Visualization of Accessory Lymphatic Pathways in Secondary Upper Extremity Lymphedema Using Indocyanine Green Lymphography

Introduction: The anatomical variations in accessory lymphatic pathways around the axillary region may work as a drainage route for excess lymphatic fluid accumulation in secondary upper extremity lymphedema. In this report, accessory lymphatic pathways extending to the shoulder, neck, and breast regions in secondary upper extremity lymphedema patients are shown using indocyanine green (ICG) lymphography. Patients and Methods: Between January 2012 and May 2015, 30 limbs of 29 patients with upper extremity lymphedema after malignant tumor resection were evaluated. ICG lymphography was performed after chronic lymphedema formation. Results: Of the 30 limbs, accessory lymphatic pathways were identified across the axillary region in 3 patients using ICG lymphography. In 2 of these 3 patients, accessory drainage lymphatics were connected to the cervical lymph nodes. In regard to the distribution of dermal backflow patterns, dermal backflow appeared in 26 patients—in the forearm in 26 patients and in the upper arm in 20 patients. Conclusions: Accessory lymphatic pathways are thought to be the drainage routes in the affected arm, which may prevent edema progression to the terminal stage. Variations in the lymphatic system are easily visualized using ICG lymphography. Understanding of accessory lymphatic routes in lymphedema patients may provide new insight for further understanding the pathophysiology of lymphedema.

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The Limitations of Implantable Mesh in Mastopexy

No abstract available

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Online Patient Resources for Gender Affirmation Surgery: An Analysis of Readability

Background: Gender affirmation surgery is an important treatment for patient with gender dysphoria. It consists of a series of complex procedures, and well-informed patients have been shown to have better outcomes. However, there are no published data regarding the readability of currently available online patient recourses for gender affirmation surgery. This study aims at identifying the most popular online resources and evaluating the readability of these documents in the context of average literacy within the United States. Methods: An online search with the terms "gender affirmation surgery," "gender reassignment surgery," "top surgery," and "bottom surgery" was performed. Location, cookies, and user account information was disabled before each search to avoid bias in the results. Readability assessment was performed using the 10 commonly used readability scales. Results: The overall mean readability level was 13.4. The mean reading level was 14 (range, 7.6–17.0) for the search term "gender affirmation surgery," 14.2 (range, 11.9–16.7) for the search term "gender reassignment surgery," 13 (range, 8.9–17.5) for the search term "top surgery," and 12.6 (range, 7.1–15.0) for the search term "bottom surgery." There was no statistically significant difference between the search terms. Conclusions: Our findings demonstrate that the articles most commonly seen by patients who perform an Internet search for information on gender reassignment surgery are more difficult than the recommended readability level.

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Reviewing the Evidence to Guide Clinical Care: Proliferative Breast Lesions in Breast Reduction Specimens

Abstract: The number of reduction mammoplasties performed in the United States continues to increase annually. Given the high incidence of breast cancer in women, it is routine practice for breast tissue excised during routine breast reductions procedures to be sent for pathology review. During pathology assessment, occult malignancy and on-occasion proliferative breast lesions of unknown and/or variable malignancy may also be present. We provide a review of commonly diagnosed atypical proliferative breast lesions in breast reduction specimens and a guide to plastic surgeons for further management.

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Nonincisional Conjoint Fascial Sheath Suspension: A Novel Technique for Minimally Invasive Blepharoptosis Correction

Background: Mild to moderate blepharoptosis, or ptosis, is relatively common among Asians, and it is not uncommon to offer ptosis correction at the time of double-eyelid surgery in this patient population. The traditional open approaches to ptosis correction are subject to scarring and prolonged recovery time, whereas the newer nonincisional approaches are marred by issues of incomplete correction or recurrence. This study describes a new nonincisional technique that overcomes the limitations of current methods by using conjoint fascial sheath (CFS) for suspension. Methods: From January 2014 to April 2015, a retrospective review was conducted on 21 patients (41 eyelids) who underwent simultaneous nonincisional ptosis correction and double-eyelid surgery. All patients had either mild or moderate ptosis without excess skin hooding and excellent or good levator palpebrae function. Results: Mild ptosis correction (1-loop CFS suspension) was performed in 25 eyelids, and moderate ptosis correction (2-loop CFS suspension) was performed in 16 eyelids. At 6 months of follow-up, 23 eyelids (56.1 %) improved to "normal" with overall improvement seen in 33 eyelids (80.0%). The mean marginal reflex distance 1 increased from 3.16 ± 0.61 mm preoperatively to 4.11 ± 0.61 mm postoperatively, which was statistically significant (P

