Sa-Ik Bang

Comparison of morbidity of donor site following pedicled muscle-sparing latissimus dorsi flap versus extended latissimus dorsi flap breast reconstruction

UNLABELLEDnThe pedicled, descending-branch muscle-sparing latissimus dorsi (MSLD) flap has been widely used for breast reconstruction following total mastectomy. However, the superiority of the MSLD flap compared to the extended latissimus dorsi (ELD) flap has not yet been described. This study compares morbidities following pedicled MSLD flap and ELD flap breast reconstruction. A total of 36 women with pedicled MSLD flaps were compared with 37 women with ELD flap breast reconstruction. The medical records were reviewed for complications and demographic data. The authors compared morbidity including donor-site seroma, limitation of shoulder movement and aesthetic contour of the donor site following MSLD flap and ELD flap breast reconstruction. The authors compared the identified parameters and set the level of significance at the 0.05 alpha level. The demographic data of the two groups were not significantly different statistically. Donor-site seroma occurred in two MSLD patients (5.6%) and in 23 ELD patients (62.2%) (p = 0.0001). Limitation of shoulder movement occurred in nine MSLD patients (25%) and in 28 ELD patients (75.7%) (p = 0.0001). Back asymmetry occurred less frequently in the MSLD group (p = 0.0297). The pedicled, descending-branch MSLD flap, with its low complication rate and associated with minimal functional and aesthetic deficits of the donor site, can be a good option for breast reconstruction.nnnLEVEL OF EVIDENCEnTherapeutic, III.

Deep superior epigastric artery perforator 'propeller' flap for abdominal wall reconstruction: A case report.

As the concept of free style perforator flap and the propeller flap is widely accepted, any region of the body can be used as a possible donor site for a perforator flap. A propeller flap is a local flap that is rotated to different extents (up to 180 degrees ) about a reliable perforator to cover adjacent defects. Rectus abdominis perforators (epigastric artery perforators) are the main perforators in the abdominal region from the deep inferior epigastric artery or the deep superior epigastric artery. Traditionally, deep inferior epigastric artery perforators have been often used in the abdominal region because they provide a dominant blood supply to abdominal skin. In the described case, a large abdominal wall defect (20.5 x 19 cm) caused by tumour resection was covered successfully using a superior epigastric artery perforator propeller flap.

Plantar reconstruction with free thoracodorsal artery perforator flaps

PURPOSEnThe 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.nnnMETHODSnFrom 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.nnnRESULTSnA 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.nnnCONCLUSIONnAn 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.

The impact of immediate breast reconstruction on post-mastectomy lymphedema in patients undergoing modified radical mastectomy

The aim of this study was to assess the impact of immediate breast reconstruction (IBR) with autologous tissue on the development of post-mastectomy lymphedema in patients undergoing modified radical mastectomy (MRM). A retrospective chart review was performed for early-stage breast cancer patients who underwent MRM between January 2001 and December 2009. Patients were categorized into two groups based on whether or not they underwent IBR. The incidence of lymphedema was assessed and compared. A total of 712 patients underwent MRM, which included 117 patients undergoing IRB. There were no significant differences between two groups except for a lower body mass index in the reconstruction group. Comparing the incidence of lymphedema using multivariate logistic regression analysis, the reconstruction group had a significantly lower incidence of lymphedema (p-value = 0.023). Breast cancer patients who underwent MRM with IBR had a significantly lower incidence of lymphedema than those in the non-reconstruction group.

Concealment, depression and poor quality of life in patients with congenital facial anomalies

