Is Elective Nighttime Operation Associated With Adverse Outcomes? Analysis in Immediate Tissue Expander-Based Breast Reconstruction.

BACKGROUND: Despite the long-standing presumption that nighttime surgery could affect adverse outcomes, its association independent of patient's general condition and disease severity remains unclear. We hypothesized that conducting elective surgery for subjects with good physical status at nighttime was not associated with increased risks of postoperative complications and aimed to examine it in tissue-expander-insertion (TEI) operation for breast reconstruction. METHOD: Patients who underwent immediate unilateral TEI-based breast reconstruction between 2014 and 2019 were enrolled. They were categorized into 3 groups based on the starting time of the TEI operation: 8 am to 6 pm (group 1), 6 pm to 8 pm (group 2), and after 8 pm (group 3). The postoperative complication rates were compared among the groups. The independent associations of each variable, including the operation starting time and adverse outcomes, were analyzed. RESULTS: In total, 1458 patients were analyzed, including 970 in group 1, 358 in group 2, and 130 in group 3. The groups showed similar baseline characteristics regarding comorbidities and the American Society of Anesthesiologists classification. Compared with group 1, group 3 was associated with significantly increased rates of overall complications including infection, reoperation, and premature removal of the tissue expander. These differences retained influences in the multivariable analyses. Group 3 showed a significantly longer hospitalization period than the other 2 groups. The complication rates did not differ between groups 1 and 2. CONCLUSIONS: Conducting TEI operation at nighttime seems to be associated with increased risks of adverse postoperative outcomes compared with conducting it during regular working hours.

Optimal Timing of Expander-to-Implant Exchange after Irradiation in Immediate Two-Stage Breast Reconstruction.

BACKGROUND: Time intervals for expander-to-implant exchange from radiation therapy have been reported to reduce device failure. This study investigated the optimal timing of expander-to-implant exchange after irradiation in terms of short- and long-term outcomes. METHODS: This retrospective review enrolled consecutive patients who underwent immediate two-stage breast reconstruction and radiation therapy to tissue expanders from 2010 to 2019. Receiver operating characteristic curves and the Youden index were used to estimate the optimal time from radiation therapy to implant placement in terms of 49-day (early) and 2-year (late) complications. Logistic regression analysis was performed to identify the risk factors for each complication. RESULTS: Of the 1675 patients, 133 were included. The 49-day and 2-year complication rates were 8.3 percent and 29.7 percent, respectively. Capsular contracture was the most common 2-year complication. The Youden index indicated that implant placement at 131 days after radiation therapy was most effective in reducing the 49-day complications, but that the 2-year complication was less significant, with lower sensitivity and area under the curve. Modified radical mastectomy, expander fill volume at radiation therapy, and size of permanent implant increased the odds of 49-day complications; none of them was associated with the odds of 2-year complications. CONCLUSIONS: To reduce short-term complications, the best time point for permanent implant placement was 131 days after radiation therapy. However, there was no significant time interval for reducing long-term complications. Capsular contracture was an irreversible complication of radiation injury that was not modified by postirradiation variables including the time from irradiation or size of permanent implant. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Comprehensive Comparison Between Shaped Versus Round Implants for Breast Reconstruction: A Systematic Review and Meta-Analysis.

BACKGROUND: Prosthetic breast reconstruction has been gaining popularity and a variety of implant options are currently available. Therefore, it is important to evaluate the safety and efficacy of newly developed shaped implants compared with those of conventional round implants. To date, few studies have investigated the outcomes of breast reconstruction with shaped versus round implants. OBJECTIVES: The present study aimed to comprehensively compare, via meta-analytic methodology, shaped and round breast implant reconstruction in terms of complication profiles and aesthetic satisfaction. METHODS: PubMed/MEDLINE, Ovid, and Cochrane databases were searched to identify relevant studies presenting the complication rates for shaped and round implant groups. The relative risks of the following complications between the groups were calculated: infection, seroma, capsular contracture, rupture, rippling, reconstruction failure, and implant exchange or removal. Outcomes of aesthetic satisfaction included aesthetic results and patient-reported outcomes. RESULTS: Meta-analysis of 8 retrospective cohort studies, representing 2490 cases of implant-based breast reconstruction, was performed. There were no significant differences in the risks of infection, seroma, capsular contracture, and reconstruction failure between the 2 groups. The risks of implant rupture and rippling were significantly reduced with shaped implants. In a subgroup analysis of shaped/textured and round/smooth implants, the risk of infection was significantly enhanced in the former, whereas incidences of other complications, including capsular contracture and reconstruction failure, were similar. Aesthetic satisfaction analysis of the 2 groups demonstrated similar outcome scores with favorable overall results. CONCLUSIONS: Our results suggest that both shaped and round implants might provide favorable breast reconstruction outcomes with similarly low complication rates and aesthetic results.

