Assessing Amounts of Genetic Variability in Key Horticultural Traits Underlying Core Korean Breeding Lines of Cut Chrysanthemums.

The cut chrysanthemum holds one of the most substantial segments of the global floriculture market, particularly in Korea. We conducted a detailed assessment of the genetic structures across the cut chrysanthemum breeding lines in Korea. Using standard and spray chrysanthemum breeding lines from leading Korean research institutes, we first compared the variability of 12 horticultural traits, revealing a wide range of variation for most traits. We found that the overall flower diameter (OFD) and ray floret length (RFL) showed a solid positive relationship, regardless of the type. From a multivariate approach, OFD, RFL, and ray floret width (RFW) show consistently high association. Genotypic and phenotypic coefficients of variation analyses further indicated the significant genetic control over most traits. However, certain traits, like the volume of flowers (VF) in standard types, are more influenced by environments. Lastly, our analysis demonstrated substantial variability in broad-sense heritability (H); plant height (PH) consistently showed high H in both types. But the number of side branches (NOSB) and VF exhibited inconsistent H scores. These findings highlight the need for type-specific breeding strategies and modulating environmental management to optimize the trait expressions depending on the H scores, which offers significant implications for future breeding strategies.

Genetic Engineering and Genome Editing Advances to Enhance Floral Attributes in Ornamental Plants: An Update.

The ornamental horticulture industry is a highly dynamic and rapidly changing market. Constant development of novel cultivars with elite traits is essential to sustain competitiveness. Conventional breeding has been used to develop cultivars, which is often laborious. Biotechnological strategies such as genetic engineering have been crucial in manipulating and improving various beneficial traits that are technically not possible through cross-breeding. One such trait is the highly desired blue-colored flower in roses and chrysanthemums, which can be achieved through transgenic technology. Advances in genome sequencing platforms have enhanced the opportunities to access the whole genome sequence in various ornamentals, facilitating the dissection of the molecular genetics and regulatory controls of different traits. The recent advent of genome editing tools, including CRISPR/Cas9, has revolutionized plant breeding. CRISPR/Cas9-based gene editing offers efficient and highly precise trait modification, contributing to various beneficial advancements. Although genome editing in ornamentals is currently in its infancy, the recent increase in the availability of ornamental genome sequences provides a platform to extend the frontiers of future genome editing in ornamentals. Hence, this review depicts the implication of various commercially valuable ornamental attributes, and details the research attempts and achievements in enhancing floral attributes using genetic engineering and genome editing in ornamental plants.

Analysis of Floral Scent and Volatile Profiles of Different Aster Species by E-nose and HS-SPME-GC-MS.

Plants from the Aster species are known to be a rich source of bioactive chemical compositions and are popularly known for their medicinal properties. To investigate the relationship between the nine species of Aster, the floral fragrance and volatile profile patterns were characterized using E-nose and HS-SPME-GC-MS. Initial optimization for fragrance analysis was performed with Aster yomena using E-nose by evaluating the scent patterns in different flowering stages. Aster yomena exhibited varied scent patterns in each flowering stage, with the highest relative aroma intensity (RAI) in the full flowering stage. PCA analysis to compare and analyze the scent characteristics of nine Aster species, showed a species-specific classification. HS-SPME-GC-MS analysis of flowers from nine Aster species revealed 52 volatile compounds including ß-myrcene, α-phellandrene, D-limonene, trans-ß-ocimene, caryophyllene, and ß-cadinene. The terpenoid compounds accounted for the largest proportion. Among the nine Aster species flowers, Aster koraiensis had sesquiterpenes as the major component, and the remaining eight varieties had monoterpenes in abundance. These results could distinguish the species according to the scent patterns and volatile components of the nine Aster species. Additionally, flower extracts from the Aster species' plants exhibited radical scavenging antioxidant activity. Among them, it was confirmed that Aster pseudoglehnii, Aster maackii, and Aster arenarius had high antioxidant activity. In conclusion, the results of this study provide fundamental data of the volatile compound properties and antioxidant activity of Aster species, offering basic information of valuable natural sources that can be utilized in the pharmaceutical, perfume, and cosmetic industries.

