A Novel Nipple Reconstruction Technique for Maintaining Nipple Projection: The Boomerang Flap

Nipple-areolar complex (NAC) reconstruction is the final step in the long journey of breast reconstruction for mastectomy patients. Successful NAC reconstruction depends on the use of appropriate surgical techniques that are simple and reliable. To date, numerous techniques have been used for nipple reconstruction, including contralateral nipple sharing and various local flaps. Recently, it has been common to utilize local flaps. However, the most common nipple reconstruction problem encountered with local flaps is the loss of nipple projection; there can be approximately 50% projection loss in reconstructed nipples over long-term follow-up. Several factors might contribute to nipple projection loss, and we tried to overcome these factors by performing nipple reconstructions using a boomerang flap technique, which is a modified C–V flap that utilizes the previous mastectomy scar to maintain long-term nipple projection.

Oncologic Safety of Immediate Breast Reconstruction for Invasive Breast Cancer Patients: A Matched Case Control Study / 한국유방암학회지

PURPOSE: The purpose of this study was to compare locoregional recurrence-free survival (LRFS) and disease-free survival (DFS) between patients undergoing mastectomy and immediate breast reconstruction (IBR) and those undergoing mastectomy alone. METHODS: A retrospective review of patients who underwent mastectomy and immediate breast reconstruction for resectable invasive breast cancer between 2002 and 2010 at a single center was conducted. These cases were matched to patients who underwent mastectomy alone in the same time period, performed by 1:2 matching. Matching control variables included age, tumor size, axillary lymph node metastasis, and estrogen receptor status. Overall, 189 patients were identified in the IBR group, and 362 patients were matched to this group. RESULTS: In the IBR group, 75 patients (39.7%) underwent conventional total mastectomy, 78 (41.3%) underwent skin-sparing mastectomy (SSM), and 36 (19.0%) underwent nipple-sparing mastectomy (NSM). The IBR group was significantly younger than the control group (41.9 and 45.1 years, respectively) (p=0.032), in spite of matching between three age groups. The DFS rates were similar between the IBR group and mastectomy alone group, at 92.0% and 89.9%, respectively, at 5-year follow-up (log-rank test, p=0.496). The 5-year LRFS was 96.2% in the IBR group and 96.4% in the mastectomy alone group (log-rank test, p=0.704), similar to data from previous reports. Subgroup analyses for SSM or NSM patients showed no differences in LRFS and DFS between the two groups. Additionally, in stage III patients, IBR did not cause an increase in recurrence. CONCLUSION: IBR after mastectomy, including both SSM and NSM, had no negative impact on recurrence or patient survival, even in patients with advanced disease.

Use of a Y-Shaped Plate for Intermaxillary Fixation

Maxillomandibular fractures usually require intermaxillary fixation as a means to immobilize and stabilize the fracture and to re-establish proper occlusion. Arch bars or intermaxillary fixation screws cannot be used for edentulous patients or for patients who have poor dental health. Here, we present a case of repeated intermaxillary fixation failure in a patient weak alveolar rigidity secondary to multiple dental implants. Because single-point fixation screws were not strong enough to maintain proper occlusion, we have used Y-shaped plates to provide more rigid anchoring points for the intermaxillary wires. We suggest that this method should be considered for patients in whom conventional fixation methods are inappropriate or have failed.

Breast Reconstruction Using a TRAM Free Flap with a Mini-Abdominoplasty Design and Flap Beveling

