Comparison of dissection with harmonic scalpel and conventional bipolar electrocautery in deep inferior epigastric perforator flap surgery: A consecutive cohort study.

Reduced tissue damage is a theoretical advantage of using an ultrasonic harmonic scalpel. We hypothesized that the harmonic scalpel would outperform electrocautery in deep inferior epigastric perforator flap surgery, possibly resulting in a shorter operative time and reduced postoperative drainage and pain. Between January and August 2015, 24 consecutive patients were assigned to immediate deep inferior epigastric perforator flap elevation (12 for bipolar electrocautery and 12 for harmonic scalpel). The main outcome variables were total operative time, flap elevation time (starting from the fascia incision), and drainage volume. We compared the number of perforators isolated and the Moon and Taylor classification of the pedicle. Data were tested for normality using the Kolmogorov-Smirnov test before analysis. Continuous variables were compared by Wilcoxon rank-sum test. Data were analyzed using the statistical software SAS, version 9.3 (SAS Institute, Cary, NC, USA). Both groups were comparable with respect to clinical characteristics (mean age, body mass index, and flap weights). There was a statistically significant difference in the operative time between dissection with the harmonic scalpel and electrocautery (305.2 vs. 380.3 min, respectively, p = 0.002). The flap elevation time was reduced, particularly when using the harmonic scalpel where its usage seems crucial for dissecting deep inferior epigastric perforators (59.8 vs. 145.9 min, respectively, p < 0.0001). No statistical difference was observed in the drainage volume and length of hospital stay between the groups. We conclude that the harmonic scalpel may be more reliable and efficient as an alternative to electrocautery.

Perforators as recipients for free flap reconstruction of the inguinal and perineal region.

OBJECTIVE: Extensive defects of the perineal or inguinal area require well vascularized free flap coverage. This area has an abundance of perforating arteries and veins based on vessels from the femoral artery and internal iliac artery. We present our experience on the use of perforators as recipient vessels in reconstructing soft tissue defects of the perineal and inguinal area with free flaps. PATIENTS AND METHODS: From March 2012 to August 2014, 13 patients underwent free flap reconstruction for soft tissue defects of the inguinal or perineal area. Perforating arteries with diameters ranging from 0.7 to 1.2 mm were used as recipient arteries. Accompanying veins or neighboring superficial veins were secured as recipient veins. RESULTS: All flaps survived attached to a recipient perforator with a diameter ranging from 0.7 to 1.2 mm. These vessels were found in the inguinal or perineal areas, regions that are supplied by the superficial circumflex iliac vessels, superficial inferior epigastric vessels, superficial and deep external pudendal vessels, lateral and medial circumflex femoral vessels, and internal pudendal vessels. There were no cases of arterial insufficiency or venous congestion, flap necrosis, or infection. A single case of hematoma beneath the flap was treated by simple evacuation. There were no donor complications. CONCLUSION: Using perforators as the recipient during free flap reconstruction of the inguinal and perinea area allows the surgeon to choose from a wider choice of vessels, and yields acceptable flap survival.

Comparative Orbital Volumes between a Single Incisional Approach and a Double Incisional Approach in Patients with Combined Blowout Fracture.

PURPOSE: Blowout fracture characterized by concurrent floor and medial wall fractures is a rare entity. We compared surgical outcomes between a single approach and a double approach in patients with orbital fracture by measuring the postoperative orbital volume. METHODS: We confirmed that 21 (8.5%) of a total of 246 patients with orbital fractures had fractures of the medial wall and floor through a retrospective chart review. Of these, 10 patients underwent the single approach and the remaining 11 patients had the double approach. We performed a statistical analysis of changes between the preoperative and postoperative orbital volumes at a 6-month follow-up. RESULTS: Compared with the contralateral, nonaffected side, the orbital volume was 115.3 (±6.09)% preoperatively and 106.5 (±6.15)% postoperatively in the single approach group and 118.2 (±11.16)% preoperatively and 108.6 (±13.96)% postoperatively in the double approach. These results indicated that there was a significant difference between the preoperative and postoperative orbital volumes in each group (P < 0.05). However there was no significant difference between the single approach and the double approach (P > 0.05). CONCLUSIONS: Our results showed that there were no significant differences in surgical outcomes between the two modalities. The treatment modality may be selected based on the surgeons' preference, as well as the fracture type.

