Inframammary Fold Incision Can Reduce Skin Flap Necrosis in Immediate Breast Reconstruction With Implant and Conjoined Fascial Flap.

BACKGROUND: Immediate breast reconstruction with implant (IBRI) can produce good aesthetic results after nipple-sparing mastectomy (NSM). Various surgical incisions can be used for NSM. The purpose of this study is to compare outcomes of using an IBRI with dual-coverage fascial flap after NSM with an inframammary fold (IMF) or a radial (Rd) incision. METHODS: We retrospectively reviewed the records of 88 women who underwent IBRI with dual-coverage fascial flap from March 2015 to June 2018. Inframammary fold incision was used in 19 patients (22 breasts) and Rd incision in 69 patients (75 breasts). In the dual-coverage method, acellular dermal matrix covered the inferomedial quadrant of the breast, and conjoined fascial flap covered the remaining inferolateral quadrant. Patient-reported satisfaction was assessed using the Breast-Q questionnaire, and plastic surgeons assessed aesthetic postoperative scores. RESULTS: Complications and reoperation rates of 2 incisions were as follows: skin flap necrosis rate showed significant difference between 2 groups (IMF, 0.0% [0/22]; Rd, 16.0% [12/75]; P < 0.05). The other complication rates, hematoma, seroma, infection, capsular contracture, and total reoperations showed no significant difference. Postoperative Breast-Q scores were higher in the IMF group (331.9 ± 10.1) than in the Rd group (311.4 ± 11.0; P < 0.05), indicating higher satisfactory rate in the IMF group than in the Rd group. Surgeon-reported scores for breast symmetry, contour, and scar appearance were also higher in the IMF group (P < 0.05). CONCLUSIONS: Immediate breast reconstruction with implant with dual-coverage fascial flap after NSM with IMF incision was associated with a lower rate of postoperative skin flap necrosis and improved patient satisfaction, compared with Rd incision. Inframammary fold incisions were associated with improved scar and breast appearance.

Comparison of Volume Retention and Biocompatibility of Acellular Dermal Matrix/Hyaluronic Acid Filler to Autologous Fat Grafts in a Mouse Model.

BACKGROUND: Although fat grafting has become a widely used technique in aesthetic and reconstructive surgeries, resorption is still a challenge. Micronized acellular dermal matrix (ADM) has been considered as a stable, biocompatible soft tissue coverage material that can be used as a volume filler. Here, we compared the bioacceptance and sustainability of ADM hyaluronic acid (HA) filler with human fat graft in a mouse model. METHODS: Harvested human fat and ADM/HA filler were injected randomly on the dorsal side of mice. Thirty-two mice were analyzed over a 7-week period with respect to volume, weight and microscopic evaluations with hematoxylin and eosin (H&E), epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF) staining. RESULTS: The volume and weight were maintained at 80% and 83%, respectively, in the ADM/HA filler group and 56.5% and 49.7%, respectively, in the fat-grafted group by the 7th week. There were no significant microscopic differences in inflammatory changes and granulation via H&E staining. At 1 and 2 weeks, EGF and VEGF immunostaining intensity scores were lower in the ADM/HA filler group. At 7 weeks, there were no significant differences in immunostaining intensity scores between the two groups. CONCLUSIONS: During the 7-week experimental period, the ADM/HA filler showed no foreign body reaction and the proper volume was well maintained. This suggests that the ADM/HA filler can possibly be used in small amounts as an alternative to autologous fat grafts. 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 Authorshttp://www.springer.com/00266.

Merkel Cell Carcinoma of the Wrist: A Case Report.

