Redo hepatic artery reconstruction for thrombosis without retransplantation in 1355 adult living donor liver transplantations.

Hepatic artery thrombosis (HAT) after liver transplantation is associated with a marked increase in morbidity, leading to graft and patient loss. We evaluated the outcomes of adult living donor liver transplantation patients with HAT under an aggressive surgical intervention. A total of 1355 recipients underwent adult living donor liver transplantation at the Seoul National University Hospital. Surgical redo reconstruction for HAT was performed in all cases except in those with graft hepatic artery injury and late detection of HAT. Postoperative HAT developed in 33 cases (2.4%) at a median time of 3.5 days. Thirty patients (90.9%) underwent redo-arterial reconstruction. The survival rates in patients with HAT were similar to the rates in those without HAT (72.7% vs. 83.8%, p = 0.115). Although graft survival rates were lower in patients with HAT (84.8%) than in those without HAT (98.0%) ( p < 0.001), the graft survival rate was comparable (92.0% vs. 98.0%, p = 0.124) in the 25 patients with successful revascularization. Biliary complication rates were higher in patients with HAT (54.5%) than in those without HAT (32.0%) ( p = 0.008). In conclusion, the successful redo reconstruction under careful selection criteria saved the graft without retransplantation in 96.0% of the cases. Surgical revascularization should be preferentially considered for the management of HAT in adult living donor liver transplantation.

Effect of Stromal Vascular Fraction on Sustained Volume Retention of Five Different Hyaluronic Acid Fillers.

BACKGROUND: The technology of manufacturing hyaluronic acid (HA) fillers is evolving to increase their safety and durability. This study aimed to compare the volume maintenance effect of stromal vascular fraction (SVF) on different types of HA fillers. METHODS: In this controlled experiment, HA fillers mixed with SVF were injected into the right upper back and HA fillers alone were injected into the left upper back of each mouse. A total of 35 mice were separated into five groups according to the type of commercially used HA filler: Juvederm Voluma XC, Restylane Lyft, Restylane Skinboosters Vital, Giselle Ligne Signature 2, and Giselle Ligne Universal. Nodule size inspection was performed on post-injection days 0, 3, and 56. Ultrasonography for maximal two-dimensional area of filler nodule measurement and histology were performed on the last day of the inspection. RESULTS: While most of the groups showed a volume reduction of over 50% on day 56, regardless of SVF administration, significant volume maintenance was observed when Giselle Ligne Signature 2 was injected with SVF. Ultrasonographic measurement of two-dimensional filler nodule size showed no significant difference regarding filler types and SVF injection. When compared with the histological results of other fillers mixed with SVF, Giselle Ligne Signature 2 showed marked increase in cell survival and extracellular matrix components in HA particles. CONCLUSION: SVF showed different efficacies in terms of volume maintenance and cell survival for various HA filler types. The SVF mixture in selective HA filler injections may improve maintenance in clinical settings. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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.

Revisional Medial Epicanthoplasty Using Reverse Z-Plasty Technique.

BACKGROUND: Medial epicanthoplasty is a common method for correcting epicanthal folds in Asians but sometimes cause unsatisfactory results. Although several procedural variations have been devised, revision techniques have earned little attention. The revision technique the authors have developed employs reverse Z-plasty to restore an overcorrected epicanthal fold. OBJECTIVES: The aim of this study was to investigate the effectiveness of the authors' reverse Z-plasty technique in restoring natural medial canthal region harmonizing with Asian face. METHODS: From January 2010 to December 2016, reverse Z-plasty was performed in patients seeking revisions after previous medial epicanthoplasties. Patients were surveyed to assess their satisfaction with surgical outcomes. Interepicanthal distance-lengthening ratios and symmetry of palpebral widths were evaluated digitally (ImageJ software) in patients who received revisional epicanthoplasty only. RESULTS: The reverse Z-plasty technique for revisional epicanthoplasty was performed in 548 Asian patients (83 males, 460 females). Most patients were pleased with the final outcomes. Only 6% submitted to later revisions of scars, which were otherwise scarcely visible after 3 months. Among 60 patients who underwent only revisional epicanthoplasty, interepicanthal distance-lengthening ratios ranged from 2.9% to 31.1% (average, 8.6%), and palpebral width symmetries improved. CONCLUSIONS: This particular technique helps restore the 3-dimensional appearance of medial canthal angle through horizontal skin and soft tissue (including muscle and ligament) restructuring, thus compensating for tissue deficiency. It is simple in design, easy to perform, and satisfactory results were achieved, conferring natural aesthetics to the medial canthal region.

