• Archives of Plastic Surgery
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• v.42 no.5
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• pp.601-607
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• 2015

Background Autologous or implant-based breast reconstruction after nipple-sparing mastectomy is increasingly preferred worldwide as a breast cancer treatment option. However, postoperative nipple-areola complex (NAC) necrosis is the most significant complication of nipple-sparing mastectomy. The purpose of our study was to identify the risk factors for NAC necrosis, and to describe the use of our skin-banking technique as a solution. Methods We reviewed cases of immediate autologous breast reconstruction after nipple-sparing mastectomy at our institution between June 2005 and January 2014. The patients' data were reviewed and the risk of NAC necrosis was analyzed based on correlations between patient variables and NAC necrosis. Moreover, data pertaining to five high-risk patients who underwent the donor skin-banking procedure were included in the analysis. Results Eighty-five patients underwent immediate autologous breast reconstruction after nipple-sparing mastectomy during the study period. Partial or total NAC necrosis occurred in 36 patients (43.4%). Univariate analysis and binary regression modeling found that body mass index, smoking history, radiation therapy, and mastectomy volume were significantly associated with NAC necrosis. Of the 36 cases of NAC necrosis, 31 were resolved with dressing changes, debridement, or skin grafting. The other five high-risk patients underwent our prophylactic skin-banking technique during breast reconstruction surgery. Conclusions NAC necrosis is common in patients with multiple risk factors. The use of the skin-banking technique in immediate autologous breast reconstruction is an attractive option for high-risk patients. Banked skin can be used in such cases without requiring additional donor tissue, with good results in terms of aesthetic and reconstructive outcomes.

• Archives of Plastic Surgery
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• v.41 no.4
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• pp.366-373
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• 2014

Background The advent of skin-sparing mastectomy has allowed for the reconstruction of the breast and nipple with improved cosmesis. However, the nipple-areolar complex (NAC) in Asian patients is more pigmented and scars easily. Therefore, commonly described incisions tend to result in poor aesthetic outcomes in Asian patients with breast cancer. Methods We describe an algorithmic approach to skin-sparing mastectomy incisions in Asian patients on the basis of the location of the biopsy scar and the tumor site and size. Four incision types are described: peri-areolar, a peri-areolar incision with a second distant skin paddle, "racquet handle," and peri-areolar with adjacent skin excision. Results 281 immediate breast reconstructions were performed between May 2001 and February 2012 after skin-sparing mastectomy. The mastectomy incisions used included the peri-areolar design (n=124, 44%), peri-areolar design with a second distant skin paddle (n=39, 14%), "racquet handle" (n=21, 7.5%), and peri-areolar design with adjacent skin excision (n=42, 14%). The traditional elliptical incision and other variants where the NAC outline was not preserved were performed in the remaining 55 patients. The average follow-up was 44.7 months during which there was 1 case of total flap loss and 7 cases of partial flap necrosis; all remaining flaps survived. 24% of the patients (68/281) underwent subsequent nipple reconstruction. Conclusions Our algorithm avoids breast incisions that are randomly placed or excessively long and prevents the unnecessary sacrifice of normal breast skin. This allows skin-sparing mastectomy and immediate breast reconstruction to be performed with a consistently achievable aesthetic result in Asian women without neglecting oncological safety.

• Archives of Plastic Surgery
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• v.44 no.4
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• pp.308-312
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• 2017

Background Donor site seroma is the most common complication after latissimus dorsi (LD) flap harvest. This study aimed to evaluate the efficacy of negative-pressure wound therapy (NPWT) in preventing donor site seroma formation after the harvest of an LD flap for breast reconstruction. Methods In this prospective matched-pair study, 40 patients in whom an LD flap was harvested for breast reconstruction were enrolled. NPWT was used in 20 patients, and in a control group composed of another 20 patients, the conventional donor site dressing technique was used. Information was collected regarding postoperative complications, the incidence of seroma, total drainage volume, the number of percutaneous seroma aspirations, and the volume aspirated. Results In the NPWT group, the incidence of seroma formation after drain removal was significantly lower than in the control group (15% vs. 70%; odds ratio=0.07; relative risk, 0.24). Both the mean percutaneous aspirated volume (P =0.004) and the number of percutaneous aspirations (P=0.001) were also significantly lower in the NPWT group. There were no significant differences in the total drainage volume or the duration of wound drainage between the NPWT dressing group and the control group (P>0.05). Conclusions This study showed that NPWT is a promising tool for reducing the incidence of seroma formation after removing the drain at the donor site after LD flap harvesting. It is a simple and safe technique.

