Small flaps in microsurgical breast reconstruction: Selection between the profunda artery perforator and small deep inferior epigastric artery perforator flaps and associated outcomes and complications.

BACKGROUND: The deep inferior epigastric artery perforator (DIEP) flap is widely used in breast reconstruction and the profunda artery perforator (PAP) flap as alternative. However, the difference between the two flaps in smaller breast reconstruction remains lacking, in particular, the donor site complications. In this case series, the results of small breast reconstruction (≤300 g) using PAP or small DIEP flaps were explored. METHODS: Unilateral immediate breast reconstruction using a free PAP flap or small DIEP flap (≤300 g) from 2011 to 2021 were reviewed retrospectively. Excluding patients with delayed reconstruction, 28 patients, including 17 PAP flaps and 11 small DIEP flaps were enrolled. Flap characteristics, breast and donor site complications, and revision surgeries were reviewed. BREAST-Q™ was used for quality-of-life assessment. RESULTS: Compared with a small DIEP flap, a PAP flap was narrow (7.5 ± 1.1 vs. 10.6 ± 0.7 cm, p < .001), short (20.0 ± 2.6 vs. 25.5 ± 1.8 cm, p < .001) and had a shorter pedicle (5.9 ± 1.6 vs. 9.1 ± 1.0 cm, p < .001). There were no significant differences in acute and late complications of wound healing and fat necrosis, but the average number of revisions in the PAP group was significantly higher (1.9 ± 1.3 vs. 0.8 ± 1.4, p = .041). Patient-reported outcomes using BREAST-Q™ displayed no significant difference between the two groups. CONCLUSION: The outcomes of PAP and small DIEP flaps at the breasts and donor sites are satisfactory, despite that a higher tendency of donor site complications in PAP flap and more aesthetic refinement required in the PAP group. The overall outcomes are acceptable.

Enhancing Philtrum Morphology Using Fat Grafting Combined with Percutaneous Rigottomy in Repaired Unilateral Cleft Lip.

BACKGROUND: Improving the philtrum morphology of patients with a secondary cleft lip deformity has been a challenge in cleft care. Combining fat grafting with percutaneous rigottomy has been advocated for treatment of volumetric deficiency associated with a scarred recipient site. This study assessed the outcome of synchronous fat grafting and rigottomy for improvement of cleft philtrum morphology. METHODS: Consecutive young adult patients ( n = 13) with a repaired unilateral cleft lip who underwent fat grafting combined with rigottomy expansion technique for enhancement of philtrum morphology were included. Preoperative and postoperative three-dimensional facial models were used for three-dimensional morphometric analyses including philtrum height, projection, and volume parameters. Lip scar was qualitatively judged by a panel composed by two blinded external plastic surgeons using a 10-point visual analogue scale. RESULTS: Three-dimensional morphometric analysis revealed a significant (all P < 0.05) postoperative increase of the lip height-related measurements for cleft philtrum height, noncleft philtrum height, and central lip length parameters, with no difference ( P > 0.05) between cleft and noncleft sides. The postoperative three-dimensional projection of the philtral ridges was significantly ( P < 0.001) larger in cleft (1.01 ± 0.43 mm) than in noncleft sides (0.51 ± 0.42 mm). The average philtrum volume change was 1.01 ± 0.68 cm 3 , with an average percentage fat graft retention of 43.36% ± 11.35%. The panel assessment revealed significant ( P < 0.001) postoperative scar enhancement for the qualitative rating scale, with mean preoperative and postoperative scores of 6.69 ± 0.93 and 7.88 ± 1.14, respectively. CONCLUSION: Synchronous fat grafting and rigottomy improved philtrum length, projection, and volume and lip scar in patients with repaired unilateral cleft lip. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Medial circumflex femoral artery perforator flap to reconstruct a complex rectovaginal fistula: A case report.

