素輪 善弘

Summary: Total breast reconstruction using only a latissimus dorsi flap (LDF) often has a problem of insufficient volume. Recently, a fat-augmented LDF has been introduced as a solution to this problem. However, there are still many cases in which augmentation with fat grafting alone is not enough to achieve symmetrical breasts. Here, we discuss a new approach for full breast reconstruction, which we refer to as tribrid reconstruction, that combines the fat-augmented LDF with a breast implant. Depending on the need for a skin island, the LDF or muscle flap is harvested and augmented with fat grafting, either to the flap itself or by injecting fat into the pectoral muscle or the subcutaneous tissue of the chest. In cases in which this does not correct asymmetry, an implant is added to enhance the breast volume. This 3-component reconstruction method was applied in 9 cases, and all achieved sufficient postoperative volume and satisfactory aesthetic results. This technique can be used in a single surgery to reconstruct both moderately sized and larger breasts.

Background: The pathogenesis of deterministic radiation damage is not clearly understood, but it has been reported that fibroinflammatory pathways are up-regulated. We hypothesized that the number of adipose-derived stem/stromal cells (ASCs) decline after radiotherapies, preventing normalization of fibrosis and angiogenesis, resulting in chronic radiation damages that progress over time. Methods: Dorsal skin of 8-week-old male BALB/cfC3H mice was irradiated with 10 Gy weekly for 4 weeks. At 1, 3, 6, 9, and 12 months after radiotherapy (n = 5, 5, 5, 5, and 4), tissue hemoglobin oxygen saturation, and time until epithelialization were evaluated. Skin biopsies were measured for thickness and CD34⁺/isolectin⁻ stem/stromal cell count. Nonirradiated (NRT) controls were evaluated at each time point as well (n = 5 each). Results: Compared with NRT controls, time until epithelialization was significantly longer at 1 month (28 ± 3, P < 0.01); not statistically different at 3 months (16 ± 2, P = 0.32); and lengthened over time at 6 months (20 ± 2, P = 0.21), 9 months (28 ± 2, P < 0.01), and 12 months (26 ± 3, P < 0.01), as did tissue oxygen saturation. The number of CD34⁺/isolectin^– ASCs decreased over time, at 1 month (5.3 ± 1.3, P = 0.01), 3 months (6.0 ± 1.4, P = 0.03), 6 months (4.0 ± 0.8, P < 0.01), 9 months (1.7 ± 0.5, P < 0.01), and 12 months (0.3 ± 0.5, P < 0.01). The subcutaneous fatty layer was significantly thinner at 3 months (116 ± 33, P < 0.01), 6 months (147 ± 22, P = 0.02), 9 months (52 ± 12, P = 0.04), and 12 months (89 ± 19, P = 0.04), but not at 1 month (141 ± 18, P = 0.43). Conclusions: After 6 months postirradiation, the number of ASCs continued to decline over time, accompanied by irreversible progression of fibrosis, atrophy, and ischemia, which resulted in impaired wound healing.

Background: There are still few studies which have addressed pain management in breast reconstruction in the acute phase. We conducted the current study in Japan to identify the effect of Pectoral Nerve Block Type II (PECS II) and Serratus Plane Block (SPB) for acute postoperative pain after tissue expander (TE) insertion. Methods: Patients who underwent TE reconstruction from January 2016 to April 2017 were divided into groups treated with (LB) and without (Control) nerve block using levobupivacaine. Participants responded a questionnaire about acute postoperative pain for 7 days after operation. Results: A total of 46 women participated in the study. On a visual scale analog (VAS) for pain at rest and during movement, pain intensity was significantly lower in the LB group than in the Control group on postoperative day (POD) 0 (p = 0.04, p < 0.001), POD 1 (both p < 0.001), and POD 2 (p = 0.008, p = 0.03). There was significantly less use of painkillers in the LB group on POD 0 (p = 0.04) and POD 1 (p = 0.02). Conclusions: Combined use of PECS II block and SPB would be effective for managing acute pain in the Japanese population after breast reconstruction using TE insertion. Level of evidence: Level IV, Therapeutic.

Obesity and its related health issues significantly burden public health systems. Brown adipose tissue holds promise for addressing metabolic disorders and balancing the body's energy, making it a key research focus. Stimulating brown adipogenesis from stem cells could advance regenerative medicine and healthcare. In our previous research, we discovered that poly-l-lysine (PLL) significantly stimulates brown adipogenesis in three-dimensional differentiation of dedifferentiated fat cells (DFATs) within fibrin gels. In this study, we evaluated polyelectrolyte (PE) nanofilms made of PLL and dextran sulfate, applied directly to DFAT surfaces to improve brown adipogenic differentiation through an innovative approach. This approach involved coating the DFAT surfaces with PE nanofilms, forming a multilayer structure that not only provided a supportive matrix but also facilitated the adsorption of essential molecules like T3 and insulin for brown adipogenesis. DFATs coated with three PE layers and encapsulated in fibrin gel showed a significant increase in the adipogenic marker UCP1 gene expression and content. This PLL-based PE nanofilm coating on DFAT surfaces can be a novel and crucial technology for promoting brown adipogenesis in regenerative medicine and healthcare.

