Byung-Joon Jeon

Risk factors for donor-site seroma formation after immediate breast reconstruction with the extended latissimus dorsi flap: a statistical analysis of 120 consecutive cases.

AbstractThe extended latissimus dorsi flap has been widely used for breast reconstruction. However, seroma at the donor site is a common complication and makes it difficult for reconstructive surgeons to choose it as a primary option. We analyzed the association between seroma and reconstructions with extended latissimus dorsi flaps. A series of 120 consecutive cases were included in this study. The average body mass index (BMI) was 22.1 kg/m2, and the mean ratio of the flap weight to the extirpated breast weight was equivalent to 101.6%. The mean age of patients was 40.3 years. Donor-site seroma was reported in 69.2% (83 cases) of the total patients. With respect to BMI, flap weight, and age, the incidence and duration of donor-site seroma showed statistically significant differences (P < 0.05). Both the incidence and duration of seroma were significantly higher and longer in patients who had high BMI (>23 kg/m2), large flap (>450 g) for reconstructions, or advanced age (>45 y). In these cases, greater attention and additional adjunctive procedures would be needed to prevent seroma.

The effects of ketorolac on microvascular thrombosis in lower extremity reconstruction.

Background: Ketorolac is commonly prescribed for relieving postoperative pain and is known to have an anticoagulation effect, though this has not been studied in a clinical series. The aim of this study was to evaluate the effects of ketorolac on microvascular thrombosis in lower extremity reconstruction. Methods: A retrospective chart review was performed for patients who underwent lower limb reconstruction with a free flap between January of 2005 and September of 2011. Patients were categorized into two groups based on the administration of ketorolac for postoperative pain relief. Complications were assessed, and the two groups were compared for vascular insufficiency, total or partial flap loss, and hematoma formation. Results: A total of 128 patients underwent microsurgical flap transfer, including 111 thoracodorsal artery perforator flaps, four latissimus dorsi myocutaneous flaps, seven deep inferior epigastric artery perforator flaps, and six anterolateral thigh flaps. Eighty patients were administrated ketorolac, and 48 patients were not. The nonketorolac group had significantly higher rates of vascular-related complications, and the difference remained significant after adjusting for confounding factors on multivariate logistic regression analysis. There was a correlation between the duration of ketorolac administration and complication rates, for which longer periods of ketorolac administration yielded lower complication rates. Conclusion: Ketorolac administration has a protective effect against the development of microvascular thrombosis and can be a preferred analgesic in free tissue transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Plantar reconstruction with free thoracodorsal artery perforator flaps

PURPOSE The plantar region presents unique challenges for reconstructive surgeons. Reconstruction using a thoracodorsal artery perforator (TDAP) flap yields favourable results in various fields of microsurgical reconstruction, but reports on the reconstruction of plantar defects are sparse. Here, the authors present their experience in the reconstruction of various defects in the plantar region using free TDAP flaps. METHODS From January 2005 to July 2011, 40 free TDAP flaps were transferred for reconstructive purposes to restore skin and soft-tissue defects in the plantar region. Hospital and outpatient records were reviewed independently for all patients. A patient questionnaire including five questions was administered to subjectively evaluate reconstructive results. RESULTS A total of 24 male and 16 female patients were enrolled in this study. The mean age was 47.8 years and ranged from 7 to 77 years. The most common cause of defect was oncology related (n=21), followed by trauma-related (n=11), diabetes-related (n=6) and other causes. The average flap size was 63.7 cm2 and ranged from 25 to 212 cm2. All flaps survived except for one, resulting in a below-knee amputation. The mean follow-up period was 20.4 months. Four patients underwent secondary revisional procedures, including simple defatting in two patients and excision of redundant skin due to flap instability in two patients. The satisfaction surveys were completed by 34 (85%) patients. Patients reported high levels of satisfaction in terms of pain, limitation of daily activities, donor site satisfaction and overall satisfaction. Most patients were satisfied and reported that they would recommend the procedure to others. CONCLUSION An appropriately thinned free TDAP flap with thick skin provided favourable outcomes with high patient satisfaction and is a valuable option for the restoration of skin and soft-tissue defects in the plantar region.

