Separate axillary incision for surgery of axillary lymph node can decrease drain amount and days to drain removal of the breast in direct-to-implant breast reconstruction.

PURPOSE: Sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) can be performed either with a separate axillary incision or through the mastectomy incision. The authors hypothesized that after SLNB or ALND through a single incision, connection of the axilla with mastectomy pocket could increase drainage. This study investigated whether a separate incision decreases drainage amount and duration in implant-based breast reconstruction. METHODS: Medical records of breast cancer patients who underwent nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction with prosthesis from March 2018 to February 2021 in a single tertiary center were reviewed. Demographic data, intraoperative details, and postoperative complications were reviewed. Breast drains were removed if the drain amount was less than 30cc for two consecutive days. Total breast drain amount, duration until removal, and prolonged drainage were compared with multivariate analysis. RESULTS: A total of 206 patients were included in the study, with separate incisions placed in 145 breasts and a single breast incision placed in 70 breasts. Mean duration and amount until drain removal were 12.8 ± 4.9 days and 817 ± 520 cc in the single incision group, respectively, and 9.9 ± 3.1 days and 434 ± 228 cc in the separate incision group, respectively Separate incision placement (p < 0.001), lower mastectomy weight (p < 0.001), and prepectoral plane of insertion (p < 0.001) were significantly associated with less drain amount and duration. None-separate incision placement (p = 0.01) and preoperative radiation therapy (p = 0.023) were significant factors for prolonged drainage. CONCLUSION: Placing a separate incision for axillary surgery during mastectomy and immediate implant-based reconstruction can decrease both drain amount and duration and reduce the risk of prolonged drainage.

Efficacy of preoperative lymphoscintigraphy in predicting surgical outcomes of lymphaticovenous anastomosis in lower extremity lymphedema: Clinical correlations in gynecological cancer-related lymphedema.

BACKGROUND: Lymphaticovenous anastomosis (LVA) is a promising microsurgical treatment for lower extremity lymphedema (LEL). Lymphoscintigraphy effectively assesses lower limb lymphatic systems before LVA, but its role in predicting the therapeutic outcomes of LVA is indeterminate. In this study we investigate the efficacy of preoperative lymphoscintigraphy using clinical findings to predict outcomes in gynecological cancer-related LEL patients who underwent LVA. METHODS: A retrospective review was conducted on consecutive gynecological cancer patients with LEL who had undergone LVA between June 2018 and June 2021. The therapeutic efficacy was assessed by measuring the change rate of the lower extremity lymphedema index (LELi) six months after surgery. Clinical data and lymphoscintigraphic findings were analyzed to assess therapeutic efficacy of LVA. RESULTS: Out of the 60 evaluated legs, 83.3% of the legs showed improved results after LVA. Univariable linear regression analysis revealed that higher preoperative LELi, and ovarian cancer were associated with superior LELi change rate (LC rate). Absence of dermal backflow (DBF) on lymphoscintigraphy was associated with inferior LC rate. Multivariable linear regression analysis identified ovarian cancer and higher preoperative LELi were independently correlated with favorable outcomes, while the absence of DBF was independently correlated with inferior outcomes. CONCLUSION: The results of this study emphasizes the effectiveness of preoperative lymphoscintigraphy, preoperative LELi, and primary malignancy as predictors of LVA outcomes in gynecological cancer-related LEL patients.

The added value of SPECT/CT lymphoscintigraphy in the initial assessment of secondary extremity lymphedema patients.

