Evaluation of the clinical efficacy of a TW3-based fully automated bone age assessment system using deep neural networks

Purpose@#The aim of this study was to evaluate the clinical efficacy of a Tanner-Whitehouse 3 (TW3)-based fully automated bone age assessment system on hand-wrist radiographs of Korean children and adolescents. @*Materials and Methods@#Hand-wrist radiographs of 80 subjects (40 boys and 40 girls, 7-15 years of age) were collected. The clinical efficacy was evaluated by comparing the bone ages that were determined using the system with those from the reference standard produced by 2 oral and maxillofacial radiologists. Comparisons were conducted using the paired t-test and simple regression analysis. @*Results@#The bone ages estimated with this bone age assessment system were not significantly different from those obtained with the reference standard (p>0.05) and satisfied the equivalence criterion of 0.6 years within the 95% confidence interval ( - 0.07 to 0.22), demonstrating excellent performance of the system. Similarly, in the comparisons of gender subgroups, no significant difference in bone age between the values produced by the system and the reference standard was observed (p>0.05 for both boys and girls). The determination coefficients obtained via regression analysis were 0.962, 0.945, and 0.952 for boys, girls, and overall, respectively (p=0.000); hence, the radiologist-determined bone ages and the system-determined bone ages were strongly correlated. @*Conclusion@#This TW3-based system can be effectively used for bone age assessment based on hand-wrist radiographs of Korean children and adolescents.

Outcome Differences of RemnantPreserving versus Non-Preserving Methods in Arthroscopic Anterior Cruciate Ligament Reconstruction: A Meta-analysis with Subgroup analysis

Purpose@#To analyze differences in clinical outcomes of arthroscopic anterior cruciate ligament reconstruction between remnant-preserving and non-preserving methods. @*Methods@#International electronical databases PubMed, Embase, and the Cochrane central database from January 1966 to December 2017 were searched for randomized controlled trials (RCTs) and observational studies that compared differences of clinical outcomes of ACL reconstruction with and without remnant preservation. A metaanalysis of these studies was performed to compare clinical outcomes. Subgroup analyses were conducted to evaluate the role of methodological quality in primary meta-analysis estimates. @*Results@#Five RCTsand six observational studies were included in this meta-analysis and subgroup analysis. The remnant-preserving method in arthroscopic ACL reconstruction showed a statistically significant difference compared to the non-preserving method regarding arthrometric evaluation (side-to-side difference). Lachman test, Lysholm scores, and IKDC subjective scores showed statistically minor difference in meta-analysis, but showed no significant difference in subgroup analysis. Remained parameters including pivot shift test, IKDC grades, incidence of cyclops lesion showed no statistically differences in meta-analysis or subgroup analysis. @*Conclusions@#This meta-analysis with subgroup analysis showed that arthroscopic remnant-preserving ACL reconstruction provided statistically significant but limited clinical relevance in terms of arthrometric evaluation. @*Results@#of Lachman test, Lysholm scores, and IKDC subjective scores demonstrated statistically minor differences.

Comparison of Harmonic scalpel and monopolar cautery for capsulectomy at the second stage of expander/implant breast reconstruction

Background@#Capsular contracture is a common complication of two-stage expander/implant breast reconstruction. To minimize the risk of this complication, capsulectomy is performed using monopolar cautery or ultrasonic surgical instrumentation, the latter of which can be conducted with a Harmonic scalpel. To date, there is disagreement regarding which of the two methods is superior. The purpose of this study was to compare postoperative outcomes between a group of patients who underwent surgery using a Harmonic scalpel and another group treated with monopolar cautery. @*Methods@#A retrospective chart review was conducted of patients who underwent capsulectomy as part of two-stage breast reconstruction between January 2018 and February 2019 and who received at least 1 month of follow-up after surgery. Operative time and postoperative outcomes, including drainage duration, were analyzed. @*Results@#In total, 36 female patients underwent capsulectomy. The monopolar group consisted of 18 patients and 22 breasts, while the Harmonic scalpel group consisted of 18 patients and 21 breasts. There was no statistically significant difference in demographics between the two groups. The Harmonic scalpel group had a significantly shorter mean drainage duration (6.65 days vs. 7.36 days) and a smaller mean total drainage volume (334.69 mL vs. 433.54 mL) than the monopolar cautery group (P<0.05). No statistically significant difference was observed with regard to seroma or hematoma formation. @*Conclusions@#The Harmonic scalpel approach for capsulectomy reduced the total drainage volume and drainage duration compared to the monopolar cautery approach. Therefore, this approach could serve as a good alternative to electrocautery.