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Reconstruction of Anterolateral Thigh Defects Using Perforator-Based Propeller Flaps

Background: Usually, anterolateral thigh (ALT) defects with width more than 8 cm cannot be closed directly. Although several methods of using local flaps exist, flap mobility of these methods is limited. We introduced a perforator-based propeller flap for such reconstruction. Their maximal mobility, which minimizes their size, is their greatest advantage. In addition, we present our technical refinements including double-axes propeller flap, the use of indocyanine green real-time angiography, and supercharged propeller flap for safer flap transfer. Patients and Methods: Seven patients underwent perforator-based propeller flap reconstruction of ALT defects. Flaps were designed cranial or caudal to the defect according to the perforator locations. To maximize mobility, flaps were designed so that the perforator was located at the periphery and closer to the defect. After rotating the flap to the defect, indocyanine green angiography was performed to determine the need for supercharge. Results: In all cases, all flaps survived completely. Defect size ranged from 12 × 11 cm to 18 × 16 cm, and flap size ranged from 7 × 5 cm to 15 × 7 cm. The number of perforators in the flap was 1 in 3 cases and 2 in 4 cases. Supercharging was performed in 3 cases. Donor-site complications, including gait disturbance, were not observed. Conclusions: This method achieves ALT defect closure with minimal donor-site morbidity and can provide prompt and aesthetically acceptable results. Indocyanine green real-time angiography and supercharging technique are also useful for safer and reliable flap transfer.

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Does the Use of Acellular Dermal Matrix Increase Postoperative Complications of the First-Stage Reconstruction of Immediate Expander-Implant Breast Reconstruction: A Matched Cohort Study

Purpose: Controversy exists regarding complications associated with the use of acellular dermal matrix (ADM). This likely stems from the heterogeneous and unmatched patient characteristics in study groups. The purpose of this study was to analyze complications in a matched cohort to identify whether ADM use increased postoperative complications of the first-stage immediate expander-implant breast reconstructions. Methods: A retrospective matched-cohort study was performed. We retrospectively reviewed prospectively collected data from patients who underwent immediate expander-implant breast reconstruction after mastectomy between February 2010 and January 2016. Independent variables included clinical characteristics, mastectomy weight, mastectomy type, expander size, initial inflation volume, number of days to drain removal, and adjuvant or neoadjuvant therapies. Different independent variables between the ADM and non-ADM groups were used for propensity score matching. After matching, a pairwise comparison of the 2 cohorts' independent variables was carried out using the Wilcoxon signed rank test and McNemar test. Incidence of complications was evaluated for the 2 matched cohorts. To adjust for ablative and reconstructive surgeons, a multivariable generalized estimating equation analysis was performed. Results: A total of 574 immediate expander-implant breast reconstructions in 533 patients were included in this study. We identified 398 reconstructions (199 for each group; ADM and non-ADM group) of matched cohorts using propensity score matching. Characteristics were similar between the 2 matched cohorts. In the matched analysis, there were no significant differences in the rate of skin flap complications (16.1% vs 16.1%, P > 0.999), seroma (4.0% vs 8.5%, P = 0.065), infection (3.0% vs 3.5%, P = 0.781), and overall complications (21.1% vs 26.1%, P = 0.251). Acellular dermal matrix was not associated with increased risk of complication when ablative and reconstructive surgeon factors were considered in a multivariable analysis (P = 0.511). Conclusions: A matched cohort analysis demonstrated that ADM usage is not associated with an increased risk of complications, including skin flap complications, seroma, and infection. Our result suggests that ADM can be safely used in immediate expander-implant breast reconstruction when necessary.