BACKGROUND: One of the most common breast reconstruction techniques that uses autologous tissue is the free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap. However, patients hesitate to choose this method because of the long transverse scar between the anterior superior iliac spines. Furthermore, traditional reconstruction using a free MS-TRAM flap entails donor site morbidities such as pain, hematoma, or seroma. Here, we introduce a mini-abdominoplasty-designed free TRAM flap with flap beveling, which can be a good method for breast reconstruction in Asian patients who have small breasts. METHODS: Breast reconstruction with free MS-TRAM flaps using the mini-abdominoplasty design and flap beveling was performed in 10 patients following mastectomy. Patient age, presurgical brassiere cup size, tumor type, operation type, excised breast weight, elevated flap weight, flap weight used for the breast, recipient vessel, operation time, day that the abdominal drain was removed, and complications associated with both the flap and donor site were documented for all flaps and patients. RESULTS: For all 10 mini-abdominoplasty-designed free TRAM flap procedures, no flap loss or donor site morbidity was noted over a mean follow-up time of 16 months. CONCLUSIONS: The mini-abdominoplasty-designed free TRAM flap can safely and satisfactorily be implanted for the reconstruction of mastectomy defects. It can transfer the lower abdominal skin and subcutaneous tissue for breast reconstruction with minimal donor site scarring and morbidity, especially in Asian patients, who generally have smaller breasts.

The Superficial Inferior Epigastric Artery Flap and its Relevant Vascular Anatomy in Korean Women

BACKGROUND: Lower abdominal soft tissue transfer is the standard procedure for breast reconstruction. However, abdominal wall weakness and herniation commonly occur postoperatively at the donor site. To reduce the morbidities of the donor site, the superficial inferior epigastric artery (SIEA) flap was introduced, but inconsistent anatomy of the SIEA has reduced its utility. In the present study, the anatomy of the superficial inferior epigastric vessels in Korean women was determined with regards to breast reconstructive surgery. METHODS: The vascular anatomies of the SIEA and superficial inferior epigastric vein (SIEV) were evaluated on 32 breast cancer patients receiving free transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy. The existence, pulsation, location, external diameter, and depth of the SIEA and SIEV were measured at the lower abdominal incision level. RESULTS: SIEA and SIEV were present in 48/64 (75.00%) and 63/64 (98.44%) hemi-abdomens, respectively. Pulsation of the SIEA was found in 44/48 (91.67%) cases. The mean locations of SIEA and SIEV were +5.79 (+/-12.87) mm, and -8.14 (+/-15.24) mm from the midpoint between the anterior superior iliac spine and symphysis pubis, respectively. The mean external diameters of SIEA and SIEV were 1.20 (+/-0.39) mm and 1.37 (+/-0.33) mm, and they were found at a mean depth of 9.75 (+/-2.67) mm and 8.33 (+/-2.65) mm, respectively. CONCLUSIONS: The SIEA was absent in 25% of Korean women and had a relatively small caliber. Therefore, careful preoperative assessment of the lower abdominal vasculature is required to achieve successful breast reconstruction using SIEA flaps.

A Retrospective Analysis of Eight Cases of Merkel Cell Carcinoma

BACKGROUND: Merkel cell carcinoma (MCC) is a rare locally aggressive cutaneous neuroendocrine carcinoma with a high incidence of local recurrence, regional lymph node metastasis, followed by distant metastasis. Because of shortage of the retrospective study, standard treatment has not been established. The purpose of this study was to present the surgical treatment and outcome of 8 patients with MCC. METHODS: We report our experiences with 8 patients who underwent treatment for MCC at our institution from 2000 through 2012. Two men and 6 women received treatment for MCC. The mean age was 76.4 years (range, 53 to 93 years). RESULTS: The follow-up period ranged from 7 to 26 months (mean, 22.9). During the follow-up period, three of 8 patients had a relapse (mean time before recurrence, 10 months; 1 month, 7 months, and 22 months). After primary surgery, 3 patients underwent radiotherapy, and 1 patient received chemotherapy. CONCLUSION: MCC is an aggressive skin cancer with a high rate of local recurrence. Complete surgical excision is the mainstay of local treatment, but adjuvant radiotherapy should be considered for better local control.