Towards the Improvement of Ornamental Attributes in Chrysanthemum: Recent Progress in Biotechnological Advances.

Incessant development and introduction of novel cultivars with improved floral attributes are vital in the dynamic ornamental industry. Chrysanthemum (Chrysanthemum morifolium) is a highly favored ornamental plant, ranking second globally in the cut flower trade, after rose. Development of new chrysanthemum cultivars with improved and innovative modifications in ornamental attributes, including floral color, shape, plant architecture, flowering time, enhanced shelf life, and biotic and abiotic stress tolerance, is a major goal in chrysanthemum breeding. Despite being an economically important ornamental plant, the application of conventional and molecular breeding approaches to various key traits of chrysanthemum is hindered owing to its genomic complexity, heterozygosity, and limited gene pool availability. Although classical breeding of chrysanthemum has resulted in the development of several hundreds of cultivars with various morphological variations, the genetic and transcriptional control of various important ornamental traits remains unclear. The coveted blue colored flowers of chrysanthemums cannot be achieved through conventional breeding and mutation breeding due to technical limitations. However, blue-hued flower has been developed by genetic engineering, and transgenic molecular breeding has been successfully employed, leading to substantial progress in improving various traits. The recent availability of whole-genome sequences of chrysanthemum offers a platform to extensively employ MAS to identify a large number of markers for QTL mapping, and GWAS to dissect the genetic control of complex traits. The combination of NGS, multi-omic platforms, and genome editing technologies has provided a tremendous scope to decipher the molecular and regulatory mechanisms. However, the application and integration of these technologies remain inadequate for chrysanthemum. This review, therefore, details the significance of floral attributes, describes the efforts of recent advancements, and highlights the possibilities for future application towards the improvement of crucial ornamental traits in the globally popular chrysanthemum plant.

Silencing of Dihydroflavonol 4-reductase in Chrysanthemum Ray Florets Enhances Flavonoid Biosynthesis and Antioxidant Capacity.

Flavonoid biosynthesis requires the activities of several enzymes, which form weakly-bound, ordered protein complexes termed metabolons. To decipher flux regulation in the flavonoid biosynthetic pathway of chrysanthemum (Chrysanthemum morifolium Ramat), we suppressed the gene-encoding dihydroflavonol 4-reductase (DFR) through RNA interference (RNAi)-mediated post-transcriptional gene silencing under a floral-specific promoter. Transgenic CmDFR-RNAi chrysanthemum plants were obtained by Agrobacterium-mediated transformation. Genomic PCR analysis of CmDFR-RNAi chrysanthemums propagated by several rounds of stem cuttings verified stable transgene integration into the genome. CmDFR mRNA levels were reduced by 60-80% in CmDFR-RNAi lines compared to those in wild-type (WT) plants in ray florets, but not leaves. Additionally, transcript levels of flavonoid biosynthetic genes were highly upregulated in ray florets of CmDFR-RNAi chrysanthemum relative to those in WT plants, while transcript levels in leaves were similar to WT. Total flavonoid contents were high in ray florets of CmDFR-RNAi chrysanthemums, but flavonoid contents of leaves were similar to WT, consistent with transcript levels of flavonoid biosynthetic genes. Ray florets of CmDFR-RNAi chrysanthemums exhibited stronger antioxidant capacity than those of WT plants. We propose that post-transcriptional silencing of CmDFR in ray florets modifies metabolic flux, resulting in enhanced flavonoid content and antioxidant activity.

Recent Progress in Enhancing Fungal Disease Resistance in Ornamental Plants.

