Chunjun Liu

The distribution of lymph nodes and their nutrient vessels in the groin region: An anatomic study for design of the lymph node flap

The groin lymph node flap transfer has been used for treatment of extremity lymphedema. The design of this flap is based on the superficial circumflex iliac artery/vein (SCIA/V), or superficial inferior epigastric artery/vein (SIEA/V). The purpose of this study is to delineate the distribution of lymph nodes in the groin area and their relationship to inguinal vessels by the use of multidirector‐row CT angiography (MDCTA).

A prospective study of breast dynamic morphological changes after dual-plane augmentation mammaplasty with 3D scanning technique.

Background The dual-plane technique has been widely used in augmentation mammaplasty procedures. However, there are some concerns about aesthetic contour maintenance for long time after muscle releasing. This study aims to track and analyze breast dynamic morphological changes after dual-plane breast augmentation with three-dimensional (3D) scanning technique. Methods Thirteen dual-plane anatomic implant augmentation patients underwent 3D scanning preoperatively (pre-OP) and postoperatively in four time points (1 month: post-1M, 3 months: post-3M, 6 months: post-6M and 12 months: post-12M). The linear distance, breast projection, nipple position, breast volume and breast surface area were measured and analyzed on the 3D models over time. Results Compared with post-12M, no significant differences were found in distances of nipple to midline, nipple to inframammary fold and sternal notch to the level of inframammary fold after 6 months in both straight-line distance and its projection on surface. The distances between sternal notch and nipple had no significant difference after post-1M. Breast volume changes had no significant difference after post-3M. The volume and area percentage of upper pole decreased while the lower pole’s increased gradually. The surface showed no significant changes after post-1M. The changes of breast projection had no significance after post-1M either. The nipple moved 1.0±0.6 cm laterally(X axis), 0.6±0.7 cm upward(Y axis) and 2.3±1.1 cm anteriorly (Z axis) at post-12M, and the differences were not significant after post-1M. Conclusions 3D scanning technique provides an objective and effective way to evaluate breast morphological changes after augmentation mammaplasty over time. Dual-plane augmentation optimizes breast shape especially in the lower pole and maintains stable aesthetic outcome during the 12 months follow-up. Most of the contour changes and the interadaptation with the implant have completed 6 months after operation. Therefore, 6 months could be chosen as a relatively stable observing period in the assessment of postoperative outcomes of dual-plane breast augmentation.

A Simple and Effective Way to Protect the Nipple-Areolar Complex During Operation: A Clinical Tip

The nipple-areolar complex is a unique and important anatomical area in breast surgery. Areolar access incisions are common1-5 because in that area, the desired plane can be dissected easily and directly. Varying degrees of injury to the nipple-areolar complex have been reported, such as dehiscence or abrasion due to implant insertion and distraction of the skin hook, especially when the diameter of the …

Simultaneous Breast Reconstruction and Treatment of Breast Cancer–related Upper Arm Lymphedema With Lymphatic Lower Abdominal Flap

BackgroundThis study was designed to introduce the key points about the transplantation of lower abdominal flap with vascularized lymph node and to evaluate the effect of breast restoration, breast reconstruction, and lymphatic transplantation to treat upper limb lymphedema after breast cancer surgery. Materials and MethodsThe study was based on the retrospective study on 10 cases of postmastectomy lymphedema during January 2008 to March 2011. All patients, aged 36 to 50 years, have had one-side upper-limb lymphedema for 3 to 5 years. Six patients had accepted radiotherapy. Four patients had a diagnosis of severe lymphedema, and 2 patients had moderate lymphedema. The isotope radiography before the operation showed obstruction of lymphatic return, and the multidetector computed tomography that followed delivered a clear picture of the abdominal flap blood supply and the blood vessels in the breasts. During the operation, the scar contracture of the axilla was completely relaxed, and all patients accepted abdominal transplantation of lower abdominal flap with vascularized lymph node. After the operation, the elastic bandages were applied for one year as an adjuvant therapy. The follow-up visits were conducted 1, 3, 6, and 12 months after the surgery. The measurement indexes included mid-upper arm circumference, clinical symptoms, and lymphoscintigraphy. ResultsAll flaps worked well. One patient was found to have delayed wound healing; one patient saw no obvious improvement in lymphedema; 7 patients with lymphedema were relieved with apparent improvement in the affected limbs’ mean perimeter and clinical symptoms; one patient recovered; and another patient was lost to follow-up. The mean reduction was 2.122 ± 2.331 cm, and the reduction of the lymphedematous limb was statistically significant between the preoperative and 12-month postoperative groups (P < 0.05). The results were good in 4 patients and excellent in one patient. ConclusionsThe transplantation of abdominal flap with vascularized lymph node and breast reconstruction, accompanied by the treatment to upper limb lymphedema and using elastic bandages as an adjuvant therapy, is considered to be an effective method to restore the configuration and function of breasts. Long-term follow-up visits are undergoing, especially the lymphoscintigraphy, 2 years after the operation.

