Defect-Oriented Versus Back Scar-Oriented Flap Design in Breast Reconstruction with Latissimus Dorsi Musculocutaneous Flap: A Patient-Reported Satisfaction Outcome Comparison Using BREAST-Q.

BACKGROUND: The design of the latissimus dorsi musculocutaneous flap in breast reconstruction has several options. To date, there have been no reports on the surgical outcomes with flap designed based on the defect shape of the mastectomy site and flap shape of the donor site. To compare patient satisfaction according to the flap design, we designed and conducted independent three sub-studies targeting fifty-three breast reconstruction patients using BREAST-Q© scale. METHODS: In study 1, there was no difference in patient satisfaction between the group with the flap designed according to the shape of mastectomy defect (defect-oriented group) that with the flap designed according to patient's wish regardless of defect shape (back scar-oriented group). In study 2, comparing the results based on the shape of the flap, vertically designed flap showed a statistically significant difference in the psychosocial well-being. In study 3, comparing the results based on the shape of the defect, no significant difference was noted. RESULTS: Even though designing a donor flap based on the shape and orientation of the mastectomy defect has no statistical significance in patient satisfaction or quality of life compared with that based on the patient preference in placement of the donor site scar, the group with the vertical donor design showed better psychosocial well-being than the group with other shapes of the donor flap. By considering the advantages and disadvantages of each flap design, enhanced patient satisfaction and durability and natural aesthetic goal can be achieved. This is the first study to compare the differences in results according to the flap design method during breast reconstruction. Patient satisfaction according to the design of the flap was investigated in the form of a questionnaire survey, and the results were displayed. In addition to breast shape, donor scars and complications were also investigated. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Posttraumatic Augmentation Rhinoplasty Using an Osseocartilaginous Cantilever Graft.

BACKGROUND: Augmentation rhinoplasty in Asians may be effectively accomplished with alloplastic materials. However, certain circumstances such as nasal bone fractures mandate the use of autologous grafts. The purpose of this study was to describe and evaluate the results of modified osseocartilaginous rib cantilever grafting for aesthetic and reconstructive rhinoplasty in patients with acute nasal bone fractures. METHODS: Forty-three patients with nasal bone fracture underwent surgical reconstruction with an autogenous rib graft. Anatomic reconstruction and dorsal augmentation were performed using 1 piece of a carved osseocartilaginous rib graft each for the bony and cartilaginous parts of the nose. The average time to surgery was 6.5 days, and patient's subjective satisfaction was scored. RESULTS: "Excellent" or "good" cosmetic outcomes were reported by 37 patients (86%). There were 3 cases of secondary revision. Donor-site morbidity was not an issue in any patient. CONCLUSIONS: Anatomic reconstruction of the nasal dorsum and refining the nasal tip using an osseocartilaginous rib graft with the cantilever technique are effective in acute nasal trauma patients who wish to enhance their nasal profile in the primary treatment setting.

Caterpillar Graft for Secondary Rhinoplasty.

BACKGROUND: Different autologous materials are recently used in the purpose of augmentation of the nasal dorsum. Despite the benefits and drawbacks, nasal reconstruction with autologous tissue remains a better method for excellent results and lower morbidity rates. METHODS: The authors harvested conchal cartilage from the ears and use it after dicing. The superficial temporal fascia was harvested from the temporal region. Diced cartilage was wrapped with superficial temporal fascia, making a roll. After creating a cavity in the nasal dorsum, the combined roll graft was inserted over the nasal dorsum in a "caterpillar" fashion. The authors have operated on 18 patients of secondary nasal deformity cases. RESULTS: The results were excellent in most of the cases. This procedure presented many advantages: optimum nasal contouring, satisfactory volume for the nasal dorsum, and with low rates of infection and exposure. CONCLUSIONS: Nasal deformities were reconstructed using crushed cartilage harvested from the concha and enclosed in temporal fascia. This procedure could provide more psychologic comfort and long-lasting appearance.

Hand Transplantation: Current Status and Immunologic Obstacles.

