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Background: In 2021, a meta-analysis showed fat graft retention varied from 26 to 83%. In a retrospective study including patients with Parry-Romberg syndrome, the younger age group had higher satisfaction scores (3.8 vs. 3.0) after fat grafting. Cell-assisted lipotransfer (CAL) could be an alternative to overcome the instability of volume loss; however, no study investigated its effect on old recipients., Methods: In an in vitro study, adipose-derived stromal cells (ASCs) from aged and young (52- and 8-weeks old) DsRed B6 mice were characterized by proliferation rates as percentages of Ki-67-positive cells. 68-week-old wild type B6 mice received 150 µL of green fluorescent protein fat (from 69-week-old B6 mice) mixed with saline, 3 x 105 aged or young DsRed ASCs (N, A, and Y groups, respectively) on the scalp (n = 6/group). After 8 weeks, graft volumes were evaluated using micro-computed tomography. Vessel densities were tracked by percentages of CD31 using immunofluorescence staining., Results: Young ASCs showed higher proliferation than the aged (47.1% and 26.2%, respectively, p < 0.05). The Y group showed the highest graft retention (median: N = 41.0%, A = 52.2%, Y = 65.2%, p < 0.05) and percentage of blood vessels (median: N = 27.7%, A = 43.5%, Y = 54.7%, p < 0.05) among the three groups., Conclusions: CAL is effective with old recipients; higher effect was observed by supplementation with younger ASCs due to higher angiogenesis stimulation. However, this is autologous grafting model, further validation of safety, toxicity, and allogenic grafting is required., Clinical Relevance Statement: The results suggest that it is clinically possible to conduct CAL for old adults using autologous ASCs. However, further validation of using allogenic ASCs from young donors to improve graft retention in old adults is required., Competing Interests: Conflict of interest: No benefits have been or will be received for the publication of this study., (Copyright © 2024 by the American Society of Plastic Surgeons.)

Background: Since nanofat was first introduced by Tonnard in 2013, numerous studies have reported positive findings with its use; however, concerns exist regarding its effects and mechanisms, and the various methods used to generate nanofat also remain unclear. The authors conducted a systematic review to evaluate the efficacy of nanofat grafting alone in plastic and reconstructive surgery., Methods: The MEDLINE, Embase, Cochrane Central, Web of Science, and Scopus databases were searched for studies related to the use of nanofat grafting alone in plastic and reconstructive surgery. Outcomes of interest were all clinical results in humans or animals., Results: Twelve studies were included. No meta-analysis was conducted due to the clinical heterogeneity of the studies. In general, included studies had a low level of evidence. Six studies ( n = 253 patients) showed significant improvements in scar characteristics based on Patient and Observer Scar Assessment Scale, FACE-Q scale, physician assessment, patient satisfaction, and Vancouver Scar Scale scores. Four studies described the benefits of nanofat in skin rejuvenation (wrinkles, fine rhytides, pigmentation, and discoloration) through photographs, questionnaires, and indentation indices. Histologic evaluation illustrated overall increases in skin thickness, collagen, and elastic fibers. Three experimental studies showed the beneficial effects of nanofat on fat grafting, diabetic wound healing, and hair growth, with compelling histological evidence. No severe complication was reported., Conclusions: Nanofat grafting shows potential benefits in scar and antiaging treatments, with conclusive histological evidence. Clinical studies of fat grafting, wound healing, and hair growth should be conducted, based on the results of this systematic review. Nanofat grafting could be a practical and safe procedure., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Cell-assisted lipotransfer, a fat graft mixed with adipose-derived stromal cells, is known to enhance fat graft retention. Previously, the authors showed that intravenous injection of adipose-derived stromal cells can improve the survival of grafted fat. In the present study, the authors investigated the effects of a secondary intravenous injection of adipose-derived stromal cells on fat grafting., Methods: Wild-type C57BL/6J (B6) mice were used as donors for grafted fat and as recipients. Adipose-derived stromal cells were harvested from green fluorescent protein and DsRed B6 mice. The recipient mice were divided into three groups: SI ( n = 10), RI1 ( n = 10), and RI2 ( n = 11). All groups received intravenous injections of green fluorescent protein adipose-derived stromal cells immediately after fat grafting. The RI1 and RI2 groups received repeated intravenous injections of DsRed adipose-derived stromal cells at 1 and 2 weeks, respectively, after fat grafting. The grafted fat volume was measured using micro-computed tomography., Results: Secondarily injected DsRed adipose-derived stromal cells were recruited to the grafted fat and resulted in a higher retention of graft volume and vascular density ( P < 0.05). The stromal-derived factor-1 and C-X-C chemokine receptor type 4 genes related to stem cell homing were highly expressed in the grafted fat and adipose-derived stromal cells ( P < 0.05). The RI2 group showed a higher graft volume and vascular density than the SI and RI1 groups ( P < 0.05)., Conclusions: A secondary intravenous injection of adipose-derived stromal cells at a 2-week interval enhances the effect of adipose-derived stromal cell enrichment in fat grafting. These findings refine clinical protocols and enhance the therapeutic value of cell-assisted lipotransfer., Clinical Relevance Statement: In a modified animal model of cell-assisted lipotransfer, the authors demonstrated that secondary intravenous administration of adipose-derived stromal cells improved retention of grafted fat., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Giant lipomas are rarely found in the head and neck region. A 67-year-old male patient presented with a massive ventral swelling of his neck extending from the lower margin of the mandible to the clavicle. The mass had slowly grown over 20 years without causing any symptoms, except for considerable psychological stress because of the disfiguration of the patient's profile appearance. Contrast magnetic resonance imaging suggested a lipomatous soft tissue lesion. The surgically removed tumor measured 32 × 20 × 4 cm. Surgery was completed without any intraoperative complications or injury to the critical structures of the neck. The patient was satisfied with the cosmetic result of the operation, and histopathological examination confirmed a lipoma.