Reconstruction of complex rectovaginal fistula is challenging, and it has a high recurrence rate. Traditional reconstruction included a local flap or a myocutaneous flap reconstruction, which is either difficult in radiated cases or that the flap is too thick for flap inset and requires multiple times of revision. Here we report successful rectovaginal fistula repair using a pedicled medial circumflex femoral artery perforator flap (MCFAP). A retrospective chart review was done to collect the information of this 63-year-old female patient who had rectovaginal fistula (RVF) resulting from concurrent radiochemotherapy for cervical cancer. She received direct repair of the RVF, but it recurred. We applied a pedicle perforator flap to successfully repair the defect. The fistula was repaired by separating the posterior vaginal wall from the anterior rectal wall. The anterior wall of the rectum was primarily repaired, leaving a defect of 4 × 5 cm in the posterior vaginal wall. A pedicled MCFAP flap was harvested from her right medial thigh and transferred via a subcutaneous tunnel for reconstruction of the posterior vaginal wall defect. The postoperative course was uneventful. Postoperative gastrointestinal series showed no more RVF, and her colostomy was taken down one year after the reconstruction. This first experience suggests that a pedicle perforator flap can be used successfully for reconstruction of a rectovaginal fistula.

In vivo vascularized scaffold with different shear-exposed models for lymphatic tissue regeneration.

Current clinical treatments on lymphedema provide promising results, but also result in donor site morbidities. The establishment of a microenvironment optimized for lymphangiogenesis can be an alternative way to enhance lymphatic tissue formation. Hemodynamic flow stimuli have been confirmed to have an influential effect on angiogenesis in tissue engineering, but not on lymphatic vessel formation. Here, the three in vivo scaffolds generated from different blood stimuli in the subcutaneous layer, in the flow through pedicle, and in an arterio-venous (AV) loop model, were created to investigate potential of lymphangiogenesis of scaffolds containing lymphatic endothelial cells (LECs). Our results indicated that AV loop model displayed better lymphangiogenesis in comparison to the other two models with slower flow or no stimuli. Other than hemodynamic force, the supplement of LECs is required for lymphatic vessel regeneration. The in vivo scaffold generated from AV loop model provides an effective approach for engineering lymphatic tissue in the clinical treatment of lymphedema.

Real-world management of abnormal scarring using topical silicone gel: expert consensus and case series from the Asian SCARS Expert Group.

Preventing abnormal scar formation and correcting non-aesthetic mature scars are important to prevent physical and psychosocial consequences of abnormal scarring. Evidence-based guidelines for scar management in Asian patients recommend first-line silicone-based products. Dermatix®* Ultra and Dermatix Ultra Kids are topical silicone gels containing a vitamin C ester that helps lighten scar tissue. Herein, we report a case series including patients with hypertrophic and keloid scars treated with Dermatix, showing that Dermatix is effective for scar treatment and prevention, as well as expert consensus supporting the safe and effective use of Dermatix.

Comparison of Facial Growth between Two Nasoalveolar Molding Techniques in Patients with Unilateral Complete Cleft Lip.

BACKGROUND: Nasoalveolar molding (NAM) has become standard treatment in the authors' craniofacial center. There are two types of presurgical NAM: the Grayson and Figueroa techniques. The Grayson method involves active alveolar molding, and the Figueroa method involves passive alveolar molding. The authors previously found no differences in number of clinic visits, costs, or 6-month postoperative outcome between the two techniques. The authors extended the previous study to evaluate facial growth between these two groups. METHODS: In this randomized single-blind study, conducted between May of 2010 and March of 2013, the authors recruited 30 patients with unilateral complete cleft lip and palate and randomized them for Grayson or Figueroa presurgical NAM. Standard lateral cephalometric measurements at 5 years were used to determine facial growth. RESULTS: Twenty-nine patients completed 5 years of follow-up. There were no statistically significant differences in facial cephalometric measurements between the two groups. CONCLUSION: Presurgical NAM using either a passive or active NAM technique produced similar facial growth patterns after unilateral cleft lip and palate repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Vascularized lymph node transplantation successfully reverses lymphedema and maintains immunity in a rat lymphedema model.