OBJECTIVESnStudies have shown that patients with congenital facial anomalies are vulnerable to depression. In addition, concealment of facial anomalies in an effort to mask handicaps is common, and these patients also often have difficulties with interpersonal relationships and in social situations. Despite this, no previous study has investigated the association between concealment of facial anomalies and depression, and a patients quality of life.nnnMETHODSnA group of 65 patients, who had been scheduled for plastic surgery, completed this study. A total of 50 patients who had congenital facial anomalies, some of whom concealed their facial anomalies (N=22), and some whom didnt (N=28), as well as 15 patient controls were interviewed and subsequently administered the Beck Depression Inventory-II (BDI-II), the Structured Clinical Interview for DSM-IV (SCID), the Millon Behavioral Medicine Diagnostic (MBMD) and the WHO Quality of Life (WHOQOL).nnnRESULTSnAmong patients with congenital facial anomalies, those who concealed their anomalies exhibited a significantly higher level of depression and anxiety; higher rates of self-accusation, dissatisfaction, hypochondria, weight loss and antisocial personality traits; and a lower quality of life than those who did not conceal their anomalies. To the contrary, no significant differences were found with respect to depression, anxiety and quality of life between the congenital facial anomaly group and controls. Further, the concealment of facial anomalies was a significant predictor for lifetime major depressive disorder (odds ratio (OR)=7.1, 95% confidence interval (CI) 1.4-37.3), after adjusting for age, gender and microtia.nnnCONCLUSIONnFacial concealment is a significant predictor of depression and poor quality of life in patients with congenital facial anomalies.

Does the reconstruction method influence development of mastectomy flap complications in nipple-sparing mastectomy?

PURPOSEnThere has been an increase in the use of nipple-sparing mastectomy (NSM) with immediate breast reconstruction for the treatment of early-stage breast cancer patients. Mastectomy flap complication including nipple loss is a major concern and usually associated with the surgical technique. The authors evaluated potential risk factors of mastectomy flap complications, especially focussing on the impact of reconstructive variables.nnnMETHODSnUsing a prospectively collected database, we reviewed 130 cases of NSM between January 2009 and December 2012. Only cases using lateral incision were included. Potential patient- and procedure-related risk factors were analysed using logistic regression analysis to investigate associations with the development of mastectomy flap necrosis.nnnRESULTSnAmong the 130 cases, 70 underwent autologous tissue reconstruction and 60 underwent two-stage prosthesis reconstruction using a tissue expander. All patient- and procedure-related characteristics were similar between the two groups. Mastectomy flap complications occurred in 21 cases (16.2%), including total nipple necrosis in 5 (3.8%) and mastectomy flap necrosis in 10 (7.7%). The autologous tissue group showed a significantly lower rate of complications than the prosthesis group (10.0% vs. 23.3%, p = 0.034), and the difference remained significant after adjusting for other factors on multivariate logistic regression analysis (p = 0.024, odds ratio = 3.259). The rate of revision surgery was also significantly lower in the autologous tissue group (1.4% vs. 15.0%, p = 0.004).nnnCONCLUSIONSnIn our study, the reconstruction method was associated with the development of necrotic complications of the mastectomy flap. Careful selection of patients and reconstruction methods may reduce the risk of mastectomy flap complications in NSM.

Improvement of Upper Extremity Lymphedema after Delayed Breast Reconstruction with an Extended Latissimus Dorsi Myocutaneous Flap

Lymphedema is a common complication after mastectomy in breast cancer patients. Many treatment options are available, but no treatment results in a complete cure. We report a case of lymphedema that occurred after modified radical mastectomy in a breast cancer patient who showed objective improvement after delayed breast reconstruction with an latissimus dorsi myocutaneous flap. A 41-year-old female patient with left breast cancer had undergone modified radical mastectomy with axillary lymph node dissection and postoperative radiotherapy 12 years previously. Four years after surgery, lymphedema developed and increased in aggravation despite conservative treatment. Eight years after the first operation, the patient underwent delayed breast reconstruction using the extended latissimus dorsi myocutaneous flap method. After reconstruction, the patients lymphedema symptoms showed dramatic improvement by subjective measures including tissue softness and feeling of lightness, and by objective measures of about 7 mL per a week, resulting in near normal ranges of volume. At a postoperative follow-up after 3 years, no recurrence was observed. Delayed breast reconstruction with extended latissimus dorsi myocutaneous flaps may be helpful to patients with lymphedema after mastectomy. This may be a good option for patients who are worried about the possibility of the occurrence or aggravation of secondary lymphedema.