Comparison of five systems of classification of diabetic foot ulcers and predictive factors for amputation

Diabetes mellitus is a common metabolic disorder. Among various complications, diabetic neuropathy and peripheral vascular disorders are closely associated with diabetic foot ulcers (DFUs). Lower extremity ulcers and amputations are ongoing problems among individuals with diabetes. There are several classification systems for DFUs; however, no prognostic system has to date been accepted as the gold standard or the optimum prediction tool for amputations. A retrospective study was designed. Demographic data and baseline laboratory data were gathered and scored or evaluated using five representative DFU classification systems. These included (i) the diabetic ulcer severity score (DUSS); (ii) University of Texas (UT) diabetic wound classification; (iii) Meggitt–Wagner classification; (iv) depth of the ulcer, extent of bacterial colonisation, phase of ulcer and association aetiology (DEPA) scoring system; and (v) site, ischaemia, neuropathy, bacterial infection and depth (SINBAD) score. Finally, a statistical analysis was performed. A total of 137 patients were included in this study. During the follow‐up, DFU had healed in 51·1% of subjects and 48·9% of the individuals underwent lower extremity amputations (LEAs). In a univariable logistic regression analysis, history of previous DFU, hypertension, neuropathy, haemoglobin, C‐reactive protein (CRP) and ankle‐brachial index (ABI) showed a statistically significant difference between the healed group and the LEA group. Moreover, the stages, grades or overall prognostic ability of all five classifications were highly associated with the overall occurrence of LEA. On multivariable logistic regression analysis of the risk of LEA, all classifications showed a significant positive trend with an increased number of amputations. All the five classification systems exhibited high sensitivity, specificity, classification accuracy, positive predictive, negative predictive and area under the curve (AUC) values. They showed substantial accuracy and their main variables were associated with LEA occurrence. The Wagner and UT systems, although they are relatively simple to assess, were better predictors of LEA.

Secondary extremity reconstruction with free perforator flaps for aesthetic purposes

Perforator flap surgery enables surgeons to tailor flaps to individual requirements with reduced donor-site morbidity. The technique allows better aesthetic results to be achieved in various fields of microsurgical reconstruction, but reports on aesthetic resurfacing and contour restoration of extremity deformities are sparse. The authors present their experience of elective reconstructions of established deformities in the extremities for aesthetic purposes using free perforator flaps. Aesthetic results were evaluated using a questionnaire and by photographic grading. From March 2006 to June 2010, 15 free flaps were transferred in 14 patients for aesthetic purposes to restore established skin and soft-tissue deformities in the extremities. Twelve flaps were transferred to lower extremities and three to upper extremities. After recreating tissue deficiencies, flaps were precisely designed and elevated with elaborate flap insetting and thickness control. Patient-assessment questionnaires were administered after surgery, and aesthetic results were evaluated using photographs by independent observers. Photographic gradings were assessed statistically using the generalised estimating equation. Eight deep inferior epigastric artery perforator free flaps and seven thoracodorsal artery perforator free flaps were used in the 14 patients. Flap sizes ranged from 8 × 14 to 14 × 38 cm, and all flaps survived well. The patient satisfaction rate was high, and aesthetic improvements were confirmed by conducting objective photographic evaluations. Statistically significant changes were detected during the photographic evaluation (p < 0.05). Secondary reconstruction using a customised free perforator flap to achieve aesthetic improvements is a valuable option for the restoration of established skin and soft-tissue deformities in the extremities.

Lateral Nail Fold Incision Technique for Venous Anastomosis in Fingertip Replantation.

BackgroundSuccessful venous anastomosis is one of the most important factors in fingertip replantation. Volar veins in the fingertip course proximally in a random pattern, which makes it difficult to find out the exact locations. Although dorsal veins in the lateral nail fold have constant location and adequate diameter for anastomosis, they have been known as hard to dissect from the immobile subcutaneous tissue. The authors present a new lateral nail fold incision technique for venous anastomosis in the fingertip amputations. MethodsFrom February 2010 to October 2010, 9 replantations using the new incision and venous anastomosis technique were performed in 9 patients. The levels of amputations were from the nail base to half of the nail bed. After repairing the proper digital arteries, a skin incision was made along the junction between the lateral nail fold and nail bed. Careful dissection was performed to isolate the veins in the lateral nail fold. After evaluation of the suitability of the vessel, venous anastomosis was performed. ResultsSeven male and 2 female patients were enrolled in this study. Appropriate dorsal veins for anastomosis could be found in 8 of 9 patients. All the replanted stumps survived without venous congestion and following additional procedures. A sizable volar or dorsal vein could not be found in 1 patient. The salvage technique was required in this patient. ConclusionsDorsal veins in the lateral nail fold can be found easily because of the constant anatomical location. The new incision on the lateral nail fold provides not only sufficient operative field for anastomosis but also additional opportunity of successful venous anastomosis in the selected cases. The authors, therefore, propose this technique as an effective method for an alternative venous anastomosis in the zone I replantation.

Donor site morbidity following DIEP flap for breast reconstruction in Asian patients: Is it different?

Despite the decrease in donor‐site morbidity with the advent of deep inferior epigastric artery perforator (DIEP) flap breast reconstruction, abdominal complications still occur. There have been few studies on donor morbidity considering the ethnic differences in the Asian population, as represented by a lower BMI with less redundant tissue and a tendency for poor scarring. In the present study, the authors investigated the incidence of abdominal complications and their risk factors following DIEP flap breast reconstruction in an Asian population.