Volumetric measurement of polyacrylamide hydrogel injected for breast augmentation using magnetic resonance imaging.

Volumetric measurement of polyacrylamide hydrogel (PAHG) is useful for surgical planning. It is not only a significant factor in the preoperative evaluation of breast augmentation, but may also directly affect the postoperative shape of the breast. The objective of the present study was to evaluate whether magnetic resonance imaging (MRI) is able to provide precise calculations of injected PAHG volumes. MRI scans of ten randomly selected patients were imported to Mimics software. The volumes of PAHG were obtained following the reconstruction of the injected PAHG. In order to assess the precision and observer independency of the technique, the volumes of PAHG were estimated by three plastic surgeons using this method. No significant differences were identified among the PAHG injection volumes calculated by the three observers (P=0.173). The intra-observer correlation coefficient was 0.964, which indicates the precision and feasibility of this method for calculating the volume of PAHG. The use of MRI in combination with Mimics software to calculate PAHG volumes is likely to be of significant clinical benefit in preoperative surgical planning.

Opinions on the “Trick” Technique to Reposition the NAC in Female-to-Male Transsexuals

Dear editor, We have read with great interest the article entitled ‘‘Shape, Position and Dimension of the Nipple Areola Complex in the Ideal Male Chest: A Quick and Simple Operating Room Technique’’ by Sara Tanini et al. [1] in Aesthetic Plastic Surgery. In this article, the authors presented their ‘‘trick’’ technique to reposition the NAC based on their anatomical study and statistical analysis. Good shape and position of the NAC were achieved in female-tomale transsexual patients with this technique. In their article, a consistent relationship between the position and shape of the NAC and the borders of the pectoral muscle was verified. Inspired by the authors, we would like to express our considerations on this technique. First, although the pectoralis major muscle is an accessible landmark in different genders and body types, a mere measurement of the distance between the NAC and the borders of the pectoral muscle, which varies from patients with diverse statures and dimension of pectoralis major muscle, is not sufficient to locate the NAC concisely. In this article, the average height of the reference group is 176 cm, which is not matched with the average height of a female. Moreover, although the reference group is the teenage male with a non-hypertrophic pectoralis major muscle, there are still obvious differences in the volume and dimension of the pectoralis major muscle between males and females. So an additional measurement of the ratio of vertical position and the longitudinal diameter of the pectoralis major muscle may further perfect the ‘‘trick’’ technique. Besides, when repositioning the NAC, the surgeon should take the patients’ postoperative workout plan into consideration as many transsexuals choose high-intensity exercise postoperatively to build up a typical male chest configuration which will hypertrophy the pectoralis major muscle and generate a more lateral projection of the NAC. Second, in this article, all patients underwent mastectomy and free NAC grafting with an obvious and elongated incision placed along the inframammary fold. But as Cori et al. indicated in their research, this incision can be applied only in cases with very large breasts ([D Cup), mastoptosis grade III and poor skin elasticity. For patients with relatively small volume breasts, less severe mastoptosis or better skin elasticity, diverse approaches like liposuction and subcutaneous mastectomy through a semicircular incision, concentric circumareolar approach or inferior pedaled mammaplasty can be performed to avoid the elongated scar with high patient satisfaction with the aesthetic result [2]. But what cannot be denied is the application of free NAC grafting achieves good areola and nipple reshaping and repositioning as well as flattened male chest contouring without an inferior NAC pedicle, which can potentially generate higher breast projection in the lower breast pole. & Chun-jun liu liuchunjun@psh.pumc.edu.cn