An added value of SPECT/CT over planar lymphoscintigraphy for initial staging in patients with secondary extremity lymphedema was investigated. Furthermore, we developed a hybrid SPECT/CT classification combining dermal backflow (DBF) of SPECT and honeycomb pattern (HP) of CT, correlated it with lymphoscintigraphic staging and clinical severity. Forty-one patients with secondary extremity lymphedema who underwent lymphoscintigraphy with SPECT/CT were included retrospectively. The severity of extremity lymphedema was assessed using CT volumetry. Lymphoscintigraphic findings were evaluated using the Taiwan Lymphoscintigraphy Staging (TLS), and CT-based and SPECT-based quantitative analysis were performed. TLS was performed by planar scintigraphy only and with SPECT/CT, respectively. The SPECT/CT findings were classified into DBF-/HP-, DBF+/HP-, DBF+/HP+, and DBF-/HP+. Based on these findings, patients were categorized into five classes: Class 1 = DBF-HP- entire limb, Class 2 = DBF+/HP- proximal/distal limb without DBF+/HP+ or DBF-/HP+, Class 3 = DBF+/HP+ proximal/distal limb without DBF-/HP+, Class 4 = Mixed DBF+/HP+ and DBF-/HP+ in proximal/distal limb, Class 5 = DBF-/HP+ entire limb. Adding SPECT/CT to planar scintigraphy showed a 15.4% modification rate in lymphoscintigraphic staging. HP volume ratio significantly increased as clinical severity and lymphoscintigraphic staging increased, while DBF volume ratio increased with severity and followed expected patterns according to lymphoscintigraphic staging. Hybrid SPECT/CT lymphoscintigraphic classification showed strong positive correlation with clinical severity and TLS. Our results demonstrated substantial modification of lymphoscintigraphic staging by adding SPECT/CT to a conventional planar scintigraphy. In addition, a hybrid SPECT/CT is expected to provide new indicators reflecting lymphoscintigraphic staging and clinical severity by providing both of functional DBF and anatomical HP information.

Effects of Prostaglandin E1 on Mastectomy Flap Necrosis in Immediate Implant-based Breast Reconstruction.

PURPOSE: Necrosis of a cutaneous flap including the nipple-areolar complex is a common complication in immediate implant-based breast reconstruction following nipple/skin-sparing mastectomy (NSM/SSM). This study aimed to evaluate the efficacy of prostaglandin E1 (PGE1) in reducing such complications. METHODS: A retrospective analysis of prospectively collected data was conducted at two centers, and the cohort consisted of patients undergoing NSM/SSM followed by immediate reconstruction with a prosthesis. Patients who were randomly allocated to the treatment group were administered daily intravenous PGE1 (10 mcg/2 mL) beginning intraoperatively through postoperative day 6. Skin flap complications including nipple/skin necrosis, delayed wound healing, and postoperative wound revision were recorded. Complication rates were compared between the PGE1 and control groups. RESULTS: A total of 276 breasts in 259 patients were included for analysis (139 breasts to the treatment group and 137 breasts to the control group). There was no difference in patient demographics between the control and treatment group. Reconstructed breasts receiving PGE1 had significantly lower rates for overall skin complications (21.6% vs. 34.3%, p=0.022) and wound revision (2.9% vs. 9.5%, p=0.025). Among NSM cases, the PGE1 group showed a significantly lower rate of nipple necrosis (15.5% vs. 29.4%, p=0.027). In the multivariate analysis, the use of PGE1 significantly reduced the risk of overall skin flap complications (odds=0.491, p=0.018), wound revision (odds=0.213, p=0.018) in NSM/SSM cases, and nipple necrosis (odds=0.357 p=0.008) in NSM cases. CONCLUSION: PGE1 can be effective in reducing risk of mastectomy flap complications in immediate implant-based breast reconstructions.

Serial Comparison of Patient-Reported Outcomes of Immediate Breast Reconstruction: Direct-to-Implant Versus Deep Inferior Epigastric Perforator Flap.

BACKGROUND: Direct-to-implant (DTI) and deep inferior epigastric artery perforator (DIEP) flaps are the two most common methods of immediate breast reconstruction. This study aimed to compare patient-reported outcomes between the two methods and to evaluate whether outcomes change over time. METHODS: The data of patients who underwent immediate breast reconstruction using DTI or DIEP flaps between July 2017 and October 2021 were retrospectively reviewed. Patients who completed the BREAST-Q Reconstruction Module at 6 months and > 12 months after reconstruction were analyzed. Mann-Whitney and Wilcoxon signed-rank test were used to compare outcome between DTI and DIEP groups, and serial comparisons were performed. RESULTS: Of 375 patients included in the analysis, 146 patients completed questionnaires > 1 year of follow-up (20.79 ± 8.55 months). The DTI and DIEP groups had 102 (69.9%) and 44 (30.1%) patients, respectively. There were no intergroup differences in the mean scores representing any of the domains at 6 postoperative months. After > 1 year of follow-up, patients who underwent DIEP-flap reconstruction had greater satisfaction with their breast reconstructions (p < 0.001) and greater satisfaction with their overall outcomes (p < 0.001). In the DTI group, satisfaction scores did not change over time in any of the domains. In the DIEP group, however, the mean scores reflecting satisfaction with the breast (p = 0.001), overall outcome (p = 0.045), psychosocial well-being (p = 0.015), and sexual well-being (p = 0.042) significantly increased over long-term follow-up relative to the scores at 6 postoperative months. CONCLUSIONS: Patient-reported outcomes improved over time in association with DIEP reconstructions, reflecting higher satisfaction levels than those associated with DTI reconstruction. 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 .

