Does Lymphovenous Anastomosis Effect Mammalian Target of Rapamycin Inhibitor-associated Lymphedema Patients?

The mammalian target of rapamycin (mTOR) inhibitors are used to prevent organ transplant rejection and are preferred over other immunosuppressants due to its low nephrotoxicity. However, mTOR inhibitors have been associated with various adverse effects including lymphedema. Although rare in incidence, previously known treatments for mTOR inhibitor-induced lymphedema were limited to discontinuation of related drugs and complex disruptive therapy with variable results. In this article, three patients who developed lymphedema in their lower limbs after using mTOR inhibitors, including two bilateral and one unilateral case, were treated with physiologic surgery methods such as lymphovenous anastomosis (LVA) and lymph node transfer. The efficacy of the treatment was evaluated. In the three cases described, cessation of the drug did not lead to any reduction in edema. The use of LVA and lymph node transfer resulted in early reductions in volume but failed to sustain over time. All patients underwent secondary nonphysiologic surgery such as liposuction resulting in sustained improvement. This series presents the first physiologic approach to mTOR inhibitor-induced lymphedema. Although further study is warranted, the physiologic surgical options may have limited success and nonphysiologic options may offer better sustainable results.

Analysis of flap thickness to breast projection ratio correlating to body mass index and age in east Asian women: Considerations in flap selection in breast reconstruction.

BACKGROUND: Several alternative flaps have been introduced and used for autologous breast reconstruction. However, as body fat distribution is different among patients, the donor of choice for sufficient breast projection varies between patients. METHODS: Patients who underwent autologous breast reconstruction from Jan 2018 to Sep 2022 were included. Age, body mass index (BMI), smoking history and hypertension, and diabetes occurrence were collected as baseline demographic data. Breast projection with five types of flap thickness was measured based on computed tomography angiography. Analysis was performed for five major autologous flaps for breast reconstruction. RESULTS: A total of 563 patients were included in the study. The mean age of the patients was 47.4 ± 7.9 (standard deviation; SD) years. The mean BMI of the patients was 24.0 ± 3.4 kg/m2. Only the correlation between flap thickness to breast projection ratio and age in the PAP flap illustrated statistical significance (p = .039), but the correlation coefficient was quite low (r = -0.087). Slim patients who had lower BMIs (under 25 kg/m2) had significantly higher sufficient flap thickness for breast reconstruction than patients with higher BMIs over 25 kg/m2 in the profunda artery perforator (PAP) flap (p < .001), the lumbar artery perforator (LAP) flap (p < .001), and the superior gluteal artery perforator (SGAP) flap (p < .001). CONCLUSIONS: The deep inferior epigastric perforator flap provided sufficient thickness and was not usually affected by age and BMI. The PAP, LAP, and SGAP flaps tended to maintain the thickness of the flap even when BMI decreased, so they are advantageous for reconstruction in slim patients. This study contributes evidence in consideration of flap selection in autologous breast reconstruction.

The Effect of 3-Dimensional-Printed Sequential Dual Drug-Releasing Patch on the Capsule Formation Around the Silicone Implant in a Rat Model.

BACKGROUND: Implant-based breast reconstruction is associated with increased risk of early infection and late-stage capsular contracture. OBJECTIVES: We evaluated the feasibility of a dual drug-releasing patch that enabled the controlled delivery of antibiotics and immunosuppressants in a temporally and spatially appropriate manner to the implant site. METHODS: The efficacy of a dual drug-releasing patch, which was 3-dimensional-printed (3D-printed) with tissue-derived biomaterial ink, was evaluated in rats with silicone implants. The groups included implant only (n = 10); implant plus bacterial inoculation (n = 14); implant, bacterial inoculation, and patch loaded with gentamycin placed on the ventral side of the implant (n = 10), and implant, bacterial inoculation, and patch loaded with gentamycin and triamcinolone acetonide (n = 9). Histologic and immunohistochemical analyses were performed 8 weeks after implantation. RESULTS: The 2 drugs were sequentially released from the dual drug-releasing patch and exhibited different release profiles. Compared to the animals with bacterial inoculation, those with the antibiotic-only and the dual drug-releasing patch exhibited thinner capsules and lower myofibroblast activity and inflammation, indicating better tissue integration and less foreign body response. These effects were more pronounced with the dual drug-releasing patch than with the antibiotic-only patch. CONCLUSIONS: The 3D-printed dual drug-releasing patch effectively reduced inflammation and capsule formation in a rat model of silicone breast reconstruction. The beneficial effect of the dual drug-releasing patch was better than that of the antibiotic-only patch, indicating its therapeutic potential as a novel approach to preventing capsular contracture while reducing concerns of systemic side effects.

