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Purpose: Epidermoid cysts are common benign skin neoplasms derived from the pilosebaceous apparatus that usually develop in hair-bearing regions such as the head and neck. Epidermal cysts rarely occur in the extremities, especially in the palmoplantar region. Therefore, they can be easily misdiagnosed as warts or calluses. Here, we present our experience treating epidermal cysts in the extremities, including a very rare case of malignant transformation into squamous cell carcinoma. Methods: This retrospective study enrolled all patients who underwent excision of epidermoid cysts in the upper and lower extremities from March 2006 to April 2021.Results: Among 249 patients, there were 10 (seven male and three female patients) who had epidermal cysts in the extremities (4.0%). All four plantar cysts were located in weight-bearing areas. One palmar epidermal cyst occurred 33 years after the trauma. There was one case of a highly recurrent epidermal cyst on the heel that was eventually diagnosed as squamous cell carcinoma arising from the cyst lining on excisional biopsy. After wide excision with a margin of 2 cm, the resulting defect was reconstructed using a free thoracodorsal artery perforator flap. Conclusion: Epidermoid cysts in the extremities, especially the palmoplantar region, are rare. Detailed history taking, including underlying diseases and trauma history, is helpful for diagnosis. Complete excision is necessary to avoid relapse and to confirm the final diagnosis, especially in cases suspected of malignant transformation arising from epidermoid cysts.

Background: Stromal vascular fraction (SVF), which plays a substantial role in wound healing, has been discussed in many recent studies concerning its positive effect on scar formation. Our study explored the effects of SVF on scar formation from partially-removed transverse rectus abdominis muscle (TRAM) flaps after inset.Methods: From December 2017 to May 2020, we enrolled 11 patients undergoing breast reconstruction performed by a single surgeon using the free TRAM flap. As a split-body, placebo-controlled study, SVF was subcutaneously injected into one side of the abdomen, and normal saline was injected into the other side of each patient. Scarring was evaluated using the Vancouver Scar Scale (VSS) and Patient Scar Assessment Questionnaire (PSAQ) at 1, 6, and 12 months after surgery, and histology was evaluated with immunofluorescence analysis at 6 months after surgery.Results: No statistically significant differences were noted in the total scores or subcategory score of the VSS and PSAQ between the test and control groups. Some patients showed more positive staining for alpha smooth muscle actin, collagen type I, and type III in the test group than in the control group. However, quantification of positively stained areas showed no statistically significant difference.Conclusion: Intraoperative SVF injection had no demonstrable clinical effect on scar quality. Histology with immunofluorescence analysis also failed to demonstrate any significant effect of SVF on scars at the microscopic level. Despite previous studies indicating the positive effects of SVF on scar quality, this pilot study questions its true effectiveness.

Background: In advanced breast cancer, reconstruction can be performed depending on the patient’s situation, and can improve the subsequent treatment and quality of life. We examined the effect of reconstruction after palliative mastectomy on survival and quality of life.Methods: Between April 2010 and April 2021, 40 patients underwent reconstruction after palliative mastectomy for stage-IV breast cancer. To evaluate postoperative satisfaction, changes in the global health and quality-of-life scores after reconstruction were evaluated using questionnaires by the European Organisation for Research and Treatment of Cancer. The survival rate according to reconstructive surgery was estimated by the Kaplan-Meier survival analysis.Results: Reconstruction methods included free transverse rectus abdominis musculocutaneous (TRAM) flap (n=3), pedicled latissimus dorsi (LD) flap (n=3), pedicled TRAM flap (n=2), pedicled LD with pedicled vertical rectus abdominis musculocutaneous flap (n=1), tissue expander insertion (n=3), and split-thickness skin graft (n=28). There were no major complications or decreased life expectancy due to reconstruction. All patients healed well and started conventional chemoradiotherapy at 31.3 days postoperatively. The quality-of-life scores increased from 37 to 83 after reconstruction. There was no difference in the survival rates between those who underwent reconstruction with split-thickness skin graft and flap operation (P>0.05). The mean survival time postoperatively was 43.9 months.Conclusion: Compared to primary closure, reconstruction of extensive soft-tissue defects after palliative mastectomy did not affect life expectancy or delay postoperative chemoradiotherapy; it led to an improved quality of life. Therefore, the extensive defects expected after palliative mastectomy should not influence indications for reconstruction surgery.

