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Flap blood glucose (FBG) measurement is proposed as a monitoring technique. A cause of long-lasting fever could be derived from fat necrosis. If the findings of low FBG correlated with fat necrosis, it could predict the poor cosmetic result and a source of fever. However, this correlation remained unsolved. The purpose of this study was to clarify this correlation in breast reconstruction.In the 180 unilateral breast cancer patients (mean age = 49.8 years) performed free abdominal flap, we retrospectively compared the group where fat necrosis occurred with the group where it did not occur (45 patients with fat necrosis vs. 135 patients without). We compared the average of FBG in each postoperative day.The average FBG was significantly lower in patients with fat necrosis in the second postoperative day (115.3 ± 27.3 vs. 126.3 ± 13.7 mg/dl, p = .026) and the third postoperative day (111.1 ± 22.1 vs. 118.8 ± 13.8 mg/dl, p = .036). Mean BMI and inserted total flap weight were significantly higher in patients with the fat necrosis group (24.8 vs. 22.9 kg/mThe possibility of fat necrosis was high for patients with low FBG in the early postoperative day.

BACKGROUND Although rates of microvascular thrombosis following free-flap breast reconstruction are low, debate persists about the optimal methods to restore blood flow and prevent ensuing flap shrinkage or fibrosis. Here we evaluate our management of microvascular compromise, including both a review of our approach for restoring blood flow and addressing the ensuing inflammatory changes following ischemia reperfusion. METHODS We conducted a retrospective review of autologous free tissue transfer breast reconstructions from 1/2010 to 1/2020. Patients who had flaps requiring take-back for salvage were identified. Management of microvascular compromise and ischemia reperfusion injury were recorded. RESULTS Of 2103 flaps were used in the breast reconstructions, 47 flaps required take-back for microvascular compromise (2.2%). Most flaps were either completely salvaged (n = 29, 61.7%) or partially salvaged (n = 5, 10.6%). Thirteen (27.7%) were a total flap loss, for an overall rate of 0.8% (including 3 flaps with no salvage attempt). Management of microvascular compromise most often included revision of the anastomosis (n = 33, 70.2%), thrombectomy (n = 27, 57.4%), tissue plasminogen activator administration (n = 26, 55.3%), and vein grafts (n = 18, 38.3%). Management of ischemia reperfusion included intraoperative steroids (n = 33, 70.2%), postoperative steroids (n = 17, 38.6%), and postoperative therapeutic anticoagulation (n = 27, 61.3%). Of 34 salvaged flaps, 5 (14.7%) had partial flap loss and/or fat necrosis on clinical examination at an average follow-up of 2.7 ± 2.8 years. CONCLUSIONS Salvage of microvascular compromise in autologous breast reconstruction should include restoration of blood flow and management of ischemia reperfusion injury. Attention to both is paramount for successful outcomes.

BACKGROUND Numerous studies have evaluated the effect of post-mastectomy radiotherapy (PMRT) on autologous breast reconstruction, but the variability of PMRT regimens and inadequate controls have made results difficult to interpret. Therefore, in this study, irradiated free-flaps are compared to non-irradiated internal controls in patients who underwent immediate bilateral reconstruction followed by unilateral PMRT to better delineate the effect of PMRT. The role of regional nodal irradiation (RNI) is also specifically assessed. METHODS Appropriate patients were identified through retrospective review. Complications such as fat necrosis, fibrosis, infection, delayed healing, and flap loss, as well as revision surgeries, among the irradiated free-flaps were compared to those on the contralateral non-irradiated side. Additional analyses were performed to evaluate the effect of patient demographics and treatment characteristics, such as RNI, on complications involving the irradiated free-flaps. RESULTS Seventy-three women were included. There was no significant difference between complication rates for the irradiated and non-irradiated free-flaps (39.7% vs. 38.4%, p = .78), although irradiated free-flaps were more likely to have fibrosis (17.0% vs. 0.0%; p

INTRODUCTION Patient selection for autologous tissue transfer for postmastectomy breast reconstruction often utilizes body mass index (BMI) to risk stratify patients, though it only estimates fat content and does not address fat distribution. This study aims to identify a measurement of abdominal subcutaneous fat thickness (ASFT) from preoperative computed tomography (CT) angiography imaging to better predict complications. METHODS A retrospective review of patients who underwent an abdominal microvascular free flap breast reconstruction was performed. The average of the bilateral distances from the lateral border of the rectus abdominus to the most proximal point of the dermis at the L4-L5 space was measured on preoperative imaging to estimate ASFT. This measurement was compared to BMI in regards to correlation with any complication, major or minor complications, and donor or recipient site complications. Statistical analysis utilized point-biserial correlations and multivariable logistic regression analyses. RESULTS Three hundred and nine cases comprising a total of 496 breast reconstructions were identified. BMI did not correlate with any of the grouped complications, while ASFT correlated with occurrence of any complication (p = .003), minor complications (p = .001), and recipient site complications (p = .001). Further analysis revealed ASFT is specifically correlated with fat necrosis (p = .005). In independent multivariable regression models, both BMI (p = .011) and ASFT (p = .001) were significant predictors of fat necrosis. The ASFT model had a BIC of 335.42 compared to the BMI model with a value of 340.89, with smaller numbers representing more predictive models. CONCLUSION Estimation of ASFT is easily performed and is a significantly better predictor of flap fat necrosis than BMI.