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 freeze-dried 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.

Choice of recipient vessels in muscle-sparing transverse rectus abdominis myocutaneous flap breast reconstruction: A comparative study

BACKGROUND: Thoracodorsal vessels (TDVs) and internal mammary vessels (IMVs) have both been widely employed as recipient vessels for use in free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps. However, whether TDVs or IMVs are preferable as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap remains controversial. The purpose of this study was to compare the clinical outcomes when TDVs were used as recipient vessels to those obtained when IMVs were used as recipient vessels for autologous breast reconstruction with a free MS-TRAM flap. METHODS: A retrospective matched-cohort study was performed. We retrospectively reviewed data collected from patients who underwent a free MS-TRAM flap for autologous breast reconstructions after mastectomy between March 2003 and June 2013. After a one-to-one matching using age, 100 autologous breast reconstructions were selected in this study. Of the 100 breast reconstructions, 50 flaps were anastomosed to TDVs and 50 to IMVs. Patient demographics and clinical outcomes including operation time, length of hospital stay, postoperative complications, and aesthetic score were compared between the two groups. RESULTS: No statistically significant differences were found between the two groups in patient demographics and clinical outcomes, including the complication rates and aesthetic scores. There were no major complications such as total or partial flap loss in either group. CONCLUSIONS: The results of our study demonstrate that both TDVs and IMVs were safe and efficient as recipient vessels in terms of the complication rates and aesthetic outcomes.

Algorithm for the management of ectropion through medial and lateral canthopexy

BACKGROUND: Patients with ectropion experience devastating symptoms. Therefore, the preventionand management of this condition are of utmost importance. To treat ectropion, it is important to perform medial and lateral canthopexy in an effective way. In this study, we propose a comprehensive algorithm for the prevention and management of ectropion based on a new classification of ectropion according to its signs and causes. METHODS: Canthopexy was performed in 68 cases according to the proposed algorithm, which starts with a categorization of the types of ectropion and ends with the recommended operative technique. To assess the results, we reviewed clinical preoperative and postoperative photographs. To evaluate improvements in patients’ symptoms, we conducted a survey with responses scored on a Likert scale. RESULTS: None of the patients had scleral show postoperatively. The average patient satisfaction score was satisfied or higher for all symptoms, and the most improved symptom was aesthetic appearance. No major complications were reported. CONCLUSIONS: For the comprehensive management of ectropion, it is crucial to consider both treatment and prevention. Through the simple surgical algorithm proposed in this study, both medically acceptable results and high levels of patient satisfaction were achieved without significant postoperative complications. We recommend using this algorithm for the comprehensive management of ectropion.