Comprehensive Analysis of Chicken Vessels as Microvascular Anastomosis Training Model

Background Nonliving chickens are commonly used as a microvascular anastomosis training model. However, previous studies have investigated only a few types of vessel, and no study has compared the characteristics of the various vessels. The present study evaluated the anatomic characteristics of various chicken vessels as a training model. Methods Eight vessels—the brachial artery, basilic vein, radial artery, ulnar artery, ischiatic artery and vein, cranial tibial artery, and common dorsal metatarsal artery—were evaluated in 26 fresh chickens and 30 chicken feet for external diameter (ED) and thicknesses of the tunica adventitia and media. The dissection time from skin incision to application of vessel clamps was also measured. Results The EDs of the vessels varied. The ischiatic vein had the largest ED of 2.69±0.33 mm, followed by the basilic vein (1.88±0.36 mm), ischiatic artery (1.68±0.24 mm), common dorsal metatarsal artery (1.23±0.23 mm), cranial tibial artery (1.18±0.19 mm), brachial artery (1.08±0.15 mm), ulnar artery (0.82±0.13 mm), and radial artery (0.56±0.12 mm), and the order of size was consistent across all subjects. Thicknesses of the tunica adventitia and media were also diverse, ranging from 74.09±19.91 µm to 158.66±40.25 µm (adventitia) and from 31.2±7.13 µm to 154.15±46.48 µm (media), respectively. Mean dissection time was <3 minutes for all vessels. Conclusions Our results suggest that nonliving chickens can provide various vessels with different anatomic characteristics, which can allow trainees the choice of an appropriate microvascular anastomosis training model depending on their purpose and skillfulness.

Microsurgical reconstruction of soft-tissue defects in digits

Injuries that cause soft tissue defects could threaten the function and viability of the involved digit. Reconstruction of such defects can be challenging and requires careful consideration in restoring both the aesthetic and functional deficit. The purpose of this review is to describe appropriate reconstructive technique using various free tissue transfers. According to the location and the size of a defect, a proper reconstructive option is indicated. Owing to the specialized mechano-sensory property of its volar soft tissue, fingertip injury, when significant defects exist, are reconstructed using specialized free flaps with appropriate histological and functional similarities. Composite tissue including bone may be required in selected cases. Additional procedures, such as secondary skin graft or division of the flap, should be done after several weeks of the first operation. Refinements and improvements in free tissue transfer allow an expanse of reconstructive options for soft tissue defect in the digit.

Oncologic Safety of Immediate Breast Reconstruction in Breast Cancer Patients Who Underwent Neoadjuvant Chemotherapy: Short-Term Outcomes of a Matched Case–Control Study

Introduction: Although the indication for immediate breast reconstruction (IBR) after skin‐sparing mastectomy (SSM) or nipple‐sparing mastectomy (NSM) has been expanded, IBR after neoadjuvant chemotherapy (NACT) is still controversial. We conducted retrospective matched case–control study to analyze oncologic outcomes between patients who underwent TM only and those who underwent IBR after SSM or NSM after NACT. Patients and Methods: A retrospective review of breast cancer patients who underwent IBR after SSM or NSM after NACT between 2008 and 2015 at a single center was conducted. These cases were maximally matched by 1:5 to patients who underwent total mastectomy (TM) alone after NACT. Matching variables included age, clinical T and N stage before NACT, response to NACT, and pathologic stage after NACT. Pathologic stage followed the 7th edition of the American Joint Committee on Cancer (AJCC) classification. Results: Overall, 31 patients were enrolled onto the IBR after SSM or NSM group (study group) and matched to 85 patients (control group). In the study group, 13 patients (41.9%) underwent NSM and 18 (58.1%) underwent SSM. Median follow‐up duration was 29.2 (range, 7–31) and 38.8 (range, 11–85) months for the study and control groups (P = .012), respectively, and median age was 37.0 (range, 26–57) and 40.0 (range, 24–56) years (P = .890), respectively. Overall survival (P = .971), disease‐free survival (P = .520), distant metastasis‐free survival (P = .795), and local recurrence‐free survival (P = .628) did not differ significantly between the 2 groups. Conclusion: IBR after SSM or NSM might be a feasible surgical treatment option even in breast cancer patients who underwent NACT. Micro‐Abstract: We analyzed oncologic outcome by matching variables including age and clinical T and N stage before immediate breast reconstruction (IBR) after neoadjuvant chemotherapy (NACT), response to NACT, and pathologic stage after NACT. IBR after skin‐sparing mastectomy or nipple‐sparing mastectomy may be a feasible surgical treatment option even in breast cancer patients who underwent NACT.