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Background Face transplantation has naturally evolved from reconstructive procedures. However, few institutions perform face transplantations, because it is time-consuming and it is necessary to justify non-vital organ transplantation. We investigated the process of organ donation from brain-dead patients and the possibility of incorporating face transplantation into the donation process. Methods A retrospective review was performed of 1,074 brain-dead patients from January 2015 to December 2016 in Korea. We analyzed the time intervals from admission to brain death decisions (first, second, and final), the causes of brain death, and the state of the transplanted organs. Results The patient base (n=1,074) was composed of 747 males and 327 females. The average period between admission to the first brain death decision was 8.5 days (±15.3). The average time intervals between the first brain death decision and medical confirmation using electroencephalography and between the first brain death decision and the final determination of brain death were 16 hours 58 minutes (±14 hours 50 minutes) and 22 hours 57 minutes (±16 hours 16 minutes), respectively. The most common cause of brain death was cerebral hemorrhage/stroke (42.3%), followed by hypoxia (30.1%), and head trauma (25.2%). Conclusions When face transplantation is performed, the transplantation team has 22 hours 57 minutes on average to prepare after the first brain death decision. The cause of brain death was head trauma in approximately one-fourth of cases. Although head trauma does not always imply facial trauma, surgeons should be aware that the facial tissue may be compromised in such cases.

Traditionally, a galeal flap has been used for skull base reconstruction. In addition to the galeal flap, several other flaps, such as the temporalis muscle flap or the free vascularized flap, can be options for skull base reconstruction, and each option has advantages and disadvantages. Certain cases, however, can be challengeable in the application of these flaps. We successfully managed to cover a skull base defect using an extended temporalis flap. Herein, we present the case and introduce this novel method.

For implant-based breast reconstruction, inadequate tissue perfusion may cause devastating complications. Tissue tension by inadequate implant volume may reduce tissue perfusion by stretching and collapsing the capillaries. The SPY system is used to perform intraoperative fluorescence angiography with indocyanine green to assess visually the blood flow and evaluate tissue perfusion. However, there is no report yet about how mastectomy flap perfusion changes with the expander-filling volume. Therefore, to analyse the changes of tissue perfusion of the mastectomy flap according to the tension level, we used the SPY system and adjusted the filling volume of the tissue expander to change the tension on the skin flap. Ten breasts of ten patients who underwent immediate two-stage, implant-based breast reconstructions were included. The expander-filling volume just before mastectomy flap blanching was set as 100%. Based on this, the expander-filling volume was reduced to 50% and increased to 150%. Ingress and egress rates were evaluated using the SPY system at each condition and analysed by a linear mixed model using least square means. The mean ingression rates were 138, 100, and 65%, and the mean egression rates were 145, 100, and 66% at 50, 100, and 150% inflation, respectively. It was objectively proven that tissue perfusion deteriorates as the tension applied on the flap increases. On the basis of this finding, we can control the amount of inflation volume of the expander or remove the skin in the pre-ischaemic condition to reduce complications of implant-based breast reconstruction.

Although there is ample evidence showing that radiation therapy increases the risk of complications of breast reconstruction, the efficacy of human acellular dermal matrix (CGCryoDerm®) in immediate tissue expander breast reconstruction in the setting of postmastectomy radiation therapy has not been fully elucidated. In this study, we report our institutional experience with pertinent refined surgical technique, and determine whether acellular dermal matrices have a protective effect in this increasingly prevalent clinical setting. Twenty-six patients who underwent immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy with at least 2 years of follow-up were retrieved. Fifteen patents were reconstructed with ADM, whereas 11 patients were reconstructed without ADM. The occurrence of complications was assessed according to the reconstruction type (with ADM vs without ADM). Furthermore, in patients reconstructed with ADM (n = 15), immunohistochemistry was performed to analyze the breast capsule with ADM compared with that without ADM in the same patient, according to the expression of alpha-smooth muscle actin (α-SMA). The occurrence of complications was significantly associated with the reconstruction type (with ADM vs. without ADM, p = 0.015). On the basis of the results of α-SMA staining, α-SMA+ myofibroblasts were relatively highly expressed throughout the breast capsule without ADM. On the contrary, α-SMA+ myofibroblasts present at the breast capsule adjacent to the ADM were scarce and irregularly scattered. Use of an acellular dermal matrix may be recommended to patients who are concerned about complications after immediate two-stage breast reconstruction in the setting of postmastectomy radiation therapy.