Dextroplantation of Left Liver Graft in Infants.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3 years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n = 17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight <6 kg: 50.0% versus 11.8%; P = 0.03). The rate of graft-to-recipient weight ratio >4% was higher in group D (60.0%) than C (11.8%; P = 0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P = 0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P > 0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P = 0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.

Compact Fat Grafting: A Novel Method to Improve Graft Retention Through Modulation of Adipocyte Size.

BACKGROUND: The viable zone where adipocytes and/or adipose-derived stem cells survive is present at the surface of graft fat tissue; however, there is controversy regarding the zone thickness. Graft retention could be improved if more adipocytes are included in the zone. OBJECTIVES: We hypothesize that a temporary reduction in adipocyte size prior to grafting could increase the number of adipocytes in the viable zone. We reduced the adipocyte size by treatment with MLN4924, which controls lipid accumulation in adipocytes, and investigated the histological and microenvironmental changes in grafted fat. METHODS: Subcutaneous fat harvested from wild-type C57BL/6J mice was chopped into small pieces; treated with dimethyl sulfoxide (control group), 0.25 µM MLN4924, or 0.5 µM MLN4924 for 4 days; and grafted into recipient C57BL/6J mice at the supraperiosteal plane of the skull. RESULTS: The reduced adipocyte size in response to MLN4924 treatment was restored within 8 weeks after fat grafting. The MLN4924-treated groups exhibited substantially greater graft volume, lower tissue hypoxia, and higher production of M2 macrophages compared with the control group. CONCLUSIONS: Grafting with compact fat that had smaller adipocytes improved the microenvironment by modulating tissue hypoxia and macrophage polarization, leading to improved graft retention. Therefore, compact fat grafting may offer a new clinical strategy without the need for stem cell manipulation.

Oncologic outcomes after immediate breast reconstruction following mastectomy: comparison of implant and flap using propensity score matching.

BACKGROUND: Although immediate breast reconstruction has been reported to be oncologically safe, no affirmative study comparing the two reconstruction methods exists. We investigated breast cancer recurrence rates in two breast reconstruction types; implant reconstruction and autologous flap reconstruction. METHODS: A retrospective cohort study was performed on propensity score-matched (for age, stage, estrogen receptor status) patients who underwent IBR after mastectomy at Seoul National University Hospital between 2010 and 2014. The main outcomes determined were locoregional recurrence-free interval (LRRFI) and disease-free interval (DFI). RESULTS: We analyzed 496 patients among 731 patients following propensity score matching (Median age 43, 247 implant reconstruction and 249 flap reconstruction). During median follow-up of 58.2 months, DFI was not different between the two groups at each tumor stage. However, flap reconstruction showed inferior DFI compared to implant reconstruction in patients with high histologic grade (p = 0.012), and with high Ki-67 (p = 0.028). Flap reconstruction was related to short DFI in multivariate analysis in aggressive tumor subsets. Short DFI after flap reconstruction in aggressive tumor cell phenotype was most evident in hormone positive/Her-2 negative cancer (p = 0.008). LRRFI, on the other hand, did not show difference according to reconstruction method regardless of tumor cell aggressiveness. CONCLUSION: Although there is no difference in cancer recurrence according to reconstruction method in general, flap-based reconstruction showed higher systemic recurrence associated with histologically aggressive tumors.

Single-stage cross-facial nerve grafting has a result equivalent to that of two-stage cross-facial nerve grafting.