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Enhancing Nitric Oxide Bioavailability via Exogen Nitric Oxide Synthase and L-Arginine Attenuates Ischemia-Reperfusion–Induced Microcirculatory Alterations

Background: Nitric oxide (NO) is an important cytoprotective agent against ischemia and reperfusion injury (IRI). Enhancing NO bioavailability via exogen NO synthases (NOSs) and L-arginine promotes conversation to NO, circumventing the problem of nonfunctioning NOSs under hypoxic and acidic conditions. In this study, the authors evaluated the therapeutic efficacy of endothelial, inducible and neuronal NOS, and L-arginine on reperfusion-induced microcirculatory alterations and hemodynamic adverse effects in the microvasculature of skeletal muscle. Methods: Vascular pedicle isolated rat cremaster model was used that underwent 2 hours of warm ischemia followed by 1 hour of reperfusion. At 30 minutes before ischemia, normal saline (control group with/without ischemia), endothelial-, inducible-, and neuronal NOSs (2 IE) and L-arginine (50 mg/kg BW) were administered systemically (IV). Ischemia-reperfusion–induced microcirculatory alterations were measured after 1 hour of reperfusion. Mean arterial blood pressure and heart frequency were measured throughout the experiment to determine hemodynamic adverse effects. Results: The isoforms of NOSs and L-arginine attenuated ischemia-reperfusion–induced vasoconstriction, improved red blood cell velocity, capillary flow, and leukocyte adherence to the endothelium wall. Hemodynamics was stable throughout the experiment. Conclusions: Enhancing NO bioavailability via exogen application of NOSs and L-arginine significantly attenuated ischemia-reperfusion–induced microcirculatory alterations in the microvasculature of skeletal muscle. Significant hemodynamic adverse effects were not present, thus demonstrating this approach might be useful for therapeutic intervention. This "pharmacologic preconditioning" could be an easy and effective interventional strategy to uphold conversation of L-arginine to NO under ischemic conditions.

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Effect of Exercise Training on the Frequency of Contracture-Release Surgeries in Burned Children

Background: Intensive physical exercise (IPE) increases strength, lean body mass, aerobic capacity, and range of motion in children with extensive burns. However, whether IPE decreases the frequency of burn scar contracture-releasing procedures in children with extensive burns is unknown. Materials and Methods: Prospectively collected surgical records of 184 children who had undergone axilla, elbow, and/or wrist contracture-releasing procedures were reviewed. All children were 7 years or older and had sustained burns of at least 40% of the total body surface area. Eighty-two children completed an IPE program, and 102 children did not. For both groups, the axilla, elbow, and wrist were examined for tightness and restricted movement. Children with contractural difficulty were prescribed a releasing procedure. Logistic regression was used to model the relationship between multiple release surgeries and group. Results: Patients in both groups had comparable injury severity. A total of 120 releases were carried out in the 82 IPE patients. In contrast, 211 releases were needed in the 102 non-IPE patients. An approximately 60% decrease in the frequency of rerelease operations was noted in IPE patients (12.5% for the IPE group and 31.8% for non-IPE group; P

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Teledermatology: Is it Beneficial to Patients?

No abstract available

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Outcomes of Geriatric Burns Treated as Outpatients

