Reverse Lymph Node Mapping Using Indocyanine Green Lymphography: A Step Forward in Minimizing Donor-Site Morbidity in Vascularized Lymph Node Transfer.

BACKGROUND: Reverse lymphatic mapping before harvesting a lymph node flap is crucial to avoid donor-site lymphedema; however, the technique is complex and unavailable in many centers. The authors introduce radioisotope-free reverse lymphatic mapping using indocyanine green and Patent Blue dye. METHODS: The authors conducted a prospective study in patients undergoing free vascularized groin lymph node transfer for postmastectomy upper extremity lymphedema. The day before surgery, 0.2 ml of technetium-99 was injected into the first and second web spaces of the ipsilateral foot. The following day, once the patient was anesthetized, indocyanine green was injected into the same web spaces of the same foot and Patent Blue dye was injected just proximal to the upper margin of the skin paddle of the lymph node flap. The main lymph nodes draining the limb were localized using indocyanine green lymphography and gamma probe. RESULTS: Thirty-nine patients underwent vascularized groin lymph node transfer with or without deep inferior epigastric artery perforator flap breast reconstruction. Navigation of the main lower extremity draining inguinal lymph nodes using the gamma probe and indocyanine green lymphography was identical in all patients. The blue-stained lymphatics in the skin paddle drained to the superficial proximal inguinal lymph node and were targeted for transfer. No donor-site lymphedema was reported, and lymphatic drainage of the lower extremity was preserved in all cases. CONCLUSIONS: Reverse lymphatic mapping using indocyanine green lymphography provides identical results to those using technetium-99 isotope scanning. However, indocyanine green is preferable in terms of safety and reproducibility and also avoids the complexity and hazards of radioisotope mapping. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Satisfactory functional and MRI outcomes at the foot and ankle following harvesting of full thickness peroneus longus tendon graft.

AIMS: To evaluate the donor site morbidity and tendon morphology after harvesting whole length, full-thickness peroneus longus tendon (PLT) proximal to the lateral malleolus for ligament reconstructions or tendon transfer. METHODS: A total of 21 eligible patients (mean age 34.0 years (standard deviation (SD) 11.2); mean follow-up period 31.8 months (SD 7.7), and 12 healthy controls (mean age, 26.8 years (SD 5.9) were included. For patients, clinical evaluation of the donor ankle was performed preoperatively and postoperatively. Square hop test, ankle strength assessment, and MRI of distal calf were assessed bilaterally in the final follow-up. The morphological symmetry of peroneal tendons bilaterally was evaluated by MRI in healthy controls. RESULTS: Among the patients, the mean pre- and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Karlsson-Peterson score were 98.7 (SD 2.5; p = 0.480) and 98.5 (SD 2.4; p = 0.480), and 98.3 (SD 2.4; p = 0.162) and 97.9 (SD 2.5; p = 0.162), respectively. There was no significant difference between square hop test bilaterally (p = 0.109) and plantar flexion peak force bilaterally (p = 0.371). The harvested limb had significantly less eversion peak force compared to the contralateral limb (p < 0.001). Evidence of probable tendon regeneration was observed in all the patients by MRI and the total bilateral peroneal tendon index (mean ratio of harvested side cross-sectional area of peroneal tendon compared with the contralateral side) was 82.9% (SD 17.4). In 12 healthy controls, peroneal tendons (mean 99.4% (SD 4.3) were found to be morphologically symmetrical between the two sides. CONCLUSION: The current study showed satisfactory clinical foot and ankle outcomes after full-thickness PLT harvesting and indicated the regenerative potential of PLT after its removal. Level of Evidence: Level IV, therapeutic retrospective case series. Cite this article: Bone Joint J 2020;102-B(2):205-211.

Evaluation of bone availability for grafts in different donor sites, through computed tomography.