Effects of conditioned medium from LL-37 treated adipose stem cells on human fibroblast migration.

Adipose stem cell-conditioned medium may promote human dermal fibroblast (HDF) proliferation and migration by activating paracrine peptides during the re-epithelization phase of wound healing. Human antimicrobial peptide LL-37 is upregulated in the skin epithelium as part of the normal response to injury. The effects of conditioned medium (CM) from LL-37 treated adipose stem cells (ASCs) on cutaneous wound healing, including the mediation of fibroblast migration, remain to be elucidated, therefore the aim of the present study was to determine how ASCs would react to an LL-37-rich microenvironment and if CM from LL-37 treated ASCs may influence the migration of HDFs. The present study conducted migration assays with HDFs treated with CM from LL-37 treated ASCs. Expression of CXC chemokine receptor 4 (CXCR4), which controls the recruitment of HDFs, was analyzed at the mRNA and protein levels. To further characterize the stimulatory effects of LL-37 on ASCs, the expression of stromal cell-derived factor-1α (SDF-1α), a CXC chemokine, was investigated. CM from LL-37-treated ASCs induced migration of HDFs in a time- and dose-dependent manner, with a maximum difference in migration observed 24 h following stimulation with LL-37 at a concentration of 10 µg/ml. The HDF migration and the expression of CXCR4 in fibroblasts was markedly increased upon treatment with CM from LL-37-treated ASCs compared with CM from untreated ASCs. SDF-1α expression was markedly increased in CM from LL-37 treated ASCs. It was additionally observed that SDF-1α blockade significantly reduced HDF migration. These findings suggest the feasibility of CM from LL-37-treated ASCs as a potential therapeutic for human dermal fibroblast migration.

Reliable transfer of multiple perforator-based pedicled flaps: Surgical technique and clinical outcomes.

PURPOSE: Although an increase in flap perfusion by incorporating multiple perforators has been demonstrated with free perforator flaps, whether the same efficacy can be achieved with pedicled flaps remains unclear, due to concerns regarding pedicle tension or kinking during flap transposition. The aim of this report was to investigate the reliability of multiple perforator-based pedicled flaps in a series of clinical cases. PATIENTS AND METHODS: Twenty-six patients undergoing soft tissue reconstruction using multiple perforator-based pedicled flaps from 2008 to 2012 were reviewed. The causes of the defects were oncologic (n = 15) or chronic wounds (n = 11). The defect sites were the trunk (n = 19), lower extremities (n = 4), head and neck (n = 2), and upper extremities (n = 1). Diverse flap types were used, including the superior gluteal artery perforator flap, the lateral femoral circumflex artery perforator flap, the medial femoral circumflex artery perforator flap, and the thoracodorsal artery perforator flap. The flaps were transposed in a rotation-and-advancement manner after skeletonizing each perforator and proximally dissecting the pedicle. The donor site was closed primarily. RESULTS: Mean flap size was 125.2 cm2 , and the mean number of perforators used was 2.3 (2-5). The mean angle of pivotal rotation for flap transposition was 132.8°. No rotation-related problems including pedicle kinking or twisting developed, and all flaps survived completely. No significant donor-site morbidity was observed. The mean follow-up period was 38.1 months. CONCLUSIONS: This report suggests that through meticulous dissection of pedicles of sufficient length, the multiple perforator-based pedicled flaps can be successfully transposed while minimizing the risk of pedicle tethering. © 2015 Wiley Periodicals, Inc. Microsurgery 37:105-111, 2017.

Reconstructing facial contour deformities using stereoscopic thoracodorsal artery perforator adipofascial flaps.