Objective: Most literature about geriatric burns has focused on inpatient management; therefore, our study investigated the effects of burn characteristics and preexisting medical comorbidities on treatment outcomes for geriatric burn patients treated as outpatients. Methods: A retrospective review was conducted for 391 patients over 65 years of age seen in the emergency department of Fukui Prefectural Hospital over a 10-year period. Charts were reviewed for age, sex, burn characteristics, burn mechanisms, preexisting medical comorbidities, and treatment outcomes. Multivariate regression analysis was used to examine the relationship between outcomes of outpatients and comorbidities, which were calculated by the Charlson comorbidity index. Results: Seventy-three patients aged 65 years and older were treated as outpatients at Fukui Prefectural Hospital. The majority (80%) of these patients had burns on less than 5% of their total body surface area. Scald burns accounted for 63% of burn mechanisms, with burns to the lower extremities being the most frequent. The mean percentage of total burn surface area was 4% in the outpatient group and 28% for the inpatient group. The mean time to healing was 24.3 days in outpatients. Of the 73 outpatients, 17 (23%) showed delayed healing. Of these 17 patients, 3 patients experienced wound infection and 2 patients had documented hypertrophic scarring. Four patients ultimately underwent excision and grafting. The common preexisting medical comorbidities in the outpatient group were congestive heart failure and diabetic mellitus. There were no significant differences for medical comorbidities between outpatients and inpatients. The Charlson comorbidity index for outpatients with delayed healing was higher than that for those without delayed healing. The Charlson comorbidity index was associated with delayed healing of outpatients, but age or total burn surface area were not. Conclusions: The characteristics of geriatric burn outpatients were distinct from those of inpatients. The weighted sum of preexisting medical comorbidities may affect wound healing among geriatric burn outpatients.

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Epineural Sheath Jacket as a New Surgical Technique for Neuroma Prevention in the Rat Sciatic Nerve Model

Background: Terminal neuromas resulting from severe nerve injuries and traumatic or surgical limb amputations can become a source of pain, and significantly impair patients' quality of life. Recently, the number of patients with peripheral nerve injuries increased due to modern war conflicts, natural disasters, and traffic accidents. This study investigated the efficacy of the epineural sheath jacket (ESJ) as a novel technique for neuroma prevention in the rat sciatic nerve model. Methods: A 20-mm segment of the right sciatic nerve was excised in 18 Lewis rats, and the animals were divided into 3 experimental groups (n = 6/group): group I—control, nerve stump without protection; group II—muscle burying group, nerve stump buried in the muscle; group III—ESJ group, nerve stump protected by ESJ. The ESJ was created from the excised sciatic nerve and applied as a "cap" over the proximal nerve stump. The presence of neuropathic pain was assessed weekly by pinprick test and Tinel sign, up to 24 weeks postsurgery. At 24 weeks, assessments, such as macroscopic evaluation, retrograde neuronal labeling analysis, histomorphometry, and neural/connective tissue ratio were performed. Results: Epineural sheath jacket significantly reduced neuroma formation, which was associated with decreased Tinel sign (16.7%, P

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The Crisis of Deficiency in Emergency Coverage for Hand and Facial Trauma: Exploring the Discrepancy Between Availability of Elective and Emergency Surgical Coverage

Introduction: Injuries are one of the most common reasons for emergency department visits, with approximately 40.2 million injury-related visits occurring in 2011. Facial, hand, and wrist injuries make up a large portion of these visits. Despite the high demand for specialists to attend to these injury-related emergency department visits, recent studies have suggested a discrepancy between elective surgical coverage and trauma care in general. The goal of this study was to determine if there was a difference between access to elective surgical procedures in comparison with on-call emergency care for facial and hand/wrist conditions in New York State. Methods: Hospitals throughout New York State, excluding New York City, were selected from the Department of Health Web site, hospitals.nyhealth.gov. A phone survey was administered between May 2012 and October 2013, to quantify the availability of elective and emergent procedures for facial and hand/wrist conditions. We compared the availability of emergency facial and hand/wrist surgical care based on hospital characteristics such as bed size and access to a surgical intensive care unit. Results: We selected 113 hospitals, and 52 hospitals participated for a response rate of 46%. A total of 88% of hospitals offered elective hand procedures, but only 27% had consistent coverage for emergency hand trauma. Furthermore, only 29 % of hospitals had a facial specialist consistently available whereas the availability for elective facial procedures was 79%. Conclusion: Our study results show a discrepancy between the availability of surgeons for elective procedures and on-call emergency care for facial and hand/wrist condition.