INTRODUCTION Venous congestion is the most common vascular complication of the deep inferior epigastric artery perforator (DIEP) flaps. Adding a second venous drainage by anastomosing a flap vein and a recipient vein (super-drainage) is considered the solution of choice. Evidence to support this procedure, had not yet been confirmed by an analysis of the literature. We aimed to provide this evidence. MATERIALS AND METHODS We searched the literature (MedLine, Scopus, EMBASE, Cochrane Library, and Google Scholar), for studies discussing venous congestion and venous super-drainage in DIEP flap for breast reconstruction. Thirteen of the 35 articles compared results between one or two venous anastomoses. Meta-analysis was performed following PRISMA guidelines. Pooled risk ratio (RRs) for congestion, fat necrosis, partial necrosis, and total necrosis with corresponding 95% confidence intervals (CI) were calculated using a fixed-effect model with the Mantel-Haenszel method. The need to return to surgery (95% CI) was estimated with a random effect model using the DerSimonian and Liard method. RESULTS We showed a statistically significant advantage of super-drainage to reduce the venous congestion of the flap (RR: 0.12, 95% CI: 0.04-0.34, p-value

Background Stacked and conjoined free flaps are increasingly utilized in autologous breast reconstruction to augment tissue transfer volume. However, there is a paucity of comparative data on abdominally-based stacked/conjoined versus non-stacked/conjoined flaps. The purpose of this study was to compare ability to match native breast size, complications, recovery, and symmetrizing procedures between these two cohorts in unilateral breast reconstruction. Methods A retrospective review of all stacked (two separate hemiabdominal)/conjoined (bipedicled full abdominal) flaps and non-stacked/conjoined (unipedicled hemiabdominal) flaps in unilateral abdominally-based autologous breast reconstructions was performed from 2011 to 2018. Variables including demographics, operative characteristics, complications, and revisions were compared in 36 stacked/conjoined patients versus 146 non-stacked/conjoined patients. Results The stacked/conjoined cohort had more DIEP flaps (91.7 vs. 65.1%) and the non-stacked/conjoined group more MS-TRAMs (34.2 vs. 6.9%, p = .000). Additionally, non-stacked/conjoined flaps had greater utilization of combined medial and lateral row perforators (p = .000). Mean flap weight was significantly higher than mastectomy weight in stacked/conjoined flaps (+110.7 g) when compared to non-stacked/conjoined flaps (-40.2) (p = .023). Average follow-up was 54.7 ± 27.5 and 54.6 ± 29.3 months, respectively. Stacked/conjoined flaps had lower fat necrosis rates (8.3 vs. 25.4%, p = .039) and had a decreased risk of fat necrosis on multivariable regression analysis (OR 0.278, p = 0.045). There were otherwise no differences in flap, breast, or donor-site complications. Stacked/conjoined flaps also had a lower rate of contralateral breast reduction (p = .041). Conclusion Stacked/conjoined flaps were associated with a lower risk of fat necrosis compared with non-stacked/conjoined flaps and had a lower rate of contralateral symmetrizing reductions in patients undergoing unilateral abdominally-based breast reconstruction.

Background and objectives To report on the outcomes and evolution of an oncoplastic mammaplasty referred to as geometric compensation mammaplasty. Methods Seventy-three patients with malignant tumours were operated on and followed up in five centres in two countries. Preoperative markings were performed using a Wise pattern. The resection of affected skin was geometrically compensated using another area of preserved skin. Results Mean pathological tumour size was 30.42 ± 21.98 mm. Twenty tumours (30.77%) were locally advanced and 15 (20.55%) were multicentric. Twenty-two patients (34.38%) were submitted to neoadjuvant chemotherapy. Cosmetic results were considered good or excellent in 59 cases (80.82%). Margins were positive in two cases (2.74%). Complications were partial wound dehiscence (n = 11; 15.07%), fat necrosis (n = 9; 12.33%), skin necrosis (n = 5; 6.85%), seromas (n = 5; 6.85%), enlarged scars (n = 7; 9.59%) and infection (n = 2; 2.74%). There were three cases of local recurrence (4.29%), two of bone metastasis (2.86%) and three of metachronous contralateral breast cancer (4.35%). No deaths were recorded within a mean follow-up of 35.33 ± 28.21 months. Conclusions The technique allowed breast conservation in situations requiring a large resection of skin in difficult positions, with a high rate of free margins, correction of ptosis, satisfactory symmetry and few complications.

BACKGROUND da Vinci robot-assisted axillary lymph node dissection (dVALND) can be a minimally invasive technique to minimize post-operative complications. OBJECTIVE To explore the clinical efficacy of dVALND in breast cancer (BC) patients for mitigating the postoperative complications than conventional ALND. METHODS Total 60 female patients with BC were admitted to our hospitals since September 2018, and these patients segregated into two groups of 30 patients each. Modified radical mastectomy for BC was performed to the patients in both groups. In Group 1 (control group), ALND was performed using conventional mode of axillary lymph node surgery. In Group 2 (Test group), the dVALND was performed using da Vinci robot-assisted surgery. Wound healing, aesthetic effect and patient's satisfaction were evaluated after conventional method and dVALND. RESULTS Postoperative complications viz., wound infection (1/30 (3.33%), p

