• Archives of Plastic Surgery
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• v.49 no.5
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• pp.587-595
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• 2022

Background The incidence of breast animation deformity (BAD) is reported to be substantial after direct-to-implant breast reconstruction with subpectoral implant placement. It has, however, never been examined if BAD can occur following prepectoral implant placement. Our primary aim was to compare the incidence and degree of BAD after direct-to-implant breast reconstruction using either subpectoral or prepectoral implant placement. Secondary aim of this study was to assess and compare the level of pain between sub- and prepectoral reconstructed women. Methods In this randomized controlled trial, patients were allocated to reconstruction by either subpectoral or prepectoral implant placement in accordance with the CONSORT guidelines. The degree of BAD was assessed by the "Nipple, Surrounding skin, Entire breast (NSE)" grading scale 12 months after surgery. The level of postoperative pain was assessed on a numerical pain rating scale. Results We found a significant difference in the degree of BAD favoring patients in the prepectoral group (23.8 vs. 100%, p < 0.0001; mean NSE grading scale score: 0.4 vs. 3.6, p < 0.0001). The subpectoral reconstructed group reported higher levels of pain on the three subsequent days after surgery. No significant difference in pain levels could be found at 3 months postoperatively. Conclusion The incidence and degree of BAD was significantly lower in women reconstructed by prepectoral direct-to-implant breast reconstruction. Unexpectedly, we found mild degrees of BAD in the prepectoral group. When assessing BAD, distortion can be challenging to discern from rippling.

• Archives of Plastic Surgery
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• v.49 no.6
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• pp.710-715
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• 2022

Background The latissimus musculocutaneous flap (LD flap) is a useful option for breast reconstruction following mastectomy. It has the advantage of obtaining sufficient tissue padding and natural shape by using autologous tissue. However, with the emergence of the skin-sparing mastectomy technique and artificial dermis matrix, direct-to-implant (DTI) breast reconstruction has become the first choice of surgery. The purpose of this study was to compare the satisfaction levels of patients who underwent DTI and LD flap with implant using patient-reported Breast-Q results. Methods A retrospective study was performed reviewing the records of 49 women who underwent immediate breast reconstruction with DTI or LD flap with implant and responded to the BREAST-Q questionnaire after the operation. The patient-reported breast-Q results were analyzed and correlated to the demographic information and intraoperative information. Results A total of 26 patients who underwent reconstruction with LD flap with implant and 23 patients with DTI were identified and responded to the questionnaire after an average of 32.3 and 10.4 months postoperation, respectively. According to the patient response to the breast-q values, satisfaction with breast was 60.0 and 57.0 points, psychosocial well-being 61.0 and 60.0 points, and sexual well-being 41.0 and 43.0 points in the two groups. Overall, there was no significant difference in the breastQ score between the two groups. Conclusion Patients who underwent DTI breast reconstruction seemed equally satisfied with the appearance and outcome of their breast reconstruction compared with LD flap with implant. Therefore, it appears that DTI is adequately replacing LD with implant.

• Archives of Plastic Surgery
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• v.32 no.3
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• pp.293-298
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• 2005

Osseointegrated prosthetic auricular reconstruction can be classified as either direct or indirect. In the $Br{\aa}nemark $ system of direct osseointegration, implants are placed into the mastoid process of the temporal bone. In the Epitec system of indirect osseointegration, implants are inserted into a three-dimensional carrier plate that is fixed to the mastoid by means of screws. We experienced forty-four cases using the indirect system and seventeen cases using the direct system. We compared with two systems by complications, such as skin reaction, implant loosening, implant loss. There were no specific differences in the skin reaction around the implants and abutments in relation to age or system used. The degree of skin reaction was different according to the conditions around the implant: in cases of virgin microtia, a skin flap was used to cover the implant, in contrast to grafted skin coverage for failed autogenous reconstruction. In both systems, the skin reaction was more severe and frequent in skin flap than in grafted skin. Loosening of the implant was more frequent in the direct system; however, accidental detachment of the implant from the abutment was more frequent in the indirect system. To reduce complications of skin reaction in osseointegrated prosthetic auricular reconstruction, it is important for soft tissue around implant to immobilize. Therefore, grafted skin is better than skin flap as soft tissue around implant. And immobilization of soft tissue around implant by wound dressing is major facter.

• Archives of Plastic Surgery
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• v.50 no.6
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• pp.541-549
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• 2023