Vascularized lymph node transplantation (VLNT) has shown inspiring results for the treatment of lymphedema. Nevertheless, it remains unclear how VLNT restores lymphatic drainage and whether or not immunity recovers after surgery. Hindlimb lymphedema model was created using rats with extensive groin and popliteal lymph node removable following with radiotherapy, and the lymphedema was confirmed using indocyanine green (ICG) lymphangiography and micro-computer tomography for volume measurement. VLNT was performed 1 month later. Volume measurement, ICG lymphangiography, histology, and immune reaction were done 1 month after surgery. VLNT successfully reduced the volume of the lymphedema hindlimb, restored lymphatic drainage function with proven lymphatic channel, and reduced lymphedema-related inflammation and fibrosis. It promotes lymphangiogenesis shown from ICG lymphangiography, histology, and enhanced lymphangiogenesis gene expression. Dendritic cell trafficking via the regenerated lymphatic channels was successfully restored, and maintained systemic immune response was proved using dinitrofluorobenzene sensitization and challenge. VLNT effectively reduces lymphedema and promotes lymphatic regeneration in the capillary lymphatic but not the collecting lymphatic vessels. Along with the re-established lymphatic system was the restoration of immune function locally and systemically. This correlated to clinical experience regarding the reduction of swelling and infection episodes after VLNT in lymphedema patients.

The Effect of Negative Pressure on Wound Healing and Regeneration in Closed Incisions under High Tension: Evidence from Animal Studies and Clinical Experience.

Closed-incision negative-pressure wound therapy (iNPWT) is known to enhance wound healing and tissue regeneration. The main aim of the present study is to investigate its effectiveness on enhancing wound healing under tension. An animal study was designed using a swine model by removing a skin flap to create a wound that could be closed primarily under tension, and iNPWT was applied. The enhancement of angiogenesis, lymphangiogenesis, collagen deposition, and tissue proliferation with reduced inflammation by iNPWT was confirmed by histology. The effect of iNPWT was further verified in patients receiving a profunda artery perforator (PAP) free flap for breast reconstruction. iNPWT was applied on the transversely designed donor site in continuous mode for 7 days, in which the wound was always closed under tension. A significant improvement in off-bed time was noted with the application of iNPWT (4.6 ± 1.1st and 5.5 ± 0.8th postoperative days in the iNPWT and control groups, respectively, p = 0.028). The control group (without iNPWT treatment) presented more cases of poor wound healing in the acute (23.1% vs. 0%) and wound breakdown in the late (23.1% vs. 8.3%) stages. The treatment of closed incisions under tension with iNPWT clinically enhances wound healing and tissue regeneration and with histological evidence.

Robotic-assisted nipple-sparing mastectomy followed by immediate microsurgical free flap reconstruction: Feasibility and aesthetic results - Case series.

BACKGROUND: The application of robotic-assisted nipple-sparing mastectomy (R-NSM) has allowed mastectomy to be performed via a small incision. Breast reconstruction with free autologous tissue results in the most natural and long-lasting results, however, its application in R-NSM can be difficult via the small incision and haven't been explored in depth. The purpose of the study was to investigate the feasibility and aesthetic outcome of free perforator flap breast reconstruction via small lateral chest wall incision after R-NSM. MATERIALS AND METHODS: A retrospective chart review was conducted to identify patients who received R-NSM and free perforator flap reconstruction as the study group and patients who received conventional nipple-sparing mastectomy (C-NSM) and free perforator flap reconstruction as the control group from January 2018 to August 2020 by single reconstructive surgeon. Patient demographic data, complications from both mastectomy and reconstruction, status of resection margin and oncological outcome were reviewed. Aesthetic outcome was evaluated by 9 plastic surgeons. RESULTS: A total of 63 patients were included of which 22 (34.9%) received R-NSM and 41 (65.1%) received C-NSM. Their demographic data, reconstruction flaps, overall complication rate and follow up time were similar. Unlike C-NSM, majority of the R-NSM groups used the thoracodorsal or lateral thoracic vessels as the recipient vessels. Patients in the R-NSM group has smaller scar and better aesthetic outcome in the symmetry of breast inframammary fold, scar location and visibility, and overall aesthetic outcome. CONCLUSION: Although with difficulty in microvascular anastomosis and flap inset and shaping, R-NSM with perforator flap reconstruction presented with equal surgical and oncological safety with C-NSM and even better aesthetic results.

Creation of a rat lymphedema model using extensive lymph node dissection and circumferential soft tissue resection: Is this a reliable model?