Autologous breast reconstructions using deep inferior epigastric perforator (DIEP) flaps create a large incision, presenting an opportunity for surgical site complications. In this pilot study, we aimed to examine outcomes in DIEP donor site incisions managed with standard dressings (control; n = 5) or closed incision negative pressure therapy (ciNPT; n = 5). We observed no significant differences between group age, body mass index, and past medical history. Both treatment groups had a similar duration of hospital stay, the number of blood transfusions, and pain scores on postoperative day 2 (P > .05). There was a trend of higher drainage (P = .251) and shorter time to incision healing (P = .067) in the ciNPT group than the control though the difference was not statistically significant. We did observe a significant improvement in scar pigmentation, vascularity, and pliability at 3, 6, and 12 months post‐surgery in the ciNPT group compared with control (P

BACKGROUND Breast reconstruction by deep inferior epigastric perforator flap (DIEP) involves only little rectus abdominis muscle sacrifice. However, the operative procedure may get complicated. We propose here a novel method involving two adjacent perforators and requiring the addition of only the superficial muscle to the flap. This novel technique, termed "deep muscle sparing transverse rectus abdominis musculocutaneous flap (DMS-TRAM)," was compared to DIEP and MS-TRAM groups. METHODS The subjects were 70 patients. The indication of DMS-TRAM was the distance between two perforators penetrating the deep fascia was

Background Thoracoacromial vein (TAv) is seldomly considered as a secondary outflow recipient option when venous congestion of deep inferior epigastric artery perforator (DIEP) flap is encountered. The purpose of this study was to present a computed tomography (CT)-based anatomy and a method of approaching TAv in performing superdrainage using superficial inferior epigastric vein (SIEV) in DIEP flap breast reconstruction. Methods For CT-based anatomical study, 42 thoracoacromial vessels (TAV) of 21 patients who underwent DIEP flap breast reconstruction were analyzed. From November 2016 to May 2018, pectoralis major (PM) muscle splitting approach to TAv in the first intercostal space was applied to 7 patients who required superdrainage via SIEV. Results TAVs at mid-first intercostal space (ICS) were located 83.5 ± 9.8 mm lateral to the sternal border (H), 41.5 ± 12.9 mm below the clavicle (V), and 11.7 ± 3.2 mm deep to the outer surface of PM muscle (D). Mean oblique distances from TAV to internal mammary vessels in the 2nd and 3rd ICS were 75.7 ± 9.7 mm and 98.2 ± 10.9 mm, respectively. Seven DIEP flaps presenting intraoperative venous congestion were successfully salvaged intraoperatively with superdrainge procedure. TAvs were harvested without cutting the PM muscle in any patient. Their mean size at anastomosis was 1.61 ± 3.2 mm (range, 0.9-2.5 mm). All flaps survived without perfusion-related complications including fat necrosis. Conclusions Harvest of TAv by muscle-splitting approach is an alternative option when additional venous anastomosis using SIEV is mandated for managing venous congestion of DIEP flap.

Subcutaneous fat necrosis of the newborn is an uncommon disorder, and although usually benign, associated hypercalcemia can lead to complications such as failure to thrive and renal failure. Many sources suggest screening for hypercalcemia for 6 months following resolution of skin lesions, but little data are available to support this recommendation. This study examines existing published literature to better guide practitioners regarding screening evaluations of asymptomatic patients with subcutaneous fat necrosis. A systematic review of the literature was conducted using a PubMed English literature search. Data from case reports and case series were collected regarding the presence of hypercalcemia and associated complications, birth history, and age of onset/resolution of skin lesions and laboratory abnormalities. Approximately half (51%) of infants reported had hypercalcemia. Most (77%) developed detectable hypercalcemia within 30 days of skin lesion onset, and 95% developed detectable hypercalcemia within 60 days of skin lesion onset. Hypercalcemia was detected in only 4% of patients > 70 days following onset of skin lesions. Seventy-six percent had resolution of hypercalcemia within 4 weeks of detection. Hypercalcemia was more prevalent in full-term vs pre-term infants (P-value = 0.054), and higher birthweight was significantly associated with an increased risk of developing hypercalcemia (P-value = 0.022). Although gestational age trended toward significance, the only statistically significant clinical feature predicting the development of hypercalcemia was higher birthweight. Current recommendations for laboratory monitoring are not evidence-based, and this study provides interim data to guide practitioners until prospective, randomized controlled trials are conducted.

Background Swellings in the hand and wrist are frequently encountered in clinical practice and fine needle aspiration cytology (FNAC) is used as a primary diagnostic modality in most of them. A wide spectrum of lesions can be encountered at these sites. The aim of this study was to report the prevalence and spectrum of hand and wrist lesions and evaluate the diagnostic role of FNAC. Methods All the patients who presented with palpable lesions in the hand or wrist between January 2011 and July 2016 were reviewed, retrospectively. Results 1312 cases were subjected to FNAC of hand and wrist swellings, of which 1136 (86.6%) cases were satisfactory. Age ranged from 5 months to 90 years with M: F = 0.7:1. 138 (12.1%) were diagnosed as inflammatory lesions, 875 (77.0%) as benign, non-neoplastic (tumor-like) lesions and 123 (10.8%) were neoplastic lesions. The inflammatory lesions included 75 cases of synovitis, 30 cases of tuberculosis, 28 cases of abscess, one case of cysticercosis, two cases of gout, and fat necrosis each. In the benign, non-neoplastic (tumor-like) lesions, the most common lesion was ganglion (775 cases). The neoplastic lesions included 78 benign lesions with the most common being giant cell tumor of tendon sheath (61 cases). There were 40 cases of mesenchymal lesions, four cases of appendageal tumors and one case of malignancy (squamous cell carcinoma). Mesenchymal lesions accounted for 3.5% (40/1136) cases. Conclusion FNAC is very useful and simple investigation for early diagnosis of lesions of hand and wrist. The lesions encountered at these sites most commonly are benign.