Fungal diseases pose a major threat to ornamental plants, with an increasing percentage of pathogen-driven host losses. In ornamental plants, management of the majority of fungal diseases primarily depends upon chemical control methods that are often non-specific. Host basal resistance, which is deficient in many ornamental plants, plays a key role in combating diseases. Despite their economic importance, conventional and molecular breeding approaches in ornamental plants to facilitate disease resistance are lagging, and this is predominantly due to their complex genomes, limited availability of gene pools, and degree of heterozygosity. Although genetic engineering in ornamental plants offers feasible methods to overcome the intrinsic barriers of classical breeding, achievements have mainly been reported only in regard to the modification of floral attributes in ornamentals. The unavailability of transformation protocols and candidate gene resources for several ornamental crops presents an obstacle for tackling the functional studies on disease resistance. Recently, multiomics technologies, in combination with genome editing tools, have provided shortcuts to examine the molecular and genetic regulatory mechanisms underlying fungal disease resistance, ultimately leading to the subsequent advances in the development of novel cultivars with desired fungal disease-resistant traits, in ornamental crops. Although fungal diseases constitute the majority of ornamental plant diseases, a comprehensive overview of this highly important fungal disease resistance seems to be insufficient in the field of ornamental horticulture. Hence, in this review, we highlight the representative mechanisms of the fungal infection-related resistance to pathogens in plants, with a focus on ornamental crops. Recent progress in molecular breeding, genetic engineering strategies, and RNAi technologies, such as HIGS and SIGS for the enhancement of fungal disease resistance in various important ornamental crops, is also described.

Alternative Splicing of the Basic Helix-Loop-Helix Transcription Factor Gene CmbHLH2 Affects Anthocyanin Biosynthesis in Ray Florets of Chrysanthemum (Chrysanthemum morifolium).

Chrysanthemum is an important ornamental crop worldwide. Some white-flowered chrysanthemum cultivars produce red ray florets under natural cultivation conditions, but little is known about how this occurs. We compared the expression of anthocyanin biosynthetic and transcription factor genes between white ray florets and those that turned red based on cultivation conditions to comprehend the underlying mechanism. Significant differences in the expression of CmbHLH2 were detected between the florets of different colors. CmbHLH2 generated two alternatively spliced transcripts, designated CmbHLH2Full and CmbHLH2Short . Compared with CmbHLH2Full , CmbHLH2Short encoded a truncated protein with only a partial MYB-interaction region and no other domains normally present in the full-length protein. Unlike the full-length form, the splicing variant protein CmbHLH2Short localized to the cytoplasm and the nucleus and could not interact with CmMYB6. Additionally, CmbHLH2Short failed to activate anthocyanin biosynthetic genes and induce pigment accumulation in transiently transfected tobacco leaves, whereas CmbHLH2Full promoted both processes when simultaneously expressed with CmMYB6. Co-expressing CmbHLH2Full and CmMYB6 also enhanced the promoter activities of CmCHS and CmDFR. Notably, the Arabidopsis tt8-1 mutant, which lacks red pigmentation in the leaves and seeds, could be complemented by the heterologous expression of CmbHLH2Full, which restored red pigmentation and resulted in red pigmentation in high anthocyanin and proanthocyanidin contents in the leaves and seeds, respectively, whereas expression of CmbHLH2Short did not. Together, these results indicate that CmbHLH2 and CmMYB6 interaction plays a key role in the anthocyanin pigmentation changes of ray florets in chrysanthemum. Our findings highlight alternative splicing as a potential approach to modulate anthocyanin biosynthesis in specific tissues.

Genome-wide analysis of the MADS-Box gene family in Chrysanthemum.