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Localized Arm Volume Index: A New Method for Body Type–Corrected Evaluation of Localized Arm Lymphedematous Volume Change

Background: Volume measurement is a common evaluation for upper extremity lymphedema. However, volume comparison between different patients with different body types may be inappropriate, and it is difficult to evaluate localized limb volume change using arm volume. Methods: Localized arm volumes (Vk, k = 1–5) and localized arm volume indices (LAVIk) at 5 points (1, upper arm; 2, elbow; 3, forearm; 4, wrist; 5, hand) of 106 arms of 53 examinees with no arm edema were calculated based on physical measurements (arm circumferences and lengths and body mass index [BMI]). Interrater and intrarater reliabilities of LAVIk were assessed, and Vk and LAVIk were compared between lower BMI (BMI, 0.98). Between lower and higher BMI groups, significant differences were observed in all Vk (V1 [P = 6.8 × 10−18], V2 [P = 3.1 × 10−13], V3 [P = 1.1 × 10−12], V4 [P = 8.3 × 10−12], and V5 [P = 3.0 × 10−14]). Regarding localized arm volume index (LAVI) between groups, significant differences were seen in LAVI1 (P = 9.7 × 10−6) and LAVI5 (P = 1.2 × 10−5); there was no significant difference in LAVI2 (P = 0.60), LAVI3 (P = 0.61), or LAVI4 (P = 0.22). Conclusions: Localized arm volume index is a convenient and highly reproducible method for evaluation of localized arm volume change, which is less affected by body physique compared with arm volumetry.

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Double Composite Tissue Z-plasty Technique for Anatomical Restoration of Severe Nasal Deformity in Secondary Unilateral Cleft Lip

Background: Patients with secondary unilateral cleft lip are regularly affected by serious nasal deformities especially of the alar and nasal floor. A large number of techniques for correction have been published, but symmetrical restoration of severe nasal deformation is difficult to achieve. We propose an innovative approach for anatomical restoration for this entity of nasal deformities to achieve long-term symmetrical appearance and muscular function. Methods: A total of 68 patients with severe nasal deformity due to secondary unilateral cleft lip underwent reconstructive surgery using a double composite tissue Z-plasty technique for anatomical restoration of cartilage, muscle, and soft tissue layers. Patient pictures were taken preoperatively and postoperatively to evaluate appearance and incisional wound healing. The surgical outcome was assessed based on a postoperative patient satisfaction survey. All occurring adverse effects were recorded. Results: All patients were followed up for at least 7 months up to 8 years; mean follow-up period was 14.6 months. Patients were highly satisfied with the aesthetic result and improved facial profile (97.1%) and healing of the incision site (94.1%). There were 4 cases of implant deviation and 2 cases of impaired ventilation due to hypertrophic scarring of the upper lip (2 patients) and relatively decreased nostril size after augmentation rhinoplasty (1 patient), respectively, requiring surgical revision 1 year postoperatively. No other complications such as bleeding, infection, flap necrosis, and sensory dysfunction were recorded. Conclusions: The double composite tissue Z-plasty technique allows for thorough anatomical restoration of cartilage, muscle, and skin layers in unilateral cleft lip nasal deformities. This single-step approach is a safe and technically easy therapeutic option that is associated with high patient satisfaction and acceptance.

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Comparison of Negative Pressure Wound Therapy and Conventional Therapy for Cranial Bone-exposed Wounds in Rabbits