BACKGROUNDS: Cross-face nerve grafting (CFNG) is an important treatment for patients with facial palsy. Currently, two-stage CFNG is frequently performed. CFNG is performed first, followed by coaptation when innervation reaches the grafted nerve ending. The present study compared single-stage CFNG with conventional two-stage CFNG. METHODS: We retrospectively reviewed data of 17 patients who underwent CFNG with zygomatic and buccal branch with hypoglossal crossover. Patients with single-stage (group 1) and two-stage (group 2) CFNG were comparatively analyzed 2 years postoperatively. There were nine and eight patients in groups 1 and 2, respectively. The patient's perioperative status was measured with imaging and animation using the Yanagihara grade, altitude, and angle differences of the oral commissure and eye closure. RESULTS: Patients in group 1 could recognize their first postoperative spontaneous movement earlier than those in group 2 (268.3 ± 25.1 days vs. 327.5 ± 51.3 days, respectively, p = 0.015). The Yanagihara grade significantly improved for patients in both groups postoperatively (group 1: 12.8 ± 5.5 to 25.3 ± 6.1, p < 0.01; group 2: 12.4 ± 5.6 to 24.3 ± 5.0, p = 0.012). Height and angle difference of the oral commissure showed a significant improvement during resting and smiling in both groups. Eye closure also showed significant improvement in both groups (group 1: 4.1 ± 0.6 to 2.6 ± 0.5, p < 0.01; group 2: 4.0 ± 0.5 to 2.8 ± 0.7, p < 0.01). There was no significant difference in the postoperative improvement rate between the groups. CONCLUSIONS: Single-stage CFNG shows results equivalent to those of two-stage CFNG. Single-stage CFNG is associated with a shorter treatment period and fewer operations.

A Revision Mandibuloplasty: Causes, Indications, Surgical Methods and Treatment Outcomes.

BACKGROUND: This paper aims to propose a classification system to categorize patients undergoing revision mandibuloplasty according to their dissatisfaction types. This paper also introduces various appropriate revision techniques and evaluates their outcomes. Through this classification system and suggested surgical techniques, surgeons can settle the disappointments experienced by patients after their primary mandibuloplasty, by realizing more natural-looking results. METHODS: The study subjects consisted of 184 patients who underwent a revision mandibuloplasty from October 2010 to March 2016, conducted by a single surgeon at a single institution. The authors were able to classify the dissatisfaction into two primary types-(1) lack of an overall slender frontal facial contour and (2) unnatural and asymmetrical overall facial appearance due to over- or inaccurate resection of the bone. A self-evaluation of patient's subjective satisfaction based on the scale from 1 to 5, both after the primary operation and after revision surgery, was compared. RESULTS: Dissatisfaction type I accounted for 145 patients (78.8 percent). The number of patients classified into dissatisfaction type II was 39 (21.2 percent). Of the patients categorized into type I, those undergoing revision surgeries due to an under-corrected mandibular tubercle and parasymphysis showed the most remarkable improvement in self-satisfaction score after reoperation-from 2.3 to 4.0. CONCLUSION: To realize a natural-looking outcome in facial look through mandibular contouring, it is important not only to carefully consider the ratio and shape essential for an optimal slender facial contour, but also to minimize unnecessary resection of the bone. 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 .

Inhibition Mechanism of Acellular Dermal Matrix on Capsule Formation in Expander-Implant Breast Reconstruction After Postmastectomy Radiotherapy.

BACKGROUND: Capsular contracture is one of the most common complications of expander-implant breast reconstruction. Recently, clinical reports have shown that use of an acellular dermal matrix (ADM) to cover breast implants decreases incidence of capsular contracture, but the underlying mechanism is unclear. Here, we examine how ADM reduces capsular formation in expander-implant breast reconstruction and identify cellular and molecular mechanisms of ADM-mediated reduction of capsular contracture in nonirradiated and irradiated patients. METHODS: Thirty patients who underwent immediate two-stage implant-based breast reconstruction were included; 15 received radiotherapy. While the tissue expander was changed to permanent silicone implant, biopsies of the subpectoral capsule and ADM capsule were performed. Capsule thickness, immunohistochemistry of α-smooth muscle actin (αSMA), vimentin, CD31, F4/80 expression, αSMA and CD31 coexpression, and relative gene expression levels of transforming growth factor (TGF)-ß1 and platelet-derived growth factor (PDGF)-B were investigated. RESULTS: Irradiated submuscular capsules were thicker than nonirradiated submuscular capsules, but the thickness of ADM capsules did not significantly differ between nonirradiated and irradiated groups. Levels of myofibroblasts, fibroblasts, vascularity, EndoMT, and macrophages were significantly lower in ADM capsules than in submuscular capsules. With the exception of EndoMT, all others were increased in irradiated submuscular capsules compared with nonirradiated submuscular capsule, while none significantly differed between nonirradiated and irradiated ADM capsules. CONCLUSIONS: Use of ADM reduced myofibroblasts, vascularity, fibroblasts, and EndoMT in capsule tissues. Moreover, ADM use decreased macrophages, a key regulator of tissue fibrosis, as well as TGF-ß1 and PDGF-B expression. We hope that these results provide basic concepts important for prevention of capsular contracture.