MADS-box family transcription factors play key roles in various developmental processes in plants. Here, we identified 108 MADS-box genes in the genome of chrysanthemum (Chrysanthemum nankingense). We classified these genes based on their phylogenetic relationships with MADS-box genes in Arabidopsis thaliana and lettuce (Lactuca sativa). Type I genes were subdivided into classes Mα (19 genes), Mß (12 genes), and Mγ (10 genes), and type II genes were subdivided into classes MIKCC (64 genes) and MIKC* (3 genes). The MIKCC class genes were further divided into 16 subclasses that included genes described in the ABCDE flower development model. Each group of MADS-box genes showed a specific pattern of conserved protein motifs and exon-intron structure. We analyzed the expression levels of each MADS-box gene in root, stem, leaf, flower bud, disc floret, and ray floret tissues. Subfamilies AGL18, FLC, and SVP contained more members in chrysanthemum. The asterid-specific TM8 subfamily and eleven Asteraceae Specific-MADS CnMADS genes were present in chrysanthemum. Chrysanthemum is the lacking members of the AGL15 subfamily. Among the genes responsible for the ABCDE model, B-class genes were expanded in chrysanthemum with three AP3 and four PI genes. One AP3 homolog functions in marginal ray floret development, whereas the two other AP3 homologs function in the development of the central disc floret. Two of the four PI genes are expressed in chrysanthemum, specifically in both types of florets. The results of this study lay the foundation for further studies of the roles of MADS-box genes in flower development in chrysanthemum and of the evolution of MADS-box genes in plants.

Cloning and Functional Characterization of Dihydroflavonol 4-Reductase Gene Involved in Anthocyanin Biosynthesis of Chrysanthemum.

Dihydroflavonol 4-reductase (DFR) catalyzes a committed step in anthocyanin and proanthocyanidin biosynthesis by reducing dihydroflavonols to leucoanthocyanidins. However, the role of this enzyme in determining flower color in the economically important crop chrysanthemum (Chrysanthemum morifolium Ramat.) is unknown. Here, we isolated cDNAs encoding DFR from two chrysanthemum cultivars, the white-flowered chrysanthemum "OhBlang" (CmDFR-OB) and the red-flowered chrysanthemum "RedMarble" (CmDFR-RM) and identified variations in the C-terminus between the two sequences. An enzyme assay using recombinant proteins revealed that both enzymes catalyzed the reduction of dihydroflavonol substrates, but CmDFR-OB showed significantly reduced DFR activity for dihydrokaempferol (DHK) substrate as compared with CmDFR-RM. Transcript levels of anthocyanin biosynthetic genes were consistent with the anthocyanin contents at different flower developmental stages of both cultivars. The inplanta complementation assay, using Arabidopsis thaliana dfr mutant (tt3-1), revealed that CmDFR-RM, but not CmDFR-OB, transgenes restored defective anthocyanin biosynthesis of this mutant at the seedling stage, as well as proanthocyanidin biosynthesis in the seed. The difference in the flower color of two chrysanthemums can be explained by the C-terminal variation of CmDFR combined with the loss of CmF3H expression during flower development.

Anthocyanins in Floral Colors: Biosynthesis and Regulation in Chrysanthemum Flowers.

Chrysanthemum (Chrysanthemum morifolium) is an economically important ornamental crop across the globe. As floral color is the major factor determining customer selection, manipulation of floral color has been a major objective for breeders. Anthocyanins are one of the main pigments contributing to a broad variety of colors in the ray florets of chrysanthemum. Manipulating petal pigments has resulted in the development of a vast range of floral colors. Although the candidate genes involved in anthocyanin biosynthesis have been well studied, the genetic and transcriptional control of floral color remains unclear. Despite advances in multi-omics technology, these methods remain in their infancy in chrysanthemum, owing to its large complex genome and hexaploidy. Hence, there is a need to further elucidate and better understand the genetic and molecular regulatory mechanisms in chrysanthemum, which can provide a basis for future advances in breeding for novel and diverse floral colors in this commercially beneficial crop. Therefore, this review describes the significance of anthocyanins in chrysanthemum flowers, and the mechanism of anthocyanin biosynthesis under genetic and environmental factors, providing insight into the development of novel colored ray florets. Genetic and molecular regulatory mechanisms that control anthocyanin biosynthesis and the various breeding efforts to modify floral color in chrysanthemum are detailed.

A comparative analysis of the complete chloroplast genomes of three Chrysanthemum boreale strains.

