External Volume Expansion: Timing and Effects on the Rate of Fat Graft Retention in BALB/c Nude Mice.

BACKGROUND/AIM: Fat grafting has been widely used for soft-tissue augmentation. External volume expansion (EVE) is a favorable tool for improvement in the rate of fat graft retention. However, few studies have focused on the most appropriate time for its implementation. In this study, BALB/c nude mice were used to investigate the effective time for the implementation of external volume expansion to improve the rate of fat retention. MATERIALS AND METHODS: Sixteen mice were divided into four groups, and EVE was performed at different time points before or both before and after fat grafting. Fat tissue from a human donor was injected into the mice following EVE. Visual assessment, micro-computed tomography analysis, and histopathological evaluation were used to assess fat retention. RESULTS: After 10 weeks, the group that underwent EVE 5 days before fat grafting demonstrated a significantly higher preserved fat volume, as determined by micro-computed tomography (p<0.05). Moreover, the group that received additional EVE after fat grafting exhibited a higher retention rate compared to the groups receiving EVE only before grafting (p<0.05). Histopathological analysis indicated that swelling, edema, and inflammation were more pronounced in the group with EVE immediately before grafting, while angiogenesis and lipogenesis were more active in the group with additional EVE after grafting. CONCLUSION: EVE is a safe and effective approach for improving the rate of fat graft retentions. Furthermore, the timing of external tissue expansion plays a crucial role in fat retention. Based on our animal study, performing EVE immediately before and after fat grafting may be an effective strategy for enhancing the rate of fat graft retentions.

Prepectoral breast reconstruction with complete anterior implant coverage using a single, large, square-shaped acellular dermal matrix.

BACKGROUND: Several studies have discussed various methods of prepectoral direct-to-implant (DTI) breast reconstruction using an acellular dermal matrix (ADM) prosthesis to achieve full coverage. However, methods for anterior coverage have rarely been reported. In this study, prepectoral DTI breast reconstruction with complete anterior implant coverage was performed using a square piece of ADM. This study aimed to introduce our prepectoral DTI technique and determine its functional and cosmetic outcomes as well as compare them with those of existing subpectoral DTI techniques. METHODS: This prospective comparative study focused on 29 patients (35 breasts) and 34 patients (35 breasts) who underwent breast reconstruction via subpectoral implant insertion (control group) and anterior coverage prepectoral implant insertion (anterior coverage group), respectively. Postoperative complications were noted, and breast symmetry was evaluated using the Vectra H2 three-dimensional scanner. The modified Kyungpook National University Hospital Breast-Q (KNUH Breast-Q) scale was used to assess the patient's subjective satisfaction with the reconstruction and postoperative quality of life. RESULTS: No remarkable differences in terms of complications (seroma, skin necrosis, nipple-areola complex necrosis, hematoma, capsular contracture, and infection) were noted in both groups. Compared with controls, considerably better results were observed among those in the anterior coverage group in terms of the mean drain removal period. Furthermore, those in the anterior coverage group showed greater symmetry on three-dimensional scans than the controls; however, this was not statistically significant. Subjective satisfaction and postoperative quality of life measured using the KNUH Breast-Q scale were not significantly different between both groups. CONCLUSIONS: Considering its stability, faster recovery time, and cosmetic benefit, prepectoral breast reconstruction with anterior implant coverage using a single, large ADM is a good choice to perform breast reconstruction with implant insertion in patients who have undergone mastectomy. LEVEL OF EVIDENCE: II.

The effects of surgical treatment and sclerotherapy for intramuscular venous malformations: a comparative clinical study.