Background Despite its many advantages, prepectoral breast reconstruction also carries the risk of implant rippling. The recent introduction of partial superior implant coverage using a pectoralis muscle slip in prepectoral direct-to-implant (DTI) breast reconstruction has shown the potential to minimize upper pole rippling. The purpose of this study was to identify factors associated with rippling and the effectiveness of our surgical technique. Methods In total, 156 patients (186 breasts) who underwent prepectoral DTI breast reconstruction between August 2019 and March 2021 were identified retrospectively. Patient data were analyzed from medical records. Univariable and multivariable logistic analyses were performed to contextualize the risks associated with rippling deformity relative to demographic characteristics and other clinical factors. Retrospective propensity-matched analysis was performed to identify the relationship between rippling deformity and the reconstruction method. Results Patients with body mass index (BMI; odds ratio [OR], 0.736; p < 0.001), those with a postoperative chemotherapy history (OR, 0.324; p = 0.027) and those who received breast reconstruction via the superior coverage technique (OR, 0.2; p = 0.004), were less likely to develop rippling deformity. The median follow-up period was 64.9 weeks, and there were no significant differences between patients in types of mastectomy, implant, or acellular dermal matrix. Patients who underwent superior coverage technique-based reconstruction showed significantly reduced rippling (OR, 0.083; p = 0.017) Conclusion Patients with higher BMI and prior postoperative chemotherapy were less likely to develop rippling deformity. The superior coverage technique can be effective in minimizing upper pole rippling.

• Archives of Plastic Surgery
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• v.40 no.4
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• pp.374-379
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• 2013

Background To date, various types of acellular dermal matrix (ADM) have been developed for clinical use. AlloDerm is the most familiar type of ADM to most surgeons in breast reconstruction. It is prepared by freeze-drying. CG CryoDerm is the first form of ADM that requires no drying process. Therefore, theoretically, it has a higher degree of preservation of the dermal structures than AlloDerm. We conducted this study to compare the clinical course and postoperative outcomes of patients who underwent direct-to-implant breast reconstructions using AlloDerm and those who did using CG CryoDerm. Methods We performed a retrospective analysis of the medical records in a consecutive series of 50 patients who underwent direct-to-implant breast reconstruction using AlloDerm (n=31) or CryoDerm (n=19). We then compared the clinical course and postoperative outcomes of the two groups based on the overall incidence of complications and the duration of drainage. Results The mean follow-up period was 16 months. There were no significant differences in the overall incidence of complications (seroma, infection, skin flap necrosis, capsular contracture, and implant loss) between the two groups. Nor was there any significant difference in the duration of drainage. Conclusions CG CryoDerm has the merits of short preparation time and easy handling during surgery. Our results indicate that CG CryoDerm might be an alternative allograft material to AlloDerm in direct-to-implant breast reconstruction.

• Archives of Plastic Surgery
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• v.51 no.5
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• pp.466-473
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• 2024

Background Impact of previous radiation therapy and neoadjuvant chemotherapy (NACT) on early complications in direct-to-implant (DTI) breast reconstruction has not been elucidated. This study investigated whether DTI reconstruction is viable in patients with NACT or a history of preoperative chest wall irradiation. Methods Medical records of breast cancer patients who underwent nipple-sparing or skin-sparing mastectomy with DTI breast reconstruction from March 2018 to February 2021, with at least 1 year of follow-up in a single tertiary center, were reviewed. Demographic data, intraoperative details, and postoperative complications, including full-thickness necrosis, infection, and removal, were reviewed. Risk factors suggested by previous literature, including NACT and preoperative chest wall irradiation histories, were reviewed by multivariate analysis. Results A total of 206 breast cancer patients were included, of which, 9 were bilateral, 8 patients (3.9%) had a history of prior chest wall irradiation, and 17 (8.6%) received NACT. From 215 cases, 11 cases (5.1%) required surgical intervention for full-thickness necrosis, while intravenous antibiotics or hospitalization was needed in 11 cases (5.1%), with 14 cases of failure (6.5%) reported. Using multivariable analysis, preoperative irradiation was found to significantly increase the risk of full-thickness skin necrosis (OR = 12.14, p = 0.034), and reconstruction failure (OR = 13.14, p = 0.005). NACT was not a significant risk factor in any of the above complications. Conclusion DTI breast reconstruction is a viable option for patients who have received NACT, although reconstructive options should be carefully explored for patients with a history of breast irradiation.

• Archives of Plastic Surgery
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• v.41 no.5
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• pp.529-534
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• 2014

Background In 2012, a new anatomic breast implant of form-stable silicone gel was introduced onto the Korean market. The intended use of this implant is in the area of aesthetic breast surgery, and many reports are promising. Thus far, however, there have been no reports on the use of this implant for breast reconstruction in Korea. We used this breast implant in breast reconstruction surgery and report our early experience. Methods From November 2012 to April 2013, the Natrelle Style 410 form-stable anatomically shaped cohesive silicone gel-filled breast implant was used in 31 breasts of 30 patients for implant breast reconstruction with an acellular dermal matrix. Patients were treated with skin-sparing mastectomies followed by immediate breast reconstruction. Results The mean breast resection volume was 240 mL (range, 83-540 mL). The mean size of the breast implants was 217 mL (range, 125-395 mL). Breast shape outcomes were considered acceptable. Infection and skin thinning occurred in one patient each, and hematoma and seroma did not occur. Three cases of wound dehiscence occurred, one requiring surgical intervention, while the others healed with conservative treatment in one month. Rippling did not occur. So far, complications such as capsular contracture and malrotation of breast implant have not yet arisen. Conclusions By using anatomic breast implants in breast reconstruction, we achieved satisfactory results with aesthetics better than those obtained with round breast implants. Therefore, we concluded that the anatomical implant is suitable for breast reconstruction.