BACKGROUND: Chrysanthemum boreale Makino (Anthemideae, Asteraceae) is a plant of economic, ornamental and medicinal importance. We characterized and compared the chloroplast genomes of three C. boreale strains. These were collected from different geographic regions of Korea and varied in floral morphology. METHODS: The chloroplast genomes were obtained by next-generation sequencing techniques, assembled de novo, annotated, and compared with one another. Phylogenetic analysis placed them within the Anthemideae tribe. RESULTS: The sizes of the complete chloroplast genomes of the C. boreale strains were 151,012 bp (strain 121002), 151,098 bp (strain IT232531) and 151,010 bp (strain IT301358). Each genome contained 80 unique protein-coding genes, 4 rRNA genes and 29 tRNA genes. Comparative analyses revealed a high degree of conservation in the overall sequence, gene content, gene order and GC content among the strains. We identified 298 single nucleotide polymorphisms (SNPs) and 106 insertions/deletions (indels) in the chloroplast genomes. These variations were more abundant in non-coding regions than in coding regions. Long dispersed repeats and simple sequence repeats were present in both coding and noncoding regions, with greater frequency in the latter. Regardless of their location, these repeats can be used for molecular marker development. Phylogenetic analysis revealed the evolutionary relationship of the species in the Anthemideae tribe. The three complete chloroplast genomes will be valuable genetic resources for studying the population genetics and evolutionary relationships of Asteraceae species.

Comparative Analysis of the Complete Chloroplast Genome of Mainland Aster spathulifolius and Other Aster Species.

Aster spathulifolius, a common ornamental and medicinal plant, is widely distributed in Korea and Japan, and is genetically classified into mainland and island types. Here, we sequenced the whole chloroplast genome of mainland A. spathulifolius and compared it with those of the island type and other Aster species. The chloroplast genome of mainland A. spathulifolius is 152,732 bp with a conserved quadripartite structure, has 37.28% guanine-cytosine (GC) content, and contains 114 non-redundant genes. Comparison of the chloroplast genomes between the two A. spathulifolius lines and the other Aster species revealed that their sequences, GC contents, gene contents and orders, and exon-intron structure were well conserved; however, differences were observed in their lengths, repeat sequences, and the contraction and expansion of the inverted repeats. The variations were mostly in the single-copy regions and non-coding regions, which, together with the detected simple sequence repeats, could be used for the development of molecular markers to distinguish between these plants. All Aster species clustered into a monophyletic group, but the chloroplast genome of mainland A. spathulifolius was more similar to the other Aster species than to that of the island A. spathulifolius. The accD and ndhF genes were detected to be under positive selection within the Aster lineage compared to other related taxa. The complete chloroplast genome of mainland A. spathulifolius presented in this study will be helpful for species identification and the analysis of the genetic diversity, evolution, and phylogenetic relationships in the Aster genus and the Asteraceae.

Immediate Reconstruction of Amputated Ear With Fascia Flap.

BACKGROUND: Various surgical methods have been used for reconstruction of an amputated ear, including microsurgical replantation and delayed reconstruction using synthetic material or autologous rib cartilage. The authors share our experience of immediate reconstruction using amputated cartilage and discuss the advantages compared to other techniques of reconstruction. MATERIALS AND METHODS: The authors retrospectively reviewed the medical records of 3 patients who underwent immediate reconstruction of amputated ear by a single operator. In the cases, the amputees were washed; the skin and cartilage were separated. The ear cartilage was fixed to its original position with non-absorbable suture. Regional fascia flap was elevated and covered the ear cartilage. The amputee skin was redraped to cover the fascia flap. Several months after the operation, photographic assessment was done. RESULTS: All 3 cases showed well-defined convolution, tolerable skin color, and patient satisfaction without any major complications. A patient showed mild temporal incision site alopecia. CONCLUSION: The above immediate reconstruction method can achieve reliable and favorable result with minimal complications.

De-epithelialized dermal flap for nipple reconstruction: A modified star flap.