Delayed Reconstruction of Nasal Tip Amputation After a Dog Bite Using a Cartilage Graft and Paramedian Forehead Flap.

The timing and method of reconstruction of an amputated nose due to a dog bite are still controversial. Here, we describe a delayed reconstruction using the paramedian forehead flap with a simultaneous cartilage graft to address a contracted nose from a dog bite. A healthy, 52-year-old patient was attacked by his acquaintance's dog, resulting nasal tip amputation that included cartilage. The composite graft was performed, and secondary healing resulted in a short nose deformity. Five months after the injury, a conchal cartilage graft and paramedian forehead flap were performed simultaneously to correct the shape of the deformity. At 1 year postoperatively, the flap survived without complications, and the short nose deformity was successfully corrected. In summary, immediate composite graft after a dog bite could result in a contracted nose, but the deformity can be corrected by a simultaneous paramedian forehead flap and cartilage graft.

Lymphatic flow velocity is a predictor of functional lymphatic vessels for lymphaticovenous anastomosis.

BACKGROUND: Indocyanine green (ICG) lymphography is widely used to localize functional lymphatic vessels for lymphaticovenous anastomosis (LVA); however, flow velocity is rarely assessed. We aimed to evaluate the correlation between lymphatic flow velocity and the presence of functional lymphatic vessels. METHODS: Data of a total of 924 lymphatic vessels from 273 lymphedema patients who underwent LVA between July 2018 and December 2020 were retrospectively reviewed. Lymph flow velocity was defined by considering the most proximal anatomic location enhanced by ICG at 30 min after injection and categorized into four groups; grade 1 (foot or hand), grade 2 (below knee or elbow), grade 3 (at/above knee or eblow), or grade 4 (axilla or groin). The presence of functional lymphatic vessels, which showed lymphatic fluid flow when the vessels were cut for anastomosis, was compared between the four groups. RESULTS: A higher rate of functional lymphatic vessels was observed among lymphatic vessels with grade 3 or 4 flow velocity compared with those with grade 1 or 2 flow velocity (67.5% vs. 44.5%; p < 0.001). These findings were consistent with the observations for lymphatic vessels with a non-linear pattern in ICG lymphography (59.4% vs. 26.5%; p < 0.001). The rate of completion of LVA at surgical sites in extremities with grade 3 or 4 flow velocity was 88.1% compared with 65.8% in extremities with grade 1 or 2 velocity (p < 0.001). CONCLUSIONS: Lymph flow velocity grading can be a simple and easy adjunctive method to determine indication for LVA in extremities with lymphedema.

Three-dimensional Volume Changes of the Reconstructed Breast Following DIEP Flap Breast Reconstruction.

