Correction of an animation deformity that developed from breast implant removal

Subpectoral implant insertion is considered to be the standard procedure for breast augmentation and reconstruction. However, in some patients who have undergone breast augmentation or reconstruction surgery with a prosthesis, implant removal may be required for various reasons, including infection or implant rupture. According to a literature review, the standard technique for implant removal has not been thoroughly investigated. This study aimed to report the case of a patient who developed animation deformity after implant removal and to suggest a technique for preventing such complications. A 51-year-old woman underwent breast augmentation surgery with silicone implants. However, the patient complained of an unpleasant foreign body sensation; hence, the implant was removed 6 months after the first operation. After removal of the implant, undesirable movement of the chest wall on both breasts occurred. Revision surgery under general anesthesia was planned 18 months after implant removal. Capsulectomy was performed on both sides, and the pectoralis major muscle was completely isolated and repositioned. The undesirable movement in the skin of the chest wall disappeared postoperatively. This case suggests the need for capsulectomy and repositioning of the pectoralis muscle to its original position during implant removal.ope

Current status of and trends in post-mastectomy breast reconstruction in Korea

Since April 2015, post-mastectomy breast reconstruction has been covered by the Korean National Health Insurance Service (NHIS). The frequency of these procedures has increased very rapidly. We analyzed data obtained from the Big Data Hub of the Health Insurance Review and Assessment Service (HIRA) and determined annual changes in the number of breast reconstruction procedures and related trends in Korea. We evaluated the numbers of mastectomy and breast reconstruction procedures performed between April 2015 and December 2018 using data from the HIRA Big Data Hub. We determined annual changes in the numbers of total, autologous, and implant breast reconstructions after NHIS coverage commenced. Data were analyzed using Microsoft Excel. The post-mastectomy breast reconstruction rate increased from 19.4% in 2015 to 53.4% in 2018. In 2015, implant reconstruction was performed in 1,366 cases and autologous reconstruction in 905 (60.1% and 39.8%, respectively); these figures increased to 3,703 and 1,570 (70.2% and 29.7%, respectively) in 2018. Free tissue transfer and deep inferior epigastric perforator flap creation were the most common autologous reconstruction procedures. For implant-based reconstructions, the rates of directto-implant and tissue-expander breast reconstructions (first stage) were similar in 2018. This study summarizes breast reconstruction trends in Korea after NHIS coverage was expanded in 2015. A significant increase over time in the post-mastectomy breast reconstruction rate was evident, with a trend toward implant-based reconstruction. Analysis of data from the HIRA Big Data Hub can be used to predict breast reconstruction trends and convey precise information to patients and physicians.ope

Delphi survey of intercontinental experts to identify areas of consensus on the use of indocyanine green angiography for tissue perfusion assessment during plastic and reconstructive surgery

Background: In recent years, indocyanine green angiography (ICG-A) has been used increasingly to assist tissue perfusion assessments during plastic and reconstructive surgery procedures, but no guidelines exist regarding its use. We sought to identify areas of consensus and non-consensus among international experts on the use of ICG-A for tissue-perfusion assessments during plastic and reconstructive surgery. Methods: A two-round, online Delphi survey was conducted of 22 international experts from four continents asking them to vote on 79 statements divided into five modules: module 1 = patient preparation and contraindications (n = 11 statements); module 2 = ICG administration and camera settings (n = 17); module 3 = other factors impacting perfusion assessments (n = 10); module 4 = specific indications, including trauma debridement (n = 9), mastectomy skin flaps (n = 6), and free flap reconstruction (n = 8); and module 5 = general advantages and disadvantages, training, insurance coverage issues, and future directions (n = 18). Consensus was defined as ≥70% inter-voter agreement. Results: Consensus was reached on 73/79 statements, including the overall value, advantages, and limitations of ICG-A in numerous surgical settings; also, on the dose (0.05 mg/kg) and timing of ICG administration (∼20-60 seconds preassessment) and best camera angle (61-90o) and target-to-tissue distance (20-30 cm). However, consensus also was reached that camera angle and distance can vary, depending on the make of camera, and that further research is necessary to technically optimize this imaging tool. The experts also agreed that ambient light, patient body temperature, and vasopressor use impact perfusion assessments. Conclusion: ICG-A aids perfusion assessments during plastic and reconstructive surgery and should no longer be considered experimental. It has become an important surgical tool.ope

Inlay graft of acellular dermal matrix to prevent incisional dehiscence after radiotherapy in prosthetic breast reconstruction