Background Mastectomy in patients with breast cancer causes spinal deformities. We evaluated the effect of delayed breast reconstruction in post-mastectomy patients on spine alignments. Methods The study included 68 patients who underwent delayed breast reconstruction by three plastic surgeons in a single tertiary hospital. We measured proximal thoracic (PT), main thoracic (MT), and thoracolumbar (TL) Cobb angles and coronal spinal balance from chest or whole spine radiographs. Results The median changes in the PT and MT Cobb angles were -0.33 and -0.34 degrees, respectively. The change in TL Cobb angle and coronal spinal balance were only measured in 29 patients with available spine radiographs. The median change in TL Cobb angle and coronal spinal balance were -0.69 degrees and 3.75 mm, respectively. The median preoperative and postoperative PT Cobb angles were 1.75 and 1.24 degrees. The difference between preoperative and postoperative PT Cobb angles was statistically insignificant (P=0.036). The median preoperative and postoperative MT Cobb angles were 1.32 and 1.09 degrees, respectively. The difference between preoperative and postoperative MT Cobb angles was statistically insignificant (P=0.221). Conclusions Delayed breast reconstruction did not result in clinically significant improvement in mastectomy-induced spinal deformity. This finding should be considered when choosing between immediate and delayed breast reconstruction.

Background The use of acellular dermal matrix (ADM) has been popularized in implant-based breast reconstruction (IBR). However, it is still controversial if ADM-associated complication rates differ with varying types of ADM products. The aim of this study was to compare postoperative complications between CGCRYODERM and DermACELL. Methods A retrospective chart review was performed on 32 patients (64 breasts) who underwent bilateral prosthetic breast reconstruction between June 2015 and December 2019. All patients received two different ADMs in each breast during the surgery. Demographic variables, operative characteristics, and postoperative outcomes were compared between the cryopreserved and pre-hydrated ADM. Results The overall major and minor postoperative complications developed in 7 and 1 out of 32 patients, respectively. Seroma and infection were the most common complications. There were no cases that infection and/or seroma involved both breasts in one individual. No significant differences were observed in terms of seroma, infection, hematoma, mastectomy flap necrosis, or drainage period between the CGCRYODERM and DermACELL groups (P=0.5637, 0.1797, 1.0000, 0.3173, and 0.2925, respectively). There was no case of reconstruction failure leading to explantation. Conclusions There were no statistically significant differences in postoperative complications between the two breasts reconstructed with CGCRYODERM and DermACELL in the same patient who underwent bilateral IBR. This is the first study to compare cryopreserved and pre-hydrated ADMs. We suggest that CGCRYODERM is a suitable option with a comparable safety profile for IBR.

Free muscle transfer for facial reanimation requires the sacrifice of motor nerves and muscles, which inevitably leads to donor site morbidity. To overcome this, the authors performed the interfascicular nerve splitting technique during neurovascular latissimus dorsi flap harvest. The aim of this study was to examine the efficacy of our interfascicular nerve splitting technique through the evaluation of donor site morbidity. Records of patients who underwent free latissimus dorsi flap using interfascicular nerve splitting technique between 2012 and 2016 were reviewed. Postoperative donor site morbidity was evaluated using electromyography, nerve conduction studies, and the Quick-Disabilities of Arm, Shoulder, and Hand questionnaire (QuickDASH). A total of 13 patients were analysed. Grades from electromyography and nerve conduction study were not significantly different between donor site and contralateral side (0.42±0.51 and 0.08±0.28, respectively, p = .073). QuickDASH scores showed different results over time. Preoperative QuickDASH scores averaged 1.57±2.34. At postoperative 6 months, the average QuickDASH score was 8.74±4.62, which was significantly different from the preoperative average (p = .001). At postoperative 12 months, QuickDASH scores averaged 2.62±3.19, which was an improvement from the postoperative 6-month score. However, it was not significantly different from the preoperative score (p = .059). The present study showed that interfascicular nerve splitting could minimize donor site morbidity. Also, our results suggest that the split nerve can function as a donor nerve. Our novel method could be a valuable option for minimizing donor site morbidity during facial reanimation surgery.