Background: Bone-exposed wounds with intact or defected periosteum are difficult to heal. To provide relevant experimental evidence for guidance of clinical therapy, we established a rabbit model to compare the efficacies of negative pressure wound therapy (NPWT) and conventional guaze dressing therapy on the healing of cranial bone-exposed wounds. Methods: Full-thickness excisional circular wounds of 2.0 cm in diameter with exposed bones covered with or without periosteum were created at the parietal regions in 88 rabbits that were further randomly divided into the following treatment groups: periosteum-intact wounds treated with conventional vaseline gauze dressings (P + Control group), periosteum-intact wounds treated with NPWT (P + NPWT group), periosteum-lacking wounds treated with conventional vaseline gauze dressings (P-Control group), and periosteum-lacking wounds treated with NPWT (P-NPWT group). The wounds of NPWT groups were treated using a negative pressure therapy assembly that was set at a continuous pressure of −125 mm Hg for 7 days, then covered with vaseline gauze. The wound healing rates, wound infection rates, hydroxyproline content, and wound tissue histology were determined and evaluated. Results: The NPWT shortened the wound healing time by approximately 5 days when compared with the conventional gauze therapy. The histological characterization of wound tissues showed that NPWT decreased the inflammatory cells infiltration, accelerated reepithelialization and facilitated the organization of collagen fibers into neat layers on postoperative day (POD) 10. The NPWT enhanced bacterial clearances, reduced infection rates and increased the hydroxyproline contents in both types of wounds on PODs 10 and 15. The immunohistochemical staining of CD31 showed the NPWT treatment resulted in a significantly increased and persistent angiogenesis, and the wounds treated with NPWT showed well developed and more functional vessels at POD 7 compared with control. Conclusions: The NPWT is a more effective therapy for bone-exposed wounds than conventional guaze dressing therapy. The NPWT can promote bone-exposed wounds healing by increasing collagen contents and vessels densities while reducing inflammatory cells infiltration, reducing wound infection rates, and inducing an ordered collagen arrangement.

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Anatomical Reconstruction of the Nasal Floor in Complete Unilateral Cleft Lip Repair

Background: Numerous methods exist for repairing unilateral cleft lips and mainly focus on cutaneous design to achieve sufficient rotation of the medial (M) cleft lip and produce a natural Cupid's bow and philtrum. However, precise nasal floor reconstruction has not been described in detail. This is the first study to introduce a technique for repairing complete unilateral cleft lips with a focus on nasal floor reconstruction. Methods: In our technique, "Straight-Line Advanced Release Technique (StART)," the nasal floor is considered a 3-dimensional cuboid structure; the M mucosal and lateral (L) mucosal flaps constituted the posterior surface. The M flap became the roof of the orbicularis oris muscle sling and the posterior side of the nasal lining. The B flap met the L lip flap at the superior border of the M flap, and together they formed the roof and anterior surface. The B flap also formed a transitional zone connecting the columella and nasal floor. Results: Seventy-two patients with complete unilateral cleft lip were treated from 2003 to 2015. The difference in the height of the nostril sills between the cleft and non-cleft sides was not significantly different from that in control patients (P = 0.472) 1 year postoperatively. Twenty operations for secondary deformities were performed: 8 for nose deformities not involving the nasal floor. The transverse scar at the alar base was concealed within the nostril. Conclusions: Nasal floor reconstruction is important in complete unilateral cleft lip repair. Our technique provides a naturally shaped, symmetrical nasal floor without conspicuous scarring.

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Vascular Endothelial Growth Factor Induction of Muscle-Derived Stem Cells Enhances Vascular Phenotype While Preserving Myogenic Potential

Background: Previous work by our group and other laboratories have revealed that muscle-derived stem cells (MDSCs) may contain both myogenic and endothelial progenitors, making MDSCs a promising option for skeletal muscle regeneration. The purpose of this study was to investigate the impact of vascular endothelial growth factor (VEGF) induction on the vascular and myogenic potential of MDSCs. Methods: Muscle-derived stem cells were isolated from 4- to 8-week-old C57BL/6J mice using a preplate technique and recombinant human VEGFa was used as the induction agent. Cellular proliferation and migration were assessed using serial imaging and wound healing assays, respectively. Myosin heavy chain staining was performed to assess MDSC myotube formation. Vascular potential of MDSCs was measured by expression of CD31 and in vitro capillary tube formation. Results: Vascular endothelial growth factor stimulation led to a dose-dependent increase in MDSC proliferation (P

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The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity

Background: Small (

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Telemedicine: From Microsurgery and Free Flaps to Total Body Skin Examination

No abstract available

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