BACKGROUND: Venous malformations (VMs) are the most common type of vascular malformations. Intramuscular venous malformations (IMVMs) are lesions involving the muscles, excluding intramuscular hemangiomas. The purpose of this study was to compare clinical outcomes between patients with IMVMs who were treated with sclerotherapy and those who were treated with surgical excision. METHODS: Of 492 patients with VMs treated between July 2011 and August 2020 at a single medical center for vascular anomalies, 63 patients diagnosed with IMVM were retrospectively reviewed. Pain, movement limitations, swelling, and quality of life (QOL) were evaluated subjectively, while radiological outcomes were assessed by qualified radiologists at the center. Complication rates were also evaluated, and radiological and clinical examinations were used to determine which treatment group (sclerotherapy or surgical excision) exhibited greater improvement. RESULTS: Although there were no significant differences in pain (P=0.471), swelling (P=0.322), or the occurrence of complications (P=0.206) between the two treatment groups, the surgical treatment group exhibited significantly better outcomes with regard to movement limitations (P=0.010), QOL (P=0.013), and radiological outcomes (P=0.017). Moreover, both duplex ultrasonography and magnetic resonance imaging showed greater improvements in clinical outcomes in the surgical excision group than in the sclerotherapy group. CONCLUSIONS: Although several studies have examined IMVM treatment methods, no clear guidelines for treatment selection have been developed. Based on the results of this study, surgical excision is strongly encouraged for the treatment of IMVMs.

Porcine training models for endoscopic and robotic reconstructive breast surgery: a preliminary study.

BACKGROUND: With recent advances in surgical techniques, minimally invasive methods for reconstructive breast surgery are being investigated. To enhance surgical proficiency through training and minimize predictable complications before human application, we conducted a preliminary experimental study of reconstructive breast surgery using a porcine model. METHODS: Between February and March 2019, four 3-month-old pigs underwent a bilateral mastectomy and immediate breast reconstruction with a latissimus dorsi (LD) flap or silicone implants. After performing the mastectomy by dissecting the pectoralis profundus in the subcutaneous plane, the pig was placed in the decubitus position, and ultrasound-guided marking was used to design the LD flap. The thoracodorsal artery was marked, and a 4-cm incision was made on the midaxillary line. An additional endoscopic incision was made in the inferior margin of the LD flap; a 2-hole approach was used for endoscopic LD flap elevation. In the silicone implant model, a silicone implant (Allergan, smooth, round type, 90 cc) was placed using a single incision (4-5 cm). RESULTS: Eight mastectomies followed by breast reconstruction with LD flap elevation or silicone implant models were performed on four pigs. Serious complications, such as active bleeding, did not occur. However, heat dispersion to the skin flap that became thinner by endoscopic dissection caused a second-degree burn in one pig. CONCLUSIONS: This preliminary study of endoscopic or robot-assisted minimally invasive reconstructive breast surgery demonstrates that a porcine training model is a highly valuable experimental model for surface anatomy verification, incision plan selection, instrument selection, operator proficiency enhancement, and complication prevention.

Aesthetic outcomes and complications following post-mastectomy radiation therapy in patients undergoing immediate extended latissimus dorsi flap reconstruction and implant insertion.

BACKGROUND: Complications of radiotherapy after implant-based reconstruction include capsular contracture development, seroma formation, and reoperation for implant removal or replacement. However, there is a lack of studies regarding aesthetic outcomes and complication rates following radiation therapy among patients undergoing latissimus dorsi (LD) flap-based reconstruction with implant insertion for volume shortage. The present study aimed to evaluate clinical and aesthetic outcomes of post-mastectomy radiation therapy (PMRT) among patients receiving both LD flap reconstruction and implant insertion. METHODS: This study comprised 66 patients who underwent mastectomy and breast reconstruction between March 2014 and July 2019. Patient demographics and outcomes were compared among patients who did and did not receive PMRT. Aesthetic outcomes were compared using gross photographs. The incidence of complications, including seroma formation, flap necrosis, nipple-areola complex necrosis, hematoma development, and capsular contractures, was compared between groups. RESULTS: No differences in aesthetic outcomes using gross photos during outpatient follow-up were observed between the radiation and control groups. No significant difference in the frequency of complications was observed between groups. CONCLUSIONS: The use of implants and LD reconstruction are inevitable in a proportion of patients due to a lack of LD flap volume. For these patients, PMRT could be safe treatment option if the necessary precautions are implemented.

Oscillatory shear stress promotes angiogenic effects in arteriovenous malformations endothelial cells.