Bacterial profile of suction drains and the relationship thereof to surgical-site infections in prosthetic breast reconstruction

BACKGROUND: Despite the increasing popularity of prosthetic breast reconstruction, scant data exist on the microbiological profile of drainage fluid from closed-suction drains and the relationship thereof to surgical-site infections (SSIs) in breast reconstruction surgery. This study aimed to determine whether bacteria isolated from drainage fluid were associated with the development of SSIs, and whether the bacterial profile of drainage fluid could be a clinically useful predictor of SSIs. METHODS: We performed a retrospective chart review of 61 women who underwent tissue expander/implant or direct-to-implant reconstructions. Patient demographics and culture studies of drainage fluid from suction drains collected on postoperative day 7 were evaluated. RESULTS: Sixteen patients (26.23%) were culture-positive, and 45 patients (73.77%) were culture-negative. The most frequently isolated bacteria were coagulase-negative staphylococci, followed by Staphylococcus aureus. SSIs were diagnosed in seven patients and were mostly resolved by systemic antibiotics; however, the tissue expander or implant was explanted in two patients. Positive culture of drainage fluid from closed-suction drains was significantly associated with the development of SSIs (P < 0.05). The positive predictive value was 37.50%,and the negative predictive value was 97.78%. CONCLUSIONS: To our knowledge, this study is the first to demonstrate a significant association between the microbiological profile of drainage fluid from closed-suction drains and the development of SSIs in patients with prosthetic breast reconstructions. The high negative predictive value suggests that microbial testing of drainage fluid from closed-suction drains may have clinical utility. Further prospective studies with larger sample sizes are required to confirm our findings.

Impact of hormonal therapy and other adjuvant therapies on contralateral breast volume change after implant-based breast reconstruction

BACKGROUND: Adjuvant therapy after breast surgery, including tamoxifen or aromatase inhibitors, improves the postoperative outcomes and long-term survival of breast cancer patients. The aim of this study was to determine whether volume changes occurred in the contralateral breast during hormonal or other adjuvant therapies. METHODS: This study reviewed 90 patients who underwent unilateral breast reconstruction between September 2012 and April 2018 using tissue expanders and a permanent implant after the surgical removal of breast cancer. The volume of the contralateral breast was measured using a cast before the first (tissue expander insertion) and second (permanent implant change) stages of surgery. Changes in breast volume were evaluated to determine whether adjuvant therapy such as hormonal therapy, chemotherapy, and radiation therapy influenced the volume of the contralateral breast. RESULTS: The group receiving tamoxifen therapy demonstrated a significant decrease in volume compared with the group without tamoxifen (−7.8% vs. 1.0%; P=0.028). The aromatase inhibitor–treated group showed a significant increase in volume compared with those who did not receive therapy (−6.2% vs. 4.5%; P=0.023). There were no significant differences between groups treated with other hormonal therapy, chemotherapy, or radiation therapy. CONCLUSIONS: Patients who received tamoxifen therapy showed a significant decrease in volume in the contralateral breast, while no significant change in weight or body mass index was found. Our findings suggest that we should choose smaller implants for premenopausal patients, who have a high likelihood of receiving tamoxifen therapy.

Clinically Significant Unclassified Variants in BRCA1 and BRCA2 genes among Korean Breast Cancer Patients / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: Unclassified variants (UVs) of BRCA1 and BRCA2 genes are not defined as pathogenic for breast cancer, and their clinical significance currently remains undefined. Therefore, this study was conducted to identify potentially pathogenic UVs by comparing their prevalence between breast cancer patients and controls. MATERIALS AND METHODS: A total of 328 breast cancer patients underwent BRCA1/2 genetic screening at the National Cancer Center of Korea. Genetic variants of BRCA genes that were categorized as unclassified according to the Breast Cancer Information Core database were selected based on allelic frequency, after which candidate variants were genotyped in 421 healthy controls. We also examined family members of the study participants. Finally, the effects of amino acid substitutions on protein structure and function were predicted in silico. RESULTS: Genetic tests revealed 33 UVs in BRCA1 and 47 in BRCA2. Among 15 candidates genotyped in healthy controls, c.5339T>C in BRCA1 and c.6029T>G, c.7522G>A in BRCA2 were not detected. Moreover, the c.5339T>C variant in the BRCA1 gene was detected in four patients with a family history of breast cancer. This nonsynonymous variant (Leu1780Pro) in the BRCA1 C-terminal domain was predicted to have an effect on BRCA1 protein structure/function. CONCLUSION: This study showed that comparison of genotype frequency between cases and controls could help identify UVs of BRCA genes that are potentially pathogenic. Moreover, ourfindings suggest that c.5339T>C in BRCA1 might be a pathogenic variant for patients and their families.