PURPOSE: Correcting facial contour deformities is a challenge, as it demands thoughtful planning on design, composition of flap, and secondary procedures. The thoracodorsal artery perforator (TDAP) flap has become a workhorse flap for various reconstructions. In this report, we present our experience of reconstructing facial contour deformities using the free TDAP adipofascial flap, focusing on its customized design. PATIENTS AND METHOD: Sixteen patients underwent correction of a facial contour deformity with free TDAP adipofascial flaps from 2002 to 2012. The causes of defects were Romberg disease (n = 7), oncological defects (n = 5), craniofacial microsomia (n = 3), and trauma (n = 1). The flaps were three-dimensionally designed in a contour map fashion to have different thickness according to the defects by adjusting the height of adipose tissue and varying tissue composition. Customized dimension of flaps having reliable perfusion were harvested with minimized sacrifice of overlying skin. RESULTS: Flap size ranged from 6 × 3 cm to 25 × 25 cm. Six flaps were based on two perforators and the other 10 on one. Five flaps were harvested in a chimeric fashion. All flaps survived completely. No donor morbidity developed in any case. Seven patients underwent secondary corrections including fat injection or liposuction. Improved contour and symmetry were achieved in all patients and was confirmed by a photographic evaluation. Mean follow-up period was 37.8months. CONCLUSIONS: Our results suggest that the stereoscopic TDAP adipofascial flaps with diligent secondary approaches may be a reliable alternative for aesthetic reconstruction of facial contour deformities. © 2015 Wiley Periodicals, Inc. Microsurgery 37:300-306, 2017.

Does the Use of Incisional Negative-Pressure Wound Therapy Prevent Mastectomy Flap Necrosis in Immediate Expander-Based Breast Reconstruction?

BACKGROUND: Mastectomy flap necrosis is one of the most common and significant complications in immediate expander-based breast reconstruction. Negative-pressure wound therapy is widely used for open wounds but is not commonly used for closed incisional wounds. However, the postoperative use of incisional negative-pressure wound therapy is demonstrated to reduce complication rates. The authors evaluate the incidence of mastectomy flap necrosis in patients with incisional negative-pressure wound therapy after immediate expander-based breast reconstruction compared with the incidence in patients with conventional dressing. METHODS: A retrospective review was conducted to identify patients who underwent immediate expander-based breast reconstruction between January of 2010 and February of 2015 at a single institution. Patients were divided into a conventional dressing group and an incisional negative-pressure wound therapy group. Patient demographics, intraoperative findings, and complications were compared between the two groups. RESULTS: A total of 228 breasts (206 patients) were included in this study. Of these, the incisional negative-pressure wound therapy group included 45 breasts (44 patients) and the conventional dressing group included 183 breasts (162 patients). The incisional negative-pressure wound therapy group had a lower overall complication rate (11.1 percent versus 27.9 percent; p = 0.019), overall mastectomy flap necrosis rate (8.9 percent versus 23.5 percent; p = 0.030), and major mastectomy flap necrosis rate (2.2 percent versus 13.7 percent; p = 0.031) compared with the conventional dressing group. CONCLUSIONS: Incisional negative-pressure wound therapy reduced the incidence of mastectomy flap necrosis. This simple and reliable dressing technique can be effective in preventing mastectomy flap necrosis in immediate expander-based breast reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Reconstruction of Head and Neck Capillary Malformations With Free Perforator Flaps for Aesthetic Purposes.

BACKGROUND: Capillary malformations (CMs) are composed of dilated capillaries and venules in the dermis layer. They appear as pink- or purple-colored lesions on the involved skin and usually follow a dermatomal distribution. Generally, laser treatment is considered the treatment of choice; however, in some patients, a surgical approach should be considered. This article presents the authors' experiences with free perforator flap transfer to the head and neck after resection of CMs for aesthetic purposes. PATIENTS AND METHODS: A total of 5 patients with CMs on their head and neck underwent operations for aesthetic purposes. After lesion debulking, defect sizes were measured and precise flaps were designed. A primary flap-thinning procedure was needed in obese patients before flap inset. The donor site was closed primarily in 4 cases. RESULTS: Thoracodorsal artery perforator free flaps were performed in all patients. The average size of harvested flaps was 146.8 cm. All flaps survived without recurrence of CM on the skin paddle of the transferred flap. Aesthetic restoration and high patient satisfaction were achieved after the surgery. CONCLUSIONS: The authors used free flaps to improve aesthetic outcomes, which have been used for reconstruction after trauma and malignancy. Free perforator flap transfer should be considered a valuable option for head and neck CMs.