Transareolar-perinipple (areolar omega) zigzag incision for augmentation mammaplasty.

BACKGROUND: Optimal augmentation mammaplasty results not only from proper implant size and breast shape, but also from the minimization of postoperative scarring, especially in patients prone to hypertrophic scars. In this context, the authors present a transareolar-perinipple (areolar omega) zigzag approach. METHODS: Between March of 2003 and June of 2012, a total of 613 patients underwent augmentation mammaplasty using a transareolar-perinipple incision. Among them, 45 patients received a classic (straight line) transareolar-perinipple incision, whereas 568 patients received a modified zigzag transareolar-perinipple incision. RESULTS: Patients' ages ranged from 21 to 60 years. Areola size varied from 2.3 to 4.5 cm in diameter. Follow-up duration ranged from 1 to 10 years, with an average of 2 years 7 months. Postoperative complications included capsular contracture, which occurred in 16 patients (2.6 percent). Nine patients (1.5 percent) had Baker class II and seven patients (1.1 percent) had Baker class III capsular contracture. Mild inferior displacement of the implant occurred in four patients (0.6 percent). The prevalence of areolar distortion was 3.4 percent. Nipple hypesthesia was found in approximately 70 percent of the patients, which returned to normal after 2 to 3 months. Based on third-party observers, 74.7 percent of patients who received zigzag transareolar-perinipple incision had excellent to good scarring results. CONCLUSIONS: The transareolar-perinipple (areolar omega) zigzag incision resulted in satisfactory postoperative scarring and surgical results in Asian patients. This method increases the opening of the areolar incision and can be performed in patients with small (<3.5 cm) areolas. This approach can be an alternative in patients who are prone to hypertrophic scarring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Feasibility of a deepithelialized superior gluteal artery perforator propeller flap for various lumbosacral defects.

Skin and soft tissue defects in the lumbosacral area are commonly encountered in the field of reconstructive surgery, and it is well documented that the superior gluteal artery perforator (SGAP) flap provides excellent coverage of these defects. In this article, we describe our experience using a modified version of the SGAP propeller flap, in which the distal redundant portion of an elevated SGAP flap is deepithelialized, thereby maximizing the effect of the soft tissue augmentation. Thirteen patients with lumbosacral soft tissue defects treated between May 2010 and June 2012 were included in this study. The wound causes were pressure ulcer (n = 9), pseudomeningocele (n = 2), and hardware exposure (n = 2). In all patients, an elevated SGAP flap was rotated 180 degrees over the defect area and the extra distal portion of the flap was deepithelialized and used as a soft tissue filler or tamponade. During the follow-up period (mean, 26 months), 12 of 13 flaps survived completely. One flap was totally necrosed due to progressive venous congestion and was reconstructed with local advancement flaps. No further complications were noted. Because of the redundancy and pliability of the tissue in the gluteal area, a flap relatively wider or longer than the defect can be elevated safely. Hence, the redundant tissue volume can be tucked inside to facilitate soft tissue augmentation of the area. We propose that the deepithelialized version of the SGAP propeller flap is an effective option for the reconstruction of various lumbosacral soft tissue defects because it offers thick and healthy soft tissue from a distant site to the defect areas.

Radiologic misunderstanding of cutaneous angiomyolipoma in the alar base.

In this article, we will examine a case of cutaneous angiomyolipoma in the right nasal alar base area of a 36-year-old man. Generally, angiomyolipoma occurs in the kidney and, histologically, has features that are similar to cutaneous angiomyolipoma: smooth muscle cells, mature adipose cells, and a convoluted thick-walled blood vessel. Clinically, renal angiomyolipoma is related to tuberous sclerosis, but cutaneous angiomyolipomas occur very rarely, with a total of only 23 cases documented in the literature, with 39% (9/23) of those cases occurring in the ear or surrounding areas. In particular, the abundance of blood vessels inside a cutaneous angiomyolipoma produces good enhancement on computed tomographic image, making it easy for the tumor to be mistaken for a vascular tumor. In this particular case, we will report about a previously unheard case of cutaneous angiomyolipoma occurring in the nasal alar base that was mistaken for a vascular tumor.

Upper arm contouring with brachioplasty after massive weight loss.