Comparative Study of Small Vessel (under 0.8 mm) Anastomosed Free Flap and Larger Vessel (over 0.8 mm) Anastomosed Free Flap; Does Supermicrosurgery Provide Sufficient Blood Flow to the Free Flap?

BACKGROUND: This study aimed to quantify the blood flow of free flaps and compare the blood flow of small vessel (<0.8 mm) and larger vessel (>0.8 mm) anastomosed free flaps. METHODS: This retrospective study included patients treated successfully with a perforator free flap in the lower extremity between June 2015 and March 2017. A color duplex ultrasound system measured the flow volume through the pedicle by analyzing the mean flow peak velocity, flow volume, and flow volume per 100 g of the flap. RESULTS: A total of 69 patients were enrolled in this study. There was no statistical difference in peak velocity between the small vessel anastomosed free flap (25.2 ± 5.6) and larger vessel anastomosed free flap (26.5 ± 5.4). Flow volume (6.8 ± 4.2 vs. 6.3 ± 3.6) and flow volume/100 g (3.6 ± 3.9 vs. 6.2 ± 6.9) also did not show significant differences. CONCLUSION: Small vessel (<0.8 mm) free flaps showed similar flow velocity and flow volume to larger vessel (>0.8 mm) anastomosed free flaps. Blood flow to the small vessel anastomosed free flap was sufficient despite its small vessel size.

Human-Mimic Submuscular and Premuscular Irradiated Rat Model: Histologic Characteristics of the Capsule Tissue in Contact with the Breast Implant.

Background: In this study, we established two rat models that mimic human submuscular and premuscular breast reconstruction. We analyzed the capsule formation according to surgical techniques and adjacent tissues, including the chest wall tissues, such as the ribs and acellular dermal matrices (ADMs) that come in contact with silicone implants. Methods: This study consisted of experiments on 12 Sprague-Dawley rats that underwent implant reconstruction using ADM. They were divided into two groups: rats that underwent dual-plane implantation (n = 6; group 1) and those that underwent premuscular implant insertion (n = 6; group 2). All rats were irradiated with 35 Gy of fractionated radiation. Three months after surgery, the histology and immunochemistry of the capsule tissues of the ADM, muscle, and chest wall were analyzed. Results: Overall capsule thickness was thicker in group 1. Based on the tissue in contact with the silicone implant, ADM had a thinner capsule, less inflammation, less fibrosis, and less vascularization than the muscle and chest wall tissues. Conclusions: This study described two rat models of clinically relevant implant-based breast reconstruction using a submuscular and premuscular plane, ADM, and irradiation. Overall, the premuscular implantation rat model was associated with a thinner capsule. The ADM in contact with the silicone implant, even after irradiation, had superior protection from radiation compared with the other tissues.

Conventional versus Robot-assisted Immediate Breast Reconstruction: Reconstructive Outcome and Patient-reported Outcome Measures (PROMs).