A Phase III, Randomized, Multi-Center, Double-Masked, Matched-Pairs, Active-Controlled Trial to Compare the Efficacy and Safety between Neuramis Deep and Restylane in the Correction of Nasolabial Folds.

BACKGROUND: We conducted this clinical study to compare the efficacy and safety between Neuramis Deep and Restylane in the correction of nasolabial folds. METHODS: In this phase III, randomized, multi-center, double-masked, matched-pairs, active-controlled trial (ClinicalTrials.gov Identifier: NCT01585220), we evaluated a total of 67 subjects (n=67). All the subjects underwent Neuramis Deep treatment on one side and Restylane on the contralateral side of the bilateral nasolabial folds at a ratio of 1:1. To compare the efficacy of Neuramis Deep and Restylane, we evaluated the Wrinkle Severity Rating Scale scores and those of the Global Aesthetic Improvement Scale. In addition, we compared the safety of Neuramis Deep and Restylane based on adverse events, physical examination, and clinical laboratory tests. RESULTS: Neuramis Deep was not inferior in improving the nasolabial folds as compared with Restylane. In addition, there was no significant difference in the efficacy between Neuramis Deep and Restylane. There were no significant differences in safety parameters between Neuramis Deep and Restylane. CONCLUSIONS: In conclusion, our results indicate that Neuramis Deep may be a safe, effective material for improving the nasolabial folds. However, further studies are warranted to compare the tolerability of Neuramis Deep and Restylane based on histopathologic findings.

Donor site morbidity following DIEP flap for breast reconstruction in Asian patients: Is it different?

BACKGROUND: Despite the decrease in donor-site morbidity with the advent of deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal complications still occur. There have been few studies on donor morbidity considering the ethnic differences in the Asian population, as represented by a lower BMI with less redundant tissue and a tendency for poor scarring. In the present study, the authors investigated the incidence of abdominal complications and their risk factors following DIEP flap breast reconstruction in an Asian population. PATIENTS AND METHODS: The authors conducted a retrospective review of DIEP flap based breast reconstructions performed in the past 5 years. Data regarding patient demographics, surgical details, and abdominal complications were collected from our prospectively maintained database and analyzed. RESULTS: A total of 217 patients who underwent DIEP flap breast reconstruction were included. There were 51 abdominal complications (23.5%), including 18 delayed wound healing, 17 hypertrophic scarring, 12 seroma formation, and 8 abdominal bulges with no hernias. Secondary procedures were performed for the donor-site complications in 36 cases. Flap height was a significant risk factor for overall donor-site morbidity. Harvesting a bipedicle flap was significantly associated with abdominal fat necrosis and hypertrophic scarring. Harvesting a flap based on perforators from both rows was significantly associated with abdominal delayed wound healing and hypertrophic scarring. CONCLUSIONS: DIEP flap breast reconstruction performed in Asian patients showed acceptable donor-site morbidity without significant complications. This study suggests that donor-site morbidity from harvesting a DIEP flap is comparable to that described in Western literatures.

Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients.

BACKGROUND: Cartilage calcification is an important factor in aesthetic auricular reconstruction using autologous rib cartilage grafts in adults, a technique that involves difficult manipulation and unexpected absorption. As a result, artificial implants or prosthetics are considered for auricular reconstruction in adult patients despite the limitations of artificial material. In this article, we present our experience with auricular reconstruction using autologous rib cartilage grafts in adult microtia patients with reliable aesthetic results and minimal complications. METHODS: A retrospective chart review was performed for 84 microtia patients ranging in age from 21 to 56 (average: 29.9) years who underwent auricular reconstruction using autologous rib cartilage grafts from March 2001 to March 2013. To validate our acceptable reconstructive results, two independent observers performed postoperative photographic evaluation of two groups (adults and children) using non-inferiority tests in addition to patient questionnaires. RESULTS: The mean operation time for rib cartilage grafts was 3 h and 53 min, and the follow-up time for all patients ranged from 6 months to 8 years. Surgery-related complications occurred in only three cases. On objective photographic evaluation, the adult group was not inferior to the child group in auricular shape, location, or symmetry. The subjective patient satisfaction evaluation reported a high satisfaction rate. CONCLUSIONS: As this study shows, aesthetic auricular reconstruction using rib cartilage grafts in adult microtia patients is possible even in cases with advanced cartilage calcification. Modification of the fabricating framework, well-preserved flap vascularity, and complete understanding of physiological aspects of rib cartilage are essential for aesthetic auricular reconstruction.