BACKGROUND: This study aimed to assess whether the reconstructed breast volume changed postoperatively following a deep inferior epigastric artery perforator (DIEP) flap. METHODS: Patients were included if they had undergone unilateral breast reconstruction with a DIEP flap at the two selected centers between April 2017 and September 2019. Serial 3-D surface imaging of both breasts was taken at 1, 3, 6, and 12 months postoperatively. The primary outcome was a volume ratio of the reconstructed to the contralateral breast. A linear mixed-effect model was used to evaluate whether the DIEP flap volume changed according to the postoperative time. RESULTS: A total of 74 patients were included in the analysis. The mean volume ratio of the reconstructed side compared with the contralateral breast at 1, 3, 6, and 12 months postoperatively were 106.9%, 105.9%, 108.7%, and 107.6%, respectively. In the linear mixed effect model, the volume ratio of the reconstructed breast did not change over time for immediate reconstructions (p = 0.376). However, there was an increase over time in delayed reconstructions (p = 0.043). Adjuvant radiation, chemotherapy, and hormone therapy did not influence the volume ratio of the reconstruced breast. Correlation analysis using repeatedly measured values showed that both reconstruced and healthy breast volumes had positive correlation with the patient's body weight (p < 0.001). On the other hand, volume ratio of the breasts was not influenced by the patient's body weight (p = 0.493). The volume ratio of the reconstructed breast significantly decreased in the upper inner (p = 0.003) and the upper outer (p = 0.006) quadrants, while increasing in the lower outer (p = 0.002) quadrant throughout the first-year postoperative period. CONCLUSION: The volume ratio of the reconstructed to the contralateral breast does not decrease postoperatively following DIEP flap breast reconstruction.

Classification of superficial lymphatic pathways in the upper extremity and incidence of lymphatic obstruction according to the lymphatic pathways in patients with unilateral upper extremity lymphedema.

BACKGROUND: Indocyanine green (ICG) lymphography is frequently used in the diagnosis of lymphedema, as well as the planning of its surgical management, but the typical anatomy of the superficial lymphatic pathways is incompletely delineated. This study aims to evaluate the topographical anatomy of superficial lymphatic vessels of the upper extremity METHODS: Sixty consecutive patients undergoing lymphaticovenular anastomosis for unilateral upper extremity lymphedema were selected. Lymphatic mapping was performed on the normal contralateral arm with ICG lymphography. A single upper arm reference line and two separate forearm reference lines (anterior and posterior) were drawn between anatomic landmarks. Lymphatic pathways were analyzed based on distances (cm) from the reference lines and were compared with those in lymphedema arms. RESULTS: Mean age of the patients were 54.6 ± 8.4 years. Three lymphatic flow pathways were identified: anterior (100%), posterior (96.6%), and posterior-ulnar lymphatic (33.3%) vessels. The anterior and posterior lymphatic vessels ran along the anterior and posterior reference lines, respectively, on the forearm (within 2 cm) and medial to the upper arm reference line. In arms with lymphedema, the absence of lymphatic flow was most commonly observed in posterior lymphatics (29/59, 49%), followed by anterior (15/60, 25%) and posterior-ulnar lymphatics (1/20, 5%). Compared to normal arms, new lymphatic flow through posterior-ulnar lymphatics was observed in 34.5% of patients (10/29) in whom posterior lymphatics was completely obstructed. CONCLUSIONS: Superficial lymphatic vessels can be classified into anterior, posterior, and posterior-ulnar lymphatic vessels. Posterior-ulnar lymphatic vessels might be least affected by lymphosclerosis in patients with lymphedema.

Influence of vertical location and spacing of perforators on perfusion in deep inferior epigastric artery perforator flap breast reconstruction: quantitative analysis using indocyanine green angiography.

Background: This study quantitatively assessed perfusion of the deep inferior epigastric artery perforator (DIEP) flap according to vertical location and vertical spacing of perforators during DIEP flap breast reconstruction. Methods: In 67 patients who underwent unilateral DIEP flap breast reconstruction between November 2018 and August 2021, flap perfusion was intraoperatively assessed using indocyanine green angiography. Perforators located at or above the umbilicus were defined as vertical zone 1 perforators and those below the umbilicus as vertical zone 2 perforators. Perfusion assessment was conducted in two stages: at stage 1, perfusion solely by single dominant perforators was assessed. At stage 2, the perfusion increment effected by adding a single additional perforator was assessed. Perfused area proportions were compared between patients with dominant perforators in zone 1 versus zone 2. The effect of adding an additional perforator to another vertical zone ("vertical spacing") was also assessed. Results: The perfused proportion was significantly higher among vertical zone 2 perforators compared with zone 1 perforators in the evaluation of single dominant perforators (70% vs. 56%; P<0.001). In the evaluation of incremented perfusion by single additional perforators, the perfused proportion was significantly higher in the vertical-spacing group compared to the no-vertical-spacing group (17% vs. 12%; P=0.004). Fat necrosis developed in 4.5 percent of the patients over at least 6 months of follow-up. Conclusions: DIEP flap perfusion can be affected by the vertical location of perforators, and flap perfusion can be augmented effectively by vertical spacing of perforators.