BACKGROUND: This study compared conventional and robot-assisted mastectomy and breast reconstruction. To the best of our knowledge, this study is the first to report the results of robot-assisted mastectomy and breast reconstruction as well as a comparison of patient-reported outcomes. METHOD: A retrospective study included 473 breasts of 423 patients who underwent conventional mastectomy and breast reconstruction and 164 breasts of 153 patients who underwent robot-assisted mastectomy and breast reconstruction from July 2019 to October 2021. Demographic and oncologic data, reconstructive outcomes, and patient-reported outcomes (BREAST-Q) were evaluated. The results of implant-based and autologous breast reconstruction were separately evaluated. RESULTS: Skin necrosis requiring surgical debridement occurred significantly more frequently in the conventional group (8.0%) than in the robot-assisted group (2.0%) in implant-based reconstruction (p=0.035). At 6-12 months, robot-assisted breast reconstruction showed a higher sexual wellbeing score for implant-based reconstruction and a higher physical wellbeing score for autologous breast reconstruction than conventional breast reconstruction according to the BREAST-Q questionnaire. CONCLUSION: Robot-assisted mastectomy and breast reconstruction was associated with less skin necrosis and better patient-reported outcomes (sexual wellbeing for implant-based reconstruction and physical wellbeing for autologous breast reconstruction) than the conventional option. Robotic surgery could be a good option for mastectomy and breast reconstruction.

Magnetic Resonance Imaging Surveillance Study of Silicone Implant-based Breast Reconstruction: A Retrospective Observational Study.

This study aimed to evaluate the results of magnetic resonance imaging (MRI) surveillance of implant-based breast reconstruction in patients with breast cancer. Methods: This retrospective observational study analyzed patients who underwent implant-based breast reconstruction and MRI surveillance by a single surgeon from March 2011 to December 2018, in a single center. All patients were informed about the recommendation of the Food and Drug Administration for MRI surveillance, and they choose to undergo MRI 3 years after surgery. Results: The compliance rate for MRI surveillance was 56.5% (169/299). MRI surveillance was performed at a mean of 45.8 (4.04 years) ± 11.5 months after surgery. One patient (0.6%) showed an abnormal finding of an intracapsular rupture of the silicone implant. Conclusions: MRI surveillance for implant rupture in implant-based breast reconstruction showed a low incidence of silent implant rupture (0.6%), whereas the compliance of MRI was relatively high (56.5%). These results raise questions about whether taking an MRI in 3-4 years is suitable for imaging surveillance of breast silicone implants. Screening recommendations should be more evidence-based, and more studies are needed to prevent unnecessary screening and patient burden.

Difference in the Occurrence of Capsular Contracture According to Tissue Characteristics in an Irradiated Rat Model.

BACKGROUND: This study was performed to evaluate the hypothesis that capsule formation varies according to the radiation dose in muscle tissues; chest wall tissues, including the ribs; and acellular dermal matrices (ADM) that are in contact with the silicone implant. METHODS: In this study, 20 Sprague-Dawley rats underwent submuscular plane implant reconstruction using ADM. They were divided into four groups: an unradiated control group ( n = 5), nonfractionated radiation at a dose of 10 Gy ( n = 5), nonfractionated radiation at a dose of 20 Gy ( n = 5), and fractionated radiation at a dose of 35 Gy ( n = 5). Three months after surgery, hardness was measured, and histologic and immunochemical analyses of the capsule tissues of the ADM, muscle tissues, and chest wall tissues were analyzed. RESULTS: As the radiation dose increased, the silicone implant became harder, but no significant difference in capsule thickness according to the radiation dose was observed. Based on the tissue in contact with the silicone implant, ADM had a thinner capsule thickness than the muscle tissues, as well as less inflammation and less neovascularization compared with the other tissues. CONCLUSIONS: This study describes a new rat model of clinically relevant implant-based breast reconstruction using a submuscular plane and ADM with irradiation. The ADM in contact with the silicone implant, even after irradiation, was protected from radiation compared with the other tissues. CLINICAL RELEVANCE STATEMENT: These research results could support the use of ADM in implant-based breast reconstruction for prevention of the capsular contracture, even after radiation.

Cadaveric Study for Safe Elevation of a Profunda Artery Perforator Flap: Anatomy of the Perforators and Obturator Nerves.