OBJECTIVE To assess the short- and long-term thermal impact of subclinical and clinical regimens of a single, non-invasive uniform ultrasound treatment session on subcutaneous adipose tissue (SAT). STUDY DESIGN Prospective, open-label, single-arm, split-side study. METHODS Patients (n = 17) were subjected to uniform ultrasound treatment, delivered in a single session with the SlimME device. The device was set to one of four treatment regimens, which differed in their durations and energy fluences during the raise and maintenance phases. Up to six abdominal regions were treated, with six patients receiving a different treatment on each side of the abdomen. Safety was assessed by measuring skin surface temperature, evaluating expected skin responses immediately and 30 min after treatment and via patient ratings of pain and discomfort. Efficacy of raising and then maintaining SAT temperatures at 48°C, was determined by routinely measuring SAT temperatures during the treatment session and by histological analysis of samples collected 7 (n = 13) or 90 (n = 4) days after treatment. RESULTS Trace to mild erythema was observed in up to 48% of the treated zones, which, in most cases, resolved within 30 minutes. No significant rise in mean skin surface temperature (≤26.5°C) was recorded following any of the four tested regimens. Overall, patients reported tolerability to treatment, with the highest mean pain score registered for the moderate and high intensity regimens (4.4 ± 1.5 and 4.9 ± 1.4, respectively). Mean SAT temperatures did not exceed 48.4 ± 2.5°C and were effectively maintained throughout the maintenance phase of the treatment session. Low-energy fluence led to localized fat coagulative necrotic lesions, surrounded by subacute rim of inflammation, while high-energy fluence induced fat coagulative necrosis alongside granulomatous panniculitis, which resolved within 90 days. CONCLUSION The tested uniform ultrasound regimens elicited SAT temperature elevations, with a subsequent energy-dependent increase in degree of fat necrosis. At the same time, the unique design spared the surrounding tissue from thermal damage and was associated with minimal discomfort. Taken together, the SlimME device constitutes an effective tool for destruction of stubborn hypodermal fat deposits. Lasers Surg. Med. © 2018 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Epipericardial fat necrosis (EFN) is an uncommon self-limiting benign condition that can present with substantial chest pain. We present a case of an otherwise healthy 42-year-old man who presented with severe chest pain in the emergency department. Initial cardiopulmonary workup was unrevealing. Contrast-enhanced thorax CT demonstrated an increased radiolucency and nodularity of anterior pericardial fat consistent with epipericardial fat necrosis. The transthoracic echocardiogram was normal, and cardiac magnetic resonance imaging confirmed the lesion. Combined anti-inflammatory therapy was started with favorable evolution.

This report documents the case of a 64-year-old African-American female with new end-stage renal disease (ESRD), diagnosed with systemic lupus erythematosus (SLE) on renal biopsy and serologies including a positive ANA (>1:2560), positive anti-Sm antibodies, low titer anti-RNP antibodies, high titer anti-Ro antibodies, anti-dsDNA antibodies, lupus anticoagulant, and hypocomplementemia. She was also noted to have tender nodules on the bilateral shins. Excisional biopsy of one of the nodules showed marked fat necrosis with "ghost cells" and patchy basophilic granular debris consistent with pancreatic panniculitis. Further examination for pancreatic pathology showed an elevated lipase of 585 U/L (reference range 8-78 U/L) and amylase of 214 U/L (reference range 25-125 U/L). However, computed tomography imaging showed no evidence of pancreatitis or pancreatic tumors. This is very similar to another case recently reported in the literature. Similarities of these two cases (African-American females with lupus nephritis on dialysis) may represent a particular subset of SLE patients at increased risk for pancreatic panniculitis.

Subcutaneous fat necrosis (SCFN) is an inflammatory disorder of the adipose tissue that commonly presents in neonates as tender subcutaneous nodules on the trunk and extremities with hypercalcemia as a potential complication. We report the case of a 3-month-old female who presented with circular alopecia of the scalp and was found to have histopathologically confirmed SCFN. Recognition of SCFN as a cause for alopecia in young infants may allow prompt screening for hypercalcemia and reduce the risk for associated morbidity and mortality.

Lipodermatosclerosis (LDS) is a well-recognized form of fibrosing panniculitis. Although chronic cases are readily diagnosed, early and evolving lesions may be clinically mistaken for cellulitis and other forms of panniculitis. Most pathologists are familiar with a pseudomembranous type of fat necrosis as a useful feature of chronic LDS. Although nonspecific, this distinctive pattern of fat necrosis helps in supporting a diagnosis of LDS in the appropriate clinical context. The histopathologic features of early and evolving LDS and those involving the dermis are less well documented. We report a case of early LDS showing extensive pseudomembranous changes in the dermis on a superficial skin biopsy where progression to a classic established lesion was documented clinically. We suspect that this previously unreported and unusual finding may be a histopathologic clue for evolving lesions of LDS.