• Archives of Reconstructive Microsurgery
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• v.13 no.2
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• pp.136-143
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• 2004

Purpose : We analyse retrospectively the clinical result of consecutive free flap and osteocutaneous flap transfer in the chronic osteomyelitis, nonunion combined with infection and soft tissue defect with infection. Materials and Methods : From December 1989 to Jun 2003, free flap and osteocutaneous flap transfer was performed in 225 patients with osteomyelitis or infected non-union. 44 cases of these patients had revealed antibitotics resistant organism in wound culture, and these 44 cases were investigated in the mechanism of the injury, recurrence of infection, radiographic union, follow-up clincal results, and postoperative complications. Results : Among the 44 cases, consecutive procedures of osteocutaneous flap transfers(26 cases) and free flaps(18 cases) were performed. Causative organisms were MRSA(20 cases), Pseudomonas aeruginosa(18 cases), acinetobacter(2 cases), and so forth. Initial bony union was obtained in the average 6.3 months. Recurrence of infection in free flap and osteocutaneous free flap were occurred in 3 and 4 cases respectively. Eventually, all the cases attained successful subsidence of the inflammation. Conclusion : Free flap and osteocutaneousflap transfer have provided the greatest improvement of surgical results in infected non-union, chronic osteomyelitis and soft tissue defect with infection. Further clincal studies maybe required to minimize failure rate.

• Archives of Plastic Surgery
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• v.35 no.4
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• pp.483-486
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• 2008

Purpose: Fingertip injuries are the most common hand injuries and may lead to significant disability. Knowledge of fingertip anatomy is mandatory to treat these injuries effectively. All surgical techniques used for coverage of fingertip injuries must be based on the nature of the injury and the patient's age. Many authors have studied the method of fingertip reconstruction because goals of these treatments should include maintaining length, sensibility, motions, and appearance. The purpose of this study is to evaluate the effect of digital artery perforator flap for fingertip reconstruction without aesthetic and functional problems. Methods: From November 2006 to March 2007, the authors performed fingertip reconstruction on 3 fingers of 3 patients, aged between 41 to 54 years (average age, 47 years) using digital artery perforator flap. Results: All fingers recovered successfully and there were no necrosis of the flap. We followed up 3 cases more than 5 months. Light touch and temperature sensation could be detected in all flaps and the static two-point discrimination test was 8 mm. Conclusion: This flap is an alternative choice for coverage of fingertip defects. This method also takes short time to procedure and to recovery. The digital artery perforator flap has never been reported in Korea, however it is considered as a useful method for treatment of fingertip injury.

• Archives of Plastic Surgery
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• v.35 no.4
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• pp.446-449
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• 2008

Purpose: Pilonidal sinus is a frequent disease that occurs mostly in hairy young men, defined as chronic inflammation and infection of the postsacral sinuses. Wide excision of the affected area is the treatment of choice. Many techniques have been described to cover the defect. However none appears to be the ideal procedure to prevent infection, recurrence, and delayed wound healing. We present the results of an alternative technique that we performed by using partial deepithelized gluteal transposition flap for reconstruction of the defect following wide excision. Methods: From October 2004 to September 2007, we performed the partial deepithelized gluteal transposition flap method on 6 patients. We modified the transposition flap techniques by deepithelialising the medial parts of the flap and burying them under the opposing edge of the flap. The results were compared with previous studies and evaluated regarding duration of surgery, size of defect, hospitalization periods, and complications. Results: All the flaps were healed well with no partial or complete loss of the flap. Hospitalization and immobilization periods were acceptably shortened. Recurrence was not seen. The aesthetic outcome was also satisfactory and all patients were satisfied with the results. Conclusion: The main advantage of our techniques is using healthy tissues to obliterate the dead space, to provide an extra-cushion, and to prevent deep dehiscence. We believe that the partial deepithelized gluteal transposition flap is a good alternative method for treatment of pilonidal sinus.