INTRODUCTION: The medical demand for lymphedema treatment is huge since the disease mechanism remains unclear, and management are difficult. Our purpose was to develop a reliable lymphedema model mimicking the clinical scenario and allows a microsurgical approach. MATERIALS AND METHODS: Male Lewis rats weighing 400 to 450 g were used to create lymphedema with groin and popliteal lymph node dissection and creation of 5 mm circumferential skin defect (n = 6). A skin incision was made and closed primarily for control group (n = 5). Evaluation included indocyanine green (ICG) lymphangiography 1 and 2 months postoperatively, volume difference between bilateral hindlimbs measured using micro-CT, and the skin was harvested for histological evaluation 2 months postoperatively. RESULTS: Larger volume differences present in the lymphedema group (17.50 ± 7.76 vs. 3.73 ± 2.66%, p < .05). ICG lymphangiography indicated dermal backflow only in the lymphedema group. Increased thickness of the epidermis was noted in lymphedema group (28.50 ± 12.61 µm vs. 15.10 ± 5.41 µm, p < .0001). More CD45+ (35.6 ± 26.68 vs. 2.8 ± 4.23 cells/high power field [HPF], p < .0001), CD3+ (38.39 ± 20.17 vs. 9.73 ± 8.62 cells/HPF, p < .0001), and CD4+ cell infiltration (11.7 ± 7.71 vs. 2.0 ± 2.67 cells/HPF, p < .0001) were observed in the lymphedema group. Collagen type I deposition was more in the lymphedema group (0.15 ± 0.06 vs. 0.07 ± 0.03, p < .0005). CONCLUSIONS: A rat lymphedema model was successfully established. The model can be applied in lymphedema related research.

Botulinum Toxin to Improve Lower Blepharoplasty Scar: A Double-Blinded, Randomized, Vehicle-Controlled Clinical Trial.

BACKGROUND: Lower blepharoplasty is a common cosmetic operation that relies on minimal postoperative scarring, but Asian patients are at higher risk than Caucasians for hypertrophic and/or widened scars. Botulinum toxin type A (BTX) injections are widely employed to alleviate dynamic facial rhytids and also can improve scar quality by reducing scar tension. The authors assessed whether simultaneous transcutaneous lower blepharoplasty and BTX injections could improve subciliary scar quality. OBJECTIVES: The objective of this study was to assess whether simultaneous transcutaneous lower blepharoplasty and BTX injections could improve subciliary scar quality. METHODS: This is a prospective, randomized, vehicle-controlled, double-blinded clinical trial. Between May 2015 and May 2018, 40 adults who underwent bilateral transcutaneous lower blepharoplasties were randomized to receive BTX (n = 20) or vehicle (normal saline; n = 20) injections into the lateral orbicularis oculi muscle immediately after wound closure. Vancouver Scar Scale, Visual Analogue Scale, and photographic scar width measurements at 3 reference points were recorded at the final clinical follow-up. RESULTS: Thirty-seven patients completed the trial. Vancouver Scar Scale and Visual Analogue Scale scores in the experimental and vehicle control groups were similar, but scar widths in the experimental group at all measured points were significantly narrower than in the vehicle control group (P < 0.001, P = 0.027, and P < 0.001 at each measured point, respectively). CONCLUSIONS: Transcutaneous lower blepharoplasty scars in Asians can be significantly narrowed by simultaneous BTX injections without additional complications.

Simultaneous Orthognathic Surgery With Asian Double Eyelid Suture Blepharoplasty.