PURPOSE: Merkel cell carcinomas are a rare type of neuroendocrine tumors of the head, neck, and extremities commonly found in older patients. Merkel cell carcinomas present as red-to-purple and nontender nodules with or without surface ulceration, usually measuring 2 cm in diameter. CASE PRESENTATIONS: An 83-year-old woman with a skin-colored nodule on the dorsal aspect of her right wrist was referred to our department for treatment. The regional lymph nodes were not palpable, and the positron emission tomography/computed tomography scan did not reveal any distant metastases. We conducted wide excision of the lesion and sentinel lymph node biopsy. The defect caused by the excision and partial bone resection was reconstructed using a radical forearm rotational flap and a split-thickness skin graft. Postoperatively, the patient received adjuvant radiation therapy. We observed wound healing and an absence of complications such as recurrence at 1-year follow-up. CONCLUSIONS: Merkel cell carcinomas are rare but aggressive neuroendocrine skin cancers, which rarely occur in the upper extremity. Our treatment of nonamputative wide excision and sentinel lymph node dissection, followed by postoperative radiation therapy, showed no local or distant recurrence. Here, we review the current literature on Merkel cell carcinomas and describe our approach of treatment.

Effect of Platelet-Rich Plasma on Ischemia-Reperfusion Injury in a Skin Flap Mouse Model.

Background: Ischemia-reperfusion (I/R) injury is a leading cause of surgical skin flap compromise and organ dysfunction. Platelet-rich plasma (PRP) is an abundant reserve of various growth factors. Activated platelets play a role in endothelial damage during I/R injury; however, exogenous PRP could inhibit the production of reactive oxygen species. The goal of this study was to investigate the effect of PRP on I/R injury. Methods: Four groups (n=30) of C57BL/6N mice with lateral thoracic artery island flaps were used. Group A, the control group, received flap elevation and repositioning. Group B received PRP and repositioning. Group C had 4 hours of ischemia and then were reperfused. Group D received PRP, had 4 hours of ischemia, and then were reperfused. The survival area of flap tissue and blood perfusion were assessed. Histological evaluation included neutrophil counts. Reactive oxygen species and proinflammatory cytokines were measured to evaluate I/R injury. Protein expression of phosphorylated apoptosis signaling regulating kinase-1 (pASK-1), p38MAPK, and pNF-κB was measured by western blot. Results: PRP treatment enhanced the survival area and perfusion of the flap, reduced neutrophil accumulation in mice subjected to I/R injury. PRP treatment also showed a protective effect, with decreases in nitric oxide, myeloperoxidase, malondialdehyde concentrations. Additionally, PRP suppresses monocyte chemotactic protein-1, TNF-α, IL-1ß, and IL-6. Finally, PRP decreased ASK-1 and NF-κB expression in tissues with I/R injury. Conclusion: PRP acts as a protective factor during flap I/R injury by reducing reactive oxygen species level and proinflammatory cytokines via decreased expression of pASK-1 and pNF-κB.

Corrective epicanthoplasty in patients with unnatural results of prior epicanthoplasty: rearrangement of the orbicularis oculi muscle above the medial canthal tendon.

BACKGROUND: Medial epicanthal fold operations are among the most frequent cosmetic procedures performed on Asians. However, in complicated patients with this procedure, as yet no effective method has been reported. We have therefore developed a modified epicanthoplasty method for correcting unnatural results in patients who have gone through prior epicanthoplasty. METHODS: In this study, corrective epicanthoplasty was performed on 85 patients in the interval from January 2006 to December 2011. The age of these patients ranged from 18 to 67 years, with a mean age of 29.3 years. The follow-up period ranged from 13 months to 5 years, with a mean of 2.8 years. The 2 major complaints leading to the procedure were either presence of a prominent incisional scar with contracted tissue around the medial canthal area or relapse of the fold. RESULTS: After the procedure, in each case, a contracted scar was released, and most patients seemed to be satisfied with the plasty. There was no case of definite relapse, hypertrophic scar, or lacrimal apparatus injury. Two patients experienced more overcorrection than anticipated. We reduced these patients' overcorrected epicanthal fold by repeating this procedure. A few patients complained about mild redness around their wounds, but after several months, most of them experienced improvement. CONCLUSIONS: We have presented a method for correction of complicated epicanthoplasty, an area in which there have been no previously reported results. This modified method is simple in design, easy to perform, and effectively corrects medial epicanthoplasty.