BACKGROUND: This cadaveric study aimed to describe the anatomy of the profunda artery perforators (PAPs). METHODS: In total, nine free cadavers with 18 upper thighs were dissected, 12 of which were from female cadavers, and 6 were from male cadavers. The average age of the cadavers was 84.7 ± 4.2 years. Dissection was performed to evaluate the anatomic position and characteristics of the femoral PAPs. The perforator distance from the gluteal sulcus, number of perforators, perforating muscles, diameter of the perforators, origin of the perforators, and number of nerves passing above and below the perforators were determined. RESULTS: The average number of perforators that penetrate the adductor magnus muscle was 2.5. The average distance from the origin of the perforators to the gluteal sulcus was 71.72 ± 28.23 mm. The average numbers of the obturator nerves passing above and below the perforator in the adductor magnus muscle were 1.3 (range, 0-4) and 0.7 (range, 0-2), respectively. CONCLUSION: The results provide a detailed anatomic basis for the PAP flap. The perforators of a PAP flap may be included in a flap with a transverse design. Sacrificing the small obturator nerves during dissection may not lead to significant donor site morbidity.

Comparative Study of DIEP and PAP Flaps in Breast Reconstruction: Reconstructive Outcomes and Fat Necrosis.

BACKGROUND: This study compared the reconstructive outcomes and fat necrosis of the profunda artery perforator (PAP) flap with those of the deep inferior epigastric perforator (DIEP) flap. METHODS: Data on all DIEP and PAP flap breast reconstructions performed between 2018 and 2021 at Asan Medical Center were compared. The overall reconstructive outcomes and presence of fat necrosis were analyzed through ultrasound evaluation performed by a board-certified radiologist. RESULTS: The PAP (n = 43) and DIEP flaps (n = 99) were used to reconstruct 31 and 99 breasts, respectively. The average age of the patients in the PAP flap group (39.1 ± 7.3 years) was lower than in the DIEP flap group (47.4 ± 7.7 years), and the body mass index (BMI) of patients undergoing PAP flap reconstruction (22.7 ± 2.8 kg/m2) was lower than those undergoing DIEP flap reconstruction (24.3 ± 3.4 kg/m2). There was no total loss of both flaps. Donor site morbidity was higher in the PAP flap group (11.1%) compared with the DIEP flap (1.0%). The rate of fat necrosis was higher in the PAP flaps (40.7%) than in the DIEP flaps (17.8%) during ultrasound. CONCLUSION: In our study, we found that PAP flap reconstruction tended to be performed in patients who were younger with lower BMIs compared with the DIEP flap. Successful reconstructive outcomes were observed in both the PAP and DIEP flaps; however, a higher rate of necrosis was observed in the PAP flap compared with the DIEP flap.

The Fate of Sensation in Noninnervated Perforator Free Flaps in the Lower Extremity.

BACKGROUND: The recovery of sensation for noninnervated perforator flaps is not well understood. This prospective study aims to evaluate the quality, tendency, and related factors for recovery of sensation. METHODS: A total of 187 patients over a 6-year period were evaluated at intervals of 3, 6, 12, and +24 months for demographic data and sensory tests [Semmes-Weinstein (SW) monofilament test, static two-point discrimination, temperature, and pain] on peripheral and central regions of the flap. Further detailed assessment using the SW monofilament test was made according to flap thickness, size, type, and recipient sites. Factors correlated to poor recovery were evaluated. RESULTS: Among the flaps tested, the 5.07 SW monofilament test revealed that the peripheral flap sensory recovery was achieved in 72% at +24 months with a significantly increasing linear trend ( P < 0.001). However, the central recovery was noted in only 26% to 28%. The two-point discrimination was achieved in 21% without a significant trend, whereas temperature and pain showed significant improvement, achieving 49% and 64% on the peripheral region and 22% and 31% for the central region, respectively. The flap thickness, size, type, and recipient sites did not exert significance. Only smoking was a significant factor, with 13 times higher odds of hindering sensory recovery. CONCLUSIONS: The SW monofilament test, temperature, and pain sensation on the periphery of the flap showed increasing trend of recovery over the +24 months. Among the various factors, only smoking attenuated recovery. Understanding the fate of sensory recovery in noninnervated perforator flaps will allow the surgeons to further customize the reconstruction based on the defect and maximize efficiency. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Maximizing the Versatility of Thin Flap from the Groin Area as a Workhorse Flap: The Selective Use of Superficial Circumflex Iliac Artery Perforator (SCIP) Free Flap and Superficial Inferior Epigastric Artery (SIEA) Free Flap with Precise Preoperative Planning.