This study aimed to assess the effectiveness and safety of BellaGel implants after implantation in Asian women and inform surgeons of another option for use in breast augmentation and reconstruction. This study was conducted in eight hospitals from November 27, 2015 to April 30, 2018. All patients underwent augmentation mammoplasty or implant-based breast reconstruction with BellaGel implants. Complication rates were compared between groups, and the cumulative hazard function was compared using the Kaplan-Meier survival analysis. Implants were grouped by surface type, and the cumulative hazard functions of total complication cases were compared. The biomechanical properties of the BellaGel implant and other company representative implants were tested using a mechanical testing machine, and surface topography was analyzed using a 3D laser scanning confocal microscope. There was a significant difference in the incidence of complications between the reconstruction (17.1%) and augmentation (4.7%) groups, but no significant difference in the complication rates of each group. There was no difference in the reoperation or revision rates between the groups. The log rank test showed a statistically significant difference in cumulative hazard function between the groups. Among the three types of implants (smooth, textured, and microtextured), the microtextured type had the lowest complication rate. The BellaGel microtexture implant had the highest maximal tensile load and displacement value. The BellaGel and Silksurface implants had the highest stored energy, although there was no significant difference. BellaGel implants can serve as a criterion for the selection of safe and effective implants among currently available implants.

Background The viable zone where adipocytes and/or adipose-derived stem cells survive is present at the surface of graft fat tissue; however, there is controversy regarding the zone thickness. Graft retention could be improved if more adipocytes are included in the zone. Objectives We hypothesize that a temporary reduction in adipocyte size prior to grafting could increase the number of adipocytes in the viable zone. We reduced the adipocyte size by treatment with MLN4924, which controls lipid accumulation in adipocytes, and investigated the histological and microenvironmental changes in grafted fat. Methods Subcutaneous fat harvested from wild-type C57BL/6J mice was chopped into small pieces; treated with dimethyl sulfoxide (control group), 0.25 μM MLN4924, or 0.5 μM MLN4924 for 4 days; and grafted into recipient C57BL/6J mice at the supraperiosteal plane of the skull. Results The reduced adipocyte size in response to MLN4924 treatment was restored within 8 weeks after fat grafting. The MLN4924-treated groups exhibited substantially greater graft volume, lower tissue hypoxia, and higher production of M2 macrophages compared with the control group. Conclusions Grafting with compact fat that had smaller adipocytes improved the microenvironment by modulating tissue hypoxia and macrophage polarization, leading to improved graft retention. Therefore, compact fat grafting may offer a new clinical strategy without the need for stem cell manipulation.

The technology of manufacturing hyaluronic acid (HA) fillers is evolving to increase their safety and durability. This study aimed to compare the volume maintenance effect of stromal vascular fraction (SVF) on different types of HA fillers.In this controlled experiment, HA fillers mixed with SVF were injected into the right upper back and HA fillers alone were injected into the left upper back of each mouse. A total of 35 mice were separated into five groups according to the type of commercially used HA filler: Juvederm Voluma XC, Restylane Lyft, Restylane Skinboosters Vital, Giselle Ligne Signature 2, and Giselle Ligne Universal. Nodule size inspection was performed on post-injection days 0, 3, and 56. Ultrasonography for maximal two-dimensional area of filler nodule measurement and histology were performed on the last day of the inspection.While most of the groups showed a volume reduction of over 50% on day 56, regardless of SVF administration, significant volume maintenance was observed when Giselle Ligne Signature 2 was injected with SVF. Ultrasonographic measurement of two-dimensional filler nodule size showed no significant difference regarding filler types and SVF injection. When compared with the histological results of other fillers mixed with SVF, Giselle Ligne Signature 2 showed marked increase in cell survival and extracellular matrix components in HA particles.SVF showed different efficacies in terms of volume maintenance and cell survival for various HA filler types. The SVF mixture in selective HA filler injections may improve maintenance in clinical settings.This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The aim of the study was to analyze the efficacy of retrograde innervation of single-stage free latissimus dorsi (LD) flap for facial reanimation by the distal stump of thoracodorsal nerve (TDN). After the main trunk of TDN was split in half to preserve the function of transverse branch, the proximal stump was coapted with the contralateral facial nerve, and the distal stump was coapted with the ipsilateral masseteric nerve, or vice versa. The length of each nerve stump and the time required for voluntary and spontaneous muscle contraction after surgical treatment were reviewed. Among a total of 30 patients, there was no statistically significant difference in the successful recovery ratio of voluntary smile (antegrade, 86.7%; retrograde, 92.3%; p = 0.323) and of spontaneous smile (antegrade, 61.5%; retrograde, 100.0%; p = 0.079). There was no significant difference in the speed of nerve regeneration of voluntary smile (antegrade, 1.32 cm/month; retrograde, 1.14 cm/month; p = 0.213) and of spontaneous smile (antegrade, 0.91 cm/month; retrograde, 1.09 cm/month, p = 0.120). Within the limitations of the study, it seems that retrograde innervation of neurovascular muscle grafts has the potential to serve as a relevant alternative to other established options of neurovascular muscle transfer, because it provides comparable results in terms of rehabilitation success.