• Archives of Plastic Surgery
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• v.39 no.4
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• pp.345-351
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• 2012

Background Cranial base defects are challenging to reconstruct without serious complications. Although free tissue transfer has been used widely and efficiently, it still has the limitation of requiring a long operation time along with the burden of microanastomosis and donor site morbidity. We propose using a reverse temporalis muscle flap and calvarial bone graft as an alternative option to a free flap for anterior cranial base reconstruction. Methods Between April 2009 and February 2012, cranial base reconstructions using an autologous calvarial split bone graft combined with a reverse temporalis muscle flap were performed in five patients. Medical records were retrospectively analyzed and postoperative computed tomography scans, magnetic resonance imaging, and angiography findings were examined to evaluate graft survival and flap viability. Results The mean follow-up period was 11.8 months and the mean operation time for reconstruction was $8.4{\pm}3.36$ hours. The defects involved the anterior cranial base, including the orbital roof and the frontal and ethmoidal sinus. All reconstructions were successful. Viable flap vascularity and bone survival were observed. There were no serious complications except for acceptable donor site depressions, which were easily corrected with minor procedures. Conclusions The reverse temporalis muscle flap could provide sufficient bulkiness to fill dead space and sufficient vascularity to endure infection. The calvarial bone graft provides a rigid framework, which is critical for maintaining the cranial base structure. Combined anterior cranial base reconstruction with a reverse temporalis muscle flap and calvarial bone graft could be a viable alternative to free tissue transfer.

• Archives of Plastic Surgery
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• v.39 no.4
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• pp.354-359
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• 2012

Background During the planning of a thoracodorsal artery perforator (TDAP) free flap, preoperative multidetector-row computed tomographic (MDCT) angiography is valuable for predicting the locations of perforators. However, CT-based perforator mapping of the thoracodorsal artery is not easy because of its small diameter. Thus, we evaluated 1-mm-thick MDCT images in multiple planes to search for reliable perforators accurately. Methods Between July 2010 and October 2011, 19 consecutive patients (13 males, 6 females) who underwent MDCT prior to TDAP free flap operations were enrolled in this study. Patients ranged in age from 10 to 75 years (mean, 39.3 years). MDCT images were acquired at a thickness of 1 mm in the axial, coronal, and sagittal planes. Results The thoracodorsal artery perforators were detected in all 19 cases. The reliable perforators originating from the descending branch were found in 14 cases, of which 6 had transverse branches. The former were well identified in the coronal view, and the latter in the axial view. The location of the most reliable perforators on MDCT images corresponded well with the surgical findings. Conclusions Though MDCT has been widely used in performing the abdominal perforator free flap for detecting reliable perforating vessels, it is not popular in the TDAP free flap. The results of this study suggest that multiple planes of MDCT may increase the probability of detecting the most reliable perforators, along with decreasing the probability of missing available vessels.

• Archives of Plastic Surgery
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• v.41 no.5
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• pp.513-519
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• 2014

Background Currently, breast conservation therapy is commonly performed for the treatment of early breast cancer. Depending on the volume excised, patients may require volume replacement, even in cases of partial mastectomy. The use of the latissimus dorsi muscle is the standard method, but this procedure leaves an unfavorable scar on the donor site. We used an endoscope for latissimus dorsi harvesting to minimize the incision, thus reducing postoperative scars. Methods Ten patients who underwent partial mastectomy and immediate partial breast reconstruction with endoscopic latissimus dorsi muscle flap harvest were reviewed retrospectively. The total operation time, hospital stay, and complications were reviewed. Postoperative scarring, overall shape of the reconstructed breast, and donor site deformity were assessed using a 10-point scale. Results In the mean follow-up of 11 weeks, no tumor recurrence was reported. The mean operation time was 294.5 (${\pm}38.2$) minutes. The postoperative hospital stay was 11.4 days. Donor site seroma was reported in four cases and managed by office aspiration and compressive dressing. Postoperative scarring, donor site deformity, and the overall shape of the neobreast were acceptable, scoring above 7. Conclusions Replacement of 20% to 40% of breast volume in the upper and the lower outer quadrants with a latissimus dorsi muscle flap by using endoscopic harvesting is a good alternative reconstruction technique after partial mastectomy. Short incision benefits from a very acceptable postoperative scar, less pain, and early upper extremity movement.

• Archives of Plastic Surgery
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• v.44 no.6
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• pp.550-553
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• 2017

Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.