Sebaceous Carcinoma Associated with Breast Cancer, Stomach Cancer, and Colon Cancer: Muir-Torre Syndrome

Muir-Torre syndrome is defined by concurrent or sequential development of internal malignancy and sebaceous neoplasm or multiple keratoacanthomas. Muir-Torre syndrome is very rare, with only 205 cases reported in the literature. We reported a patient with Muir-Torre syndrome with three internal malignancies. A 64-year-old patient with a history of breast cancer, stomach cancer and colon cancer visited our department for treatment of the skin lesion that occurred five years before on the left cheek. The lesion was excised completely with a resection margin of 1 cm, followed by full-thickness skin graft from left postauricular area for reconstruction. Histopathology revealed a 0.2 x 0.2 x 0.1 cm sized sebaceous carcinoma with 4 mm safety margin. The skin graft was well taken within 7 days after surgery and the patient was discharged to outpatient follow-up. There was no complication related with surgery. Muir-Torre syndrome is very rare, as are sebaceous gland tumors. So if a cancer of the sebaceous gland is diagnosed, screening workup for internal malignancy is recommended. Because of its good prognosis, surgical removal of primary or metastatic cancers may be curative and should be attempted where possible.

Penoscrotal Extramammary Paget's Disease with Multiple Lymph Node Metastasis

No abstract available.

Magnetic Resonance Imaging-Based Volumetric Analysis and Its Relationship to Actual Breast Weight

BACKGROUND: Preoperative volume assessment is useful in breast reconstruction. Magnetic resonance imaging (MRI) and mammography are commonly available to reconstructive surgeons in the care of a patient with breast cancer. This study aimed to verify the accuracy of breast volume measured by MRI, and to identify any factor affecting the relationship between measured breast volume and actual breast weight to derive a new model for accurate breast volume estimation. METHODS: From January 2012 to January 2013, a retrospective review was performed on a total of 101 breasts from 99 patients who had undergone total mastectomy. The mastectomy specimen weight was obtained for each breast. Mammographic and MRI data were used to estimate the volume and density. A standard statistical analysis was performed. RESULTS: The mean mastectomy specimen weight was 340.8 g (range, 95 to 795 g). The mean MRI-estimated volume was 322.2 mL3. When divided into three groups by the "difference percentage value", the underestimated group showed a significantly higher fibroglandular volume, higher percent density, and included significantly more Breast Imaging, Reporting and Data System mammographic density grade 4 breasts than the other groups. We derived a new model considering both fibroglandular tissue volume and fat tissue volume for accurate breast volume estimation. CONCLUSIONS: MRI-based breast volume assessment showed a significant correlation with actual breast weight; however, in the case of dense breasts, the reconstructive surgeon should note that the mastectomy specimen weight tends to overestimate the volume. We suggested a new model for accurate breast volume assessment considering fibroglandular and fat tissue volume.

Outcomes of Surgical Management of Xanthelasma Palpebrarum

BACKGROUND: Xanthelasma palpebrarum (XP) is a benign disorder manifesting as yellowish cholesterol-laden plaques on the eyelids. This paper presents the outcomes in patients with XP who have undergone surgical excision as the main modality of treatment. METHODS: A retrospective review of patients who received surgery for xanthelasma palpebrarum from March 2007 to March 2011 was conducted. Patients were classified into four grades according to the location and extent of the lesion, with grade I being the mildest and grade IV being the most diffuse. Simple excision was performed in grade I and II lesions, while local flaps and skin grafts were performed in the more advanced grades. RESULTS: Ninety-five cases from March 2007 to March 2011 were included in this study. 66 cases (70%), were treated by simple excision. Twenty-four cases (25%) and 5 cases (5%) were treated by simple excision in combination with or without local flaps and skin grafts. In approximately 1/4 of the patients, orbicularis oris muscle involvement was observed. 4 patients (4.2%) developed scar contracture postoperatively, which required a secondary procedure. Recurrence was reported in 3 patients (3.1%). Otherwise. There were no other reports of major complications or disfigurement. CONCLUSIONS: We found that for lesions involving the deep dermis and/or muscle, surgical excision was the most appropriate therapeutic option.