Factors influencing postoperative abdominal pain in DIEP flap breast reconstruction.

BACKGROUND: Identification of a subgroup of patients with severe postoperative pain is important for adequate pain management for enhanced, fast recovery after deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. The purpose of this study was to identify factors influencing postoperative abdominal pain in patients undergoing DIEP flap breast reconstruction. METHODS: Consecutive patients who underwent unilateral breast reconstruction using DIEP free flaps from October 2018 to July 2020 were included in this study. Visual analog scale (VAS)-guided postoperative pain scores were documented every 3 hours until 48 hours postoperatively. Factors affecting patient-reported pain scores were analyzed using a linear mixed-effects model. Independent variables included patient characteristics, history of previous open abdominal surgery, and operative factors including the flap size, flap weight, use of a unipedicled or bipedicled flap, number of perforators, timing of reconstruction, and use of a catheter-based subcutaneous plane block in the abdomen. A catheter was placed above the rectus fascia during closure, and analgesics were continuously infused during the 48 hours using an ON-Q Pain Relief System (I-Flow Co., Lake Forest, CA, USA). RESULTS: Fifty-five patients were included in the analysis. In the linear mixed effect model using multiple clinical variables, the harvested flap weight was significantly associated with the degree of pain (ß coefficient =0.157, P=0.008). The pain degrees significantly decreased according to postoperative days (ß coefficient =-0.649, P<0.001). The flap type (unipedicle or bipedicle), number of perforators, timing of reconstruction, and history of previous abdominal surgery did not influence pain degrees. The use of subcutaneous plane block did not affect the degree of pain or dose of analgesics used. CONCLUSIONS: A larger flap weight is associated with an increased degree of pain in patients undergoing DIEP flap breast reconstructions. Vigorous pain management might be necessary when a large flap is elevated.

Lymphoscintigraphic Findings as Indicators of Lymphaticovenous Anastomosis Outcome in Patients With Extremity Lymphedema: A Retrospective Cohort Study.

PURPOSE: This study was performed to evaluate the usefulness of lymphoscintigraphy in predicting the surgical outcomes of lymphaticovenous anastomosis (LVA) in a patient with extremity lymphedema. PATIENTS AND METHODS: We retrospectively evaluated 133 patients with extremity lymphedema who underwent lymphoscintigraphy followed by LVA surgery from February 2018 to March 2020. Lymphoscintigraphic findings were evaluated on the following parameters: the extent of dermal backflow (small/large), lymphatic flow patterns (trunk flow pattern/proximal-restricted pattern/distal-restricted pattern), visualization of lymph nodes, and collateral lymphatic vessels. The mean circumferential difference change before and after surgery, circumferential reduction (CR) rate (%), was used as the clinical outcome variables. RESULTS: A decrease in circumference was observed in 93 (69.9%) of 133 patients after LVA. The extent of dermal backflow and lymphatic flow patterns was significantly correlated with improved clinical outcomes after LVA. The large extent of the dermal backflow group showed a more significant CR rate than the small extent (19.27% vs 1.24%, P = 0.005). The TP group showed the most significantly decreased CR rate to 21.46%, and the proximal-restricted pattern and distal-restricted pattern groups were -2.49% and -5.33%, respectively (P < 0.001). Multivariate analysis revealed that dermal backflow and lymphatic flow patterns were independent predictors of therapeutic outcome (P < 0.001). CONCLUSIONS: Our study demonstrates that pretreatment lymphoscintigraphy may help predict the therapeutic effect of LVA in patients with extremity lymphedema. Furthermore, dermal backflow and lymphatic flow patterns are independent predictors of CR rate after LVA surgery for extremity lymphedema.

Pure hemi-periareolar incision versus conventional lateral radial incision mastectomy and direct-to-implant breast reconstructions: comparison of indocyanine green angiographic perfusion and necrosis of the nipple.