Background:Cell-assisted lipotransfer, a technique involving free fat grafting mixed with adipose-derived stromal cells, has gained popularity for enhancing fat graft retention. In terms of stem cell delivery, intravenous injection can be a novel alternative with clinical value. However, the effects

Purpose We aimed to compare breast-related complications between hypofractionated adjuvant postmastectomy radiation therapy (PMRT) and conventional fractionated radiation therapy (RT) in patients with breast cancer undergoing reconstruction by reconstruction surgery type. Methods and Materials Data from a total of 396 patients with breast cancer who underwent breast reconstruction after mastectomy between 2009 and 2018 were retrospectively reviewed. All patients received adjuvant PMRT according to either a conventional fractionation or hypofractionation schedule. We analyzed breast-related complications according to the timing of breast reconstruction (immediate or delayed). In cases of delayed reconstruction, only PMRT delivered before final delayed reconstruction was included. A major breast complication was defined as a breast-related toxicity that required reoperation or rehospitalization after the end of RT. Results The median follow-up time was 35.3 months (range, 8.8-122.7 months). Of all patients, 267 received immediate breast reconstruction and 129 received delayed breast reconstruction. In patients with immediate breast reconstruction, 91 were treated with conventional RT and 176 received hypofractionated RT. The occurrence of major breast-related complications did not differ significantly between the 2 fractionation regimens. Hypofractionated RT did not increase major wound problems (infection and dehiscence) compared with conventional RT. Furthermore, major contracture occurred significantly less frequently in hypofractionated RT. Of the patients who had delayed breast reconstruction, 48 received conventional RT and 81 received hypofractionated RT. There was no difference in the incidence of major breast complications between these 2 RT groups, and no difference in major breast complications were reported for either 1- or 2-stage delayed reconstruction. A time interval of >10 months between PMRT and final definitive reconstruction had a significantly lower incidence of major breast complications. Conclusions Hypofractionated RT appears to be comparable with conventional fractionated RT in terms of breast-related complications in patients with breast cancer undergoing reconstruction, regardless of breast reconstruction type. An ongoing prospective randomized trial should confirm our findings.

Background Medial epicanthoplasty is a common method for correcting epicanthal folds in Asians but sometimes cause unsatisfactory results. Although several procedural variations have been devised, revision techniques have earned little attention. The revision technique the authors have developed employs reverse Z-plasty to restore an overcorrected epicanthal fold. Objectives The aim of this study was to investigate the effectiveness of the authors’ reverse Z-plasty technique in restoring natural medial canthal region harmonizing with Asian face. Methods From January 2010 to December 2016, reverse Z-plasty was performed in patients seeking revisions after previous medial epicanthoplasties. Patients were surveyed to assess their satisfaction with surgical outcomes. Interepicanthal distance-lengthening ratios and symmetry of palpebral widths were evaluated digitally (ImageJ software) in patients who received revisional epicanthoplasty only. Results The reverse Z-plasty technique for revisional epicanthoplasty was performed in 548 Asian patients (83 males, 460 females). Most patients were pleased with the final outcomes. Only 6% submitted to later revisions of scars, which were otherwise scarcely visible after 3 months. Among 60 patients who underwent only revisional epicanthoplasty, interepicanthal distance-lengthening ratios ranged from 2.9% to 31.1% (average, 8.6%), and palpebral width symmetries improved. Conclusions This particular technique helps restore the 3-dimensional appearance of medial canthal angle through horizontal skin and soft tissue (including muscle and ligament) restructuring, thus compensating for tissue deficiency. It is simple in design, easy to perform, and satisfactory results were achieved, conferring natural aesthetics to the medial canthal region. Level of Evidence: 4