The Efficacy and Safety of Platelet-Rich Plasma and Adipose-Derived Stem Cells: An Update

During the past decade, many studies using platelet-rich plasma (PRP) or adipose-derived stem cells (ASCs) have been conducted in various medical fields, from cardiovascular research to applications for corneal diseases. Nonetheless, there are several limitations of practical applications of PRP and ASCs. Most reports of PRP are anecdotal and few include controls to determine the specific role of PRP. There is little consensus regarding PRP production and characterization. Some have reported the development of an antibody to bovine thrombin, which was the initiator of platelet activation. In the case of ASCs, good manufacturing practices are needed for the production of clinical-grade human stem cells, and in vitro expansion of ASCs requires approval of the Korea Food and Drug Administration, such that considerable expense and time are required. Additionally, some have reported that ASCs could have a potential risk of transformation to malignant cells. Therefore, the authors tried to investigate the latest research on the efficacy and safety of PRP and ASCs and report on the current state and regulation of these stem cell-based therapies.

Breast reconstruction using the transverse rectus abdominis musculocutaneous (TRAM) free flap

Breast reconstruction is achieved through surgical procedures following mastectomy after breast cancer or trauma using implants or autologous tissue to restore the breast morphology. Reconstruction can physically and emotionally restore a patient's self confidence after the loss of a breast. The method of breast reconstruction is determined by several factors, such as the patient's general medical condition, the extent of the mastectomy, and donor site suitability when opting for autologous flap transplantation. Generally, we can classify breast reconstruction procedures into two broad categories: breast implantation after tissue expansion of the skin of the chest, and flaps using autologous tissue. Of the breast reconstruction methods using autologous tissue, the transverse rectus abdominis musculocutaneous free flap is advantageous over the the transverse rectus abdominis musculocutaneous (TRAM) pedicled flap in that it is easy to obtain the desired shape of the breast, the inframammary fold is maintained, and there is decreased donor site morbidity because the rectus abdominis muscle can be utilized sparingly. Moreover, the TRAM free flap can have an abdominoplasty effect in women who have excessive abdominal fat. However, the procedure is time consuming because microanastomosis of the pedicle and recipient vessel is necessary after flap elevation. Although there are several issues, such as the high cost of surgery, which should be resolved, breast reconstruction can provide support to many women who are emotionally and physically distressed due to breast cancer.

Small Bowel Strangulation after Free TRAM Breast Reconstruction in Post-hysterectomy Patient: A Case Report

PURPOSE: The rectus abdominis myocutaneous flap is currently the most commonly used donor site of immediate and delayed breast reconstruction surgery, for its versatility and ease of handling, as well as sufficient blood supply. Despite many advantages of rectus abdominis flap, morbidity of donor site is considered as inevitable shortcoming. The authors recently faced a devastating complication, small bowel obstruction that led to strangulation, after delayed breast reconstruction with free transverses rectus abdominis myocutaneous (TRAM) flap. And we would like to report it, because abdominal pain after TRAM flap is a common symptom and can be overlooked easily. METHODS: A 56-year-old female patient who had history of receiving total abdominal hysterectomy 20 years ago underwent delayed breast reconstruction with TRAM flap transfer. She complained abdominal discomfort and pain from third postoperative day, postoperative small bowel obstruction that arose from strangulated bowel and prompt emergency operation was done. RESULTS: After resection of the strangulated bowel and reanastomosis, quickly her symptoms were relieved, and there were no further problems during her hospital stay. 7 days after her emergency operation she was discharged. CONCLUSION: In patients with previous abdominal surgical history, prolonged ileus can lead to bowel strangulation, so surgeons should always consider the possibility, and must be aware of abdominal symptoms in patients who receive free TRAM flap operations.

A Case Report of Breast Reconstruction with Free TRAM Flap in HIV-Infected Patient

PURPOSE: Despite the increasing number of patients with HIV (human immunodeficiency virus) infection, surgical experience with these patients remains limited in aesthetic and reconstructive surgery. The authors performed breast reconsruction with free TRAM (Transverse Rectus Abdominis Muculocutaneous) flap in HIV infected patient firstly in Korea. METHODS: A 53-years-old female with HIV positive underwent delayed breast reconstruction with free TRAM flap and 6 months lateral nipple reconstruction was performed. All procedures were performed according to the HIV infection control guidelines provided by the Korea Centers for Disease Control and Prevention. RESULTS: There were no complications such as infection, hematoma and flap loss and symmetry of breast was achieved. CONCLUSION: When the operation is performed in line with the guidelines of HIV infection control, breast reconstruction with free flap is possible and can obtain successful results.