BACKGROUND: As the obese population increases in Korea, the number of patients who are trying to lose weight has been increasing steadily. In these patients, skin laxity and deformation of the body contour occurs, which could possibly be corrected by various body contouring surgeries. Here, we introduce the brachioplasty method and our experience of various body contouring surgeries performed in our center. METHODS: From November 2009 to August 2011, five cases of brachioplasty were performed. When the patient presented with sagging of the lateral inframammary crease and bat wing deformity in the axilla, extended brachioplasty was performed; in this case, the deformation of the axilla and lateral chest was corrected at the same time. A traditional brachioplasty was performed when contouring was needed only for skin laxity in the upper arm. RESULTS: Complications, such as hematomas or nerve injuries, were not evident. Some patients experienced partial wound dehiscence due to tension or hypertrophic scars found during the follow-up. In general, all of the patients were satisfied with the improvement in their upper arm contour. CONCLUSIONS: Given the demands for body contouring surgery, the number of brachioplasty surgical procedures is expected to increase significantly, with abdominoplasty comprising a large portion of these surgeries. For the brachioplasty procedure, preparation and preoperative consultation regarding design of the surgery by experienced surgeons was important to prevent complications such as nerve damage or hematoma formation.

Treatment for intramuscular lipoma frequently confused with sarcoma: a 6-year restrospective study and literature review.

INTRODUCTION: Intramuscular lipoma is a very rare form of lipoma, known to be categorized as an infiltrating lipoma due to its tendencies to infiltrate the muscle or the synovium. Contrary to other subcutaneous lipomas, even after surgical removal, the rate of local recurrence ranges at a high rate from 50∼80% and differential diagnosis with liposarcoma is very difficult. PATIENTS AND METHODS: A retrospective chart review was conducted for a total of 27 patients. Before performing a surgery based on the types of mass, a radiologic imaging study was performed. An intraoperative frozen biopsy was performed on every patient and the results were compared. The progress was monitored every 3 to 6 months for recurrence or struggles with rehabilitation. RESULTS: There were 13 male and 14 female patients with an average age of 54.6. The average tumor size was 8.2 cm (1.1 cm∼31.6 cm). Excision was performed using a wide excision. All 27 individuals were initially diagnosed as intramuscular lipoma; however, 1 of the patients was rediagnosed as liposarcoma in the final checkup. The patients had an average of 3 years and 1 month of follow-up and did not suffer recurrences. CONCLUSION: Thus, it is essential that a frozen biopsy is performed during the surgery in order to identify its malignancy. And a wide excision like malignant tumor operation is a principle of treatment.

The stem cell potential and multipotency of human adipose tissue-derived stem cells vary by cell donor and are different from those of other types of stem cells.

Human adipose tissue-derived mesenchymal stem cells (AT-MSCs) from various sites are applied in tissue engineering and cell therapy. The condition of AT-MSCs depends on the donor's age, body mass index (BMI), and gender. AT-MSCs from 66 human donors were analyzed, and the cells were sorted according to donor age (10-19 years: n = 1; 20-29 years: n = 5; 30-39 years: n = 12; 40-49 years: n = 22; 50-59 years: n = 12; 60-69 years: n = 9, and 70 years or older: n = 5), BMI (under 25, 25-30, and over 30), and gender (19 males and 48 females). Additionally, AT-MSCs were compared to bone marrow MSCs and chorionic tissue-derived MSCs. We measured the MSC yield, growth rate, colony-forming units, multipotency, and surface antigens. AT-MSC proliferation was greater in cells isolated from individuals aged less than 30 years compared to the proliferation of AT-MSCs from those over 50 years old. BMI was correlated with osteogenic differentiation potency; increased BMI enhanced osteogenesis. Adipogenic differentiation was more strongly induced in cells isolated from donors aged less than 30 years compared to those isolated from other age groups. Also, a BMI above 30 was associated with enhanced adipogenic differentiation compared to cells isolated from individuals with a BMI below 25. Bone marrow MSCs were strongly induced to differentiate along both osteogenic and adipogenic lineages, whereas AT-MSCs predominantly differentiated into the chondrogenic lineage. Therefore, the type of regeneration required and variations among potential donors must be carefully considered when selecting MSCs for use in applied tissue engineering or cell therapy.