BACKGROUND: This study aimed to evaluate the usefulness of the selective use of the superficial circumflex iliac artery perforator (SCIP) and the superficial inferior epigastric artery (SIEA) flap as a workhorse flap from the groin area with precise preoperative surgical planning. METHODS: A total of 79 free flap reconstructions were performed in the study period; 35 SCIP free flaps and 19 SIEA free flaps were performed in the study period. Detailed preoperative surgical planning was performed using computed tomography (CT) angiography and color Doppler ultrasound. Detailed anatomical information of the flaps and reconstructive outcomes were evaluated. RESULTS: Flap characteristics between SCIP free flaps and SIEA free flaps were similar. The average transverse distance of the perforator from anterior superior iliac spine was 15.91 cm in SCIP free flaps and 43.15 cm in SIEA free flaps. The overall flap success rate was 96.4%. Majority of the patients achieved satisfactory contour without debulking surgery. Donor site morbidity was minimal with one case of wound dehiscence. CONCLUSION: The selective use of the SCIP and SIEA free flap in groin area is a safe and useful technique. The surgical outcomes were reliable and similar between the SCIP and SIEA free flaps. Preoperative vascular planning using CT angiography and color Doppler ultrasound is essential for selecting the proper flap.

Comparative Analysis of Preoperative High Frequency Color Doppler Ultrasound versus MR Lymphangiography versus ICG Lymphography of Lymphatic Vessels in Lymphovenous Anastomosis.

BACKGROUND: Despite the extensive use of various imaging modalities, there is limited literature on comparing the reliability between indocyanine green (ICG) lymphography, MR Lymphangiogram (MRL), and high frequency color Doppler ultrasound (HFCDU) to identify lymphatic vessels. METHOD: In this study of 124 patients, the correlation between preoperative image findings to the actual lymphatic vessel leading to lymphovenous anastomosis (LVA) was evaluated. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and simple detection were calculated. Subgroup analysis was also performed according to the severity of lymphedema. RESULTS: Total of 328 LVAs were performed. The HFCDU overall had significantly higher sensitivity for identifying lymphatic vessels (99%) over MRL (83.5%) and ICG lymphography (82.3%)(p < 0.0001). Both ICG lymphography and HFCDU had 100% specificity and PPV. The NPV was 3.6%, 6.5% and 57.1% respectively for MRL, ICG lymphography, and HFCDU. All modalities showed high sensitivity for early stage 2 lymphedema while HFCDU showed a significantly higher sensitivity for late stage 2 (MRL:79.7%, ICG:83.1%, HFCDU:97%) and stage 3 (MRL:79.7%, ICG:79.7%, HFCDU:100%) over the other two modalities (p < 0.0001). CONCLUSION: This study demonstrated while all three modalities are able to provide good information, the sensitivity may alter as the severity of lymphedema progresses. The HFCDU will provide the best detection for lymphatic vessels throughout all stages of lymphedema. However, as each modality provides different and unique information, combining and evaluating the data according to the stage of lymphedema will be able to maximize the chance for a successful surgical outcome.

Using Duplex Ultrasound for Recipient Vessel Selection.

BACKGROUND: Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result. METHODS: Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel. RESULTS: Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery. CONCLUSION: As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.

The Use of Color Duplex Ultrasound for Local Perforator Flaps in the Extremity.

BACKGROUND: The local flaps, especially perforator and keystone flaps, are used as first-line treatment option in reconstruction of small tomoderate-sized defect of the extremity. However, the high complication rate associated with these flaps may hinder this usage. METHODS: This article reviews the technical and clinical aspect of using color duplex ultrasound )CDU) in the preoperative, intraoperative, and postoperative period for propeller and keystone flaps. RESULTS: CDU allows the surgeon to understand the anatomical aspect of the perforator such as the location, point of penetration on the deep fascia, subcutaneous pathway )axiality) and physiological aspect such as velocity and flow volume. Understanding and utilizing this information will allow accurate preoperative design, intraoperative decision making, and postoperative monitoring, leading to better outcome. CONCLUSION: Carefully designed local perforator flaps based on anatomy and physiology using CDU will be a powerful armamentarium for reconstruction of the lower extremity.