Breast implant-associated ALCL (BIA-ALCL) is an extremely rare type of T-cell lymphoma. According to the American Society of Plastic Surgeons (ASPS), it was first reported in 1997 and 993 cases were reported worldwide by January 2021. Scar capsule is formed around the breast implant, and effusion exists surrounding the implant. BIA-ALCL arises either from the peri-implant capsule or seroma. We tried to understand the pathogenesis of BIA-ALCL by validating the difference in immune response according to implant texture with next generation sequencing (NGS) analysis and identifying the relevant genetic variables. Peri-implant capsule tissues were collected during the implant removal surgery and used for RNA-Seq. Breast implants were inserted for either breast reconstruction or aesthetic purposes. Implant types were grouped following the surface texturing; macrotextured, microtexturedm and smooth. Three macrotextured, four microtextured, and three smooth type samples were used in this study. After aligning the data to the GRCh38 genomic reference with a STAR aligner, the expression level was quantified using RSEM. Differentially expressed gene analysis was performed between groups using DESeq2 based on the obtained TPM values. Gene set enrichment analysis (GSEA) and enrichR were performed to obtain enriched pathways. In addition, the proportion of the cell type of the dataset was calculated using CIBERSORTx.DEG analysis identified a total of 185 up-regulated genes and 81 down-regulated genes between groups (Fold change > 2, fold change < 0.5, Q-value Citation Format: Sanyeowool An, Jeong Hyun Ha, Youngil Koh, Ung Sik Jin, Sung-Soo Yoon. Identification of the pathway of BIA-ALCL by analyzing the difference in immune response according to the texture of the breast implant [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 3360.

Purpose This study investigated whether hypofractionated adjuvant radiotherapy (RT) increased breast-related complication(s) compared to conventional fractionated RT in reconstructed breast cancer patients. Methods We conducted a retrospective review including 349 breast cancer patients who underwent immediate breast reconstruction following mastectomy or breast-conserving surgery (BCS) between 2009 and 2018 at two institutions. All patients were treated with adjuvant RT via either a conventional fractionated or hypofractionated regimen. We defined a major breast complication as a breast-related toxic event requiring re-operation or re-hospitalization during the follow-up period after the end of RT. Results The median follow-up was 32.3 months (4.8–118.5 months); 126 patients had conventional fractionated RT, and 223 patients received hypofractionated RT. In patients with mastectomy, there was no significant difference in the occurrence of any or major breast-related complications between the two fractionation regimens. In patients undergoing BCS, incidence of any breast complication showed no difference between two RT groups and no major breast complication was reported as well. Hypofractionated RT did not increase major wound problem (infection and dehiscence) compared to conventional RT. Incidence of major contracture was significantly lower in hypofractionated RT. Conclusions There was no significant difference in the occurrence of any or major breast-related complications between the two different fractionation regimens, even in patients with mastectomy. Hypofractionated RT may be used comparable to conventional fractionated RT in terms of breast-related complications in reconstructed breast cancer patients. The prospective randomized trial would be necessary to clarify this issue.

The position of the left side liver graft is important, and it could lead to complications of the hepatic vein (HV) and portal vein (PV), especially in a small child using a variant left lateral section (vLLS) graft. The purpose of this study was to evaluate the outcome of a novel technique for the implantation of a vLLS graft to the right side (dextroplantation) in infants. For 3 years, 10 consecutive infants underwent dextroplantation using a vLLS graft (group D). The graft was implanted to the right side of the recipient after 90° counterclockwise rotation; the left HV graft was anastomosed to inferior vena cava using the extended right and middle HV stump, and PV was reconstructed using oblique anastomosis without angulation. Surgical outcomes were compared with the historical control group (n = 17, group C) who underwent conventional liver transplantation using a vLLS during infancy. Group D recipients were smaller than group C (body weight6 kg: 50.0% versus 11.8%; P = 0.03). The rate of graft-to-recipient weight ratio4% was higher in group D (60.0%) than C (11.8%; P = 0.01). Surgical drains were removed earlier in group D than in group C (15 versus 18 postoperative days [PODs]; P = 0.048). Each group had 1 PV complication (10.0% versus 5.9%); no HV complication occurred in group D, but 3 HV complications (17.6%) occurred in group C (P 0.05). Hospital stay was shorter in group D than in group C (20 versus 31 PODs; P = 0.02). Dextroplantation of a vLLS graft, even a large-for-size one, was successful in small infants without compromising venous outcomes, compared with conventional vLLS transplantation. We could remove the surgical drains earlier and reduce hospital stays in cases of dextroplantation.