Outcomes of Surgery for Dermatofibrosarcoma Protuberans and Risk Factor Analysis for Recurrence

PURPOSE: Dermatofibrosarcoma protuberans is a relatively rare tumor that originates from the dermis and subcutaneous tissue. It is generally known that this tumor easily recurs but can be successfully treated with a wide excision. Therefore, this study was conducted to investigate postoperative outcomes and risk factors for recurrence in patients with dermatofibrosarcoma protuberans who were treated at a single institution for 20 years. METHODS: We retrospectively reviewed the medical records of 35 patients who had underwent surgery between June 1992, and September 2010. The patients were assessed in terms of predilection site and size of the tumor, the incidence according to sex, discrepancy between biopsy results and histopathological diagnosis of the surgical specimen, additional treatment after recurrence, recurrence rate and the time interval to recurrence. RESULTS: In multivariate analysis, the depth and site of the tumor were significant risk factors for tumor recurrence. The recurrence rate was significantly higher in tumors occurring in the upper extremity than those occurring in other regions(p=0.0348). In addition, the recurrence rate was significantly higher in tumors with involvement of the fascia and the deeper structures(p=0.0324, odds ratio=6, relative risk=1.588). Since dermatofibrosarcoma protuberans has strong invasiveness, its tissue involvement is difficult to evaluate accurately. CONCLUSION: The results of this study shows that involvement of the fascia and the deeper structures and occurrence in the upper extremity were associated with tumor recurrence. Therefore, clinicians should be aware of these risk factors to achieve better treatment outcomes.

Usefulness of the Purse-string Suture Technique for Aesthetic Breast Reconstruction Surrounding the Nipple-areolar Complex

PURPOSE: In cases of breast reconstruction with a free transverse rectus abdominis musculocutaneous(TRAM) flap after skin-sparing mastectomy with nipple-areolar complex(NAC) removal, the flat contour of the flap's skin paddle can easily look unnatural and dissatisfying. Reconstructed NAC on the flap surface lacks the elevated contour that the normal areola possesses, resulting in an unnatural final result. Therefore, we would like to introduce a novel method to improve this problem and report the satisfactory results we obtained. METHODS: Operations were conducted on 19 patients who underwent immediate breast reconstruction with a free TRAM flap and skin-sparing mastectomy from January 2009 to January 2010, with a mean follow-up of nine months. While the TRAM free flap was being inset, a purse-string suture was carried out on the dermal layer of skin flap to create a slight protrusion with Gore-Tex(R) sutures. RESULTS: The elevated mound surrounding the NAC was well maintained for an average follow-up period of nine months. Nipple projection was also well maintained. There was no complaint about breast contour or nipple height reduction. In addition, there was no reported incidence of other complications. CONCLUSION: The purse-string suture technique presents a more natural breast silhouette around the NAC and helps to maintain nipple projection. Furthermore, it does not require any supplementary incisions or complicated skills. There has been no report of additional complications using this technique.

Role of Reactive Oxygen Species in the Adipogenesis of Adipose-derived Stem Cells