Maximizing the Flap Inflow in a Foot Reconstruction: Ultrasonographic Evaluation of Artery Flow in Accordance with the Angle of the Ankle.

SUMMARY: Adequate arterial inflow is mandatory for a successful free tissue transfer. Maximizing this inflow appears to be especially important during distal lower extremity reconstruction, where perfusion pressures can be significantly lower than in the trunk or head and neck. In the current study, the authors used color and pulsed-wave Doppler ultrasonography to analyze blood flow volumes in the foot in accordance with the ankle position. Twenty feet of 10 healthy subjects were included in the analyses. All subjects were examined by Doppler ultrasonography at three different ankle angles (dorsiflexion at 90 degrees, relaxed position, and complete plantar flexion). The average flow volumes of the dorsalis pedis artery varied dramatically at the different ankle positions, as follows: dorsiflexion, 19.81 ± 3.88 ml/minute; relaxed position, 11.71 ± 4.72 ml/minute; and plantar flexion, 3.47 ± 1.41 ml/minute. The average flow volume of the posterior tibial artery also varied dramatically at these different ankle positions: dorsiflexion, 9.08 ± 8.25 ml/minute; relaxed position, 14.78 ± 2.45 ml/minute; and plantar flexion, 19.03 ± 5.03 ml/minute. The ankle position dramatically affects the flow velocity in the anterior and posterior tibial vessels, which is an important consideration when performing free tissue transfer reconstruction of the foot. Ankle dorsiflexion would be recommended when using the anterior tibial artery as a recipient vessel, whereas plantar flexion of the ankle would be advised when the posterior tibial artery is used as a recipient vessel.

Reconstruction Using Free Flaps for Diabetic Heel Defects: Outcomes and Risk Factor Analysis.

BACKGROUND: Overall success rate after diabetic foot reconstruction using free flap has been acceptable, but certain parts of the foot like the heel remains more challenging. PATIENTS AND METHODS: This retrospective study reviewed 37 patients reconstructed with free flaps for diabetic foot ulcer on the heel region from 2008 to 2017. Flap outcome in addition to various risk factors were analyzed; arterial status on heel, the American Society of Anesthesiologists (ASA) physical status, smoking, hypertension, hypercholesterolemia, chronic renal failure patient, hemoglobin A1c level, C-reactive protein, and osteomyelitis. RESULTS: Overall flap survival was 73% and resulted in limb salvage and functional ambulation. Total flap loss was 27% and the majority ended up with high-level amputation. Among the risk factors evaluated, the arterial status of the heel and ASA status significantly increased the odds for failure. When both arterial branches to the heel were impaired, the odds of failure were 80 times higher to fail (p< 0.05). CONCLUSION: The vascularity of the surrounding tissue of the defect plays a critical role in overall success of diabetic heel reconstruction. Aggressive debridement using the angiosome concept is necessary to assure surrounding tissue has a good circulation. Despite the high chance of failure, success will lead to limb salvage and to reasonable functional ambulation whereas failure to salvage the heel will lead to higher level amputation. This warrants microsurgeons to make an effort to perform reconstruction to the heel defect after obtaining maximal vascularity after angioplasty.

Geometric Measurements of Nipple Position in Breasts Reconstructed with Transverse Rectus Abdominis Musculocutaneous Flap: A 5-Year Prospective Study.