Background: Cell-assisted lipotransfer is a process in which fat grafting is supplemented with autologous adipose-derived stromal cells. Since the efficacy of the technique was demonstrated, studies have focused on the mechanism by which cell-assisted lipotransfer enhances the rate of graft survival. However, the microenvironmental changes in donor and recipient tissue associated with cell-assisted lipotransfer remain unclear., Methods: The authors introduced an animal model of cell-assisted lipotransfer using two different transgenic reporter mice. Donor fat from green fluorescent protein-expressing C57BL/6J mice and donor adipose-derived stromal cells from DsRed-expressing C57BL/6J mice were co-transplanted into recipient C57BL/6J mice. During adipose remodeling after cell-assisted lipotransfer, the fate of each donor adipocyte and donor adipose-derived stromal cell was traced using immunofluorescent staining with the whole-mount method., Results: Adipose-derived stromal cell supplementation altered inflammation and promoted angiogenesis and subsequent revascularization in recipient tissue. Tracing at postoperative week 4 revealed that surviving donor adipose-derived stromal cells participated in angiogenesis by differentiating into endothelial cells. Moreover, newly differentiated fat from donor adipose-derived stromal cells and recipient tissue integrated with surviving donor fat, leading to improved retention of the graft. Adipose-derived stromal cell supplementation resulted in a quantitative difference in angiogenesis and adipogenesis during adipose remodeling according to the concentration of adipose-derived stromal cells., Conclusions: The authors characterized the dynamic changes occurring in donor adipose-derived stromal cells and fat and recipient tissue by tracing these cellular components following cell-assisted lipotransfer. The authors' findings highlight the therapeutic value of cell-assisted lipotransfer in tissue transplantation.

Background: The reverse sural artery perforator flap has been widely used in reconstruction of the lower extremity. However, along with the high rate of flap necrosis, sural nerve injury is one of the most frequent complications. This cadaveric study investigated a simple sural nerve preservation technique during reverse sural artery perforator flap surgery., Methods: Cadaver dissection was performed on 40 cadaver lower legs, to investigate the pattern of sural nerve distribution. The points where the lateral and medial sural cutaneous nerves penetrate the deep fascia were measured. The converging point of these nerves into the sural nerve was also recorded. Furthermore, the sural nerve was split until no tethering was observed, to simulate the sural nerve-sparing reverse sural artery perforator flap., Results: Twenty-nine legs (72.5 percent) showed the lateral and medial sural cutaneous nerves converging to become the sural nerve (combined pattern); seven (17.5 percent) and four legs (10.0 percent) demonstrated the diminished and parallel types, respectively. The distances between the lateral malleolus and the fascia-penetrating point of the lateral and medial sural cutaneous nerves were 29.9 ± 3.3 cm and 18.8 ± 5.6 cm, respectively. In the combined type, the point of convergence was 13.6 ± 4.2 cm from the lateral malleolus. Nerve splitting was successfully performed in all combined cases, without injuring the nerve fascicles., Conclusions: The medial sural cutaneous nerve enters the deep fascia significantly more distally than does the lateral sural cutaneous nerve. Furthermore, using nerve splitting, the medial sural cutaneous nerve can be kept intact during reverse sural artery perforator flap surgery.