OBJECTIVE: To quantify the bone volume that can be safely withdrawn from 3 donor sites: (1) the mandibular symphysis, (2) the oblique mandibular line and (3) the skullcap. METHODOLOGY: For the symphysis, 200 tomographic exams were evaluated by the extension of the anterior loop of mental foramen, by the nerve, by the distance of the foramens, by the distance between the vestibular cortical and the lingual plates and by the distance between the apexes, or lower anterior teeth, and the mandibular base, using the "distance" tool of the I-CAT Vision, in the panoramic and parasagittal reformations. For the oblique line, 70 TCFC exams were analyzed retrospectively in panoramic and parasagittal reformations, evaluating the thickness of the vestibular cortical and the distance between the cortical and the mandibular canal. For the cranial bone, a hexagonal donor site located in parietal area was considered. RESULTS: The average dimensions of the bone blocks that can be safely removed from the region of the mandibular symphysis are: 32.27 mm in length, 4.87 mm in height and 4 mm in thickness, providing a volume of 628.61 mm3 available for grafting. In the oblique line, the available bone volume for grafting was 859.61 mm3. In the region of the cranial vault, multiplying the average bone thickness by the area of the hexagon, an average volume of 2,499 mm3 was obtained. CONCLUSIONS: Comparing the donor sites, the bone availability in the cranial vault is 3 times greater than in the mandibular posterior region, and at least 2 times greater than in the mandibular symphysis.

Gender Disparity between Donor Sites of the Trochlea Used for Autologous Osteoarticular Transfer: An MRI Analysis.

The purpose of this study was to assess potential gender differences in size of the lateral and medial trochlea of the male and female knee as well as the variation within gender of potential osteochondral autograft transfer (OAT) donor site area. Two hundred and twelve skeletally mature patients, 106 males and 106 females, who underwent a 3T magnetic resonance imaging of the knee for a variety of indications were utilized for analysis. Exclusion criteria included degenerative arthritis, trochlear dysplasia, and poor image quality. Medial and lateral femoral trochlear cartilage width was obtained using a linear radiologic measurement tool. Widths were measured from a reproducible anatomic location representing the maximal trochlear dimension in a region where donor plugs are commonly harvested. Trochlear width was also plotted as a function of patient height. Statistical analysis was performed using a two-sample t-test. The mean and standard deviation of the lateral trochlear cartilage width (mm) for males and females were 23.38 +/- 2.14 and 20.44 +/- 2.16, respectively (p < 0.00001). The mean and standard deviation of the medial trochlear cartilage width (mm) for males and females were 14.16 +/- 2.17 and 11.78 +/- 2.03, respectively (p < 0.00001). The overall range in trochlear width for both the lateral and medial sides was 22.22 and 19.73 mm for males and females, respectively. A graft measuring 10 mm could represent as little as 34% of the lateral trochlea in males versus as much as 65% in females. Our results indicate that donor OAT plug diameter relative to available trochlear cartilage width will vary significantly both between genders and individual patients. Trochlear width variability and its potential implications on donor site morbidity may be an important consideration when contemplating osteochondral plug harvest for OAT or other indications. The level of evidence is IV.

Evaluation of bone availability for grafts in different donor sites, through computed tomography

Abstract Objective To quantify the bone volume that can be safely withdrawn from 3 donor sites: (1) the mandibular symphysis, (2) the oblique mandibular line and (3) the skullcap. Methodology For the symphysis, 200 tomographic exams were evaluated by the extension of the anterior loop of mental foramen, by the nerve, by the distance of the foramens, by the distance between the vestibular cortical and the lingual plates and by the distance between the apexes, or lower anterior teeth, and the mandibular base, using the "distance" tool of the I-CAT Vision, in the panoramic and parasagittal reformations. For the oblique line, 70 TCFC exams were analyzed retrospectively in panoramic and parasagittal reformations, evaluating the thickness of the vestibular cortical and the distance between the cortical and the mandibular canal. For the cranial bone, a hexagonal donor site located in parietal area was considered. Results The average dimensions of the bone blocks that can be safely removed from the region of the mandibular symphysis are: 32.27 mm in length, 4.87 mm in height and 4 mm in thickness, providing a volume of 628.61 mm3 available for grafting. In the oblique line, the available bone volume for grafting was 859.61 mm3. In the region of the cranial vault, multiplying the average bone thickness by the area of the hexagon, an average volume of 2,499 mm3 was obtained. Conclusions Comparing the donor sites, the bone availability in the cranial vault is 3 times greater than in the mandibular posterior region, and at least 2 times greater than in the mandibular symphysis.