BACKGROUND: After breast reconstruction, nipple position and other long-term changes in the reconstructed breast relative to the contralateral breast remain poorly understood. In this prospective cohort study, the authors performed serial nipple position measurements over 5 years in patients who had undergone breast reconstruction with a transverse rectus abdominis musculocutaneous (TRAM) flap. The effects of adjuvant radiotherapy on nipple position over time were also investigated. METHODS: The authors studied 150 patients who had undergone nipple-sparing mastectomy, using radial incision followed by immediate unilateral pedicled TRAM flap breast reconstruction. Measurements of sternal notch-to-nipple, midline-to-nipple, and inframammary fold-to-nipple distances were performed 1 day before reconstruction and 6, 12, 36, and 60 months after surgery, on patients' reconstructed and nonoperated breasts. RESULTS: The average sternal notch-to-nipple distance increased in both reconstructed and nonoperated breasts at every follow-up visit, with an average difference of 0.393 cm at the 60-month visit (p < 0.0001). Comparing the pattern of distance change, reconstructed breasts tend to change more slowly than nonoperated breasts until 36 months postoperatively. In irradiated breasts, the sternal notch-to-nipple distance was significantly smaller than in nonirradiated breasts, and nipple position changed minimally between 1 and 3 years after surgery. CONCLUSIONS: Nipple position in TRAM flap-reconstructed breasts changed over time compared with that in nonoperated breasts, especially along the vertical axis. The pattern of nipple position change in reconstructed breasts became similar to nonoperated breasts 3 years after surgery. In patients who had undergone adjuvant radiation therapy, nipple position remained consistent for 1 to 3 years. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Comparative Study of 2 Different Innervation Techniques in Facial Reanimation: Cross-face Nerve Graft-Innervated Versus Double-Innervated Free Gracilis Muscle Transfer.

Recently, 1-stage double innervation with the masseter nerve and the cross-face nerve graft (CFNG) has gained popularity owing to its outcomes of powerful and synchronous muscle contraction. In this study, we compared CFNG- and double-innervated free gracilis muscle transfer (FGMT) for facial palsy reconstruction.A total of 49 patients with facial palsy who underwent facial reanimation surgery from August 2013 to January 2017 were enrolled. The CFNG group (18 patients) underwent 2-stage CFNG innervation, whereas the double-innervated FGMT group (31 patients) underwent dual coaptation with end-to-end masseter nerve and end-to-side CFNG. The FACEgram software was used for evaluating smile excursion, symmetry index, spontaneous smile occurrence, Terzis' score including palsy pathogenesis, and clinical progress.In the CFNG group, the smile excursion at rest increased (P = 0.000); however, there was increased smile excursion both at rest and during smiling in the double-innervated FMGT group (rest P = 0.002, smile P = 0.028). Improvement of the symmetry index was observed only in the FMGT group (rest P = 0.001, smile P = 0.000). There was no significant difference in Terzis' scores. The average time to the first visible muscle contracture was statistically significantly shorter in the double-innervated FGMT group (P = 0.035). With respect to spontaneous smile achievement, the double-innervated FGMT group (25.8%) showed a satisfactory outcome.Cross-face nerve graft-innervated FGMT improved only smile excursion at rest, whereas double-innervated FGMT provided improvement in both the resting and smiling postures. Furthermore, the double-innervated FGMT group showed a higher symmetry index. However, the 2 operations did not show a significant difference in functional aspects.

Impact of Venous Outflow Pattern on Flap Compromise in Head and Neck Reconstruction: Review of 309 Radial Forearm Free Flaps.

There is ongoing controversy regarding the most appropriate venous drainage pattern for anastomosing the radial forearm free flap in head and neck reconstruction. Although the various perforator flaps have been used in our practice, the authors evaluated the impact of venous outflow pattern on the incidence of only the radial forearm free flap compromise for minimizing the bias. The authors retrospectively reviewed 309 radial forearm free flaps used for head and neck reconstruction following cancer ablation (January 2005 to December 2015), and evaluated the association between the incidence of venous insufficiency and the choice of venous system in the flap and at the recipient site, the number of venous anastomoses, and the combination of flap and recipient venous systems. No significant association was found between the incidence of venous insufficiency and the risk factors evaluated. Compared with single or dual anastomosis involving only the vena comitantes, dual anastomosis involving distinct venous systems was associated with lower incidence of venous insufficiency (P = 0.039). The dual anastomosis of separate venous system was correlated with lower incidence of venous insufficiency compared with the single or dual anastomosis of vena comitantes only (P = 0.039).