Use of the pectoralis major, serratus anterior, and external oblique fascial flap for immediate one-stage breast reconstruction with implant.

BACKGROUND: Skin- or nipple-sparing mastectomy facilitates immediate one-stage reconstruction with an implant. Traditionally, an acellular dermal matrix or a muscle flap has been used because the inferolateral portion of the implant cannot be covered by the pectoralis major muscle. However, this method has drawbacks, including infection, cost, and donor-site morbidity. Therefore, we used an autologous conjoined fascial flap composed of the pectoralis major, serratus anterior, and external oblique fascia in patients with small-to-medium breasts. METHODS: A series of 11 immediate breast reconstructions in 11 patients was carried out from March 2010 to June 2011. The conjoined fascial flap and smooth round implants were used in all patients. Postoperative photographs were evaluated by a blinded panel and scored on a four-point scale. Patient satisfaction was evaluated by a postoperative questionnaire that had five items designed to evaluate quality of life with the reconstruction. RESULTS: The mean body mass index was 23.2 kg/m(2), follow-up period was 30.9 months, and implant volume was 286.3 cc. Regarding complications, we observed one case of partial skin flap necrosis and one case of seroma accumulation in the axilla, both of which healed with conservative care. The mean overall breast satisfaction score was 3.18 ± 0.5. CONCLUSIONS: The conjoined fascial flap is a viable alternative for immediate one-stage breast reconstruction with an implant. We recommend appropriate patient selection with a body mass index greater than 20 kg/m(2) and small-to-medium sized nonptotic breasts. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

The economic burden of the 2009 pandemic H1N1 influenza in Korea.

BACKGROUND: Although there have been numerous studies concerning the 2009 pandemic H1N1 influenza, limited data are available on the economic burden of the pandemic. The present study was undertaken to help policy makers prepare for future H1N1 pandemics. METHODS: We assessed the socioeconomic burden of the 2009 pandemic H1N1 influenza that infected 3,082,113 patients in South Korea, which represents 6.6% of the population of South Korea. Data were obtained from the National Health Insurance Claims database using claims submitted from 1 August 2009 to 31 July 2010. Costs were converted to United States dollars (US$). RESULTS: The annual socioeconomic costs of the 2009 pandemic H1N1 influenza were US$1.09 billion (0.14% of the national GDP). Direct costs included US$322.6 million (29.6% of total costs) of direct medical costs, with an additional US$105.4 million (9.7% of total cost) of direct non-medical costs. The indirect costs totaled US$662.5 million (60.8% of total cost). The economic impact was much higher for men than for women due to the fact that indirect costs were 2.2-times higher because of the higher male wage. Also direct medical costs peaked for patients in the children and adolescent groups. CONCLUSIONS: These findings demonstrate the socioeconomic burden associated with the 2009 pandemic H1N1 influenza in Korea and can be used for future pandemic planning.

Restoration of the medial epicanthal fold: reverse skin redraping method in patients unsatisfied with epicanthoplasty.

BACKGROUND: Many Asians receive epicanthoplasty to improve their medial epicanthal fold.Excessive performance of such surgery may cause multiple unwanted results, but there is no report on any restoration method for an overcorrected result of epicanthoplasty. Accordingly, the authors have created a new method for reversely restoring the excessively corrected medial epicanthal fold using skin-redraping epicanthoplasty (Plast Reconstr Surg. 2007;119:703-710). METHODS: During the interval between January 2009 and April 2011, 35 patients received surgery for restoration of the epicanthal fold using the authors' method, which involves sufficiently elevating the skin flap and redraping it to reconstruct the epicanthal fold. This method is very simple to design and perform, and it effectively covers the excessively exposed lacrimal lake. In addition, it can be used independently of the type of prior epicanthoplasty. RESULTS: After the surgery, 2 patients experienced overcorrection, and we repeated the epicanthoplasty. In the other patients, there was no severe complication except for mild redness, a condition that improved after several months. The mean measured distance between the medial canthi after the surgery was 36.8 mm, corresponding to a total lengthening effect of 4.5 mm. This improved the aggressive facial expression caused by the exposed lacrimal lake, and the eyes no longer appeared to be too close together. Moreover, in the case of patients who had more visible scars due to prior epicanthoplasty on the medial epicanthal area, the overall scar length decreased. CONCLUSIONS: This method is simple in design and easy to perform. It can also control the degree of restoration with an additional advantage of reducing a prior scar. Using this method, we could effectively restore the overcorrected epicanthal fold.