BACKGROUND: Vascular endothelial cells (ECs) are subject to continuous shear stress due to blood circulation. Mechanical stress due to high shear flow can also cause arteriovenous malformation (AVM) when ECs respond hyper-sensitively to shear flow. This study was conducted to test the hypothesis that angiogenesis could be promoted in response to mechanical stress via regulation of pro-angiogenic factors in AVM cells. METHODS: ECs were extracted from the tissue samples from six AVM patients and six normal patients. Shear stress at 7 dynes/cm2 were applied for 24 h. Before and after application of shear stress to each group, RT-PCR was performed to access the expression levels of angiopoietin2(AGP2), aquaporin1(AQP1) and TGFßR1. Immunofluorescences was also performed to evaluate the level of protein expressions. RESULTS: In both normal and AVM tissues, AGP2 and TGFßR1 under the shear stress showed increased expression in the ECs compared to the non-sheared samples. When AVMs and normal arterial vasculature were compared, the expression levels of both AGP2 and TGFßR1 in AVMs were higher when compared to normal arterial vasculature with or without shear stress. Immunofluorescence-based protein analysis also confirmed shear-induced AGP2 and TGFßR1 in both samples of normal and AVM patients. CONCLUSIONS: AVMs exhibited higher sensitivity to shear stress by producing higher expressions of some marked genes and proteins that regulate the endothelial functions upon exposure to shear stress. While the physiological mechanism for AVMs remain elusive, our study shows the plausibility of physical stress imposed by the shearing flow can cause the occurrence of AVMs.

Long-Term Outcomes of the Minimal Skin Incision Technique for Correcting Severe Microform and Minor-Form Cleft Lip With Philtrum Reconstruction Through the Intraoral Incision.

BACKGROUND: Because the traditional technique is known to cause visible scarring, it is challenging to yield optimal outcomes while treating a severe type of microform and minor-form cleft lip. The authors present a new refined technique with minimal skin incision and philtrum formation through an intraoral incision. METHODS: The surgical technique involves single Z-plasty or double or triple unilimb Z-plasty to restore an elevated cupid's bow peak and overlapping of an orbicularis oris muscle flap to create the philtrum through an intraoral incision. Cleft lip nasal deformity was corrected with reverse-U incision and V-Y plasty. RESULTS: Eighteen patients were operated between September 2008 and June 2017. Patient age at the time of surgery ranged from 3 to 12 months. The duration of follow-up ranged from 12 months to 7 years (mean, 36 months). The elevated cupid's bow was corrected by performing single Z-plasty in 6 patients, double unilimb Z-plasty in 7 patients, and triple unilimb Z-plasty in 5 patients. In all cases, the notch or elevated cupid's bow was corrected, the surgical scar was minimal, and philtrum reconstruction was satisfactory. Minor scar revision was performed in 4 patients. Cleft lip nasal deformity was corrected in fifteen patients. CONCLUSIONS: The technique adopted here causes minimal scarring, facilitates the formation of an anatomical philtrum, preserves the continuity and function of the muscle, and presents sufficient elevation of the philtral column.

Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review.

Massive hemoptysis is one of the most dreaded of all respiratory emergencies and can have a variety of underlying causes. In 90% of cases, the source of massive hemoptysis is the bronchial circulation. Diagnostic studies for massive hemoptysis include radiography, bronchoscopy, and computed tomography (CT) of the chest. Bronchoscopy and chest radiography have been considered the primary methods for the diagnosis and localization of hemoptysis. Many researchers currently suggest that CT should be performed prior to bronchoscopy in all cases of massive hemoptysis. Bronchial artery embolization (BAE) is a safe and effective nonsurgical treatment for patients with massive hemoptysis. However, nonbronchial systemic arteries can be a significant source of massive hemoptysis and a cause of recurrence after successful BAE. Knowledge of the bronchial artery anatomy, together with an understanding of the pathophysiologic features of massive hemoptysis, are essential for planning and performing BAE in affected patients. In addition, interventional radiologists should be familiar with the techniques, results, and possible complications of BAE and with the characteristics of the various embolic agents used in the procedure.