Minqiang Xin

Breast augmentation by autologous fat injection grafting: management and clinical analysis of complications.

Autologous fat is an excellent soft-tissue filler, given its abundance and ease of harvest. Nevertheless, the technique is accompanied by postoperative complications such as fat necrosis, calcification, and sclerotic nodules. These problems directly influence surgical efficacy.Computed tomography or magnetic resonance imaging was used to confirm the location of abnormal adipose tissue preoperatively. Depending on the characteristics of the lesion, the liquefied fat was aspirated or the sclerotic lesion excised. Pressurized dressings were used postoperatively for both techniques.Seventeen patients who experienced complications after autologous fat injection were treated. Pathologic examination of excised samples demonstrated changes including fat necrosis, calcification, hyalinization, and fibroplasia.Intramammary autologous fat injection should only be used with caution. Selecting suitable indications and correct surgical techniques make autologous fat grafting an ideal method for breast augmentation. Strictly controlling the injection volume and injecting diffusely in multiple layers to allow fat granules to distribute evenly within the breast, are effective methods to reduce postoperative complications.

Fate of adipose-derived stromal vascular fraction cells after co-implantation with fat grafts: evidence of cell survival and differentiation in ischemic adipose tissue.

Background: Some studies have suggested that adipose-derived stromal vascular fraction is a potential cell source responsible for the improved quality and long-term retention of fat grafts, but studies that have clearly demonstrated the survival and differentiation potential of the implanted stromal vascular fraction cells as being dynamic phenomena have not been widely reported. Methods: The authors isolated stromal vascular fraction cells from C57BL/6J-GFP mice. Green fluorescence protein–positive stromal vascular fraction cells were mixed with minced inguinal adipose tissue harvested from C57BL/6J mice and then co-implanted into BALB/c nude mice. The survival of implanted green fluorescence protein–positive stromal vascular fraction cells was tracked by in vivo fluorescence imaging for 56 days. Immunofluorescence staining was used to analyze the differentiation of green fluorescence protein–positive stromal vascular fraction cells occurring in ischemic adipose tissue at 7, 14, 28, 35, 42, or 56 days. Results: The fluorescence signal intensity fell drastically within the first 14 days after co-implantation and continued to decrease thereafter, with 17.3 percent signal intensity (relative to day 1) at 56 days. Immunofluorescence staining revealed that some green fluorescence protein–positive cells can spontaneously differentiate into adipocytes from day 7, and some of the implanted stromal vascular fraction cells can incorporate into new blood vessels. Conclusions: The authors show convincing evidence for dynamic changes of stromal vascular fraction cells after co-implantation with fat grafts. The results prove the principle that implanted stromal vascular fraction cells can survive in the ischemic microenvironment of fat grafts and participate in the process of adipogenesis and angiogenesis.

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.

The efficacy of preoperative vascular mapping by MDCTA in selecting flap in abdominal flap breast reconstruction.

Abstract:  Current methods of breast reconstruction using abdominal tissue include the transverse abdominal myocutaneous (TRAM) flap, deep inferior epigastric arterial perforator (DIEP) flap, superficial inferior epigastric arterial (SIEA) flap, and some other composite flaps. Because of the variant vascular anatomy in abdominal region, it is hard to choose an appropriate flap for a specific patient without accurate preoperative vascular mapping. This study was drawn to address the efficacy of preoperative vascular mapping by multidetector‐row computed tomographic angiography (MDCTA) in selecting flap in abdominal flap breast reconstruction. A total of 34 breast reconstructions using abdominal flap from December 2006 to July 2009 were included. In all the patients included, MDCTA was performed preoperatively. Three indexes were obtained including choice of flaps, operation time, and flap complication rate. Then, these data were compared with the former data stored in the databank of our hospital from January 2004 to December 2006, before MDCTA was introduced in our center. Among the 34 patients, the flap selection was: SIEA flaps 11.8%, DIEP flaps 61.8%, TRAM flaps 11.8%, and bilateral flaps 14.7%. The correlate indexes from the data bank were as follows: SIEA flap 0; DIEP flaps 51.7%; TRAM flaps 32.8%; bilateral flaps 15.5%. p < 0.05 occurred between the comparison of SIEA, DIEP, and TRAM flap choice in the two groups. The operation time in the study group was as follows: SIEA flap (4.02 ± 0.46) hours, DIEP flap (6.23 ± 1.42) hours, TRAM flap (4.72 ± 1.53) hours, Bilateral flap (7.86 ± 1.16) hours; while the former correlate data were: DIEP (9.67 ± 1.74) hours, TRAM flap (6.64 ± 1.83) hours, bilateral flap (11.83 ± 1.35) (all the three comparison p < 0.05). The total flap complication rate was about 5.9% in the test group; while in the databank, it was 12.1% (p < 0.05). With the accurate mapping of vascular territory in abdomen by MDCTA, we could easily select a suitable abdominal flap for breast reconstruction, and we can also simplify the procedure to save operation time and make the process more safely.

Improvement of Fat Graft Survival with Autologous Bone Marrow Aspirate and Bone Marrow Concentrate: A One-Step Method.