Donor Site Evaluation After Osteochondral Autograft Transplantation for Capitellar Osteochondritis Dissecans.

BACKGROUND: Osteochondral autograft transplantation (OAT) for capitellar osteochondritis dissecans (OCD) requires harvesting of tissue from the asymptomatic knee joint. However, donor site morbidity (DSM) in such cases remains unclear. PURPOSE: To evaluate DSM and postoperative radiographic findings in patients undergoing OAT for advanced capitellar OCD. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Eighty-six juvenile athletes underwent OAT for advanced capitellar OCD. The 2000 International Knee Documentation Committee subjective score, rate of return to sports, and symptoms in the donor knee were assessed at a mean follow-up of 86 months (range, 28-185 months). Additionally, 49 of the 86 patients were assessed by radiographic and magnetic resonance imaging (MRI) findings of the knee donor site. DSM was defined according to the usual criterion (persistent symptoms for >1 year or the need for subsequent intervention) and a stricter criterion (the presence of any symptoms, such as effusion, patellofemoral complaints, crepitation, unspecified disturbance, stiffness, pain/instability during activities, and osteoarthritic change). The stricter criterion was also used to allocate patients into a DSM group and a no-DSM group. RESULTS: Two and 11 patients were determined to have DSM according to the usual and stricter criteria, respectively. All patients returned to the competitive level of their sports. The mean International Knee Documentation Committee score was 99.0. MRI findings showed abnormal signal intensity in 17 patients (35%) and hypertrophic changes in 11 patients (22%) at the donor harvest sites. The MOCART (magnetic resonance observation of cartilage repair tissue) score was higher in the no-DSM group (mean, 68.2) than in the DSM group (mean, 52.9) (P = .027). CONCLUSION: OAT for juvenile athletes with advanced capitellar OCD provided good clinical outcomes. The DSM rate was relatively low (2.3%) with the usual criterion but high (12.8%) with the stricter criterion. MRI showed an abnormal signal intensity and hypertrophy in some cases.

Incorporation of 3D stereophotogrammetry as a reliable method for assessing scar volume in standard clinical practice.

Significant disfigurement and dysfunction is caused by hypertrophic scarring, a prevalent complication of burn wounds. A lack of objective tools in the assessment of scar parameters makes evaluation of scar treatment modalities difficult. 3D stereophotogrammetry, obtaining measurements from 3D photographs, represents a method to quantitate scar volume, and a 3D camera may have use in clinical practice. To validate this method, scar models were created and photographed with a 3D camera. Measurements from 3D image analysis of these scar models were compared to physical measurements of scar model volume. Reliability of 3D image analysis was assessed with both scar models and burn patient scars. Measurements of scar models by two independent observers were compared to determine inter-rater reliability, and measurements from 3D images of burn patient hypertrophic scars were compared to determine the consistency of the method between observers. The time taken for patient photography was recorded. No significant differences were found between the two methods of volume calculation (p = 0.89), and a plot of the differences showed agreement between the methods. The correlation coefficient between the two observers' measurements of scar model volume was 0.92, and the intra-class correlation coefficient for patient scar volume was 0.998, showing good reliability. The time required to capture 3D photographs ranged from 2 to 6 min per patient, showing the potential for this tool to be efficiently incorporated into clinical practice. 3D stereophotogrammetry is a valid method to reliably measure scar volume and may be used to objectively measure efficacy of scar treatment modalities to track scar development and resolution.

Fibular donor site following non vascularized harvest: clinico-radiological outcome at minimal five year follow-up.