Preoperative magnetic resonance imaging-based breast volumetry for immediate breast reconstruction.

BACKGROUND: Preoperative breast magnetic resonance imaging (MRI) is a routine test for oncologic evaluation. However, determining breast volume using a preoperative MRI obtained as a part of oncologic evaluation has not yet been attempted for immediate breast reconstruction. The study introduces the benefit of MRI-based volumetry, not only in autologous breast reconstruction but also in implant-based breast reconstruction. METHODS: Forty patients preparing for autologous breast reconstruction with a deep inferior epigastric artery perforator (DIEP) flap and 30 patients for implant-based breast reconstruction from June 2011 to June 2012 were included in this study. In every DIEP case, we collected data about actual resected breast tissue weight during mastectomy and final flap weight inserted intraoperatively. Computed tomography (CT) was for preoperative CT angiography for microsurgical breast reconstruction, whereas MRI was performed for oncologic evaluation. In every implant-based reconstruction case, MRI-based breast volume was measured in the same way for DIEP patients and resected breast tissue weight was measured intraoperatively. In addition, we also added or subtracted the breast volume by any modification, such as reduction and augmentation on the ipsilateral or contralateral side. To determine the accuracy of MRI-based volumetry, Pearson correlation coefficients were calculated to quantify the correlation between CT and MRI-based volumetry data and intraoperative volume measurements. RESULTS: For DIEP patients, the mean resected breast tissue weight during mastectomy was more closely related to the mean estimated breast volume using MRI than to the mean estimated breast volume using CT (Pearson coefficient 0.928 and 0.782; p = 0.001). MRI gave a closer correlation to final flap weight than CT (Pearson correlation coefficient 0.959 and 0.873; p = 0.001). For implant-based reconstruction patients, the breast volume measured by MRI correlated closely with the actual mean weight of resected breast specimens (0.937; p = 0.001). Mean net implanted volume was more closely related to mean estimated breast volume using MRI than to mean resected breast tissue weight during mastectomy (0.893 and 0.880; p = 0.001). CONCLUSIONS: Reliable volumetric information can be obtained using MRI for breast implant volume and autologous tissue needed in optimizing symmetry in breast reconstruction. 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 www.springer.com/00266 .

Evaluating the effectiveness of cryopreserved acellular dermal matrix in immediate expander-based breast reconstruction: a comparison study.

BACKGROUND: CGCryoDerm was first introduced in 2010 and offers a different matrix preservation processes for freezing without drying preparation. From a theoretical perspective, CGCryoDerm has a more preserved dermal structure and more abundant growth factors for angiogenesis and recellularization. In the current study, the authors performed a retrospective study to evaluate freezing- and freeze-drying-processed acellular dermal matrix (ADM) to determine whether any differences were present in an early complication profile. METHODS: Patients who underwent ADM-assisted tissue expander placement for two stage breast reconstruction between January of 2013 and March of 2014 were retrospectively reviewed and divided into two groups based on the types of ADM-assisted expander reconstruction (CGDerm vs. CGCryoDerm). Complications were divided into four main categories and recorded as follows: seroma, hematoma, infection, and mastectomy skin flap necrosis. RESULTS: In a total of 82 consecutive patients, the CGCryoDerm group had lower rates of seroma when compared to the CGDerm group without statistical significance (3.0% vs. 10.2%, P=0.221), respectively. Other complications were similar in both groups. Reconstructions with CGCryoDerm were found to have a significantly longer period of drainage when compared to reconstructions with CGDerm (11.91 days vs. 10.41 days, P=0.043). CONCLUSIONS: Preliminary findings indicate no significant differences in early complications between implant/expander-based reconstructions using CGCryoderm and those using CGDerm.

Hepatic differentiation of human adipose tissue-derived mesenchymal stem cells and adverse effects of arsanilic acid and acetaminophen during in vitro hepatic developmental stage.