Optimal Reconstruction Method for Large Radionecrosis Following Breast Cancer Treatment: Utility of Free Transverse Rectus Abdominis Myocutaneous Flap Using Contralateral Internal Mammary Artery as Recipient.

INTRODUCTION: In extensive radionecrosis following radiotherapy for breast cancer (BC) treatment, the defect after excision can be reconstructed with a transverse rectus abdominis myocutaneous (TRAM) flap. In this study, we report outcome of free TRAM flap using contralateral internal mammary artery (IMA) as a recipient in comparison with pedicled TRAM. METHODS: We reviewed cases of chest wall radionecrosis following BC treatment during the past 8 years. Radionecrosis involving full-thickness soft tissue with defect sizes greater than 10 × 10 cm were included. We compared the outcomes of patients who underwent reconstruction with either pedicled TRAM flaps or free TRAM flaps. We used IMA as a recipient for free TRAM flap, whereas we used contralateral superior epigastric artery-based flap for pedicled TRAM. RESULTS: A total of 14 BC patients underwent chest wall reconstruction due to radionecrosis: 7 received pedicled TRAM flaps, 5 received free TRAM flaps, and 2 were excluded because of the small defect size. The pedicled and free TRAM groups were similar in patient demographics and defect size. However, distal flap loss rate was significantly higher in the pedicled TRAM group compared with the free TRAM group (P = 0.028). There was no difference in abdominal hernia incidence between the 2 groups (P = 0.100). CONCLUSIONS: Wide chest wall defects caused by radionecrosis following BC treatment can be successfully reconstructed with a free TRAM flap that uses a contralateral IMA as a recipient. The free TRAM flap demonstrates a lower rate of distal flap loss than the pedicled TRAM flap, hence reduces the risk of severe morbidity.

A Nipple-Areolar Complex Reconstruction in Implant-Based Breast Reconstruction Using a Local Flap and Full-Thickness Skin Graft.

INTRODUCTION: Nipple-areolar complex reconstruction is the final step of the reconstructive procedure in breast cancer patients. Nowadays, a combination of a local flap for nipple reconstruction and skin grafting or tattooing for areola reconstruction is deemed a first choice. In this paper, we are combining the techniques of local flap and full-thickness skin graft from the upper inner thigh for simultaneous reconstruction of the nipple and areola. PATIENTS AND METHODS: From January, 2016 to December, 2017, 23 female patients with an absent unilateral nipple-areolar complex due to post-oncological mastectomy and immediate implant-based breast reconstruction were subjects of the study. On an out-patient clinic basis, the percentage of the nipple projection loss was calculated at the intervals of 3 , 6 and 12 months postoperatively. At the final visit, the patient's subjective satisfaction on the reconstructed areola compared to the normal contralateral side was evaluated using a visual analogue scale. RESULTS: Over the course of time, the mean nipple projection loss was 20.16 ± 12.88, 31.78 ± 11.63 and 34.69 ± 12.01% at 3 , 6 and 12 months postoperatively, respectively. Patients' overall satisfaction on the grafted areola was as follows; the largest number of patients (8 patients) had a 'good' satisfaction 12-months postoperatively. Out of 21 patients, those who considered the result to be 'poor' and 'disappointing' each accounted for 1 and 3 patients. CONCLUSION: The combination of nipple-areolar complex reconstruction technique introduced in this study has proven to be a safe and efficacious alternative in patients with implant-based reconstruction requiring small- to medium-sized nipple projection, especially when the skin envelope is too tight for a local flap only. 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 .

Opportunistic Biopsy of Internal Mammary Lymph Nodes During Immediate Breast Reconstruction After Mastectomy for Breast Malignancies.