Intravascular fasciitis of the lower lip.

Intravascular fasciitis is a rare, unusual variant of nodular fasciitis. It most commonly involves the head and neck, upper extremity, lower extremity, and trunk. Only 4 cases involving the oral cavity have been reported previously in the literature. Here we present an additional case with a review of the literature.

Treatment of axillary osmidrosis with the use of Versajet.

Axillary osmidrosis is a distressing problem. Since the secretion from apocrine glands is believed to be responsible for malodour, many treatment modalities have been developed to remove the glands. Local surgery with the excision of the apocrine glands has been proved to be most effective. We introduce the treatment of axillary osmidrosis, using Versajet (Versajet hydrosurgery system, Smith & Nephew, Memphis, TN, USA). From October 2010 to February 2012, 31 patients (21 females and 10 males) whose age ranged from 12 to 63 years were treated. All patients were followed up for 13.1 months on average. Thirty patients were very satisfied and recommended this procedure and one patient was satisfied with the result. We experienced one haematoma and one wound dehiscence. Excision of glands, using Versajet, makes the operation a simple and efficient procedure. Moreover, precise and even debridement reduces complications by preserving the skin flap and subdermal plexus.

Modified gluteal fold V-Y advancement flap for vulvovaginal reconstruction.

The gluteal fold V-Y advancement flap is a good option for the reconstruction of a vulvovaginal defect because it is thin, sensate, reliable, and has matched local skin quality. However, in situations where wider and deeper vulvovaginal reconstruction is needed, advancement of the flap alone may not be sufficient to create tension-free closure. To overcome these limitations, we designed a modified gluteal V-Y advancement flap, which has 1 or 2 additional transposition flaps at the base of the conventional advancement flap.This study includes a total number of 16 patients who had received vulvovaginal reconstruction with our new technique between March 2008 and April 2011. The causes of the defects were vulvar cancer in 13 patients and extramammary Paget disease in 3 patients. We examined the location and size of the defect, the flap design, and postoperative clinical courses. The mean follow-up period was 10.6 months, and the defect sizes ranged from 8 × 6 to 15 × 12 cm. Overall, 11 of 16 patients were reconstructed with bilateral modified gluteal fold V-Y advancement flaps, and 5 patients were treated with a unilateral flap. All flaps survived without major complications, and the aesthetic and functional results were satisfactory. The modified gluteal fold V-Y advancement flap is useful and reliable for the reconstruction of wide and deep vulvovaginal defects. It can cover the defect without tension, and the complications associated with it are rare.

Asian upper lid blepharoplasty surgery.

Upper lid blepharoplasty is the most common plastic surgery procedure in Asia and has consistently maintained its position as cultural acceptance and techniques have evolved. Asian upper lid blepharoplasty is a complex procedure that requires comprehensive understanding of the anatomy and precise surgical technique. The creation of the supratarsal crease has gone through many evolutions in technique but the principles and goals remain the same: a functional, natural-appearing eyelid crease that brings out the beauty of the Asian eye. Recent advances have improved functional and aesthetic outcomes of Asian upper lid blepharoplasty.

Orbital roof reconstruction using porous polyethylene sheet with embedded titanium.

Calvarial defects, including the orbital roof defect that occurs after trauma or oncologic resection, require immediate reconstruction to avoid complications such as enophthalmos, diplopia, and transmission of the cerebral pulse to the eye. In these cases, autologous bone grafts or various alloplastic materials have been used.Between January 2010 and December 2010, 5 patients underwent surgery for orbital roof reconstruction using porous polyethylene sheet with embedded titanium, which was developed for reconstruction of inferomedial wall of the orbit. One patient underwent surgery because of tumor excision; the other patients, because of trauma. Two patients had intracranial hemorrhage and 3 patients had a defect in the supraorbital rim. We reconstructed the supraorbital rim and the orbital roof using a combination of calvarial bone graft and the porous polyethylene sheet with embedded titanium. The sheet was bended and trimmed according to the shape of the orbital defect, and it was fixed on the remaining adjacent bone using a microplate.There were no complications during the follow-up period. The patients were satisfied with the external appearance.In conclusion, the orbital roof reconstruction using porous polyethylene sheet with embedded titanium was an easy and a time-efficient procedure with satisfactory results.