In the present study, we differentiated hepatocyte-like cells (HLCs) from human adipose tissue-derived mesenchymal stem cells (AT-MSCs). The hepatic differentiation was confirmed by increases in hepatic proteins or genes, the cytochrome P450 (CYP) activities, albumin secretion, and glycogen storage. To determine the developmental toxic effect of arsanilic acid (Ars) and acetaminophen (AAP) on the hepatic development, the differentiating cells were treated with the test chemicals (below IC12.5) from day 4 to day 13. The enzymatic activities of lactate dehydrogenase (LDH), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) did not significantly differ in response to Ars treatment. AAP treatment increased the activities of all enzymes in a dose-dependent manner, significantly at concentrations of 2.5 and 5 mM of AAP. On the expressions of hepatic genes for Ars, the expressions were significantly inhibited by more than 0.5 mM for Albumin (ALB), but only 2.5 mM for α-feto protein (AFP). In the AAP-treated group, the expressions of ALB and AFP were significantly decreased at the concentrations exceeding 0.625 mM. The activities of CYP3A4 were not changed by both treatments. The activities of CYP1A2 were increased by AAP, whereas it was decreased by Ars treatment. In conclusion, AAP could cause serious adverse effects during the hepatic development as compared to Ars.

Estimation of eighth costal cartilage in surgical timing of microtia reconstruction.

There is controversy over the optimal timing of microtia reconstruction. The eighth costal cartilage, which is used to shape the helix framework, can be one of the key factors determining surgical timing of microtia reconstruction. Nevertheless, it is difficult to predict the length of the eighth costal cartilage preoperatively. The aim of the present study was to suggest clinical predictors of the length of the eighth cartilage by assessing the correlation between the actual length of the eighth cartilage and preoperative measurements of the cartilage length using three-dimensional rib-cage computed tomography (3D rib-cage CT). A retrospective analysis was performed on a total of 97 patients who underwent preoperative 3D rib-cage CT and auricular reconstruction using a rib cartilage graft between January 2010 and February 2013. The length of the eighth costal cartilage on 3D rib-cage CT was measured preoperatively, and the length of the harvested eighth rib cartilage was measured intraoperatively. We analyzed the association between the preoperative and intraoperative measured length of the eighth rib, with patient age, height, weight, and body mass index. Preoperative measurement using 3D rib-cage CT showed a high correlation with actual cartilage length. Height and weight correlated more strongly with length than with age. This study describes the usefulness of 3D rib-cage CT for preoperative measurement of the length of the eighth costal cartilage. The measurement of the eighth rib cartilage on 3D rib-cage CT could be a useful aid for reconstructive surgeons in planning microtia reconstruction.

Microtia reconstruction using tissue expanders without skin grafts from groin region.

BACKGROUNDS: Microtia reconstruction is a multistage procedure for which a variety of surgical strategies have been devised. Most surgeons continue to employ the long-established two-stage procedures described by Nagata and Firmin, which use autogenous rib cartilage for auricular reconstruction. The groin area is the most common donor site for full-thickness skin grafts in auricular elevation, the second stage. In this article, we present a new method that uses tissue expanders before auricular elevation, which provides the necessary skin and creates satisfactory results without groin scarring. METHODS: The surgical procedure is composed of three stages. In the first stage, we performed the rib-cartilage graft as previously described. In the second stage, a 45-ml rectangular tissue expander was inserted subcutaneously at the postauricular mastoid region. The skin flap was expanded for 3-4 months before auricular elevation. In the next stage, the expanded postauricular skin flap was advanced to the mastoid area and set into the auriculocephalic sulcus after removing of the tissue expander. The estimated remnant skin flap and dog-ears were marked and then excised. After a defatting procedure, the harvested skin was reused for the elevation procedure, obviating the need for full-thickness skin from the groin. RESULTS: Between January 2011 and January 2014, 62 cases of microtia were treated with our method. The final results showed no major complications and satisfactory aesthetics, with fine structure, symmetry, maintenance of the auriculocephalic angle, and erect stability of the cartilage framework. CONCLUSION: Various procedures using tissue expanders have been introduced in microtia reconstruction. However, they utilized complicated strategies for tissue expanders or obtained suboptimal aesthetic results. With our simple and reproducible methods, we can obtain satisfactory aesthetic results using expanded skin without the additional morbidity of a donor site. Despite the addition of an operation procedure, patient satisfaction with regard to the lack of groin scarring was much higher than expected.