BACKGROUND: This study evaluated the feasibility of direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision without extension and with the aid of indocyanine green angiographic evaluation on the mastectomy skin flap. METHODS: Patients who underwent immediate direct-to-implant breast reconstruction from December 2018 to February 2020 were included. After nipple-sparing mastectomy, indocyanine green angiographic evaluation of perfusion to nipple-areola complex was performed by video recording with a near infrared camera, and nipple perfusion time and perfusion pattern were analyzed. Patients were divided into a pure hemi-periareolar incision group and conventional lateral radial incision groups to compare nipple perfusion and surgical outcomes. RESULTS: A total of 61 breasts in 56 patients were included. Pure hemi-periareolar incision was used in 41 breasts, and conventional lateral radial incisions were used in 20 breasts. Nipple perfusion time was significantly increased in the pure hemi-periareolar incision group (79.6±65.8 vs. 43.2±49.8 seconds, P=0.031). While minor nipple-areola complex necrosis was significantly increased in the pure hemi-periareolar incision group (19.5% versus 0%; P=0.044), major nipple-areola complex necrosis (2.4% versus 5.0%; P>0.999) was not significantly different between the two groups. The rates of nipple-areola complex necrosis were 0%, 16.7%, and 63.6% in rapid, delayed, and no perfusion groups, respectively (P<0.001). No nipple perfusion pattern was a significant predictor for nipple-areola complex necrosis in univariable and multivariable analyses (P<0.001). There was no case of reconstruction failure. CONCLUSIONS: Immediate direct-to-implant breast reconstruction after nipple-sparing mastectomy using pure hemi-periareolar incision can be safely performed using indocyanine green angiographic evaluation on the mastectomy skin flap.

Prediction of the Ideal Implant Size Using 3-Dimensional Healthy Breast Volume in Unilateral Direct-to-Implant Breast Reconstruction.

Background and objectives: There is no consensus regarding accurate methods for assessing the size of the implant required for achieving symmetry in direct-to-implant (DTI) breast reconstruction. The purpose of this study was to determine whether the ideal implant size could be estimated using 3D breast volume or mastectomy specimen weight, and to compare prediction performances between the two variables. Materials and Methods: Patients who underwent immediate DTI breast reconstruction from August 2017 to April 2020 were included in this study. Breast volumes were measured using 3D surface imaging preoperatively and at postoperative three months. Ideal implant size was calculated by correcting the used implant volume by the observed postoperative asymmetry in 3D surface imaging. Prediction models using mastectomy weight or 3D volume were made to predict the ideal implant volume. The prediction performance was compared between the models. Results: A total of 56 patients were included in the analysis. In correlation analysis, the volume of the implant used was significantly correlated with the mastectomy specimen weight (R2 = 0.810) and the healthy breast volume (R2 = 0.880). The mean ideal implant volume was 278 ± 123 cc. The prediction model was developed using the healthy breast volume: Implant volume (cc) = healthy breast volume × 0.78 + 26 cc (R2 = 0.900). The prediction model for the ideal implant size using the 3D volume showed better prediction performance than that of using the mastectomy specimen weight (R2 = 0.900 vs 0.759, p < 0.001). Conclusions: The 3D volume of the healthy breast is a more reliable predictor than mastectomy specimen weight to estimate the ideal implant size. The estimation formula obtained in this study may assist in the selection of the ideal implant size in unilateral DTI breast reconstruction.

Comparison of the second and third intercostal spaces regarding the use of internal mammary vessels as recipient vessels in DIEP flap breast reconstruction: An anatomical and clinical study.

BACKGROUND: The purpose of this study was to compare the anatomical features of the internal mammary vessels (IMVs) at the second and third intercostal spaces (ICSs) with regard to their use as recipient vessels in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: A total of 38 consecutive DIEP breast reconstructions in 36 patients were performed using IMVs as recipient vessels between March 2017 and August 2018. The intraoperative findings and postoperative complications were analyzed. Anatomical analyses were performed using intraoperative measurements and computed tomography (CT) angiographic images. RESULTS: CT angiographic analysis revealed the mean diameter of the deep inferior epigastric artery to be 2.42±0.27 mm, while that of the deep inferior epigastric vein was 2.91±0.30 mm. A larger mean vessel diameter was observed at the second than at the third ICS for both the internal mammary artery (2.26±0.32 mm vs. 1.99±0.33 mm, respectively; P=0.001) and the internal mammary vein (IMv) (2.52±0.46 mm vs. 2.05±0.42 mm, respectively; P<0.001). Similarly, the second ICS was wider than the third (18.08±3.72 mm vs. 12.32±2.96 mm, respectively; P<0.001) and the distance from the medial sternal border to the medial IMv was greater (9.49±2.28 mm vs. 7.18±2.13 mm, respectively; P<0.001). Bifurcations of the IMv were found in 18.4% of cases at the second ICS and in 63.2% of cases at the third ICS. CONCLUSIONS: The IMVs at the second ICS had more favorable anatomic features for use as recipient vessels in DIEP flap breast reconstruction than those at the third ICS.