PURPOSE: The long-term donor site outcome of non vascularized fibular harvest in paediatric age group is not well studied. We evaluated clinical and radiological characteristics of fibular harvest site in children at a minimum five year follow-up. METHODS: The patients with donor legs underwent both physical and radiographic examination. Clinical parameters evaluated were pain, neuromuscular weakness, and standing tibiocalcaneal hindfoot valgus in the donor limb. Radiologically, longitudinal non continuity in regeneration, medullary canal reformation, Malhotra grading, and lateral distal tibial angle (LDTA) were documented. RESULTS: Sixteen patients (18 legs) were available for follow-up. The average follow-up was 6.23 ± 1.1 years. None of the patients reported pain or neuromuscular weakness related to the donor leg. Five patients reported cosmesis issues related to exaggerated ankle valgus. Medullary canal restoration was seen in 3/14 regenerated fibulae. Harvested legs had overall higher fibular station than contralateral unintervened ankles. Non continuity in regeneration were seen in 4/18 legs. There was clinical hindfoot valgus, abnormal LDTA, and fibular station in these patients. Clinical valgus matched better with a combination of fibular station and LDTA (83.3%) rather than fibular station or LDTA (75%) alone. CONCLUSIONS: Fibular regeneration was complete in more than 75% legs at follow-up of > five years but remodeling and reformation of medullary canal was delayed. Long-term fibular non regeneration was persistently responsible for development of ankle valgus deformity. Middle lower third fibular junction is critical area for non restoration of medullary canal and non continuity.

Aesthetic improvements of radial forearm flap donor site by autologous fat transplantation.

Despite its reliability, radial forearm (RF) flap is still affected by high donor site morbidity with poor cosmetic and functional outcomes after coverage with skin grafts. Having fat grafting demonstrated promising and effective filling and rejuvenating properties, we considered and tested it as a valuable alternative to dermal substitutes for the aesthetic improvement of RF flap donor site. Thirty-three patients with previous RF free flap reconstruction and poor donor site outcomes after full-thickness skin grafting to RF region were evaluated for secondary fat injection to improve outcomes. Objective and subjective assessments of results with standardized ultrasonographic soft tissue thickness measurements, cutaneous sensibility tests with the pressure-specified sensory device and scar assessment scale (POSAS) have been performed. Bivariate statistical analyses were performed comparing outcomes with contralateral healthy forearm. All cases showed significant improvement in soft tissue thickness (p< 0.031), cutaneous sensibility and scar appearance, with improved patient's and observers' scar assessment scores (<0.001). In conclusion, fat transplantation is an effective procedure that provided us with an adjunctive autologous layer in-between skin graft and underlying fascia, as well as a rejuvenating effect on skin and scars.

Donor limb assessment after vascularized groin lymph node transfer for the treatment of breast cancer-related lymphedema: Clinical and lymphoscintigraphy findings.

INTRODUCTION: Vascularized lymph node transfer is an established treatment for secondary lymphedema. Different donor sites of lymph node flap have been described. In our institute, vascularized groin lymph node (VGLN) flap is the workhorse flap for treating breast cancer-related lymphedema (BCRL). Potential complications of VGLN flap harvesting include seroma formation, thigh dysaesthesia, and iatrogenic lymphedema. METHODS: Between August 2013 and June 2016, 30 consecutive patients with a mean age of 60 years underwent VGLN transfer for BCRL. Reverse mapping of lower limb lymphatics with patent blue solution was performed in all cases. The donor limb conditions were assessed clinically with limb circumference measurement and radiologically with lymphoscintigraphy. Postoperative lymphoscintigraphy findings and transport indexes were compared between the donor and nonoperated limbs. RESULTS: The mean follow-up period was 22.11 ±â€¯7.83 months. Three (10%) patients developed groin seroma and 18 (60%) patients complained of transient thigh dysaesthesia. There was no clinically detectable donor limb lymphedema. Lymphoscintigraphy was performed at a mean of 13 months after operation. The mean transport indexes of the nonoperated limbs and donor limbs were 2.04 and 3.32, respectively. For the donor limbs, all patients had normal distribution pattern of contrast uptake. No dermal backflow pattern was demonstrated. CONCLUSION: With good knowledge of groin anatomy and meticulous surgical skills, VGLN flap can be harvested without causing major consequence to the donor limb.

Influence of CT-based depth correction of renal scintigraphy in evaluation of living kidney donors on side selection and postoperative renal function: is it necessary to know the relative renal function?