BACKGROUND: As the indications for postmastectomy radiotherapy expand, innovative solutions are required to reduce operative complications and reconstructive failure after prosthetic breast reconstruction. In this study, we investigated the effectiveness of acellular dermal matrix (ADM) inlay grafts in preventing postoperative wound dehiscence of irradiated breasts in the context of prosthetic breast reconstruction. METHODS: A retrospective analysis was conducted of 45 patients who received two-stage prosthetic reconstruction and radiotherapy following mastectomy. An ADM graft was placed beneath the incisional site during the second-stage operation in 19 patients using marionette sutures, whereas the control group did not receive the ADM reinforcement. Patient demographics and complications such as wound dehiscence, capsular contracture, peri-prosthetic infection, cellulitis, and seroma were compared between the two groups. RESULTS: During an average follow-up period of 37.1 months, wound dehiscence occurred significantly less often in the ADM-reinforced closure group (0%) than in the non-ADM group (23.1%) (P=0.032). There was no significant difference between the two groups in relation to other complications, such as capsular contracture, postoperative infection, or seroma. CONCLUSIONS: The ADM inlay graft is a simple and easily reproducible technique for preventing incisional dehiscence in the setting of radiotherapy after prosthetic breast reconstruction. The ADM graft serves as a buttress to offload tension during healing and provides a mechanical barrier against pathogens. Application of this technique may serve to reduce complications in prosthetic breast reconstruction after radiotherapy.ope

Archives of Plastic Surgery in the current Warring States period of plastic surgery journals

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Primary involvement of NADPH oxidase 4 in hypoxia-induced generation of reactive oxygen species in adipose-derived stem cells

We have previously demonstrated that hypoxia stimulates adipose-derived stem cells (ASCs) through the generation of reactive oxygen species (ROS). However, the precise mechanism involved in the ROS generation by ASCs is not well understood. We sought to investigate in this work: (1) which subtype of NADPH oxidase (Nox) is primarily expressed in ASCs; (2) where Nox4 is localized in ASCs; and (3) whether silencing of Nox4 attenuates hypoxia-enhanced function of ASC. We used 2',7'-dichlorofluorescin diacetate (DCF-DA) as an indicator of ROS generation and found that the fluorescence intensity of DCF-DA was significantly increased after hypoxia exposure (2% oxygen). In addition, hypoxia enhanced the proliferation and migration of ASCs and upregulated the mRNA expression of Oct4 and Rex1. Quantitative analysis of mRNA expression of Nox family in ASCs demonstrated that Nox4 is primarily expressed in ASCs, while immunofluorescence assay showed that Nox4 is mainly localized in the perinuclear region and overlaps with Mitotracker, a mitochondria marker. Silencing of Nox4 by siRNA treatment downregulated the RNA and protein expression of Nox4, which significantly reduced the ROS generation under hypoxia. In addition, Nox4 silencing significantly reduced the proliferation and migration of ASCs and downregulated the mRNA expression of Oct4 and Rex1. Phosphorylation of platelet-derived growth factor receptor-β, AKT, and ERK1/2 also diminished following Nox4 silencing. In a nutshell, these results suggest that Nox4 is primarily expressed in ASCs and plays a pivotal role in the hypoxia-enhanced stimulation of ASCs.ope

The traditional versus endoscopic-assisted latissimus dorsi harvest in oncoplastic surgery: A long term comparison of breast volume, aesthetics, and donor site outcomes

Background/objective: Volume replacement with the latissimus dorsi (LD) is an option for patients after partial mastectomy. Although potential benefits of using the endoscopic technique have been previously described, previous studies have not assessed long term volume and aesthetic outcomes compared to traditional methods. In this study, we aim to compare the endoscopic, latissimus only harvest to the traditional latissimus with skin paddle method. Methods: Eleven patients underwent breast reconstruction with the traditional LD flap harvesting method; 9 underwent endoscopically assisted LD flap reconstruction. The difference between preoperative and >1 year postoperative volumes were recorded. Patient satisfaction and surgeon-based observer assessment of the breast aesthetic and donor site scar were compared between the two techniques. Results: Compared to the traditional group, there was a significant mean volume reduction in the endoscopic group (70.3 vs 21.7 cc, p = 0.0023). Operative time was also longer in the endoscopic group than in the traditional group (368 vs 257 min, p < 0.001). In observer assessment criteria, the result of the donor site scar assessment was superior in the endoscopic group in terms of vascularity (p = 0.0038), relief (p = 0.0023), and pliability (p = 0.053). Conclusion: Patients' attitudes and feelings about the scar were better in the endoscopic group than in the traditional group. However, compared to the endoscopic group, the traditional group achieved a better breast cosmetic result and better retention of volume postoperatively, possibly due to incorporation of the skin flap and adipo-fascial tissue.ope