Reverse gracilis muscle flap: an alternative means of skin coverage for recurrent infection after TKA.

PURPOSE: Poor wound-healing and skin necrosis are serious but not unusual complications after total knee arthroplasty, and when skin or soft tissue necrosis occurs, reconstructions in the knee area need thin, pliable, tough skin flaps. METHODS: A 62-year-old man, who previously underwent multiple TKR operations due to recurrent infection, was transferred from another hospital after a gastrocnemius muscle rotation flap failed. We decided to treat the affected area with a reverse gracilis muscle flap. After confirming that the secondary pedicle was intact by Doppler sonography, muscle dissection was extended to the entry of the secondary pedicle. The proximal tendon of the gracilis muscle was transected, and the muscle was rotated 180° and placed at the recipient site. RESULTS: The aim is to report a case of reconstruction at the anterior knee using a reverse gracilis muscle flap that achieved an excellent final clinical result. CONCLUSION: This case suggests that the indications for a reverse gracilis muscle flap could be broadened when other flaps are not available for knee prosthesis coverage.

Heating Pretreatment of the Recipient Site Enhances Survival of Transplanted Fat in a Mouse Model.

BACKGROUND: Despite several studies about the preparation of the recipient site in fat grafting, optimizing techniques with clinical usefulness is still necessary. Through previous animal studies reporting that heat can increase tissue vascular endothelial growth factor and vascular permeability, the authors hypothesize that pretreatment heating of the recipient site will increase retention of grafted fat. METHODS: Twenty 6-week-old female BALB/c mice had two pretreatment sites on their back, one for the experimental temperatures (44°C and 48°C) and the other for the control. A digitally controlled aluminum block was used to apply the contact thermal damage. Human fat (0.5 mL) was grafted on each site and harvested on days 7, 14, and 49. The percentage volume and weight, histologic changes, and peroxisome proliferator-activated receptor gamma expression, a key regulator of adipogenesis, were measured by the water displacement method, light microscopy, and quantitative real-time polymerase chain reaction, respectively. RESULTS: The harvested percentage volumes were 74.0% ± 3.4%, 82.5% ± 5.0%, and 67.5% ± 9.6% for the control, 44°C-pretreatment, and 48°C-pretreatment groups, respectively. The percentage volume and weight of the 44°C-pretreatment group was higher than the other groups ( P < 0.05). The 44°C-pretreatment group exhibited significantly higher integrity with fewer cysts and vacuoles than the other groups. Both heating pretreatment groups showed markedly higher rates of vascularity than the control group ( P < 0.017), and also increased the expression of peroxisome proliferator-activated receptor gamma over two-fold. CONCLUSION: Heating preconditioning of the recipient site during fat grafting can increase the retention volume and improve the integrity, which is partly explained by increased adipogenesis in a short-term mouse model. CLINICAL RELEVANCE STATEMENT: Tanning could be an alternative pretreatment for fat grafting.

Better survival of random pattern skin flaps through the use of epigallocatechin gallate.