PURPOSE: Stem cells continue to receive research attention in the clinical fields, and adipose-derived stem cells(ADSCs) have been shown to be a good source raw material. Many plastic surgeons are researching the ADSC adipogenesis with a view of conducting clinical trials, and many attempts have been made to identify the factors that promote the adipogenesis of ADSCs, but comparatively few correlation studies have been undertaken to explore the relation between reactive oxygen species(ROS) and the ADSC adipogenesis. We undertook this study is to investigate the effects of ROS on ADSC adipogenesis. METHODS: ADSCs were isolated and cultured from abdominal adipose tissue, and cultured in different media; 1) DMEM(control), 2) adipogenesis induction culture medium, 3) adipogenesis induction culture medium with ROS(20 microM/50 microM H2O2), 4) adipogenesis induction culture medium containing ROS(20 microM/50 microM H2O2) and antioxidant(10 microM/20 microM Deferoxamine). We compared adipogenesis in these different media by taking absorbance measurements after Oil-Red O staining every 5 days. RESULTS: After culturing for 20 days, significant differences were observed between these various culture groups. Absorbance results showed significantly more adipogenesis had occurred in media containing adipogenesis induction culture medium and H2O2(in a H2O2 dose-dependently manner) than in media containing adipogenesis induction culture medium and no H2O2(p<0.001). Furthermore, in media containing adipogenesis induction culture medium, H2O2, and antioxidant, absorbance results were significantly lower than in adipogenesis induction culture medium and H2O2(p<0.001). CONCLUSION: These findings suggest that ROS promote the adipogenesis of ADSCs. We suggests that ROS could be used in the adipose tissue engineering to improve fat cell differentiation and implantable fat tissue organization.

Effect of Botulinum Toxin A on Capsule Formation in Submuscular Breast Implant Insertion: Rabbit Experimental Model

We examined the effects of botulinum toxin after submuscular implant insertion, observing the degree of capsule formation after restricting movement of muscle. 12 female Newzeland white rabbits weighing 2.5~3.0 kg were used in our study. A skin incision 5cm in length was made to above the Latissimus Dorsi muscle followed by a 4cm incision on the muscle. An implant was inserted under the muscle. Botulinum toxin was injected at the right side of the 12 rabbit Latissimus Dorsi muscles (experimental group). Then rabbits were dived in two group, 6 rabbits each. Saline was injected at the left side of the 6 rabbit Latissimus Dorsi muscles (control group) and nothing was given to the others (negative control group). The 12 rabbits were euthanized after 6 months and the capsule surrounding the implant was excised along with adjacent tissue. The thickness of the capsule was taken from 5 locations from the stained tissue and the results were statistically analyzed. There was no statistical significant difference among the groups. Restriction of muscular movement did not have a significant effect in the formation of capsule formation.

Effect of Platelet-rich Plasma(PRP) on Regeneration of Rat Sciatic Nerve in a Silicone Chamber

PURPOSE: The purpose of this study is to determine the effect of platelet-rich plasma(PRP) on rat sciatic nerve regeneration in a 10mm silicone chamber. METHODS: A total of 6 inbred Lewis rats were used in this study. Bilateral sciatic neurectomy was performed on each rat. On one side, silicone chambers containing PRP solutions were implanted; on the contralateral side, the chambers without PRP were implanted as a control. In 12 weeks post-implantation, chambers were retrieved and both gastrocnemius muscles were excised. Nerves biopsy samples were examined under a light microscope after Masson trichrome staining. RESULTS: Cross sections of the midpoints of PRP treated nerves were significantly larger and appeared more mature than those of controls. CONCLUSION: Based on morphological evidence, PRP has a positive effect on neural regeneration, and it may therefore be useful for treating peripheral nerve injuries.

Intravenous Pyogenic Granuloma in Sentinel Vein: A Case Report

PURPOSE: Lobular capillary hemangioma is a vascular tumor that commonly occurs as a cutaneous lesion. Intravenous pyogenic granuloma is a rare form of lobular capillary hemangioma that usually occurs in the veins of the neck and the upper extremities. METHODS: A 41-year-old man presented with 3 months history of nodules on the left temporal area and these lesions were clinically mistaken for a typical lipoma or epidermal cyst, but the nodules appeared unusually vascular with sentinel veins on excision. RESULTS: On the histopathologic examination, the excised tissue was observed as an intraluminal polypoid mass, which was attached to the vein via a fibrovascular stalk and capillaries in a loose edematous fibromyxoid stroma, and so the lesions were confirmed to be intravenous pyogenic granuloma. At 6 months after excision, there has been no recurrence and the patient is asymptomatic. CONCLUSION: Intravenous pyogenic granuloma is a rare variant of lobular capillary hemangioma. This article describes the surgical and histopathological findings of treating pyrogenic granuloma.