• Archives of Plastic Surgery
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• v.48 no.5
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• pp.483-493
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• 2021

Background Direct-to-implant (DTI) breast reconstruction after nipple-sparing mastectomy (NSM) with the use of acellular dermal matrix (ADM) provides reliable outcomes; however, the use of ADM is associated with a higher risk of complications. We analyzed our experiences of post-NSM DTI without ADM and identified the predictive factors of adverse surgical outcomes. Methods Patients who underwent NSM and immediate DTI or two-stage tissue expander (TE) breast reconstruction from 2009 to 2020 were enrolled. Predictors of adverse endpoints were analyzed. Results There were 100 DTI and 29 TE reconstructions. The TE group had a higher rate of postmastectomy radiotherapy (31% vs. 11%; P=0.009), larger specimens (317.37±176.42 g vs. 272.08±126.33 g; P=0.047), larger implants (360.84±85.19 g vs. 298.83±81.13 g; P=0.004) and a higher implant/TE exposure ratio (10.3% vs. 1%; P=0.035). In DTI reconstruction, age over 50 years (odds ratio [OR], 5.43; 95% confidence interval [CI], 1.50-19.74; P=0.010) and a larger mastectomy weight (OR, 1.65; 95% CI, 1.08-2.51; P=0.021) were associated with a higher risk of acute complications. Intraoperative radiotherapy for the nipple-areolar complex increased the risk of acute complications (OR, 4.05; 95% CI, 1.07-15.27; P=0.039) and the likelihood of revision surgery (OR, 5.57; 95% CI, 1.25-24.93; P=0.025). Conclusions Immediate DTI breast reconstruction following NSM is feasible in Asian patients with smaller breasts.

• Archives of Plastic Surgery
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• v.46 no.6
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• pp.535-543
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• 2019

Background A high incidence of breast animation deformity (BAD) has been reported following immediate breast reconstruction with subpectorally placed implants. The aim of this study was to assess and compare the incidence of BAD in women who underwent either subpectoral or prepectoral immediate breast reconstruction. Therefore, we developed a grading tool and tested its reproducibility in a clinical setting. Methods Video recordings of 37 women who had undergone unilateral or bilateral immediate breast reconstruction were evaluated by two consultant plastic surgeons. The degree of BAD was assessed by our grading tool, named the Nipple, Surrounding Skin, Entire Breast (NSE) grading scale, which evaluates the degree of tissue distortion in three areas of the breast. Blinded assessments were performed twice by each observer. Results Eighteen patients were reconstructed with subpectoral implant placement and 19 with prepectoral implant placement. Using the NSE grading scale, we found a significant difference in the degree of BAD between the groups, in favor of patients who underwent prepectoral immediate breast reconstruction (0.2 vs. 4, P=0.000). Inter- and intraobserver agreement was moderate (74%) to strong (88%). Conclusions The incidence and severity of BAD was significantly lower in women reconstructed with a prepectorally placed implant than in those who underwent subpectoral immediate breast reconstruction. All patients reconstructed using the subpectoral technique had some degree of BAD. The inter- and intraobserver agreements were high when using the NSE grading scale, suggesting it is an easy-to-use, reproducible scale for assessing BAD in women who undergo immediate breast reconstruction.

• Archives of Plastic Surgery
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• v.45 no.5
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• pp.441-448
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• 2018

Background Previously, surveys have been used to investigate breast reconstruction statistics. Since 2015, breast reconstruction surgery after mastectomy has been covered by the National Health Insurance Service in Korea, and data from breast reconstruction patients are now available from the Health Insurance Review and Assessment Service (HIRA). We investigated statistics in breast reconstruction in Korea through statistics provided by the HIRA Big Data Hub. Methods We investigated the number of cases in mastectomy and breast reconstruction methods from April 1, 2015 to December 31, 2016. Data were furnished by the HIRA Big Data Hub and accessed remotely online. Results were tabulated using SAS Enterprise version 6.1. Results The 31,155 mastectomy cases included 7,088 breast reconstruction cases. Implant-based methods were used in 4,702 cases, and autologous methods in 2,386. The implant-based reconstructions included 1,896 direct-to-implant and 2,806 tissue-expander (2-stage) breast reconstructions. The 2-stage tissue-expander reconstructions included 1,624 expander insertions (first stage) and 1,182 expander-to-permanent-implant exchanges (second stage). Of the autologous breast reconstructions, 705 involved latissimus dorsi muscle flaps, 498 involved pedicled transverse rectus abdominis myocutaneous (TRAM) flaps, and 1,183 involved free-tissue transfer TRAM flaps, including deep inferior epigastric perforator free-tissue transfer flaps. There were 1,707 nipple-areolar complex reconstructions, including 1,565 nipple reconstructions and 142 areola reconstructions. The 1-year mean number of breast reconstructions was 4,050. Conclusions This was the first attempt to evaluate the total number of breast reconstruction procedures using accurate, comprehensive data, and our findings may prove valuable as a foundation for future statistical studies of breast reconstruction procedures in Korea.