC asymmetry.

The Usefulness of Surgical Treatment in Slow-Flow Vascular Malformation Patients.

BACKGROUND: Many difficulties exist in establishing a treatment plan for slow-flow vascular malformation (SFVM). In particular, little research has been conducted on the surgical treatment of SFVMs. Thus, we investigated what proportion of SFVM patients were candidates for surgical treatment in clinical practice and how useful surgical treatment was in those patients. METHODS: This study included 109 SFVM patients who received care at the authors' clinic from 2007 to 2015. We classified the patients as operable or non-operable, and analyzed whether the operability and the extent of the excision varied according to the subtype and location of the SFVM. Additionally, we investigated complications and self-assessed satisfaction scores. RESULTS: Of the 109 SFVM patients, 59 (54%) were operable, while 50 (46%) were nonoperable. Total excision could be performed in 44% of the operable SFVM patients. Lymphatic malformations were frequently non-operable, while capillary malformations were relatively operable (P=0.042). Total excision of venous malformations could generally be performed, while lymphatic malformations and combined vascular malformations generally could only undergo partial excision (P=0.048). Complications occurred in 11% of the SFVM patients who underwent surgery; these were minor complications, except for 1 case. The average overall satisfaction score was 4.19 out of 5. CONCLUSIONS: Based on many years of experience, we found that approximately half (54%) of SFVM patients were able to undergo surgery, and around half (44%) of those patients were able to fully recover after a total excision. Among the patients who underwent surgical treatment, high satisfaction was found overall and relatively few complications were reported.

Reconstruction of Large Facial Defects via Excision of Skin Cancer Using Two or More Regional Flaps.

BACKGROUND: Free-flap surgery and skin grafting can be used to reconstruct large facial defects that may result after skin cancer removal by Mohs micrographic surgery (MMS). However, these two methods may produce low postsurgical patient satisfaction with aesthetics, and free-flap surgery may produce an undue burden for the majority of skin cancer patients, who are of advanced age. Hence, the authors examined outcomes of large facial defect reconstruction using multiple flaps. METHODS: Among patients undergoing MMS for skin cancer at Pusan National University Hospital between January 2013 and December 2015, we evaluated 7 patients (2 males, 5 females; average age, 73.14 years) treated for large facial defects from basal cell carcinoma. Based on operative and follow-up records, we investigated the number and type of flaps used, postsurgical complications, and patients' post-surgical satisfaction. RESULTS: Two and 3 types of flaps were used for 5 and 2 patients, respectively. Most frequently used were nasolabial flaps (7 times in 6 patients) and forehead flaps (once in each of 4 patients). The average follow-up period was 14 months, with no complications-including necrosis, hematoma, or wound dehiscence-observed. Post-surgical satisfaction averaged 4.4 out of a maximum of 5 points. CONCLUSIONS: Reconstruction using two or more flaps for large facial defects after skin cancer removal using MMS produced satisfactory outcomes while preventing aesthetic problems. Practitioners should consider using multiple flaps when choosing a reconstruction method for large facial defects following skin cancer removal.