Background It remains unknown whether perfusion mapping using the SPY system can predict mastectomy skin flap necrosis in each type of breast surgery. We analyzed intraoperative indocyanine green (ICG) angiography images of breast cancer patients who underwent nipple-sparing mastectomy (NSM) with implant-based breast reconstruction, and evaluated the perfusion of the nipple-areolar complex (NAC) with the SPY Elite system to predict NAC necrosis with a single quantitative value. Methods We analyzed nipple perfusion in 30 patients from October 2016 to November 2018. After NSM, ICG injection and SPY angiography were performed to characterize NAC perfusion before immediate reconstruction. The nipple perfusion rate was measured by analyzing fluorescence at the central point of the nipple, and the presence of NAC necrosis was evaluated at 5 days and 1 month postoperatively. Results Three of the 30 patients developed NAC necrosis that secondarily healed within 1 month, and five developed NAC necrosis and underwent surgical debridement within 1 month. Seven of eight patients with a perfusion rate

Background Monitoring free muscle flaps with skin grafts is difficult. To intensify the monitoring process for this type of flap, a small skin paddle was included in the flap and analyzed its effects. Methods A retrospective analysis of all patients who underwent scalp reconstruction with a free latissimus dorsi flap and skin graft between 1994 and 2016 was conducted. Flap monitoring was proceeded using a combination of clinical examination and handheld Doppler for both types of flaps. Results A total of 71 patients were included in this study and were divided into a study group (skin paddle included; n = 30) and a control group (conventional method; n = 41). The time between initial surgery to pedicle exploration was significantly shorter in the study group (11.3 ± 2.5 vs 79.8 ± 42.6 hours; P = .024). The flap salvage rate was significantly higher in the study group (100% vs 16.7%; P = .048). Conclusion The efficacy of flap monitoring and flap salvage outcomes were improved by including a small monitoring skin flap.

Transverse rectus abdominis myocutaneous flap is one of the most commonly used reconstruction tools after oncological mastectomy. However, post-operative donor-site morbidities remain an issue to be addressed. In this study, we retrospectively reviewed patients with either immediate or delayed breast reconstruction using a free muscle-sparing type I transverse rectus abdominis myocutaneous flap only, performed by a single surgeon, regarding the donor-site morbidity. From January 2012 to July 2017, the study subjects summed up to 615 patients, in a single institution. Preoperative planning and actual surgical techniques were outlined including the evaluation of the location of the perforators using a three-dimensional abdominal computed tomography angiography scan, minimal fascia sacrifice, beveled dissection and minimization of the tension on the central abdomen during closure. During a 1-year follow-up, a total of 33 patients (5.4%) were complicated with any donor-site morbidity. Those in need of secondary revision on their donor-sites accounted for 23 patients (69.7%). No factor was found statistically significant to increase the risk of donor-site morbidity. Many surgical techniques have been devised for closure of the donor-site in transverse rectus abdominis myocutaneous flap patients. And, several factors have been proposed as increasing the risk of donor-site morbidity. Although all the suggested predictive factors failed to prove its significance on increasing the risk, a set of preoperative planning and surgical techniques employed in our study has proven to be both safe and efficient in lowering the postoperative donor-site morbidities.

Treacher Collins syndrome is a congenital disorder that is characterized with a wide range of cranio-facial deformities. Zygomatic hypoplasia or aplasia is one of the key features, and surgical reconstruction of the consequent depression on the zygomatic area is deemed necessary by many patients. Various surgical options are available—injectables, alloplastic materials, autologous grafting, and autogenous tissue transfer. It depends on each patient which technique to use. Here, we present a clinical case, in which bilateral free groin flaps were adopted in attempt to resolve the remnant aesthetic deformity associated with zygomatic depression, despite a series of previous surgical efforts, in a 25-year-old Treacher Collins syndrome male patient.