Removal of Polyacrylamide Hydrogel Injected in Different Layers for Breast Augmentation

Background: The complications of polyacrylamide hydrogel (PAAG) injected for breast augmentation have captured the attention of the physicians and patients. More and more patients are seeking for the removal of it. In this article, we analyzed the effectiveness of the removal of PAAG injected for breast augmentation by using an inferior periareolar incision under the direct visualization. We got to know the extents of the removal of PAAG injected in different layers. Methods: Fifty patients (99 breasts) for the removal of PAAG were randomly selected. On the basis of the preoperative and postoperative MRI, the patients were divided into four groups according to whether the PAAG infiltrated to the subcutaneous tissue and muscles or not. In each group, the volumes of PAAG before and after the removal were calculated to analyze the removal amount of the PAAG injected in different layers. Results: The mean volume of injected PAAG was 264.81 ml. The mean volume of residual PAAG was 9.18 ml. The mean percentage of the removed PAAG was 96.49%. There was no significantly difference in preoperative volume of injected PAAG among different groups p=0.992). There was significantly difference in postoperative volumes of residual PAAG after removal among different groups (p=0.000). Conclusions: The PAAG injected for breast augmentation and degenerated tissue could be removed using the direct visualization method to obtain successful removal of the great amount of PAAG. The PAAG without infiltrated to the subcutaneous tissue and muscles was most easily removed. The infiltration of the subcutaneous tissue and muscles increased the difficulty of the removal the PAAG.

Opinions on Treatment of Breast Animation Deformity with Selective Nerve Ablation

Dear editor, We have read with great interest the article entitled ‘‘Treatment of Breast Animation Deformity in ImplantBased Reconstruction with Selective Nerve Ablation’’ by Dustin L. Eck et al [1] in Aesthetic Plastic Surgery. In this article, the authors presented their experience on treating animation deformity following breast reconstruction with subpectoral implants. A complete correction of animation deformities had been achieved with selective pectoral nerve ablation without obvious muscle atrophy. Inspired by the authors, we would like to express our considerations on this innovative technique. Firstly, though no obvious muscle atrophy was observed with subjective evaluation, given that repeated fat graftings were performed, the volume preservation of the pectoral major after nerve ablation wasn’t ascertained and should be assessed with computed tomography or ultrasound tests. Furthermore, except the evaluation of muscle volume, objective assessment of the dysfunction of the upper limb like Dysfunction of Arm, Shoulder and Hand (DASH) questionnaire is needed because the pectoral major is crucial to some normal shoulder movements like adduction and medial rotation. Secondly, what kind and how much nerve resection is necessary to prevent postoperative muscle twitching should be deliberated. In this study, only a bipolar electrocautery was used and an incomplete denervation of the muscle was performed. Some studies concerning denervation of the latissimus dorsi muscle flap, which is often used to provide adequate tissue coverage for implants in breast reconstruction like the pectoral major, indicated that, even with permanent ablation of the thoracodorsal nerve in the distal branches, patients still experienced a high rate of recurrence of muscular contraction in long-term follow-up and high potentials were recorded at the breast site in the electromyogram test [2]. Those can be attributed to incomplete nerve division and spontaneous reinnervation due to the sprouting of the severed proximal nerve stump following the vascular pedicle bed or regeneration from adjacent nerves. Permanent and sufficient denervation of the latissimus dorsi muscle was achieved when the resection length of the thoracodorsal nerve reached 4 cm or more [3]. It is reasonable to suspect that some similar results may occur in selective nerve ablation of the pectoral major and main nerve trunk section may be needed to achieve exact and complete correction of the animation deformity. Finally, although a high rate of animation deformity in the subpectoral technique has been demonstrated in the previous studies, from our experience, obvious animation deformity rarely occurs. There may be several factors ascribed to this. Firstly, the animation of the pectoral major doesn’t equate to the animation deformity resulting from the implant dislocation. Secondly, some attachments between the pectoral major and rib are bound to be severed & Chun-jun Liu liuchunjun@psh.pumc.edu.cn