Introduction Suction-assisted lipectomy (SAL) has been considered a relative contraindication for autologous breast reconstruction due to reservations about size and integrity of perforator vessels. Such patients are often not considered ideal candidates for breast reconstruction utilizing deep inferior epigastric perforator (DIEP) and superficial inferior epigastric artery (SIEA) flaps. The aim of this article is to describe our experience with these flaps after SAL. Methods Retrospectively, patient charts from 2005 to 2015 were analyzed and 9 patients (13 flaps) were identified who received breast reconstruction after prior donor-site SAL. Eight patients underwent DIEP and 1 patient an SIEA flap breast reconstruction. The patients' average age was 47.7 (ranging 33-64) years and their BMI 26.0 (ranging 21.1-36.5). Preoperative radiologic studies were obtained for all patients via either Doppler ultrasound or cross-sectional imaging to assess abdominal perforators. Abdominal SAL took place between 2 and 20 years before reconstruction. Results On average, 2.4 (ranging 1-4) perforators with a mean diameter of 0.68 mm (ranging 0.2-2.5 mm) were included per DIEP flap and anastomosed to the internal mammary arteries. Median follow-up period was 1.2 (ranging 0.5-9.6) years without any flap loss, flap necrosis, hematoma, or unplanned reoperation. One breast seroma and one fat necrosis occurred. All patients had a successful reconstruction and finished treatment at our institution. Conclusion Our results show that DIEP and SIEA flaps are safe and effective options for breast reconstruction in patients with previous abdominal SAL. Extensive preoperative patient evaluation and perforator imaging is important in identifying suitable candidates within this patient population.

Background and Objectives Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. Methods A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. Results Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. Conclusions DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.

Epipericardial fat necrosis is a rare cause of chest pain. It presents as pleuritic pain in an otherwise healthy patient. Computed tomography has proved to be the most effective diagnostic imaging technique because of its ability to reveal typical alterations in the cardiophrenic space. As far as we know, sonographic findings concerning this entity have not been reported in the literature. We report 4 cases admitted to our institutional emergency department with chest pain. Among other tests, chest wall sonography was requested in these patients and showed special findings that should be evaluated with chest computed tomography.

Background Non-invasive devices for fat reduction involving high-intensity focused ultrasound (HIFU) are attracting attention. HIFU can deliver energy to the desired depth and can ablate subcutaneous adipose tissue (SAT), but purpura and pain may still limit its use. Objectives The aim of this study was to investigate the effects of a novel HIFU device for fat destruction with a contact cooling system compared to HIFU without contact cooling. Methods A group of three pigs were administered a series of four HIFU treatments with or without contact cooling over a period of 12 weeks. Energy fluence parameters ranged from 60 to 300 J/cm2 . Immediately after the treatment and at 1, 4, and 12 weeks, the tissue was studied by hematoxylin and eosin (H&E), Masson-trichrome, toluidine blue, CD68 staining, and transmission electron microscopy. Three human volunteers also received treatment with this HIFU device with cooling and were evaluated subjectively and objectively by computed tomography (CT). Results HIFU treatment with a contact cooling decreased the skin surface temperature and prevented epidermal damage. Ecchymosis was observed on the non-cooled area immediately after HIFU treatment, but not on the cooled area. Histological analyses on both areas (cooled and non-cooled) revealed disrupted adipocytes in the treatment area immediately, at 1 and 4 weeks following treatment. Lipophagic histiocytic fat necrosis was evident at 4 weeks. Finally, at 12 weeks all inflammation subsided, and the lobules were markedly atrophied with reduced SAT thickness. The human volunteers experienced reduction of a few centimeter-range reduction in waist circumference after 4 weeks and pain was tolerable without bruising. Conclusions HIFU treatment with a cooling system efficiently destroyed adipocytes. This novel HIFU device with an added contact cooling system may provide an effective, safe and less painful treatment as a non-invasive device for fat reduction. Lasers Surg. Med. 48:878-886, 2016. © 2016 Wiley Periodicals, Inc.

Introduction Potential challenges associated with immediate small breast reconstruction include an inadequate size of the donor site, a thinner skin envelope and limited selection of implants. We present immediate postmastectomy reconstruction of small breasts with a laparoscopically harvested pedicled omental flap (LHPOF) in five Korean women. Methods From December 2014 to July 2015, we performed immediate postmastectomy reconstruction with an LHPOF in five breast cancer patients. Data on the patients’ age; body mass index; tumour size; site, type and weight of the mastectomy specimen; operative time; hospital stay; complications; postoperative chemotherapy or radiation therapy; and follow-up duration were reviewed in this retrospective clinical study. Results The mean mastectomy specimen weight was 212 g (range: 104–272 g). The mean operative time was 298 min (range: 240–380 min), and the mean harvesting time was 75 min (range: 65–90 min). There were no flap-related complications such as fat necrosis or flap loss and no donor site-related complications such as bowel dysfunction, an epigastric bulge or hernia during the follow-up period (average: 8.2 months, range: 5–11 months). The cosmetic results were satisfactory. Discussion The LHPOF can be useful for immediate postmastectomy reconstruction of small breasts, because it provides a soft and naturally ptotic appearance of the reconstructed breast (versus implant-based reconstruction) with low donor-site morbidity (versus other autologous tissue reconstruction approaches).