BACKGROUND: Multiple approaches for nipple reconstruction exist, and none is considered superior to all others. The star flap is one of the most popular methods for nipple reconstruction, but gradual height loss is a major concern. We present a new modification of the star flap that incorporates a de-epithelialized dermal flap, along with the associated surgical results. METHODS: We reviewed the medical records of patients who underwent nipple reconstruction using the modified star flap method. The design was different from the conventional star flap in that the lateral wings were changed into a trapezoidal shape and de-epithelialized dermal flaps were added. The patients were followed up at 2, 4, 6, and 12 months postoperatively, and nipple height was measured. The postoperative nipple height achieved using the modified method was compared with that obtained using the traditional method. RESULTS: From February 2013 to June 2017, 32 patients received surgery using the modified star flap, and 18 patients who underwent nipple reconstruction before 2013 comprised the conventional method group. All patients had undergone breast reconstruction with an abdominal tissue-based flap. The mean follow-up period was 14.4 months in the modified method group and 17.3 months in the conventional method group. The mean maintenance of projection at 12 months postoperatively was 56.28%±18.58% in the modified method group, and 44.23%±14.15% in the conventional method group. This difference was statistically significant (P<0.05). CONCLUSIONS: The modified method using a de-epithelialized dermal flap provides reliable maintenance of projection in patients who have undergone abdominal tissue-based breast reconstruction.

Protective Effect of Botulinum Toxin against Ultraviolet-Induced Skin Pigmentation.

BACKGROUND: Hyperpigmentation following ultraviolet irradiation has cosmetic concerns. Botulinum toxin type A can favorably affect skin pigmentation. However, the mechanism of skin pigmentation is unclear. METHODS: In vitro, human epidermal melanocytes were co-cultured with human keratinocytes. After cells were treated with botulinum toxin type A, cell morphology, proliferation, and dendricity were analyzed, and immunofluorescence, tyrosinase activity, and melanin contents were determined. To evaluate the effect of botulinum toxin type A on ultraviolet B-irradiated mouse skin, ultraviolet B alone was applied to one side of the back of each mouse as a control, whereas ultraviolet B plus injection of botulinum toxin type A was applied to the contralateral side. Skin pigmentation, histology, and the number of dihydroxyphenylalanine-positive melanocytes were evaluated. The L* colorimeter value was measured. Enzyme-linked immunosorbent assay determinations of basic fibroblast growth factor, interleukin-1 alpha, and prostaglandin E2 were performed. RESULTS: Immunohistochemical staining revealed botulinum toxin type A in the cytoplasm of melanocytes and in the positive control. In vitro, melanocyte dendricity and melanin contents were decreased slightly but significantly (p < 0.05) after botulinum toxin type A treatment. In vivo, botulinum toxin type A suppressed skin pigmentation. The number of dihydroxyphenylalanine-positive melanocytes was also significantly lower than in the control side. Tyrosinase activity and melanin content were also significantly reduced (p < 0.05). Botulinum toxin type A also significantly reduced the amounts of basic fibroblast growth factor, interleukin-1 alpha, and prostaglandin E2 (all p < 0.05). CONCLUSION: Botulinum toxin type A can suppress epidermal melanogenesis through both direct and indirect mechanisms.

Subnasal Lip Lifting in Aging Upper Lip: Combined Operation with Nasal Tip Plasty in Asians.