BACKGROUND: This study was designed to explore the clinicopathological factors associated with internal mammary lymph node (IMN) metastasis in radiologically IMN-negative breast malignancies and to discuss the clinical value of opportunistic biopsy during immediate breast reconstruction using free flaps, where the internal mammary vessels are the recipient. METHODS: We retrospectively reviewed patients who received curative total mastectomy for breast malignancy followed by immediate reconstruction using transverse rectus abdominis myocutaneous (TRAM) free flap. Suspicious lymph nodes encountered during dissection of the third intercostal space for the recipient vessels were biopsied. Clinicopathological variables and the clinical impact associated with IMN metastasis were analyzed. RESULTS: Among 269 patients who underwent immediate reconstruction using a TRAM free flap, suspicious lymph nodes were identified and biopsied in 54 (20.1%) patients, and IMN metastasis was confirmed in 12 (22.2%) of these (4.5% of all reconstructions). Five patients were positive despite negative axillary lymph nodes and 11 underwent therapeutic plan modifications. Multivariate analysis revealed that IMN metastasis was independently associated with medial tumor location, invasive tumor >2 cm, and positive human epidermal growth factor receptor-2 status (P < 0.05). CONCLUSIONS: Aggressive IMN evaluation and biopsy in a subset of patients during immediate breast reconstruction using a TRAM free flap provided an additional opportunity for accurate breast cancer staging and appropriate adjuvant treatment, while minimizing unnecessary complications.

Direct thrombectomy as a salvage technique in free flap breast reconstruction.

BACKGROUND: Breast reconstruction with microvascular free tissue transfer has become a widely used method. Despite a high rate of success, a compromised flap necessitating re-exploration can occur. Here, we introduce direct thrombectomy as a flap salvage technique, and compared the results with conventional thrombectomy. METHODS: A total of 488 patients who underwent breast reconstruction using a free transverse rectus abdominis myocutaneous flap between March 2009 and February 2014 were retrospectively analyzed. Flap salvage was conducted by either conventional thrombectomy using a Fogarty catheter, or direct thrombectomy via either a side branch or additional incisions at the stump of the main pedicle at the distal end of the thrombus. RESULTS: Flap compromise necessitating re-exploration due to extensive pedicle thrombosis was identified in 30 patients (6.1%). Direct thrombectomy was used in 9 patients, and conventional thrombectomy in 21 patients. Direct thrombectomy had a significantly higher success rate of flap salvage than conventional thrombectomy (88.9% vs. 47.6%; P = .049). CONCLUSIONS: In the event of vascular thrombosis after free flap breast reconstruction, direct thrombectomy at the proximal pedicle stump beside the anastomosis opening appears to be an effective and reliable option that minimizes vessel trauma related to conventional catheter use. © 2016 Wiley Periodicals, Inc. Microsurgery 37:402-405, 2017.

Immediate Nipple Reconstruction During Implant-Based Breast Reconstruction.

BACKGROUND: Nipple reconstruction is usually performed as a separate procedure, several months after the primary breast reconstruction. This study compared the outcomes of immediate and delayed nipple reconstructions during implant-based breast reconstructions. METHODS: A retrospective review was conducted of patients who underwent nipple reconstruction, after implant-based breast reconstruction, between September 2014 and August 2015. The nipple was simultaneously reconstructed following tissue expander removal and implant placement. The reconstructed nipple was evaluated immediately after surgery and 1 year later using objective measurements of nipple dimension and position, and a subjective assessment. RESULTS: Sixty-one patients were included in the study, undergoing either immediate (n = 37) or delayed (n = 24) nipple reconstructions. Patients undergoing immediate nipple reconstructions had a significantly lower chance of radiotherapy (p = 0.018) and demonstrated a shorter period of tissue expansion (p = 0.011) than those undergoing delayed reconstructions. In the objective evaluations, nipple projections and symmetries between the groups were similar at the 1-year postoperative assessment. In the subjective reviews, esthetic breast mound outcomes were higher among those undergoing immediate reconstructions than among those undergoing delayed reconstructions; similar nipple symmetry and shape outcomes were obtained for both groups. CONCLUSION: In cases of implant-based breast reconstruction, immediate nipple reconstruction concurrent with breast reconstruction provides satisfactory esthetic results compared with conventional delayed nipple reconstruction, in properly selected patients. 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 .

Living donor liver transplantation for an infant with osteogenesis imperfecta and intrahepatic cholestasis: report of a case.

Osteogenesis imperfecta (OI) is a group of genetic disorders characterized by bone fragility and connective tissue manifestations. We report a successful liver transplantation (LT) in an 8-month-old boy with OI and cholestatic biliary cirrhosis. After 4 cycles of intravenous pamidronate, LT was performed under intravenous anesthesia using a left lateral section from his mother without mechanical retractors. The operation time was 420 min and estimated blood loss was 520 mL requiring one unit of RBC transfusion. He was discharged without surgical complications. Therefore, LT should be considered for patients with end stage liver disease and OI under organic multidisciplinary cooperation.

Effect of perioperative transfusion of old red blood cells on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous flap surgery for breast reconstruction.