Introduction A novel method of high-volume hydrodissection that provides both subfascial and intramuscular perforator dissection of deep inferior epigastric perforators has been safely demonstrated in animals. This manuscript demonstrates our preliminary results when translating this technique to humans. Methods A retrospective review was performed of all free-flap breast reconstructions utilizing the high-volume hydrodissection technique performed by the senior author (DS) at the University of Florida Medical Center from January 2014 to June 2015. Results Twenty-one patients underwent 31 free-flap breast reconstructions during the study period utilizing the high-volume hydrodissection technique. No patients were lost to follow-up which averaged 8.2 months. Complications included 1 partial flap necrosis (

Background Lipodermatosclerosis (LDS) is a chronic fibrosing panniculitis associated with venous insufficiency. Although LDS is often a clinical diagnosis, it can be confused with other panniculitides. Microscopic examination is therefore essential to support the diagnosis in this condition. Histopathologic changes, however, have not been extensively defined. The purpose of this study was to characterize the histopathologic spectrum of this condition correlated with clinical manifestation. Methods A total of 25 cases were collected retrospectively, and the clinical information and histopathologic findings were reviewed. Results Of 25 patients, the female to male ratio was 4 : 1. The mean age was 54 years (range, 31-74 years). Clinical features were acute in eight (32%), subacute in 12 (48%), and chronic in five (20%). The microscopic study mostly demonstrated vascular stasis changes of varying degrees depending on the age of the lesion. Adipocyte necrosis with thickened septa, extravasation of erythrocytes, and lymphocytic infiltration were major findings in the early lesions. In the chronic lesion, lipomembranous fat necrosis with microcyst formation, vascular stasis changes in subcutaneous tissue, and septal fibrosis were predominant features. Iron deposition or hemosiderin extending to the subcutaneous layer was always seen in all specimens at the subacute and chronic stages. Conclusion The diagnosis of LDS still needs clinicopathologic correlation. The constellation of findings including septal fibrosis, lipomembranous fat necrosis, prominent vascular changes of stasis, and erythrocytic extravasation can be used to define LDS histopathologically. Interestingly, iron deposition in the subcutaneous tissue is a useful finding for this chronic condition.

Background To achieve an unnoticeable postoperative scar in patients with little abdominal skin laxity for breast reconstruction by deep inferior epigastric artery perforator (DIEP) flap, we devised a new design called the low-rise scar DIEP flap; the skin paddle of this flap is located lower with a smaller vertical width, and more adipose tissue is elevated to obtain enough volume. The purpose of this report is to evaluate the utility of the low-rise scar DIEP flap compared with that of the conventionally designed flap. Methods Twelve patients who underwent low-rise scar DIEP flaps (study group) and 11 patients who underwent conventionally-designed DIEP flaps (control group) were included in the present study. The distance from the umbilicus to horizontal scar was divided by the patient's height. The length of the scar was divided by the abdominal circumference. These ratios were compared between groups. Results All flaps survived completely and no recipient site complication was observed, except for one case in the control group with small-range fat necrosis. No donor site complication was observed in either group. The distance ratio was significantly larger in study group (

The aim of this study was to analyze outcomes of patients who had prior abdominal operations and underwent DIEP flap breast reconstruction and to describe technical strategies to insure well-vascularized flap-harvest minimizing abdominal donor-site complications. All patients who underwent DIEP flap breast reconstruction between 2004 and 2014 were reviewed and divided into a control group (CG) and a scar group (SG). Patient demographics, operative details, flap and donor-site complications were analyzed and compared. For all of the scars, DIEP flap design was not modified, but a standardized approach was developed according to the type and location of the scar, available vascular pedicle, perforator locations, and the required flap tissue for breast reconstruction. Two hundred and eighty patients underwent 292 flaps in CG and 107 underwent 111 flaps in SG. Pfannenstiel, McBurney, laparoscopic, midline and subcostal were the most common previous incisions. There were no significant differences between groups regarding demographics, flap and mastectomy weight, active smoking, or radiation status (P > 0.05). No significant differences were observed in DIEP flap loss (P = 0.909), partial flap loss (P=0.799), or fat necrosis (P=0.871) and in the rate of abdominal donor-site complications between groups (P > 0.05). SG had a significantly higher mean operative time than CG (P=0.034). Medial raw was a negative risk-factor for flap complications, while BMI (>25.1 kg/m2 ) and smoking-history were significant predictors for donor-site complications. With careful preoperative planning and appropriate technical strategies, successfully DIEP flap breast reconstruction can be performed without increased flap and donor-site complications in patients with preexisting abdominal scars. © 2015 Wiley Periodicals, Inc. Microsurgery 37:282-292, 2017.