The Effect of Low-Dose Nitroglycerin Ointment on Skin Flap Necrosis in Breast Reconstruction after Skin-Sparing or Nipple-Sparing Mastectomy

BACKGROUND: Skin flap necrosis is a common complication after mastectomy and breast reconstruction. It has been proven that nitroglycerin ointment, as a topical vasodilator, can decrease the rate of skin flap necrosis after mastectomy and breast reconstruction. However, nitroglycerin can cause several side effects, including headache, dizziness, and hypotension. The purpose of this study was to evaluate whether the application of a low dose of nitroglycerin ointment reduced the rate of skin flap necrosis in breast reconstruction after skin-sparing or nipple-sparing mastectomy. METHODS: A total of 73 cases of breast reconstruction after nipple-sparing and skin-sparing mastectomy at our institution from March 2012 to January 2017 were retrospectively studied. Of these patients, 52 received nitroglycerin ointment (4.5 mg) application to the skin around the nipple-areolar complex from August 2015 to January 2017, while 21 received fusidic acid ointment from March 2012 to August 2015. The number of patients who experienced necrosis of the breast skin flap was counted in both groups. RESULTS: Skin flap necrosis developed in 2 (3.8%) patients who were treated with nitroglycerin ointment and 5 (23.8%) patients who did not receive nitroglycerin ointment treatment. Patients who did not receive nitroglycerin ointment treatment had a significantly higher risk of mastectomy skin flap necrosis than patients who did (odds ratio=7.81; 95% confidence interval, 1.38 to 44.23; P=0.02). CONCLUSIONS: Low-dose nitroglycerin ointment administration significantly decreased the rate of skin flap necrosis in patients who underwent breast reconstruction after skin-sparing or nipple-sparing mastectomy, without increasing the incidence of the side effects of nitroglycerin.

Comparison of the Effectiveness of Ablative and Non-Ablative Fractional Laser Treatments for Early Stage Thyroidectomy Scars

BACKGROUND: Open thyroidectomy is conventionally performed at the anterior side of neck, which is a body part with a comparatively great degree of open exposure; due to this, postoperative scarring may cause distress in patients. We aimed to compare the effects of ablative and nonablative fractional laser treatments on thyroidectomy scars. We examined medical records in a retrospective manner and analyzed scars based on their digital images by using the modified Manchester Scar Scale (mMSS). METHODS: Between February 2012 and May 2013, 55 patients with thyroidectomy scars were treated with ablative (34 patients) or nonablative (21 patients) fractional laser. Each patient underwent 4 laser treatment sessions in 3–4 week intervals, 1–2 months postoperatively. Scar improvement was assessed using patient images and the mMSS scale. RESULTS: The mean decrease in scar score was 3.91 and 3.47 in the ablative and nonablative groups, respectively; the reduction between 2 groups did not exhibit any significant difference (P=0.16). We used the scale once again to individually evaluate scar attributes. The nonablative group accounted for a considerably higher color score value (P=0.03); the ablative group accounted for a considerably higher contour score value (P<0.01). Patient satisfaction was high and no complications occurred. CONCLUSIONS: Both types of fractional laser treatments can be used successfully for thyroidectomy scar treatment with minimal complications; however, results indicate that higher effectiveness may be obtained from the use of ablative and nonablative lasers for hypertrophic scars and early erythematous scars, respectively. Therefore, the appropriate laser for scar treatment should be selected according to its specific characteristics.