BACKGROUND: The main objective of contemporary orthognathic surgery is to correct dentofacial deformities. Nonetheless, many adjunct procedures to enhance the esthetic outcome in orthognathic surgical cases have been successfully incorporated to improve patient satisfaction. The authors report our preliminary experience of performing simultaneous orthognathic surgery with Asian double eyelid suture method blepharoplasty in the same surgical setting. METHOD: This case series report includes all 19 consecutive cases presenting to the Chang Gung Craniofacial Center for combined orthognathic surgery with Asian double eyelid suture method blepharoplasty. The double eyelid crease height was measured as the vertical line between the upper eyelid margin (eyelid lash) and the upper eyelid crease, observed at the mid-pupillary line with the eyes in primary gaze. RESULTS: There were no complications or relapse reported within this time period. There was significant improvement in the left and right mid-pupillary double eyelid crease height postsurgery. There were no statistically significant differences between the left and right mid-pupillary double eyelid crease heights after surgery indicating good eyelid crease height symmetry bilaterally was obtained. CONCLUSIONS: Orthognathic surgery combined with suture method blepharoplasty can be safely performed in the same surgical setting without inappropriate rise in costs or operating room time. This case series demonstrates that excellent esthetic results can be obtained in simultaneous bimaxillary orthognathic surgery with suture method Asian blepharoplasty.

Fate of Fat Grafting In Vivo and In Vitro: Does the Suction-Assisted Lipectomy Device Matter?

BACKGROUND: Recently, there has been increasing research interest in identifying the effect of liposuction procedures on fat graft survival in order to clarify whether different harvest techniques affect the quality of fat grafts. OBJECTIVES: The aim of this study was to investigate the effect of 2 liposuction methods on the survival and regeneration potential of grafted fat tissue. The proliferation and differentiation potentials of adipose-derived stem cells (ASCs) isolated by both methods was also investigated. METHODS: Fat grafts were collected from patients who underwent liposuction procedures by 2 different methods: traditional suction-assisted liposuction (TSAL) and vibration amplification of sound energy at resonance (VASER). One portion of the lipoaspirates was implanted into the subcutaneous layer of nu mice for 4 and 12 weeks. ASCs were isolated from the other portion of the lipoaspirate and subjected to proliferation and differentiation assays. RESULTS: Although in vivo fat grafting presented similar adipose tissue survival for the 2 different liposuction methods, more angiogenesis and less fibrosis was observed in the VASER group based on histologic evaluation. Furthermore, VASER-derived ASCs presented better quality in terms of cell differentiation capacity. CONCLUSIONS: The in vivo study confirmed better graft angiogenesis with less inflammation, apoptosis, and scar formation in the VASER group. ASCs harvested with VASER exhibited increased differentiation capacity compared with those obtained by TSAL, and represent an excellent source for fat grafting and regenerative medicine.

Surgical Outcomes of Secondary Alveolar Bone Grafting and Extensive Gingivoperiosteoplasty Performed at Mixed Dentition Stage in Unilateral Complete Cleft Lip and Palate.

Secondary alveolar bone grafting (SABG) is associated with donor site morbidities. We aimed to compare the outcomes of SABG and extensive gingivoperiosteoplasty (EGPP) at the mixed dentition stage. This single-blinded, randomized, prospective trial enrolled 50 consecutive patients with unilateral complete cleft lip and palate who had residual alveolar bone cleft, of which 44 (19 SABG, 25 EGPP) completed the study. Bone volumes before surgery, 6 months postoperatively, and 1-year postoperatively were compared using computed tomography. The Bergland scale score was recorded at 6 months postoperatively. Both groups had the same preoperative alveolar cleft volume. On the Bergland scale, 21, 3, and 1 patient in the EGPP group and 16, 2, and 1 patient in the SABG group were classified as types I, II, and IV, respectively, which did not show significant difference. With perioperative orthodontic treatment, the 1-year residual bone defect volume in both groups did not show significant difference (SABG 0.12 cm3 vs. EGPP at 0.14 cm3, p > 0.05). The study was not able to reveal much difference between SABG and EGPP combined with perioperative orthodontic treatment.

The effect of cleft maxillary distraction osteogenesis on the levator veli palatini and velopharyngeal function.