Background Abdominal wall flaps are routinely used in reconstructive procedures. In some patients inadequate venous drainage from the deep vein may cause fat necrosis or flap failure. Occasionally the superficial inferior epigastric vessels (SIEV) are of sufficient size to allow for microvascular revascularization. This study looked at the ratio of the sub- and suprascarpal fat layers, the number of deep system perforators, and SIEV diameter to determine any correlation of the fat topography and SIEV. Methods 50 abdominal/pelvic CT angiograms (100 hemiabdomens) were examined in women aged 34–70 years for number of perforators, SIEV diameter, and fat pad thickness above and below Scarpa's fascia. Data was analyzed using multivariate model. Results The average suprascarpal and subscarpal layers were 18.6 ± 11.5 mm and 6.2 ± 7.2 mm thick, respectively. The average SIEV diameter was 2.06 ± 0.81 mm and the average number of perforators was 2.09 ± 1.03 per hemiabdomen. Hemiabdomens with suprascarpal thickness>23 mm had greater SIEV diameter [2.69 mm vs. 1.8 mm (P 23 mm to aid in superficial drainage. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Background Superdrainage using superficial inferior epigastric vein (SIEV) has been often used to overcome occasional venous insufficiency in deep inferior epigastric perforator (DIEP) flap. However, a consensus regarding its clinical benefits is lacking. The aim of this review was to evaluate the efficacy of superdrainage using SIEV on clinical outcome in DIEP flap breast reconstruction by meta-analytic methodology. Methods Medline, Ovid and Google Scholar were searched to obtain all relevant publications. Pooled risks for perfusion-related complications were compared between the superdrainage group and control group by Mantel–Haenszel test. Results Six studies representing 1,376 cases (842 superdrainage and 534 control group) were enrolled, all of which were retrospective cohort studies. Superdrainage had little influence on the risk of total flap loss (RR: 0.97, 95% CI: 0.36–2.57). There were trends toward decreasing risks of partial flap loss (RR: 0.59, 95% CI; 0.18–1.94) and fat necrosis (RR: 0.87, 95% CI: 0.58–1.30) in the superdrainage group, though they were not significant. The risk of partial flap necrosis in which partial flap loss and fat necrosis were combined, was reduced 20% in the superdrainage group, although statistical significance was not achieved (RR: 0.80, 95% CI: 0.57–1.11). The risk of flap congestion decreased significantly in the superdrainage group (RR: 0.06, 95% CI: 0.01–0.51). Conclusions Although there is obvious benefit of SIEV superdrainage in reducing the risk of flap congestion, evidence supporting its use to prevent flap compromise is still insufficient. Further studies would be required. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Thin women have not traditionally been considered ideal candidates for autologous breast reconstruction. The purpose of this study was to examine the use of deep inferior epigastric perforator (DIEP) flap reconstruction in thin women undergoing immediate unilateral breast reconstruction. A retrospective review of 1,040 consecutive patients was performed. In total, 381 patients met the inclusion criteria. To improve clinical interpretability, patients were divided into three groups based on body mass index: “thin” (BMI ≤ 22.99), “traditional” (>23 and ≤29.99), and “obese” (BMI >30) candidates. Flap characteristics were compared to mastectomy weights, and postoperative complications were analyzed. In all groups, flap size was generally more than sufficient to match the mastectomy specimen, as flap weight:mastectomy weight ratio ws greater than 1 in all groups with no significant difference between groups (1.1 in thin patients, 1.0 in traditional patients, and 1.0 in obese patients). Fat necrosis prevalence was lowest in the thin group (12.5%), compared to the traditional (15.9%, P = 0.443) or obese (14.4%, P = 0.698) groups. Prevalence of breast infection were lower in the thin patients (5.2%) versus the traditional (8.7%, P = 0.287) or obese (14.4%, P = 0.033). Abdominal wound healing complications and seroma were also lowest in thin patients. DIEP flap breast reconstruction may be an effective method for unilateral breast reconstruction in thin patients, with sufficient flap weights and lower incidence of complications than in heavier patients. As such, low BMI may not present a barrier in the reconstruction of a breast mound matching native breast size. © 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

Twenty 10-month-old Japanese Black steers were used to evaluate the effects of clay on fat necrosis and carcass characteristics. Ten steers (Clay group) were fed the clay (50 g/day) during 10-30 months of age. The other 10 steers (Control group) were not fed it. There was no significant difference in body weight or average daily gain between the two groups (P > 0.05). The occurrence of fat necrotic mass in the Clay group (30%) was lower (P < 0.05) than that in the Control group (90%) at slaughter. The size of necrotic masses in the Clay group was smaller (P < 0.05) than that in the Control group. There was no significant difference in the marbling score, beef color, Longissimus muscle area or subcutaneous fat thickness between the two groups. These results suggest that the clay prevented the occurrence of fat necrosis and did not affect the carcass characteristics in Japanese Black steers.

Subcutaneous fat necrosis (SCFN) of the neonate is a rare panniculitis of early life that occurs in association with gestational diabetes and preeclampsia, as well as perinatal asphyxia, hypothermia, and trauma. A characteristic feature of this condition is its self-limiting and monophasic nature. We report a highly unusual case of delayed SCFN in a male neonate involving an anatomically discrete eruption, reminiscent of erythema nodosum, occurring many weeks after his original eruption had resolved.

In 1957, a case of dimpled skin alterations in pigs on a farm was described. The dimpled appearance of the skin was assumed to be due to subcutaneous fat necrosis. Presumably based on that report, the term ‘fat necrosis’ was adopted and used in textbooks where it can be found until today. In the presented case, two five-month-old pigs with multifocal irregular dimpling and cobblestone-like skin changes resembling skin alterations termed ‘subcutaneous fat necrosis’ were investigated. Histology showed that the thickness of the subcutaneous adipose tissue of the dimpled skin area was markedly lower than that of the cobblestone-like area. Biochemical analysis revealed that skin from the cobblestone-like area had a higher proportion of unsaturated fatty acids than the dimpled skin area. The results suggest that the dimpled skin appearance of the pigs examined in this study is due to a lower thickness of the outer backfat layer.