Acellular Dermal Matrix as a Core Strut for Projection in Nipple Reconstruction: Approaches for Three Different Methods of Breast Reconstruction

BACKGROUND: The objective of this paper was to describe a novel technique for improving the maintenance of nipple projection in primary nipple reconstruction by using acellular dermal matrix as a strut in one of three different configurations, according to the method of prior breast reconstruction. The struts were designed to best fill the different types of dead spaces in nipple reconstruction depending on the breast reconstruction method. METHODS: A total of 50 primary nipple reconstructions were performed between May 2012 and May 2015. The prior breast reconstruction methods were latissimus dorsi (LD) flap (28 cases), transverse rectus abdominis myocutaneous (TRAM) flap (10 cases), or tissue expander/implant (12 cases). The nipple reconstruction technique involved the use of local flaps, including the C-V flap or star flap. A 1×2-cm acellular dermal matrix was placed into the core with O-, I-, and L-shaped struts for prior LD, TRAM, and expander/implant methods, respectively. The projection of the reconstructed nipple was measured at the time of surgery and at 3, 6, and 9 months postoperatively. RESULTS: The nine-month average maintenance of nipple projection was 73.0%±9.67% for the LD flap group using an O-strut, 72.0%±11.53% for the TRAM flap group using an I-strut, and 69.0%±10.82% for the tissue expander/implant group using an L-strut. There were no cases of infection, wound dehiscence, or flap necrosis. CONCLUSIONS: The application of an acellular dermal matrix with a different kind of strut for each of 3 breast reconstruction methods is an effective addition to current techniques for improving the maintenance of long-term projection in primary nipple reconstruction.

The Relationship of a Combination of Human Adipose Tissue-Derived Stem Cells and Frozen Fat with the Survival Rate of Transplanted Fat

BACKGROUND: The survival rate of grafted fat is difficult to predict, and repeated procedures are frequently required. In this study, the effects of the freezing period of harvested adipose tissue and the addition of human adipose tissue-derived stem cells (ASCs) on the process of fat absorption were studied. METHODS: Adipose tissue was obtained from patients who underwent a lipoaspirated fat graft. The fat tissue was cryopreserved at -20degrees C in a domestic refrigerator. A total of 40 nude mice were used. The mice in the experimental group received three different subcutaneous injections in the back: an injection of fresh fat and ASCs, an injection of fat that had been frozen for one month and ASCs, and an injection of fat that had been frozen for two months and ASCs. The control mice received fat grafts without ASCs. The mice were sacrificed at four or eight weeks after the procedure, and the grafted fat tissues were harvested. The extracted fat was evaluated using photographic analysis, volume measurements, and histological examination. RESULTS: In the control group, the fat resorption rates four weeks after transplantation in the grafts of fresh fat, fat that had been frozen for one month, and fat that had been frozen for two months were 21.14%, 22.46%, and 42.56%, respectively. In the experimental group, the corresponding resorption rates were 6.68%, 13.0%, and 33.9%, respectively. CONCLUSIONS: ASCs can increase the fat graft survival rate. The use of ASCs in fat grafting can reduce the need for repeated fat grafts and provide good long term results.

Nipple-Areola Complex Necrosis after Nipple-Sparing Mastectomy with Immediate Autologous Breast Reconstruction

BACKGROUND: Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution. METHODS: We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis. RESULTS: Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery. CONCLUSIONS: NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

Stabilizing Morbidity and Predicting the Aesthetic Results of Radial Forearm Free Flap Donor Sites