Intraoperative Intercostal Nerve Block for Postoperative Pain Control in Pre-Pectoral versus Subpectoral Direct-to-Implant Breast Reconstruction: A Retrospective Study.

Background and Objectives: Patients undergoing mastectomy and implant-based breast reconstruction have significant acute postsurgical pain. The purpose of this study was to examine the efficacy of intercostal nerve blocks (ICNBs) for reducing pain after direct-to-implant (DTI) breast reconstruction. Materials and Methods: Between January 2019 and March 2020, patients who underwent immediate DTI breast reconstruction were included in this study. The patients were divided into the ICNB or control group. In the ICNB group, 4 cc of 0.2% ropivacaine was injected intraoperatively to the second, third, fourth, and fifth intercostal spaces just before implant insertion. The daily average and maximum visual analogue scale (VAS) scores were recorded by the patient from operative day to postoperative day (POD) seven. Pain scores were compared between the ICNB and control groups and analyzed according to the insertion plane of implants. Results: A total of 67 patients with a mean age of 47.9 years were included; 31 patients received ICNBs and 36 patients did not receive ICNBs. There were no complications related to ICNBs reported. The ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 6, p = 0.047), lower maximum VAS scores on the operative day (5 versus 7.5, p = 0.030), and POD 1 (4 versus 6, p = 0.030) as compared with the control group. Among patients who underwent subpectoral reconstruction, the ICNB group showed a significantly lower median with an average VAS score on the operative day (4 versus 7, p = 0.005), lower maximum VAS scores on the operative day (4.5 versus 8, p = 0.004), and POD 1 (4 versus 6, p = 0.009), whereas no significant differences were observed among those who underwent pre-pectoral reconstruction. Conclusions: Intraoperative ICNBs can effectively reduce immediate postoperative pain in subpectoral DTI breast reconstruction; however, it may not be effective in pre-pectoral DTI reconstruction.

Co­transplantation of tonsil­derived mesenchymal stromal cells in bone marrow transplantation promotes thymus regeneration and T cell diversity following cytotoxic conditioning.

Bone marrow (BM) transplantation (BMT) represents a curative treatment for various hematological disorders. Prior to BMT, a large amount of the relevant anticancer drug needed to be administered to eliminate cancer cells. However, during this pre­BMT cytotoxic conditioning regimen, hematopoietic stem cells in the BM and thymic epithelial cells were also destroyed. The T cell receptor (TCR) recognizes diverse pathogen, tumor and environmental antigens, and confers immunological memory and self­tolerance. Delayed thymus reconstitution following pre­BMT cytotoxic conditioning impedes de novo thymopoiesis and limits T cell­mediated immunity. Several cytokines, such as RANK ligand, interleukin (IL)­7, IL­22 and stem cell factor, were recently reported to improve thymopoiesis and immune function following BMT. In the present study, it was found that the co­transplantation of tonsil­derived mesenchymal stromal cells (T­MSCs) with BM­derived cells (BMCs) accelerated the recovery of involuted thymuses in mice following partial pre­BMT conditioning with busulfan­cyclophosphamide treatment, possibly by inducing FMS­like tyrosine kinase 3 ligand (FLT3L) and fibroblast growth factor 7 (FGF7) production in T­MSCs. The co­transplantation of T­MSCs with BMCs also replenished the CD3+ cell population by inhibiting thymocyte apoptosis following pre­BMT cytotoxic conditioning. Furthermore, T­MSC co­transplantation improved the recovery of the TCR repertoire and led to increased thymus­generated T cell diversity.