Laparoscopic cholecystectomy (LC) for complicated acute cholecystitis is associated with high rates of complications and conversion to open cholecystectomy. Percutaneous transhepatic gallbladder drainage (PTGBD) is a safe and effective treatment for acute inflammation of the gallbladder. This study was a retrospective analysis of patients who underwent an LC with or without PTGBD for complicated acute cholecystitis at our hospital between January 2002 and January 2007. Patients were classified into 3 groups: group 1, patients who underwent an LC without preoperative PTGBD (n=60); group 2, patients who underwent an early scheduled LC within 7 days of PTGBD (n=35); and group 3, patients in whom the LC was delayed for a mean of 19.9 days (range, 14 to 39 d) after PTGBD (n=38). The conversion rate to open cholecystectomy and the postoperative complication rate were lower in group 3 than in group 1 (P<0.05). Elective delayed LC after PTGBD may lower the conversion and complication rates of patients with complicated acute cholecystitis.

Arteriovenous malformations are high flow lesions that remain a challenge in the field of plastic surgery, interventional radiology, and neurosurgery. This is especially true for large lesions requiring a comprehensive team approach. From March 2001 to August 2004, six patients with arteriovenous malformation having extensive involvement of the skin underwent selective embolization followed by resection and reconstruction with anterolateral thigh perforator flap. The age of patients ranged from 22 to 43 years (average, 29 years); four were male and two were female. The size of the defect ranged from 8 x 10 cm to 12 x 14 cm. During the follow-up period from 3 months to 41 months, two patients required ancillary procedures to improve their aesthetic appearances. All patients achieved acceptable contour, appearance, and sensation without any incidence of recurrences. The anterolateral thigh perforator flap provides a large, thin and sensible flap. The anatomy of the flap is relatively constant and reliable. Despite the extensive involvement of arteriovenous malformation of the face, with selective embolization, maximal resection, and coverage with a well-vascularized tissue, it can be safely removed and successfully reconstructed.

Background: The platysma flap has often been used for reconstructions of the head and neck, but the arterial anatomy of the platysma itself has not been clarified., Methods: The anterolateral neck skin in five sides of four fresh cadavers that had been injected systemically with a lead oxide-gelatin mixture was elevated and divided into three layers: the skin with adipofascial tissue over the platysma, the platysma, and the adipofascial tissue under the platysma. Radiographs were taken of each specimen using the soft x-ray system., Results: The anterolateral neck skin was chiefly supplied by branches of the submental, facial, superior thyroid, transverse cervical, and occipital arteries, and it was found that the vasculature of the arterial branches can be classified into three groups. In all of the groups, the arterial branches penetrated the platysma and did not run long in the platysma layer. The platysma was supplied by only small vessels from the arterial branches. Furthermore, there was little connection between the vascular plexus of the platysma and that of the skin layer with adipofascial tissue above the platysma and the platysma located in the subcutaneous tissue., Conclusions: The platysma flap should be considered fasciocutaneous rather than musculocutaneous. Therefore, the platysma flap should usually be elevated with the deep adipofascial tissue under the platysma. Flap survival is threatened if it is elevated without the adipofascial tissue under the muscle as with a usual musculocutaneous flap.

A significant clinical problem in reconstructive surgery is partial loss of a pedicled flap. To resolve this problem, various methods of vascular augmentation have been developed; "supercharging" is one of those techniques. A new rat flap model was developed for investigation of the supercharging procedure, and the efficacy of the arterial supercharging method was examined. The purpose of this study was to investigate how an arterial supercharging procedure could generate large flap survival areas with different supercharging positions in rats. On the basis of the vascular anatomical features of rats, a circumferential skin flap from the lower abdomen to the back, measuring 4 x 12 cm, was marked. The flap was divided along the dorsal midline. Forty rats were divided into four experimental groups, as follows: group 1 (control), flaps based only on the deep circumflex iliac artery and vein; group 2, flaps supercharged with the ipsilateral superficial inferior epigastric artery; group 3, flaps supercharged with the contralateral superficial inferior epigastric artery; group 4, flaps supercharged with the contralateral deep circumflex iliac artery. On the fourth postoperative day, the flaps were evaluated with measurements of necrosis and survival areas. Microfil (Flow Tech, Inc., Carver, Mass.) was then injected manually throughout the body, and the vascular changes produced by supercharging were angiographically evaluated. Compared with group 1 (control), the flap survival areas were significantly greater in distally supercharged flaps in groups 3 and 4 (mean flap survival, 91.2 +/- 5.2 percent and 90.5 +/- 10.6 percent, respectively; p < 0.001) and in proximally supercharged flaps in group 2 (45.9 +/- 4.1 percent, p < 0.05). Angiographic assessment of the flaps that survived completely revealed marked dilation of the choke veins among the territories and reorientation of dilated veins along the axes of the flaps. This study suggests that distal arterial supercharging (contralateral superficial inferior epigastric artery or contralateral deep circumflex iliac artery) is more effective than proximal arterial supercharging (ipsilateral superficial inferior epigastric artery) in increasing flap survival. Although the rat skin flap may not be analogous to human flaps, distal arterial supercharging might have useful therapeutic potential in increasing flap survival in clinical practice.