BACKGROUND: The radial forearm flap is a versatile, widely used flap. However, the possibility of donor site complications has led to concern over its use. Some surgeons prefer using other flaps whose donor sites can be closed primarily with less morbidity, including avoiding unpleasant scarring. However, in our experience, donor site stability of the radial forearm flap can be reliably achieved by using well-implemented specific procedures. Here, we present a collection of donor site cases of the radial forearm flap and investigate factors that affect the aesthetic results as the basis for a reference for selecting a radial forearm flap. METHODS: In this retrospective study, we reviewed 171 cases in which a radial forearm flap was used for free tissue transfer after resecting head and neck cancer. We focused on donor site morbidity rates. Each operation involved a detailed procedure designed to minimize donor site morbidity. Moreover, statistical investigations were conducted for 22 cases to determine factors affecting the scar appearance. RESULTS: Only one case developed total skin graft necrosis as a major complication. Scar-related aesthetic results were acceptable, and the body-mass index, body weight, diabetes, and cardiac problems were significant factors related to the appearance of scars. CONCLUSIONS: Performing the radial forearm flap using a well-implemented detailed technique helps achieve acceptable donor site morbidity results. The aesthetic results were more promising for patients without excess body weight, diabetes, or cardiac problems. Therefore, anxiety about donor site morbidity should not be a reason to avoid selecting the radial forearm flap in suitable patients.

Medial Wall Orbital Reconstruction using Unsintered Hydroxyapatite Particles/Poly L-Lactide Composite Implants

BACKGROUND: Poly-L-lactide materials combined with hydroxyapatite (u-HA /PLLA) have been developed to overcome the drawbacks of absorbable materials, such as radiolucency and comparably less implant strength. This study was designed to evaluate the usefulness of u-HA/PLLA material in the repair of orbital medial wall defects. METHODS: This study included 10 patients with pure medial wall blow-out fractures. The plain radiographs were taken preoperatively, immediately after, and 2 months after surgery. The computed tomography scans were performed preoperatively and 2 months after surgery. Patients were evaluated for ease of manipulation, implant immobility, rigidity and complications with radiologic studies. RESULTS: None of the patients had postoperative complications, such as infection or enophthalmos. The u-HA/PLLA implants had adequate rigidity, durability, and stable position on follow-up radiographic studies. On average, implants were thawed 3.4 times and required 14 minutes of handling time. CONCLUSION: The u-HA/PLLA implants are safe and reliable for reconstruction of orbital medial wall in terms of rigidity, immobility, radiopacity, and cost-effectiveness. These thin yet rigid implants can be useful where wide periosteal dissection is difficult due to defect location or size. Since the u-HA/PLLA material is difficult to manipulate, these implants are not suitable for use in complex 3-dimensional defects.

Comparison of the Complications in Vertical Rectus Abdominis Musculocutaneous Flap with Non-Reconstructed Cases after Pelvic Exenteration

BACKGROUND: Perineal reconstruction following pelvic exenteration is a challenging area in plastic surgery. Its advantages include preventing complications by obliterating the pelvic dead space and minimizing the scar by using the previous abdominal incision and a vertical rectus abdominis musculocutaneous (VRAM) flap. However, only a few studies have compared the complications and the outcomes following pelvic exenteration between cases with and without a VRAM flap. In this study, we aimed to compare the complications and the outcomes following pelvic exenteration with or without VRAM flap coverage. METHODS: We retrospectively reviewed the cases of nine patients for whom transpelvic VRAM flaps were created following pelvic exenteration due to pelvic malignancy. The complications and outcomes in these patients were compared with those of another nine patients who did not undergo such reconstruction. RESULTS: Flap reconstruction was successful in eight cases, with minor complications such as wound infection and dehiscence. In all cases in the reconstructed group (n=9), structural integrity was maintained and major complications including bowel obstruction and infection were prevented by obliterating the pelvic dead space. In contrast, in the control group (n=9), peritonitis and bowel obstruction occurred in 1 case (11%). CONCLUSIONS: Despite the possibility of flap failure and minor complications, a VRAM flap can result in adequate perineal reconstruction to prevent major complications of pelvic exenteration.