Hand transplantation is the most common form of modern composite tissue allotransplantation, with 89 cases reported worldwide since 1998. The procedure is a treatment option for complex injuries that leave patients with structural, functional, and aesthetic deficits that cannot be addressed by other means. Successful application of this technology requires a multidisciplinary approach, incorporating not only skilled hand surgeons, transplant surgeons, and transplant immunologists, but also hand therapists, psychiatrists, medical specialists, anesthesiologists, and so on. Its long-term results depend on proper patient selection, a technically successful operation, postoperative rehabilitation, and an immunotherapy protocol that prevents rejection. Recent advances in transplant immunology are shifting the focus from immunosuppression to immunoregulation. Despite the enormous antigen load associated with composite tissue allografts, hand transplant has become a clinical reality, with immunosuppression comparable to that of solid-organ transplants. Our understanding of hand transplantation is still evolving, and ongoing research is needed to improve functional outcomes and to decrease the morbidity associated with long-term immunosuppression. This review discusses the current protocols for upper extremity donation, transplant receipt, surgical techniques, postoperative rehabilitation and immunosuppression, nerve regeneration, functional outcomes, ethical issues, and financial considerations.

Abdominal Wall Transplant Surgery.

The evolution and success of intestinal and multi-visceral transplantation over the past 20 years have raised the issue of difficult or even impossible abdominal closure, a topic rarely encountered in other fields of transplantation. Different techniques have been proposed to address this topic. The choice depends on the transplant team's expertise and/or the availability of a plastic surgery service. Abdominal wall transplant is a type of composite tissue allograft that can be utilized to reconstitute the abdominal domains of patients who undergo intestinal transplant, and the results are encouraging. It is an effective option to achieve primary abdominal closure after intestinal transplant. In its full-thickness form, it may be useful for monitoring rejection or viability of visceral organs. Our aim is to review the role of abdominal wall transplant in achieving tension-free closure of the abdomen.

Progressive fingertip necrosis after nail avulsion injury in a patient with ulnar artery hypoplasia: A case report.

RATIONALE: Slowly progressive hand ischemia is mostly associated with medical illness such as vasculitis, and in patients with smoking history, Buerger disease is often considered first. However, despite the very low incidence of vascular anatomical anomalies, they can lead to hand ischemia. And if there is no consideration for them, proper treatment cannot be selected. PATIENT CONCERNS: A 42-year-old male smoker presented with a slowly progressing 5th fingertip necrosis following blunt trauma. DIAGNOSES: Angiography revealed congenital hypoplasia of ulnar artery, and excluded Buerger disease or hypothenar hammer syndrome. INTERVENTIONS AND OUTCOMES: We reconstructed the necrotic fingertip using a 2nd toe pulp free flap to reflect the patient's need. LESSONS: In this case report, the authors emphasize that the possibility of anatomical anomaly should be considered as a cause of the ischemia. Vascular imaging should be undertaken to investigate the cause of ischemia of the hand.

Improvement of Infraorbital Rim contour Using Medpor.

BACKGROUND: Asymmetry of the infraorbital rim can be caused by trauma, congenital or acquired disease, or insufficient reduction during a previous operation. Such asymmetry needs to be corrected because the shape of the infraorbital rim or midfacial skeleton defines the overall midfacial contour. METHODS: The study included 5 cases of retruded infraorbital rim. All of the patient underwent restoration of the deficient volume using polyethylene implants between June 2005 and June 2011. The infraorbital rim was accessed through a subciliary approach, and the implants were placed in subperiosteal space. Surgical outcomes were evaluated using preoperative and postoperative computed tomography studies. RESULTS: Implant based augmentation was associated with a mean projection of 4.6 mm enhancement. No postoperative complications were noted during the 30-month follow-up period. CONCLUSION: Because of the safeness, short recovery time, effectiveness, reliability, and potential application to a wide range of facial disproportion problems, this surgical technique can be applied to midfacial retrusion from a variety of etiologies, such as fracture involving infraorbital rim, congenital midfacial hypoplasia, lid malposition after blepharoplasty, and skeletal changes due to aging.