BACKGROUND: Surgical skin flaps are useful, but flap necrosis is a common problem. Epigallocatechin gallate (EGCG), the major polyphenol of green tea, has been investigated as a neovascularization agent to counteract necrosis. OBJECTIVES: To evaluate the effect of EGCG on random pattern skin flap survival. MATERIALS AND METHODS: The rat dorsal skin flap model was employed. One hundred rats were divided into five groups of equal size. Experimental Group A received local injection of EGCG to the flap, experimental Group B received topical application of EGCG, control Group C received local injection of saline, control Group D received topical application of an acetone-olive oil mixture, and control Group E received no treatment. The surviving area of the flap, regional blood perfusion, capillary density, and vascular endothelial growth factor (VEGF) expression were evaluated. RESULTS: We observed a larger area of skin flap survival in Groups A and B than in the control groups. Doppler measurement showed greater perfusion in Groups A and B, and the capillary density and VEGF expression were significantly higher in the experimental animals. CONCLUSION: The EGCG treatment enhanced neovascularization and regional perfusion and, as a result, improved skin flap survival.

The effect of epidermal growth factor on autogenous fat graft.

Autogenous fat grafting is widely used for the correction of soft tissue contour deformity. However, the high absorption rate results in the need for overcorrection, and graft longevity is unpredictable. The authors hypothesized that epidermal growth factor (EGF), a potent stimulator of neovascularization, would improve fat graft survival. The experiment used two groups of New Zealand White Rabbit ear. Inguinal fat was harvested and injected with EGF or saline (n = 24, each group). The 48 cases of fat grafting were managed for observation of volume and morphologic change. The fat was harvested 3 months after the autogenous graft. The survival rate and the degree of neovascularization were measured. The grafts in the EGF group had a significantly higher survival rate than those in the control group. Histologic examination of the grafts demonstrated an increase in neovascularization and maintenance of fat cell morphology. These findings show that EGF can enhance fat graft survival and degree of neovascularization. Further well-controlled studies are required before EGF is used for clinical purposes.

Insulin Promotes Adipose-Derived Stem Cell Differentiation after Fat Grafting.

BACKGROUND: Adipose-derived stem cells are used to enhance fat graft survival. However, their mechanism of action when grafted is controversial. The grafted cells can be replaced by connective tissue or survive at the recipient site and differentiate. Insulin is a powerful agent used to induce their differentiation to adipocytes. The purpose of this study was to elucidate the fate of grafted adipose-derived stem cells in nonvascularized fat grafts with or without insulin. METHODS: Fat was harvested from a female human donor who had undergone reduction mammaplasty. The authors also isolated and cultured adipose-derived stem cells expressing green fluorescent protein from transgenic Sprague-Dawley rats. Injection of free fat graft, the adipose-derived stem cells, phosphate-buffered saline, and insulin was performed on the four paravertebral points of the back of each mouse (n = 30) as follows: group A (control group) received adipose tissue and phosphate-buffered saline; group B received adipose tissue and adipose-derived stem cells; group C received adipose tissue, adipose-derived stem cells, and phosphate-buffered saline; and group D received adipose tissue, adipose-derived stem cells, and insulin. Green fluorescent protein expression was evaluated using an in vivo imaging system. The volume of transplanted fat was evaluated at 8 weeks after graft with six histologic parameters. The fat graft was immunostained with green fluorescent protein, 4',6-diamidino-2-phenylindole, and perilipin. Statistical analysis was performed using a one-way analysis of variance test. RESULTS: The fat graft volume was significantly higher in group D (p < 0.05). Histologic examination revealed reduced fibrosis and increased cysts, vacuoles, integrity, and vascularity in group D. The green fluorescent protein and perilipin co-positive area was more apparent in group D compared with groups B and C. CONCLUSION: Insulin could enhance the survival and differentiation of adipose-derived stem cells in nonvascularized fat grafts.

Secondary Reconstruction of Frontal Sinus Fracture.