PURPOSE: To analyse the influence of CT-based depth correction in the assessment of split renal function in potential living kidney donors. METHODS: In 116 consecutive living kidney donors preoperative split renal function was assessed using the CT-based depth correction. Influence on donor side selection and postoperative renal function of the living kidney donors were analyzed. Linear regression analysis was performed to identify predictors of postoperative renal function. RESULTS: A left versus right kidney depth variation of more than 1 cm was found in 40/114 donors (35%). 11 patients (10%) had a difference of more than 5% in relative renal function after depth correction. Kidney depth variation and changes in relative renal function after depth correction would have had influence on side selection in 30 of 114 living kidney donors. CT depth correction did not improve the predictability of postoperative renal function of the living kidney donor. In general, it was not possible to predict the postoperative renal function from preoperative total and relative renal function. In multivariate linear regression analysis, age and BMI were identified as most important predictors for postoperative renal function of the living kidney donors. CONCLUSIONS: Our results clearly indicate that concerning the postoperative renal function of living kidney donors, the relative renal function of the donated kidney seems to be less important than other factors. A multimodal assessment with consideration of all available results including kidney size, location of the kidney and split renal function remains necessary.

Computed tomography-guided bone block harvesting from the mandibular ramus / Toma de bloque óseo de rama mandibular guiada por tomografía computadorizada

SUMMARY: The aim of this study was to ascertain the distance from the mandibular canal to the lateral, medial and upper zones of the mandibular ramus in order to identify safety margins that reduce the risk of nerve injuries in the process of removing a bone graft. A descriptive study was conducted, analyzing bilaterally 20 CBCT exams from different patients, taking measurements at 4 points in the central, lateral and medial areas of the corresponding mandibular ramus, which was located at a distance of 5 mm between each line, starting at the distal point of the second molar. Forty hemimandibles were included in this study, estimating a vertical distance for the 4 points of analysis, from between 16 and 17 mm, a distance laterally of 5 mm approximately and medially approximately from 3 to 3.9 mm; the lateral zone was significantly larger than the medial zone. It is estimated that the maximum achievement of a bone block from the area posterior to the second molar must be 13 mm deep and 3 mm laterally to minimize the risks of injuries to the inferior alveolar neurovascular bundle.

RESUMEN: El objetivo de esta investigación fue conocer la distancia que existe desde el canal mandibular a la zona lateral, medial y a la zona superior de la rama mandibular a fin de identificar márgenes de seguridad que minimicen el riesgo de lesiones nerviosas en el proceso de retiro de un injerto óseo. Se realizó un estudio descriptivo, analizando bilateralmente 20 exámenes CBCT de pacientes distintos, realizando mediciones en 4 puntos de la zona central, lateral y medial de la rama mandibular correspondiente, los cuales fueron ubicados con distancia de 5 mm entre cada línea, iniciando en el punto distal del segundo molar. Cuarenta hemimandíbulas fueron incluidas en esta investigación, estimando una distancia vertical, para los 4 puntos de análisis, de entre 16 y 17 mm, una distancia hacia lateral de 5 mm aproximadamente y hacia medial aproximadamente de 3 a 3,9 mm; la zona lateral fue significativamente mas grande que la zona medial. Se estima, que la obtención máxima de un bloque óseo desde la zona posterior al segundo molar debe ser con 13 mm de profundidad y 3 mm desde lateral para minimizar los riesgos de lesiones al paquete neurovascular alveolar inferior.

Influence of outflow-obstructed liver volume and venous communication development: A three-dimensional volume study in living donors.

Living donor liver transplantation using the left liver graft with the middle hepatic vein (MHV) is a well-established procedure. Following such procedures, outflow obstruction occurs in remnant livers. However, the effects of the outflow-obstructed liver volume (LVOut-Ob ), with or without venous communication development, remain unclear. The aim of the study is to investigate effects of outflow-obstructed regions by focusing on short-term outcomes and remnant liver hypertrophy in left liver procurement donors. Of 532 donors, we collected data from 119 undergoing left liver procurement with the MHV. Postoperative hepatic parameters, venous communication development, and liver hypertrophy were evaluated in 2 donor groups based on LVOut-Ob . The left liver was procured with the MHV in 119 donors, who formed 2 more groups based on the median LVOut-Ob : large-outflow-obstruction group (n = 60; LVOut-Ob ≥ 263 mL) and small-outflow-obstruction (n = 59; LVOut-Ob < 263 mL) group. Postoperative liver function parameters were significantly impaired in the large-outflow-obstruction group compared with the small-outflow-obstruction group. Postoperative venous communication developed in 52 (66.7%) of 78 donors analyzed. Hypertrophy ratios in remnant right livers and right paramedian sectors were significantly higher in the small-outflow-obstruction group than in the large-outflow-obstruction group (P = 0.01 and P = 0.02, respectively). The liver hypertrophy ratio of outflow-obstructed regions was better, especially in small regions developing venous communication (P = 0.001). The postoperative morbidity rate did not differ significantly (P = 0.66). In conclusion, the procurement of the left liver graft with the MHV was safely performed with minimal morbidity by assessing the donor remnant right liver volume with and without outflow obstruction. Attention should be paid that postoperative hepatic parameters and remnant liver hypertrophy were impaired in the remnant livers with large outflow-obstructed regions compared with those with small outflow-obstructed regions. Liver Transplantation 23 1531-1540 2017 AASLD.