Nipple–areolar complex reconstruction is the final step of the reconstructive procedure in breast cancer patients. Nowadays, a combination of a local flap for nipple reconstruction and skin grafting or tattooing for areola reconstruction is deemed a first choice. In this paper, we are combining the techniques of local flap and full-thickness skin graft from the upper inner thigh for simultaneous reconstruction of the nipple and areola. From January, 2016 to December, 2017, 23 female patients with an absent unilateral nipple–areolar complex due to post-oncological mastectomy and immediate implant-based breast reconstruction were subjects of the study. On an out-patient clinic basis, the percentage of the nipple projection loss was calculated at the intervals of 3 , 6 and 12 months postoperatively. At the final visit, the patient’s subjective satisfaction on the reconstructed areola compared to the normal contralateral side was evaluated using a visual analogue scale. Over the course of time, the mean nipple projection loss was 20.16 ± 12.88, 31.78 ± 11.63 and 34.69 ± 12.01% at 3 , 6 and 12 months postoperatively, respectively. Patients’ overall satisfaction on the grafted areola was as follows; the largest number of patients (8 patients) had a ‘good’ satisfaction 12-months postoperatively. Out of 21 patients, those who considered the result to be ‘poor’ and ‘disappointing’ each accounted for 1 and 3 patients. The combination of nipple–areolar complex reconstruction technique introduced in this study has proven to be a safe and efficacious alternative in patients with implant-based reconstruction requiring small- to medium-sized nipple projection, especially when the skin envelope is too tight for a local flap only. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

PURPOSE/OBJECTIVE(S) The efficacy and safety of hypofractionated RT has been demonstrated, but little is known about how hypofractionated RT affects breast-related complications after breast reconstruction. This study investigated whether hypofractionated adjuvant radiotherapy (RT) increased breast-related complication(s) compared to conventional RT in reconstructed breast cancer patients. MATERIALS/METHODS We analyzed breast-related complications of the patients who underwent breast reconstruction following mastectomy or breast-conserving surgery (BCS) between 2009 and 2018 at two institutions. Of all, 349 patients received immediate breast reconstructions and 129 had delayed breast reconstructions. All patients were treated with adjuvant RT using conventional fractionation (1.8-2.0 Gy for 5-7 weeks) or hypofractionation (2.4-3.0 Gy for 4-6 weeks). In case of delayed reconstruction, all patients had received post-mastectomy RT (PMRT) before reconstructive surgery was performed. A major breast complication was defined as a breast-related toxic event requiring re-operation or re-hospitalization during the follow-up period after the end of RT. RESULTS The median follow-up was 32.3 months (4.8-118.5 months) for patients of immediate reconstruction and 43.5 months (6.5-119.7 months) for those of delayed reconstruction. In patients underwent immediate reconstruction following mastectomy, there was no significant difference in the incidence of any (30.1% vs 14.2% at 1 year; P = 0.064) or major breast-related complications (11.2% vs 7.7% at 1 year; P = 0.420) between conventional and hypofractionated RT regimens. In patients who underwent BCS followed by immediate reconstruction, incidence of any breast complication showed no difference between two RT groups (23.5% vs 17.3% at 1 year; P = 0.301) and no major breast complication was reported as well. Hypofractionated RT did not increase major wound problem including infection and dehiscence compared to conventional RT (P = 0.948). The incidence of major contracture was significantly lower in hypofractionated RT in this group of patients (P = 0.033). In patients underwent delayed reconstruction followed by mastectomy, no significant difference was found in the incidence of any (33.7% vs 34.1% at 1 year; P = 0.570) and major breast complications (12.0% vs 20.1% at 1 year; P = 0.623) in conventional versus hypofractionated RT. The two fractionation regimens showed no significant difference in the incidence of major wound problem as well (P = 0.397). The longer interval (> 10 months) between PMRT and the delayed reconstruction (HR, 0.28; P = 0.011) and the less body mass index (< 23) (HR, 0.36; P = 0.016) significantly decreased major breast complications. CONCLUSION Hypofractionated RT did not increased the incidence of any or major breast-related complications compared to conventional fractionation in the breast cancer patients who underwent reconstruction.