Fractures of frontal sinus account for 5%-12% of all fractures of facial skeleton. Inadequately treated frontal sinus injuries may result in malposition of sinus structures, as well as subsequent distortion of the overlying soft tissue. Such inappropriate treatment can result in aesthetic complaints (contour deformity) as well as medical complications (recurrent sinusitis, mucocele or mucopyocele, osteomyelitis of the frontal bone, meningitis, encephalitis, brain abscess or thrombosis of the cavernous sinus) with potentially fatal outcomes. Frontal contour deformity warrants surgical intervention. Although deformities should be corrected by the deficiency in tissue type, skin and soft tissue correction is considered better choice than bone surgery because of minimal invasiveness. Development of infection in the postoperative period requires all secondary operations to be delayed, pending the resolution of infectious symptoms. The anterior cranial fossa must be isolated from the nasal cavity to prevent infectious complications. Because most of the complications are related to infection, frontal sinus fractures require extensive surgical debridement and adequate restructuring of the anatomy. The authors suggest surgeons to be familiar with various methods of treatment available in the prevention and management of complications following frontal sinus fractures, which is helpful in making the proper decision for secondary frontal sinus fracture surgery.

The Trapezius Muscle Flap: A Viable Alternative for Posterior Scalp and Neck Reconstruction.

BACKGROUND: The trapezius muscle flap is not usually the first reconstructive option for skin and soft tissue defects in the posterior neck and scalp due to surgeons' unfamiliarity with the surgical anatomy and developments in free tissue transfer techniques. The goals of this study were to describe the clinical use of trapezius flaps in posterior neck and scalp reconstruction, and to investigate the vascular anatomy of trapezius flaps in Asians in order to obtain information facilitating the safe design and elevation of flaps in which most of the muscle is preserved. METHODS: A retrospective chart review was performed of 10 patients who underwent trapezius muscle flap for posterior neck and scalp defects. We also performed an anatomical study of 16 flaps harvested from 8 preserved Asian adult cadavers and evaluated the main landmarks relevant for trapezius muscle flap. RESULTS: In the anatomical study, the mean vertical height from the inferior angle of the scapula to the point at which the superficial cervical artery penetrated the trapezius was 4.31±2.14 cm. The mean vertical height of the trapezius muscle flap pivot point was 9.53±2.08 cm from the external occipital protuberance. Among the 10 flaps, partial necrosis on the overlaid skin graft occurred in 1 patient and postoperative seroma occurred in another patient. CONCLUSIONS: Vascular variations in the trapezius muscle flap are uncommon in Asians, but when present, such variations appear to have little impact on harvesting the flap or on its circulation. The trapezius muscle flap is a viable alternative for posterior neck and scalp reconstruction.

Wound Healing Effects of Rose Placenta in a Mouse Model of Full-Thickness Wounds.

BACKGROUND: Rosa damascena, a type of herb, has been used for wound healing in Eastern folk medicine. The goal of this study was to evaluate the effectiveness of rose placenta from R. damascena in a full-thickness wound model in mice. METHODS: Sixty six-week-old C57BL/6N mice were used. Full-thickness wounds were made with an 8-mm diameter punch. Two wounds were made on each side of the back, and wounds were assigned randomly to the control and experimental groups. Rose placenta (250 µg) was injected in the experimental group, and normal saline was injected in the control group. Wound sizes were measured with digital photography, and specimens were harvested. Immunohistochemical staining was performed to assess the expression of epidermal growth factor (EGF), vascular endothelial growth factor (VEGF), transforming growth factor-ß1 (TGF-ß1), and CD31. Vessel density was measured. Quantitative analysis using an enzyme-linked immunosorbent assay (ELISA) for EGF was performed. All evaluations were performed on postoperative days 0, 2, 4, 7, and 10. Statistical analyses were performed using the paired t-test. RESULTS: On days 4, 7, and 10, the wounds treated with rose placenta were significantly smaller. On day 2, VEGF and EGF expression increased in the experimental group. On days 7 and 10, TGF-ß1 expression decreased in the experimental group. On day 10, vessel density increased in the experimental group. The increase in EGF on day 2 was confirmed with ELISA. CONCLUSIONS: Rose placenta was found to be associated with improved wound healing in a mouse full-thickness wound model via increased EGF release. Rose placenta may potentially be a novel drug candidate for enhancing wound healing.

Endoscopically assisted malarplasty: one incision and two dissection planes.