[Superficial Circumflex Iliac Artery Perforator flap (SCIP flap): Revival of the inguinal donor site?] / Lambeau de SCIP : renouveau du site donneur inguinal ?

The SCIP flap based on a superficial circumflex iliac perforator artery (SCIA) was described for the first time by Koshima in 2004 as a large and thin groin flap, with a low morbidity. The purpose of this study is to demonstrate the benefits of SCIP flap to cover cutaneous defects. We present a retrospective study from January 2007 to August 2016. Twelve patients had a SCIP flap reconstruction in the plastic surgery department of Amiens hospital. Thirteen flaps were performed. The average preoperative doppler mapping time was 8minutes. The average size of flaps was 62.5cm2 [21; 180cm2]. The average time required for raising flaps was 61min [52; 82min]. It has not been observed any complication of the flap or donor site. The SCIP flap has a thin paddle and the donor site morbidity is minimal. The surgical technique is safe, accessible and precision is increased by preoperative color doppler mapping. The many strengths of the SCIP flap make it a must in the algorithm for defects management and come to revitalize the inguinal donor site.

Estimation of Right-Lobe Graft Weight From Computed Tomographic Volumetry for Living Donor Liver Transplantation.

BACKGROUND: The objective of the study was to establish a right-lobe graft weight (GW) estimation formula for living donor liver transplantation (LDLT) from right-lobe graft volume without veins (GVw/o_veins), including portal vein and hepatic vein measured by computed tomographic (CT) volumetry, and to compare its estimation accuracy with those of existing formulas. Right-lobe GW estimation formulas established with the use of graft volume with veins (GVw_veins) sacrifice accuracy because GW measured intra-operatively excludes the weight of blood in the veins. Right-lobe GW estimation formulas have been established with the use of right-lobe GVw/o_veins, but a more accurate formula must be developed. METHODS: The present study developed right-lobe GW estimation formulas based on GVw/o_veins as well as GVw_veins, using 40 cases of Korean donors: GW = 29.1 + 0.943 × GVw/o_veins (adjusted R2 = 0.94) and GW = 74.7 + 0.773 × GVw_veins (adjusted R2 = 0.87). The proposed GW estimation formulas were compared with existing GVw_veins- and GVw/o_veins-based models, using 43 cases additionally obtained from two medical centers for cross-validation. RESULTS: The GVw/o_veins-based formula developed in the present study was most preferred (absolute error = 21.5 ± 16.5 g and percentage of absolute error = 3.0 ± 2.3%). CONCLUSIONS: The GVw/o_veins-based formula is preferred to the GVw_veins-based formula in GW estimation. Accurate CT volumetry and alignment between planned and actual surgical cutting lines are crucial in the establishment of a better GW estimation formula.

Comparison between anterolateral thigh, radial forearm, and peroneal artery flap donor site thickness in Asian patients-A sonographic study.