Background: Stem cells have proven to be beneficial to fat graft survival, but a one-step method of cell-assisted lipotransfer is still missing. In the present work, the authors improved the fat graft survival using bone marrow aspirate and bone marrow concentrate, to ensure that both liposuction and cell-assisted lipotransfer were included in the same procedure. Methods: Bone marrow aspirate was collected from the iliac crest of the rabbits. Bone marrow concentrate was obtained using density gradient centrifugation and labeled with PKH26 fluorescent cell linker. Rabbits were divided into three groups: group A, bone marrow aspirate; group B, bone marrow concentrate; and group C, phosphate-buffered saline buffer as a blank control. The implanted mixture contained 1.5 ml of adipose granule and 1 ml of bone marrow aspirate or bone marrow concentrate. The rabbits were subjected to fluorescence imaging in vivo at four time points. Grafts were harvested and analyzed at 4 weeks and 12 weeks after fat grafting. Results: Bone marrow cell fluorescence signals were observed in the rabbits’ injection regions during a follow-up of 12 weeks. The fat grafts of group A and B showed a better weight and volume retention, living quality, adipocyte viability, and angiogenesis after transplantation. The results of living tissue imaging also showed that the implanted bone marrow cells could contribute to fat graft survival by multilineage differentiation and could also contribute to adipogenesis and angiogenesis. Conclusion: Both bone marrow aspirate and bone marrow concentrate improved the survival and angiogenesis of grafted fat tissue.

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.

The relationship between the thickness of de-epithelialization and occurrence of sebaceous cysts at the incision site after mastopexy and reduction mammaplasty.

Periareolar sebaceous cysts at the incision site after mastopexy and reduction mammaplasty are very unpleasant complications that affect the surgical result and the degree of patient satisfaction. The author sought to investigate the cause and prevention of such sebaceous cysts. Sixty patients undergoing mastopexy or reduction mammaplasty were randomly divided into 2 groups. Periareolar de-epithelialization was performed to a depth of superficial layer of the dermis in group A and nearly the full thickness of the dermis in group B, and the incidence of sebaceous cysts was compared between these 2 groups. Patients were followed-up for 2 to 4 years. In group A, sebaceous cysts at the incision site were found in 4 patients (13.3%); however, no sebaceous cysts occurred in group B. Increasing the thickness of de-epithelialization appears to decrease the incidence of sebaceous cysts at the incision site.

Reoperation for the Removal of Polyacrylamide Hydrogel in the Breast: Use of Periareolar Approach under Direct Visualization

After China announced a ban on polyacrylamide hydrogel (PAAG) in 2006, many patients desired the surgical removal of it. To minimize the length of incisions, some surgeons a adopted cannula aspiration and suction technique [1–4]. However, we found that not only is this technique inefficient for complete removal of PAAG, the injury caused by repeated aspiration also results in diffusion of PAAG into the healthy peripheral tissue. Blind removal is likely to result in the following problems: First, PAAG is in the form of a gelatinous mass when inserted into the body. Because it is composed of a large quantity of granules, it is difficult to aspirate out with a cannula, even after dilution with a large amount of normal saline solution. Second, PAAG infiltrates into peripheral tissue and it cannot be removed by suction. Third, in some cases, when PAAG was injected into the breast, multilevel repeated aspirations were applied to allow diffusion of PAAG into the tissue. As such, it was difficult to remove the PAAG when it was mixed with the normal tissue. Fourth, when removal is performed blindly, the exact range and amount of PAAG cannot be determined even when preoperative imaging results are available for guidance. Furthermore, injury caused by repeated aspiration resulted in many tunnels in the peripheral tissue, and these tunnels filled with hydrogel. The outcome of this approach was the formation of a mixed structure comprised of hydrogel and normal tissue, thus making an open excision very difficult. We found that the more times a patient underwent aspiration, the greater the amount of hydrogel mixed with the tissue. Subsequently, the formed mass became denser and removal became more difficult. In addition, hydrogel is an excellent bacteria culture medium. When it is not completely removed, the residual hydrogel in the incision results in nonunion and induces infection (Fig. 1). Subsequently, this induces further infection in the interhydrogel space and produces systemic symptoms. Clinically, either acute or chronic infection symptoms or fistulation occurs in the aspiration point, and it takes a long time to recover from this complication. In our patients, an inferior periareolar arc incision was used to remove the PAAG under direct visualization. Dissection was completed along the surface of the mammary gland downward to the inferior edge of the gland. A radial incision then was made on the mammary gland. Generally, residual PAAG and degenerated tissue could be

Repetitive arterial crisis of deep inferior epigastric perforator flap after mental stress: a case report.

The authors report a case of mental stress-induced repeatedly failing microsurgical flap. A 33-year-old female patient underwent a left breast reconstruction with deep inferior epigastric perforator flap. Repetitive arterial crisis occurred postoperatively, which eventually led to flap necrosis. In this case, there was clear correlation between the arterial crisis and mental factors. Mental stress may lead to arterial crisis.