Several Opinions on Quantifying Dynamic Deformity After Dual Plane Breast Augmentation

Dear Editor, We have read with great interest the article entitled ‘‘Quantifying Dynamic Deformity After Dual Plane Breast Augmentation’’ by Marcelo Recondo Cheffe et al. [1] in Aesthetic Plastic Surgery. In this article, the authors presented a prospective study on 32 women who underwent primary dual plane breast augmentation (DPBA) with at least 1 year of follow-up, obtaining photographs taken of the patient under NPC and under MPC at postoperative 12 months. They came to the conclusion that their study proposed a simple and objective method for quantification of dynamic breast deformity (DBD) in patients who underwent breast augmentation through the dual plane technique. We would like to congratulate Marcelo Recondo Cheffe and coworkers on their paper [1]. In the past decade, our hospital has treated more than 1000 patients with breast augmentation through the dual plane technique, and we would like to express our opinion on the quantification of dynamic deformity after dual plane breast augmentation. First, due to the lack of a self-control group for the 32 research subjects, we can’t figure out whether the dual plane technique gives rise to DBD in patients, or whether some patients showed inherent DBD before receiving DPBA. Moreover, the researchers didn’t include a control of breast augmentation under different planes (subglandular, submuscular). Consequently, it’s difficult to determine whether DBD is a characteristic phenomenon of DPBA or if different planes of breast augmentation have an equal potential to produce DBD. Despite the fact that the researchers didn’t explain the possible mechanism of DBD, we’d like to put forward some speculations to explain the formation of DBD. This deformity occurs when the pectoralis major muscle (PMM) is divided at its inferior origin along the inframammary fold, with subsequent muscle contraction of the residual upper part of the PMM, resulting in distortion of the breast and position modification of the nipple. As for submuscular breast augmentation, without any division of the PMM and with subsequent relatively balanced contraction of the intact PMM, it may have less potential to produce DBD when compared with DBPA. Because the breast implant is planted between the PMM and nipple, subglandular breast augmentation is analogous to submuscular breast augmentation having less potential to produce DBD. In addition, we consider that other significant factors may exert an effect on their measurement, such as different respiratory states [2]. We highly recommend that researchers obtain images when the patient holds her breath at the end of normal exhalation. Only in this way, can we exclude the impact of different respiratory states. Finally, with our years of clinical experience on DBPA, 3D scanning, beyond question, is the most precise and reliable technique to assess DBD after patients have undergone DPBA. Obviously, it is quite unreliable for us to evaluate DBD, a kind of morphological breast change in three-dimensional space, through comparing two groups of measurements of several linear segments acquired in two& Chun-jun liu liuchunjun@psh.pumc.edu.cn

An innovative method for intraoperative shaping and positioning of the nipple-areola complex in reduction mammaplasty and mastopexy.

Issues of hypertrophic circumareolar scars and malpositioning or irregularity of the nipple–areola complex (NAC) are frequently associated with breast reduction or mastopexy techniques that rely on an ample excision of skin around the areola, either alone or associated with a vertical incision. To avoid such problems, many efforts have been made to improve the accuracy of preoperative marking for the future NAC. However, the correct design and position of the NAC may be difficult to achieve for the patient at the end of the procedure after closure of the skin incisions. This article describes a novel, simple, and effective method for intraoperative shaping and positioning of the NAC. The described method is based on using a specially designed surgical instrument to determine the best position, diameter, shape, and configuration of a new NAC. This study aimed to demonstrate the efficacy of this method to reduce the common complications of the periareolar region in reduction mammaplasty and mastopexy.Level of Evidence IVThis 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 at www.springer.com/00266.