Surgical treatment of masseteric venous malformations and outcomes.

Intramuscular venous malformations are often misdiagnosed as other types of tumors with similar presentations. We describe here the typical presentation of a venous malformation within the masseter muscle, including the physical findings and imaging, and present our experience with the surgical excision of these lesions. This is a review of 10 patients with venous malformations localized to the masseter muscle who presented to our institution between 2008 and 2011. The patients included 6 females and 4 males. Of these venous malformations, 80% were noted in childhood, and the remainder manifested later in adolescence. Pain, swelling, and facial asymmetry were the presenting complaints. Magnetic resonance imaging, Doppler ultrasonography, and whole-body blood scintigraphy were used to characterize the lesions. All patients were treated by total resection of the lesion while preserving the marginal mandibular branch of the facial nerve. Magnetic resonance imaging showed the lesions to be isointense with surrounding muscle on T1-weighted images and hyperintense on T2-weighted images. Gross examination of the resected specimens revealed multicolored tissue with dilated vascular channels, frequently containing phleboliths. After the operation, all patients showed improvement in both symptoms and appearance. This improvement was sustained at a mean follow-up of 21 months. Masseteric venous malformations typically present with a pattern of clinical and imaging findings that should allow surgeons to distinguish them from other diseases in the cheek area. Complete surgical excision is a treatment option for these patients and can be performed without facial nerve injury or excessive bleeding. This procedure can result in excellent outcomes for localized intramasseteric venous malformation.

Augmentation mammoplasty with silicone implant using transumbilical approach at a subpectoral level.

Endoscopic placement of breast implants has been described through an umbilical incision. Limitations include the fact that only inflatable implant can be used through umbilical approach. The purpose of this study is to describe the authors' evolutionary transumbilical technique with cohesive silicone gel implant insertion and to retrospectively analyze preliminary results. The authors' technique is the placement of a cohesive silicone gel implant using a transumbilical approach in a subpectoral plane. Patients who were selected had mammary hypoplasia without ptosis and who requests breast augmentation with a scarless and natural feel breast were considered candidates. The technique and indications are presented thoroughly. From June of 2011 to January of 2012, 42 women aged 23 to 46 years (average, 31.6 years) underwent the endoscopic transumbilical breast augmentation. All patients had round silicone implants placed in the retropectoral pocket location. The results of this study indicate that transumbilical technique is highly successful. Complication included transient periumbilical bulging (5 patients, 11.9%), hypertrophic scar needing revision (1 patient, 2.3%), and conversion to other breast incision due to capsular contracture (3 of 84 breasts, 3.5%). Transumbilical breast augmentation with prefilled implant is a safe and attractive technique for breast implant placement in selected patients. With this inventory modification, the result can permit surgeons expanded spectrum of implant selection for transumbilical approach.

Is late seroma a phenomenon related to textured implants? A report of rare complications and a literature review.

BACKGROUND: Late seroma is an infrequent complication that manifests as fluid collection in the periprosthetic space at least 1 year after breast enlargement surgery. Interest in late seroma has grown with the potential connection between breast implants and anaplastic large cell lymphoma (ALCL), which presents with clinical symptoms similar to those of late seroma. This report presents a case of late seroma experienced by a patient with a history of multiple implant ruptures and a review of the relevant literature. METHODS: Details are reported for a patient who presented with sudden swelling of an augmented breast that was initially suspected to be symptomatic of ALCL. A literature search of PubMed regarding this phenomenon also was conducted. RESULTS: The literature review identified 14 articles on late seroma involving 60 patients, including the reported case. Analyses included epidemiology, etiology, and management strategy. Although a detailed statistical analysis was not performed, 55 cases (92 %) of late seroma occurred that involved patients with textured implants. No evidence-based guideline for the management of late seroma has been established, although the patients were managed successfully in all cases using various strategies. CONCLUSIONS: The reported case and data from the literature provide evidence of a relationship between textured implant use and late seroma. Based on their review, the authors offer "sequential treatment steps," from conservative treatment to surgical management, which will be helpful for successful management of future late seroma cases. However, further study is needed to clarify the relationship, if any, between a particular type of textured implant and the development of late seroma. LEVEL OF EVIDENCE V: 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 www.springer.com/00266 .