Empirical Treatment of Highly Suspected Nontuberculous Mycobacteria Infections Following Aesthetic Procedures

BACKGROUND: Infection caused by nontuberculous mycobacteria (NTM) has been increasing. Awareness of this infection is crucial yet problematic. Delayed management may lead to destructive results. We empirically treated a series of patients with clinical suspicion of NTM infection prior to the identification of the pathogen. METHODS: A total of 12 patients who developed surgical site infections between January 2011 and February 2014 were reviewed. Patients with a skin and subcutaneous infection resistant to standard management over two weeks, and previous history of aesthetic procedures within three months were regarded as highly suspected of having an NTM infection. A variety of diagnostic modalities were examined simultaneously, along with starting empirical treatment including a combination of clarithromycin and moxifloxacin, and surgical debridement. RESULTS: All wounds healed completely within 4 weeks. The mean follow-up duration was 7.2 months, and none of the patients developed relapse. Specific NTM pathogens were identified in six patients. Eight patients showed caseating granuloma implying an NTM infection. One patient showed an uncommon Stenotrophomonas infection, which was successfully treated. Three patients had no evidence of a pathogen despite repeated microbial tests. Complications such as scarring, pigmentation, and disfigurement were common in all the patients. CONCLUSIONS: NTM should be considered in the differential diagnosis of an unusual skin and soft-tissue infection. We propose an empirical regimen of clarithromycin and moxifloxacin as an efficient treatment option for an NTM infection.

Comparison of Mechanical Stability between Fibular Free Flap Reconstruction versus Locking Mandibular Reconstruction Plate Fixation

BACKGROUND: The fibular free flap has been used as the standard methods of segmental mandibular reconstruction. The objective of mandibular reconstruction not only includes restored continuity of the mandible but also the recovery of optimal function. This paper emphasizes the advantage of the fibular free flap reconstruction over that of locking mandibular reconstruction plate fixation. METHODS: The hospital charts of all patients (n=20) who had a mandibular reconstruction between 1994 and 2013 were retrospectively reviewed. Eight patients had plate-only fixation of the mandible, and the remaining 12 had vascularized fibular free flap reconstruction. Complications and outcomes were reviewed and compared between the 2 groups via statistical analysis. RESULTS: Overall complication rates were significantly lower in the fibular flap group (8.3%) than in the plate fixation group (87.5%; p =0.001). Most (7/8) patients in the plate fixation group had experienced plate-related late complications, including plate fracture or exposure. In the fibular flap group, no complications were observed, except for a single case of donor-site wound dehiscence (1/12). CONCLUSION: The fibular free flap provides a more stable support and additional soft tissue support for the plate, thereby minimizing the risk of plate-related complications. Fibular free flap is the most reliable option for mandibular reconstruction, and we believe that the flap should be performed primarily whenever possible.

Comparison of Mechanical Stability between Fibular Free Flap Reconstruction versus Locking Mandibular Reconstruction Plate Fixation

BACKGROUND: The fibular free flap has been used as the standard methods of segmental mandibular reconstruction. The objective of mandibular reconstruction not only includes restored continuity of the mandible but also the recovery of optimal function. This paper emphasizes the advantage of the fibular free flap reconstruction over that of locking mandibular reconstruction plate fixation. METHODS: The hospital charts of all patients (n=20) who had a mandibular reconstruction between 1994 and 2013 were retrospectively reviewed. Eight patients had plate-only fixation of the mandible, and the remaining 12 had vascularized fibular free flap reconstruction. Complications and outcomes were reviewed and compared between the 2 groups via statistical analysis. RESULTS: Overall complication rates were significantly lower in the fibular flap group (8.3%) than in the plate fixation group (87.5%; p =0.001). Most (7/8) patients in the plate fixation group had experienced plate-related late complications, including plate fracture or exposure. In the fibular flap group, no complications were observed, except for a single case of donor-site wound dehiscence (1/12). CONCLUSION: The fibular free flap provides a more stable support and additional soft tissue support for the plate, thereby minimizing the risk of plate-related complications. Fibular free flap is the most reliable option for mandibular reconstruction, and we believe that the flap should be performed primarily whenever possible.