Simple Correction of Alar Retraction by Conchal Cartilage Extension Grafts

BACKGROUND: Alar retraction is a challenging condition in rhinoplasty marked by exaggerated nostril exposure and awkwardness. Although various methods for correcting alar retraction have been introduced, none is without drawbacks. Herein, we report a simple procedure that is both effective and safe for correcting alar retraction using only conchal cartilage grafting. METHODS: Between August 2007 and August 2009, 18 patients underwent conchal cartilage extension grafting to correct alar retraction. Conchal cartilage extension grafts were fixed to the caudal margins of the lateral crura and covered with vestibular skin advancement flaps. Preoperative and postoperative photographs were reviewed and analyzed. Patient satisfaction was surveyed and categorized into 4 groups (very satisfied, satisfied, moderate, or unsatisfied). RESULTS: According to the survey, 8 patients were very satisfied, 9 were satisfied, and 1 considered the outcome moderate, resulting in satisfaction for most patients. The average distance from the alar rim to the long axis of the nostril was reduced by 1.4 mm (3.6 to 2.2 mm). There were no complications, except in 2 cases with palpable cartilage step-off that resolved without any aesthetic problems. CONCLUSIONS: Conchal cartilage alar extension graft is a simple, effective method of correcting alar retraction that can be combined with aesthetic rhinoplasty conveniently, utilizing conchal cartilage, which is the most similar cartilage to alar cartilage, and requiring a lesser volume of cartilage harvest compared to previously devised methods. However, the current procedure lacks efficacy for severe alar retraction and a longer follow-up period may be required to substantiate the enduring efficacy of the current procedure.ope

TGF-β2 and collagen play pivotal roles in the spheroid formation and anti-aging of human dermal papilla cells

Dermal papilla cells (DPCs) tend to aggregate both in vitro and in vivo, which increases the hair inductivity of DPCs. However, the underlying mechanism of spheroid formation is unknown. We investigated whether collagen expression in human DPCs (hDPCs) is involved in the spheroid formation and hair inductivity of hDPCs and further examined the underlying molecular mechanism of collagen upregulation. The expression of diverse collagens, such as COL13A1 and COL15A1, was upregulated in three dimensional (3D)-cultured or intact DPCs, compared to 2D-cultured hDPCs. This collagen expression was a downregulated in aged hair follicle, and aged DPCs were difficult to aggregate. Blocking of COL13A1 and COL15A1 by small interfering RNA reduced aggregation, while induced senescence of hDPCs in vitro. Further, transforming growth factor-β2 (TGF-β2) expression decreases with aging, and is involved in regulating the expression of COL13A1 and COL15A1. Addition of recombinant TGF-β2 delayed cellular senescence, and recovered spheroid formation in aged hDPCs by upregulating collagen levels. On the contrary, knock-out of TGF-β2 induced the aging of DPCs, and inhibited spheroid formation. These results suggested that COL13A1 and COL15A1 expression is downregulated with aging in DPCs, and upregulation of collagen by TGF-β2 induces the spheroid formation of DPCs. Therefore, TGF-β2 supplement in DPC culture medium could enhance the maintenance and hair inductivity of DPCs.ope

The Role of Macrophage Migration Inhibitory Factor in Adipose-Derived Stem Cells Under Hypoxia

Background: Adipose-derived stem cells (ASCs) are multipotent mesenchymal stem cells characterized by their strong regenerative potential and low oxygen consumption. Macrophage migration inhibitory factor (MIF) is a multifunctional chemokine-like cytokine that is involved in tissue hypoxia. MIF is not only a major immunomodulator but also is highly expressed in adipose tissue such as subcutaneous adipose tissue of chronic non-healing wounds. In the present study, we investigated the effect of hypoxia on MIF in ASCs isolated from healthy versus inflamed adipose tissue. Methods: Human ASCs were harvested from 17 patients (11 healthy adipose tissue samples, six specimens from chronic non-healing wounds). ASCs were treated in a hypoxia chamber at <1% oxygen. ASC viability, MIF secretion as well as expression levels of MIF, its receptor CD74, hypoxia-inducible transcription factor-1α (HIF-1α) and activation of the AKT and ERK signaling pathways were analyzed. The effect of recombinant MIF on the viability of ASCs was determined. Finally, the effect of MIF on the viability and production capacity of ASCs to produce the inflammatory cytokines tumor necrosis factor (TNF), interleukin (IL)-6, and IL-1β was determined upon treatment with recombinant MIF and/or a blocking MIF antibody. Results: Hypoxic treatment inhibited proliferation of ASCs derived from healthy or chronic non-healing wounds. ASCs from healthy adipose tissue samples were characterized by a low degree of MIF secretion during hypoxic challenge. In contrast, in ASCs from adipose tissue samples of chronic non-healing wounds, secretion and expression of MIF and CD74 expression were significantly elevated under hypoxia. This was accompanied by enhanced ERK signaling, while AKT signaling was not altered. Recombinant MIF did stimulate HIF-1α expression under hypoxia as well as AKT and ERK phosphorylation, while no effect on ASC viability was observed. Recombinant MIF significantly reduced the secretion of IL-1β under hypoxia and normoxia, and neutralizing MIF-antibodies diminished TNF-α and IL-1β release in hypoxic ASCs. Conclusions: Collectively, MIF did not affect the viability of ASCs from neither healthy donor site nor chronic wounds. Our results, however, suggest that MIF has an impact on the wound environment by modulating inflammatory factors such as IL-1β.ope