Aesthetic auricular reconstruction with autologous rib cartilage grafts in adult microtia patients

BACKGROUNDnCartilage calcification is an important factor in aesthetic auricular reconstruction using autologous rib cartilage grafts in adults, a technique that involves difficult manipulation and unexpected absorption. As a result, artificial implants or prosthetics are considered for auricular reconstruction in adult patients despite the limitations of artificial material. In this article, we present our experience with auricular reconstruction using autologous rib cartilage grafts in adult microtia patients with reliable aesthetic results and minimal complications.nnnMETHODSnA retrospective chart review was performed for 84 microtia patients ranging in age from 21 to 56 (average: 29.9) years who underwent auricular reconstruction using autologous rib cartilage grafts from March 2001 to March 2013. To validate our acceptable reconstructive results, two independent observers performed postoperative photographic evaluation of two groups (adults and children) using non-inferiority tests in addition to patient questionnaires.nnnRESULTSnThe mean operation time for rib cartilage grafts was 3 h and 53 min, and the follow-up time for all patients ranged from 6 months to 8 years. Surgery-related complications occurred in only three cases. On objective photographic evaluation, the adult group was not inferior to the child group in auricular shape, location, or symmetry. The subjective patient satisfaction evaluation reported a high satisfaction rate.nnnCONCLUSIONSnAs this study shows, aesthetic auricular reconstruction using rib cartilage grafts in adult microtia patients is possible even in cases with advanced cartilage calcification. Modification of the fabricating framework, well-preserved flap vascularity, and complete understanding of physiological aspects of rib cartilage are essential for aesthetic auricular reconstruction.

Negative-pressure wound dressings to secure split-thickness skin grafts in the perineum

Several researches have shown that negative‐pressure wound dressings can secure split‐thickness skin grafts and improve graft survival. However, in anatomically difficult body regions such as the perineum it is questionable whether these dressings have similar beneficial effects. In this study, we evaluated the effects of negative‐pressure wound dressings on split‐thickness skin grafts in the perineum by comparing wound healing rate and complication rate with that of tie‐over dressings. A retrospective chart review was performed for the patients who underwent a split‐thickness skin graft to reconstruct perineal skin defects between January 2007 and December 2011. After grafting, the surgeon selected patients to receive either a negative‐pressure dressing or a tie‐over dressing. In both groups, the initial dressing was left unchanged for 5 days, then changed to conventional wet gauze dressing. Graft success was assessed 2 weeks after surgery by a single clinician. A total of 26 patients were included in this study. The mean age was 56·6 years and the mean wound size was 273·1 cm2. Among them 14 received negative‐pressure dressings and 12 received tie‐over dressings. Negative‐pressure dressing group had higher graft taken rate (P = 0·036) and took shorter time to complete healing (P = 0·01) than tie‐over dressing group. The patients with negative‐pressure dressings had a higher rate of graft success and shorter time to complete healing, which has statistical significance. Negative‐pressure wound dressing can be a good option for effective management of skin grafts in the perineum.

Association of congenital microtia with environmental risk factors in South Korea

BACKGROUNDnThough there are reports regarding congenital microtia in various populations, few studies have focused on patients in South Korea. The objectives of the present study were to investigate the characteristics of microtia in South Korea and demonstrate the contribution of environmental risk factors to the occurrence of microtia.nnnPATIENTS AND METHODSnWe performed a retrospective chart review of congenital microtia patients who presented to our institution between January 2002 and December 2010. A case-control study was performed in 169 microtia patients and 128 controls to investigate the impact of environmental and prenatal factors on the development of congenital microtia. The data were gathered by personal interviews and detailed questionnaires filled out by the patients parents.nnnRESULTSnA total of 374 microtia patients were included in the present study. Most cases were sporadic, and most were male. Unilateral microtia was more common, especially on the right side, while bilateral microtia occurred in only 25 patients. Two hundred forty-three patients had isolated microtia with no other congenital anomalies. In subgroups divided by type, lobule-type microtia was more common than concha-type microtia, and patients with anotia were the least common. Risk factors analyzed using multivariate regression models between groups, resident area during pregnancy, threatened abortion history, rubella vaccination, medication history during the first trimester, and alcohol consumption during the first trimester had significant impacts on the development of isolated microtia.nnnCONCLUSIONSnThe characteristics of congenital microtia in South Korea are similar to those in other populations, including the predominance of sporadic occurrence, male gender, lobule type, and isolated microtia. Several environmental risk factors can have significant impacts on the development of microtia.