BACKGROUND: The objective of this study was to illustrate a novel technique for lifting of the aging upper lip with nasal tip plasty in Asians. With this procedure, a shortening of the philtrum, an increase of the vermilion, and a natural and nicer mouth can be obtained, with increase of the tip of the nose simultaneously. METHODS: Thirty patients were the subjects of this study. Incisions were made bilaterally beginning at the alar fold, entering nostrils, and rising medially on the skin below the lower margin of the medial crura. Excess skin of the philtrum was eliminated in two separate pieces and the muscle was suspended to the base of the nose with interrupted stitches. RESULTS: All patients expressed a high degree of satisfaction. The average ratio between the L1 reference line and the height of the upper lip measurement preoperatively was 0.43 ± 0.05. This ratio was improved postoperatively to an average of 0.32 ± 0.05. The nasolabial angle was 91.31 ± 4.19 degrees before surgery and 105.62 ± 5.04 degrees after surgery. The angle of the upper lip was 48.97 ± 2.41 degrees before surgery and 38.21 ± 3.34 degrees after surgery. CONCLUSIONS: Lip lift is an effective tool for correcting a natural tendency of the upper lip to cover the upper teeth during aging. There is a dramatic improvement in the patient's facial aesthetic appearance during smiling and at rest. The authors strongly recommend this technique as part of the surgical procedure to achieve a youthful face. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

The complete chloroplast genome of an economic plant, Chrysanthemum morifolium 'Baekma'.

Chrysanthemum morifolium (Dendranthema grandiflorum), known as florist's daisy is an important ornamental and medicinal plant of the Asteraceae family. The complete chloroplast genome sequence of one economic cultivar 'Baekma' was 151,060 bp in length with a large single copy (LSC) region (82,862 bp), a small single copy (SSC) region (18,294 bp) and two inverted repeats (IRs) (24,952 bp). It contained 130 genes, including 85 protein-coding genes, 8 rRNAs and 37 tRNAs. The overall GC content was 37%. Phylogenetic analysis showed that C. morifolium 'Baekma' was grouped together with other Chrysanthemum species.

Mandibular reconstruction using customized three-dimensional titanium implant.

Mandibular defects lead to severe deformation and functional deficiency. Vascularized osteocutaneous tissue has been widely used to reconstruct the mandible. However, it is technically challenging to shape this type of grafts in such a manner that they resemble the configuration of the mandible. A 48-year-old female patient who underwent anterolateral thigh (ALT) flap coverage after a tongue cancer excision was diagnosed with a tumor recurrence during the follow-up. A wide excision mandibulectomy and mandibular reconstruction with an ALT flap and a titanium implant were performed. The prefabricated titanium implant was fixed to the condyle. Then, an ALT flap was harvested from the ipsilateral thigh and anastomosed. After confirming that the circulation of the flap was intact, the implant was fixed to the parasymphysis. On the radiograph taken after the surgery, the prosthesis was well positioned and overall facial shape was acceptable. There was no postoperative complication during the follow-up period, 1 year and 2 months. The prefabricated implant allows the restoration of facial symmetry without harvesting autologous bone and it is a safe and effective surgical option for mandibular reconstruction.

Asymptomatic Deep Vein Thrombosis during Free Flap: Concerns in Free Flap Surgery.

BACKGROUND: Venous insufficiency is the most frequent cause of failure in free flap reconstruction of the lower extremity. When deep vein thrombosis is detected during preoperative assessment of the lower extremity, decisions regarding treatment plans become difficult, and no relevant guidelines regarding surgery and preoperative treatment of patients with deep vein thrombosis who need a free flap transfer are currently available. METHODS: To find a relevant guideline in decision-making regarding surgery and preoperative treatment of patients with deep vein thrombosis who require free flap reconstruction, a systematic literature review was conducted searching MEDLINE, PubMed Central, Cochrane, and Embase databases for articles published between 1996 and 2015. In addition, the authors introduced six of their cases of deep vein thrombosis diagnosed before free flap surgery in which the flap survived. RESULTS: The literature review identified two articles that discussed intraoperative deep vein thrombosis diagnosed in three patients, including the reported cases. Analyses included epidemiology, cause, and management strategy. A consensus for the management of asymptomatic deep vein thrombosis before free flap surgery is still lacking. In the authors' cases, successful flap transfer was possible by proceeding with an appropriate preoperative evaluation, intensive anticoagulation treatment, intraoperative reperfusion procedure, and postoperative care. CONCLUSION: Preoperatively detected asymptomatic deep vein thrombosis is not a contraindication for free flap reconstruction, and a flap transfer can be successfully performed with suitable planning and management. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.