BACKGROUND: Le Fort I maxillary distraction with the rigid external distraction (RED) device is performed to correct severe midface retrusion in cleft patients, but it may adversely affect velopharyngeal function. OBJECTIVES: This study aims to investigate the angular changes in the levator veli palatini (LVP) and its influence on velopharyngeal function after maxillary distraction using 3-dimensional computed tomography (3D CT) scan volume rendered images. METHODS: This was a retrospective study of 12 patients. Group 1 had no velopharyngeal function deterioration and group 2 had velopharyngeal function deterioration. Preoperative and 1 year postoperative CT scans were analyzed with Mimics v10 software. Segmentation of the LVP and the nasopharyngeal airway was performed and volumetric images were obtained. Six measurements were made: (1) the angle between the levator plane and the Frankfort horizontal, (2) the angle between the levator plane and the soft palate plane, (3) the angle between the 2 LVP muscles, (4) the pharyngeal depth, and (5, 6) the movement of the inferior pharyngeal point with respect to the horizontal and vertical planes. The independent samples t test, Mann-Whitney test, and paired t tests were used for statistical analyses (P < 0.05). RESULTS: Group 2 had statistically significant reduction in the angle between the levator plane and Frankfort horizontal as well as the soft palate plane. Group 1 had a statistically significant increase in the pharyngeal depth and movement of the inferior pharyngeal point with respect to the horizontal plane. CONCLUSION: A decrease in the angle between the levator plane and the Frankfort horizontal or the soft palate plane was associated with velopharyngeal function deterioration.

Repair of Tessier no. 3 and no. 4 craniofacial clefts with facial unit and muscle repositioning by midface rotation advancement without Z-plasties.

BACKGROUND: The accepted surgical correction of Tessier no. 3 and no. 4 craniofacial clefts is the use of interdigitating skin flaps along the line of the facial cleft, which frequently results in unsightly facial scars, poor skin color match, and an unnatural facial expression. The authors report their technique of midface rotation-advancement concept to repair these craniofacial clefts. METHODS: Fourteen patients who had undergone Tessier no. 3 and no. 4 cleft repair over a 35-year period (1976 to 2010) at the craniofacial center in Chang Gung Memorial Hospital were retrospectively reviewed. Five patients (group 1) were operated on using Z-plasty principles. Nine (group 2) were operated on using the rotation-advancement technique; six of them had Tessier no. 3 clefts and three had Tessier no. 4 clefts. Seven of those nine patients were primary cases; the other two had secondary or tertiary revisions. Patient photographs were reviewed to assess outcomes. RESULTS: Group 1 had a less overall satisfactory result in terms of scar quality, color matching, or natural facial expression. Overall, a much improved appearance with a higher satisfaction rate was demonstrated in group 2. Patients in group 2 who were surgically treated with the midface rotation advancement technique, though their medial canthus and alar base might not have been well repositioned, still had much better results. CONCLUSIONS: Midface rotation advancement avoided significant scarring with poor skin color matching and unnatural facial expressions. This technique is applicable to either the primary repair or secondary revision of Tessier no. 3 and no. 4 craniofacial clefts. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Maxillary distraction osteogenesis in the adolescent cleft patient: three-dimensional computed tomography analysis of linear and volumetric changes over five years.

OBJECTIVE: To assess the results of maxillary distraction osteogenesis with the Rigid External Distraction System using three-dimensional computed tomography scan volume-rendered images with respect to stability and facial growth at three time frames: preoperative (T0), 1-year postoperative (T1), and 5-years postoperative (T2). DESIGN: Retrospective analysis. SETTING: Tertiary. PATIENTS: A total of 12 patients with severe cleft maxillary hypoplasia were treated between June 30, 1997, and July 15, 1998. The mean age at surgery was 11 years 1 month. INTERVENTIONS: Le Fort I maxillary distraction osteogenesis. Distraction was started 2 to 5 days postsurgery at a rate of 1 mm per day. The consolidation period was 3 months. No face mask was used. A paired t test was used for statistical analysis. MAIN OUTCOME MEASURES: Overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes. RESULTS: From T0 to T1, there were statistically significant increments of overjet, ANB, and SNA and maxillary, pterygoid, and mandibular volumes. The T1 to T2 period demonstrated a reduction of overjet (30.07%) and ANB (54.42%). The maxilla showed a stable SNA and a small but statistically significant advancement of the ANS point. There was a significant increase in the mandibular volume. However, there was no significant change in the maxillary and pterygoid volumes. CONCLUSIONS: Maxillary distraction osteogenesis demonstrated linear and volumetric maxillary growth during the distraction phase without clinically significant continued growth thereafter. Overcorrection is required to take into account recurrence of midface retrusion over the long term.