PURPOSE: This study aimed to determine the thicknesses of the three locations used as donor sites for radial forearm (RF), anterolateral thigh (ALT), and peroneal flaps and to determine probable contributing factors of the thickness. METHODS: This study included 201 healthy participants (mean age: 45.8 ± 17.2 years; male: 114; female: 87; BMI: 24.3 ± 4.3). Sonography was used to measure the thickness of flap donor sites. Forward stepwise regressions were conducted to determine the contributing factors of flap thickness. RESULTS: The RF flap (0.28 ± 0.08 cm) was thinner than peroneal flap (0.47 ± 0.17 cm) (P < 0.0001), and peroneal flap was thinner than ALT flap (0.98 ± 0.4 cm) (P < 0.0001). Flap type (P < 0.001, 95%CI: 0.33-0.41), BMI (P < 0.001, 95%CI: 0.02-0.033), gender (P < 0.001, 95%CI: -0.3 to -0.17), and age (P = 0.002, 95%CI: -0.005 to -0.001) were the contributing factors of flap thickness. In the subgroup analysis, BMI was the only contributing factor of RF flap thickness (P < 0.001). For ALT and peroneal flaps, age, gender, and BMI were the contributing factors (P < 0.001). The coefficient of BMI was 0.005 in RF flap, 0.01 in peroneal flap, and 0.04 in ALT flap. CONCLUSIONS: The RF flap was found thinner than peroneal flap, and peroneal flap was found thinner than ALT flap. The BMI effects on RF and peroneal flaps were much less than that on ALT flap. Therefore, the RF and peroneal flaps would be the better choice in obese patients with soft tissue defects where a thin flap is needed.

Minimizing injury to the donor area in follicular unit extraction (FUE) harvesting.

BACKGROUND: Follicular Unit Extraction (FUE) is considered to be a minimally invasive procedure, and the injury to the donor area caused by a sharp punch may result in dermal fibrosis and clinically observed hypopigmentation. OBJECTIVE: To evaluate with advanced image processing the efficacy of using 0.9% normal saline in minimizing the injury to the donor area in FUE donor harvesting. PATIENTS AND METHODS: The term acute extraction (AE) is used to describe the donor harvesting technique, whereby a follicular unit (FU) is removed with a punch that is aligned parallel with the exit angle of the hair follicle. The term vertical extraction (VE) describes the technique where a FU is removed in like manner, but normal saline is injected intradermally prior to harvesting so the punch being perpendicular to the skin. Thirty-five patients were selected for this study to apply both harvesting techniques and then to compare the differences in wound surface size and skin mass removed by the punch. RESULTS: A significant reduction in the mean values of wound surface and skin mass was recorded in vertical extraction compared to those in acute extraction. CONCLUSION: The injection of normal saline prior to harvesting proved to be very efficient in minimizing skin injury in FUE harvesting.

Management of chest deformity caused by microtia reconstruction: Comparison of autogenous diced cartilage versus cadaver cartilage graft partial filling techniques.

BACKGROUND: Efforts to prevent chest wall deformity after costal cartilage graft are ongoing. In this study, we introduce a new method to prevent donor site deformation using irradiated cadaver cartilage (ICC) and compare this method to the autogenous diced cartilage (ADC) technique. METHODS: Forty-two pediatric patients comprised the ADC group (n = 24) and the ICC group (n = 18). After harvesting costal cartilage, the empty perichondrial space was filled with autologous diced cartilage in the ADC group and cadaver cartilage in the ICC group. Digital photographs and rib cartilage three-dimensional computed tomography (CT) data were analyzed to compare the preventive effect of donor site deformity. We compared the pre- and postoperative costal cartilage volumes using 3D-CT and graded the volumes (grade I: 0%-25%, grade II: 25%-50%, grade III: 50%-75%, and grade IV: 75%-100%). RESULTS: The average follow-up period was 20 and 24 months in the ADC and ICC groups, respectively. Grade IV maintenance of previous costal cartilage volume was evident postoperatively in 22% of patients in the ADC group and 82% of patients in the ICC group. Intercostal space narrowing and chest wall depression were less in the ICC group. There were no complications or severe resorption of cadaver cartilage. CONCLUSIONS: ICC support transected costal ring and prevented stability loss by acting as a spacer. The ICC technique is more effective in preventing intercostal space narrowing and chest wall depression than the ADC technique. CLINICAL TRIAL REGISTRY: Samsung Medical Center Institution Review Board, Unique protocol ID: 2009-10-006-008. This study is also registered on PRS (ClinicalTrials.gov Record 2009-10-006).