Background and Objectives The effect of postmastectomy radiation therapy (PMRT) on immediately reconstructed abdominal wall-based tissue remains imprecisely defined. We evaluated evidence from all fields involved in care of the breast cancer patient in order to advance a unified recommendation regarding this therapeutic sequence. Methods We performed a MEDLINE and manual reference search to identify studies of PMRT with immediate autologous breast reconstruction. Inclusion criteria required studies to describe patients, flaps, and complication rates. Analyses were based on a random effects model. Surgical and radiation oncology literature was reviewed. Results Eleven retrospective studies of 337 patients with an average follow-up of 18–60 months (out of 268 patients) were selected for inclusion. Overall rates of fat necrosis, revisional surgery, volume loss, and fibrosis/contracture ranged from 16.9% to 35.4%. One out of 260 patients experienced total flap loss. There was an increased probability of fat necrosis in the irradiated breast (OR = 3.13, 95% CI = 1.42–6.89, P = 0.005) among three studies with non-irradiated controls. Five studies evaluated aesthetics with variable outcomes. Conclusions There is mixed evidence for the utility of PMRT with immediate autologous abdominal wall breast reconstruction. Further investigation requires prospective studies with collaboration among surgical oncologists, radiation oncologists, and plastic surgeons. J. Surg. Oncol. 2015 111:251–257. © 2014 Wiley Periodicals, Inc.

Background This study investigated which zonal tissue would be more secure from the risk of fat necrosis between Holm zones II and III and examined the risk factors of fat necrosis in a clinical series of medial row perforator-based deep inferior epigastric artery perforator (DIEP) flaps. Patients and Methods A retrospective chart review was performed for patients undergoing unilateral breast reconstructions with medial row perforator DIEP flaps. Data regarding patients, operation-related characteristics, and complications including fat necrosis were collected. Fat necrosis was mainly diagnosed by ultrasound examination, and its location was also assessed. Results A total of 103 cases were analyzed. Fat necrosis was diagnosed in 13.6% of patients and developed more frequently in zone III (7.8%) than in zone II (4.9%). In risk factor analysis, the inset rate, the weight ratio of the inset flap to harvested flap, was significantly associated with the development of fat necrosis. The flaps with inset rates more than 79% showed 16 times higher risk of fat necrosis than those below 79% in multivariate analysis. The incidence of fat necrosis in zone III was significantly increased in the high inset rate group when compared with the low inset rate group, whereas the incidence in zone II did not change. Conclusions In unilateral breast reconstruction using medial row perforator DIEP flaps, fat necrosis developed more frequently in zone III than in zone II, and this tendency was more prominent in high inset rate group. Not transferring excessive contralateral tissue including lateral zone III tissue might be helpful for reducing the risk of fat necrosis. © 2014 Wiley Periodicals, Inc. Microsurgery 35:272–278, 2015.

Objective:Todescribeatechniqueofoncoplasticmammaplasty,referredtoasgeometriccompensation,whichissuitablefortumorsclosetotheskin in areas not included in the classic preoperative drawings for mammaplasty. Materials and Methods: Seventeen patients with malignant tumors were included. Preoperative markings followed the “Wise‐pattern” technique. The resection of affected skin was geometrically compensated with another area of preserved skin. Results:Themeanageofthepatientswas52.88 � 12.14years.Meanpathologicaltumorsizewas43.82 � 31.39mm.Therewere7(41.18%)locally advanced tumors. Six patients (35.29%) were submitted to neoadjuvant and the remainder to adjuvant chemotherapy. Radiotherapy was indicated in allcases.Fifteenpatients(88.24%)receivedhormonetherapy.Ptosiswascorrectedinallcases.Theaestheticresultwasratedexcellentinsevencases (41.18%), good in 7 (41.18%), and fair in three cases (17.65%). Surgical margins were free. A seroma developed in one case (5.88%), small fat necrosis in three (17.65%), and enlarged scar in one (5.88%). There were no recurrences within 28.24 � 18.02 months. Conclusions: The technique allowed breast conservation in situations requiring large resection of affected skin, with free surgical margins, correction of ptosis, satisfactory symmetry, and few complications. J. Surg. Oncol. . 2014 Wiley Periodicals, Inc.

Early neovascularization is important for autologous fat transplant survival. SVF cells are ideal seed cells. Both vascular endothelial growth factor (VEGF) and SVF cells can promote neovascularization. However, the half-life (about 50 min) of VEGF is too short to sustain an adequate local concentration. We have investigated whether VEGF-polylactic acid (PLA) nano-sustained release microspheres plus SVF cells can improve neovascularization and survival of transplanted fat tissues. SVF cells were harvested and constructed VEGF-PLA nano-sustained release microspheres in vitro. Human fat tissues was mixed with SVF cells plus VEGF-PLA, SVF cells alone or Dulbecco's modified Eagle's medium as the control. These three mixtures were injected into random sites in 18 nude mice. Two months later, the transplants were weighed and examined histologically; and capillaries were counted to quantify neovascularization. Hematoxylin-eosin (HE) and anti-VEGF stains were applied to reveal cell infiltration. The mean wet weight of fat in the SVF plus VEGF-PLA, SVF alone, and control transplants were 0.18 ± 0.013 g, 0.16 ± 0.015 g, and 0.071 ± 0.12 g, respectively; the differences between groups were statistically significant. More vessels were present in the SVF plus VEGF-PLA transplants than in the other two types. Transplants mixed with SVF cells also had an acceptable density of capillaries. Histological analysis revealed that both the SVF plus VEGF-PLA and SVF alone transplants, but not the control transplants, were composed of adipose tissue, and had less fat necrosis and less fibrosis than control specimens. SVF plus VEGF-PLA transplants had significantly greater capillary density and VEGF expression than the other two transplant groups. Thus transplanted fat tissue survival and quality can be enhanced by the addition of VEGF-PLA nano-sustained release microspheres plus SVF cells.