Asian society is uniquely concerned about the distinctive facial features associated with malar prominence. Various methods of reduction malarplasty have been developed and are currently being applied. In this study, a new approach to malarplasty was experimentally assessed between December of 1999 and August of 2001. After having received careful observations of their facial features and full counseling sessions, 32 patients were selected. These patients had three distinctive characteristics: (1) severe zygomatic arch prominence and normal zygomatic body prominence, (2) desire for only a reduction of the lateral prominence, and (3) desire for a less invasive surgery. Through a short incision in the temporal area, the authors performed the dissection as two different planes. Endoscopic dissection between the superficial layer of deep temporal fascia and the temporoparietal fascia to the zygomatic body and blunt dissection under the deep layer of the deep temporal fascia to the zygomatic arch were performed. Complete osteotomy of the zygomatic arch and an incomplete osteotomy of the zygomatic body were then performed with a reciprocating saw. Finally, the zygomatic arch for the zygoma infraction was pressed manually. The major advantages of this procedure are its simplicity and the short operation and recovery time, with little bleeding and edema.

Prevention of implant malposition in inframammary augmentation mammaplasty.

BACKGROUND: Implant malposition can produce unsatisfactory aesthetic results after breast augmentation. The goal of this article is to identify aspects of the preoperative surgical planning and intraoperative flap fixation that can prevent implant malposition. METHODS: This study examined 36 patients who underwent primary dual plane breast augmentation through an inframammary incision between September 1, 2012 and January 31, 2013. Before the surgery, preoperative evaluation and design using the Randquist formula were performed. Each patient was evaluated retrospectively for nipple position relative to the breast implant and breast contour, using standardized preoperative and postoperative photographs. The average follow-up period was 10 months. RESULTS: Seven of 72 breasts were identified as having implant malposition. These malpositions were divided into two groups. In relation to the new breast mound, six breasts had an inferiorly positioned and one breast had a superiorly positioned nipple-areolar complex. Two of these seven breasts were accompanied with an unsatisfactory breast contour. CONCLUSIONS: We identified two main causes of implant malposition after inframammary augmentation mammaplasty. One cause was an incorrect preoperatively designed nipple to inframammary fold (N-IMF) distance. The breast skin and parenchyma quality, such as an extremely tight envelope, should be considered. If an extremely tight envelope is found, the preoperatively designed new N-IMF distance should be increased. The other main cause of malposition is failure of the fascial suture from Scarpa's fascia to the perichondrium through an inframammary incision. As well, when this fixation is performed, it should be performed directly downward to the perichondrium, rather than slanted in a cranial or caudal direction.

Effects of the diabetic condition on grafted fat survival: an experimental study using streptozotocin-induced diabetic rats.

BACKGROUND: Autologous fat grafts have been widely used for cosmetic purposes and for soft tissue contour reconstruction. Because diabetes mellitus is one of the major chronic diseases in nearly every country, the requirement for fat grafts in diabetes patients is expected to increase continuously. However, the circulation complications of diabetes are serious and have been shown to involve microvascular problems, impairing ischemia-driven neovascularization in particular. After injection, revascularization is vital to the survival of the grafted fat. In this study, the authors attempted to determine whether the diabetic condition inhibits the survival of injected fat due to impaired neovascularization. METHODS: The rat scalp was used for testing fat graft survival. Forty-four seven-week-old male Sprague-Dawley rats were allocated to a diabetic group or a control group. 1.0 mL of processed fat was injected subcutaneously into the scalp of each rat. The effect of diabetes was evaluated by calculating the volume and the weight of the grafted fat and by histologically analyzing the fat sections. RESULTS: The surviving fat graft volume and weight were considerably smaller in the diabetic group than in the control group (P<0.05), and histological evaluations showed less vascularity, and more cysts, vacuoles, and fibrosis in the diabetic group (P<0.05). Cellular integrity and inflammation were not considerably different in the two groups. CONCLUSIONS: As the final outcome, we found that the presence of diabetes might impair the survival and the quality of fat grafts, as evidenced by lower fat graft weights and volumes and poor histologic graft quality.