BACKGROUND: Transfusion with old red blood cells (RBCs) was associated with adverse clinical outcomes. The effect of perioperative transfusion of old RBCs on postoperative complications after free muscle sparing transverse rectus abdominis myocutaneous (TRAM) flap surgery was retrospectively investigated. METHODS: Two hundred sixty-one patients undergoing breast reconstruction were assigned to two groups: no transfusion and transfusion groups. Transfused patients were further divided according to the RBC storage duration (fresh, ≤14 days; old, >14 days). Postoperative complications such as vascular thrombosis, hematoma, and flap congestion were noted. RESULTS: Patients who received old blood (n = 34), compared with those received fresh blood (n = 40) or no transfusion (n = 187), had a higher incidence of postoperative complications (44.1% vs. 20.0% or 12.8%, P < 0.05). CONCLUSIONS: Perioperative transfusion of old RBCs can be associated with an increase in postoperative complications after free muscle sparing TRAM flap surgery.

Improvement of Shoulder Motion in Two-Stage Dual-Plane Implant-Based Breast Reconstruction followed by Radiation Therapy through Delayed Prepectoral Conversion.

Background Although prepectoral implant-based breast reconstruction has recently gained popularity, dual-plane reconstruction is still a better option for patients with poor-quality mastectomy skin flaps. However, shoulder morbidity is aggravated by subpectoral reconstruction, especially in irradiated patients. This study aimed to demonstrate shoulder exercise improvement in subpectoral reconstruction by delayed prepectoral conversion with an acellular dermal matrix (ADM) inlay graft technique at the time of expander-to-implant exchange after irradiation. Methods Patients with breast cancer treated for expander-to-implant exchange after subpectoral expander insertion and subsequent radiotherapy between January 2021 and June 2022 were enrolled. An ADM inlay graft was inserted between the pectoralis major muscle and the previously inserted ADM. The ADM was sutured partially overlapping the pectoralis muscle from the medial side with the transition part, to the muscle border at the lateral side. Perioperative shoulder joint active range-of-motion (ROM) for forward flexion, abduction, and external rotation was also evaluated. Results A total of 35 patients were enrolled in the study. Active shoulder ROM significantly improved from 163 degrees preoperatively to 176 degrees postoperatively in forward flexion, 153 to 175 degrees in abduction, and 69 to 84 degrees in external rotation. There was no difference in patient satisfaction regarding the final outcome between the conventional prepectoral reconstruction group and the study group. Conclusion Shoulder exercises in irradiated patients who underwent subpectoral reconstruction were improved by delayed prepectoral conversion using an ADM inlay graft. It is recommended that subpectoral reconstruction not be ruled out due to concerns regarding muscle contracture and shoulder morbidity in radiation-planned patients with poor mastectomy skin flaps.

Hybrid Lymphovenous Anastomosis Surgery Guided by Intraoperative Mesenteric Intranodal Lymphangiography for Refractory Nontraumatic Chylous Ascites: A Case Report.

Refractory chylous ascites can cause significant nutritional and immunologic morbidity, but no clear treatment has been established. This article introduces a case of a 22-year-old female patient with an underlying lymphatic anomaly who presented with refractory chylous ascites after laparoscopic adnexectomy for ovarian teratoma which aggravated after thoracic duct embolization. Ascites (>3,000 mL/d) had to be drained via a percutaneous catheter to relieve abdominal distention and consequent dyspnea, leading to significant cachexia and weight loss. Two sessions of hybrid lymphovenous anastomosis (LVA) surgery with intraoperative mesenteric lymphangiography guidance were performed to decompress the lymphatics. The first LVA was done between inferior mesenteric vein and left para-aortic enlarged lymphatics in a side-to-side manner. The daily drainage of chylous ascites significantly decreased to 130 mL/day immediately following surgery but increased 6 days later. An additional LVA was performed between right ovarian vein and enlarged lymphatics in aortocaval area in side-to-side and end-to-side manner. The chylous ascites resolved subsequently without any complications, and the patient was discharged after 2 weeks. The patient regained weight without ascites recurrence after 22 months of follow-up. This case shares a successful experience of treating refractory chylous ascites with lymphatic anomaly through LVA, reversing the patient's life-threatening weight loss. LVA was applied with a multidisciplinary approach using intraoperative mesenteric lipiodol, and results showed the possibility of expanding its use to challenging problems in the intraperitoneal cavity.