Comparison of surgical outcomes of free flap reconstructions performed by expert microsurgeons and trainees who completed a structured microsurgical training program in a teaching hospital.

BACKGROUND: Few studies have evaluated clinical outcomes of novice surgeons trained in a microsurgical training program. Herein, we describe successful free flap reconstructions performed by trainees who completed a structured microsurgical training program. METHODS: The Microsurgical Skills Training Course, a laboratory-based structured microsurgical training program, was developed and used for microsurgical training. Three trainees (postgraduate years 6 and 7) who completed the training course during residency were assigned to perform free flap reconstructions between March 2015 and February 2019. Clinical outcomes of free flap reconstruction were assessed. A retrospective propensity-score-matched analysis was performed between the trainee and expert microsurgeon groups. RESULTS: A total of 161 patients were included. Of them, 67 (25 of the trainee group and 42 of the expert group) were propensity score-matched. No flap failure developed in either matched group (p>0.999). Rates of overall complications, partial flap loss, and emergent reoperation due to vascular compromise were not significantly different between the two groups (p=0.384, p=0.525, and p=0.322, respectively), whereas those of donor complications and overall operation time were significantly higher in the trainee group than the expert group (p=0.002 and p<0.001, respectively). CONCLUSION: The use of a structured microvascular training program in qualified teaching hospitals may help trainees achieve independence as microsurgeons and favorable clinical outcomes.

Lymphaticovenular Anastomosis for Treatment of Lymphedema Developed After Liver Transplantation: A Case Report.

OBJECTIVE: Secondary lymphedema of the extremities usually develops well after lymph node dissection or radiation therapy in oncologic surgery. In this report, we present a case of lymphedema developed after liver transplantation and treatment by lymphaticovenular anastomosis (LVA). METHODS: A 52-year-old man was diagnosed with hepatocellular carcinoma in April 2016, and a liver transplantation was performed in June 2016. After the liver transplantation, left lower leg swelling developed, and the symptom became severe for around a year. Two years after liver transplantation, lymphoscintigraphy and indocyanine green lymphography were performed, and the patient was diagnosed with lymphedema caused by proximal lymphatic obstruction. LVA was performed at the ankle and superior knee areas. RESULTS: The difference between the left and right knee circumference was decreased from 5.3 cm to 3.4 cm at 6 months postoperatively. The lower extremity lymphedema index of the left leg was decreased from 291.9 to 288.1 at 6 months after surgery. A quality of life measure for limb lymphoedema survey showed that all 4 categories (function, appearance, symptoms, and mood) were improved at 6 months after surgery. CONCLUSION: Lymphedema can develop after liver transplantation, and early LVA surgery can be effective for the treatment of lymphedema developed after liver transplantation.

The influence of contralateral breast augmentation on the development of complications in direct-to-implant breast reconstruction.

BACKGROUND: Simultaneous contralateral augmentation in direct-to-implant (DTI) breast reconstruction may increase the risk of skin flap necrosis on the reconstruction side due to increased tension on the skin flap when implants are larger than the original breast size. The purpose of this study was to evaluate whether the contralateral augmentation procedure affects complications in unilateral DTI breast reconstruction. METHODS: Patients who underwent immediate unilateral DTI breast reconstruction from January 2013 to July 2017 were included in this study. Data were collected through retrospective review of individual medical records. The primary outcome variable was the development of perioperative complications including skin flap necrosis. Univariable and multivariable logistic regression analyses were performed to identify risk factors for complications. RESULTS: A total of 121 patients who underwent unilateral immediate DTI breast reconstruction were included in this study. Twenty-one patients (17.4%) underwent simultaneous contralateral augmentation mammoplasty and 100 patients (82.6%) underwent DTI without contralateral augmentation. Overall complications were not different between the contralateral augmentation and no-augmentation groups (23.8% vs. 31%, respectively, p = 0.512). The frequency of skin flap necrosis in the augmentation group (14.3%) was not significantly different from that in the no-augmentation group (18.0%, p > 0.999). In multivariable analysis, mastectomy weight was the only predictor for complications (p = 0.053) and contralateral augmentation was not associated with development of complications. CONCLUSION: Contralateral breast augmentation in DTI breast reconstruction is not a risk factor for complications and can be safely performed in selected patients.