Background Breast cancer survival rates have increased significantly, underscoring the importance of enhancing long-term health-related quality of life. Breast reconstruction following mastectomy has emerged as a common approach that contributes to improved health-related quality of life. Nonetheless, chronic pain following breast reconstruction is a prevalent issue that has a negative impact on overall well-being. Methods To examine recent findings on chronic pain after breast reconstruction and progress in pain management, we performed a review of the literature through independent searches using the MEDLINE database within NIH National Library of Medicine PubMed. Results The review suggested that autologous reconstruction causes chronic postsurgical pain, especially at specific donor sites, whereas implant-based reconstruction does not seem to increase the risk of chronic pain. Moreover, certain operational and patient factors are also associated with chronic pain. Appropriate pain management can reduce chronic pain and prevent the transition from acute to chronic pain. Conclusion This scoping review evaluated the characteristics of long-term chronic pain after breast reconstruction. The findings provide patients with important treatment information and will assist with their decision on their preferred treatment.

Background: Chronic pain is relatively common after breast cancer surgery, including breast reconstruction. Autologous fat grafting (AFG) has gained attention as a novel method for breast reconstruction, and recent clinical studies have also shown effects of AFG on alleviation of chronic pain after breast cancer surgery. Our objective was to conduct a scoping review of studies that have examined these effects with clearly defined clinical outcomes. Methods: A literature search was conducted using three databases: PubMed, MEDLINE, and Google Scholar, following PRISMA guidelines and the Arkesy and O’Malley framework. The search focused on clinical studies of the effects of AFG on chronic pain after breast cancer surgery. All studies reporting functional outcomes, return to work, and secondary surgery in a repeat operation were identified. Results: Of the 148 studies identified in the search, 11 studies with a total of 684 patients were included in the review. The average volume of fat grafted was approximately 128 mL over an average of 1.6 sessions. The most common time point for assessment was 1 year post-AFG. In all studies with an evidence level of 3 or lower, AFG showed positive results in alleviating pain after breast cancer surgery. However, one of the three randomized controlled trials did not show clinically significant effects. Conclusions: Most of the studies examined in this review suggested pain-relieving effects of AFG. However, there was one randomized controlled trial in which these effects were not confirmed, indicating a need for further accumulation of cases and performance of new, well-designed randomized controlled trials.

Abstract In developing three‐dimensional (3D) human skin equivalents (HSEs), preventing dermis and epidermis layer distortion due to the contraction of hydrogels by fibroblasts is a challenging issue. Previously, a fabrication method of HSEs was tested using a modified solid scaffold or a hydrogel matrix in combination with the natural polymer coated onto the tissue culture surface, but the obtained HSEs exhibited skin layer contraction and loss of the skin integrity and barrier functions. In this study, we investigated the method of HSE fabrication that enhances the stability of the skin model by using surface plasma treatment. The results showed that plasma treatment of the tissue culture surface prevented dermal layer shrinkage of HSEs, in contrast to the HSE fabrication using fibronectin coating. The HSEs from plasma‐treated surface showed significantly higher transepithelial electrical resistance compared to the fibronectin‐coated model. They also expressed markers of epidermal differentiation (keratin 10, keratin 14 and loricrin), epidermal tight junctions (claudin 1 and zonula occludens‐1), and extracellular matrix proteins (collagen IV), and exhibited morphological characteristics of the primary human skins. Taken together, the use of plasma surface treatment significantly improves the stability of 3D HSEs with well‐defined dermis and epidermis layers and enhanced skin integrity and the barrier functions.

Summary: Lymphaticovenous anastomosis (LVA), which involves connecting lymphatic vessels to veins under a microscope, is widely performed around the world as a surgical treatment for lymphedema due to its relatively low patient burden and consistent efficacy. One of the crucial points of LVA is identifying suitable lymphatic vessels from among many lymphatic vessels and connecting them at the most effective site, but in practice, this is not easy to do. To overcome this issue, we have been able to effectively drain lymph by connecting lymphatic vessels to veins just before the occluded site using a lymphatic wire that was just recently developed in Japan. The device guides the subcutaneous deep collecting lymphatic vessels from the peripheral relatively superficial lymphatic vessels. While this special wire is typically adapted in the lower limbs, we have confirmed its effectiveness in upper limb lymphedema as well. Overall, this approach shows promise for improving the accuracy and success rates of LVA procedures, which can have significant benefits for patients with upper limb lymphedema. In this article, we share our experience using lymphatic wire for upper limb lymphedema cases.

Reprogramming of mature adipocytes is an attractive research area due to the plasticity of these cells.

INTRODUCTION: An oronasal fistula is a challenging post-operative complication of palatoplasty due to impaired velopharyngeal function or its high recurrence rate. Muscle repositioning, a key procedure in palatoplasty, causes dead space at the junction between the hard and soft palates. Consequently, thin oral and nasal mucosae are prone to break down and form fistulas. In this study, we used basic fibroblast growth factor-impregnated collagen gelatin sponge (bFGF-CGS) in primary palatoplasty to reduce fistula formation. METHODS: This retrospective study assessed the complications and efficacy of bFGF-CGS to reduce fistula formation. Patients who underwent primary palatoplasty with bFGF-CGS were included. The same number of patients who underwent primary palatoplasty without bFGF-CGS was included as a control group. The outcomes included post-operative oronasal fistula formation, delayed healing, bleeding, and infection. RESULTS: Both groups included 44 patients. Except for age at palatoplasty, there were no statistically significant demographic differences between the two groups; however, the rates of fistula formation in the study and control group were 2.3% and 13.6%, respectively. There were no infections among the patients. CONCLUSIONS: The grafting of bFGF-CGS in primary palatoplasty was safe and probably effective in reducing post-operative oronasal fistula formation.

BACKGROUND: Photoacoustic tomography is a noninvasive vascular imaging modality that uses near-infrared pulsed laser light and ultrasound to visualize vessels. We previously demonstrated the utility of photoacoustic tomography for anterolateral thigh flap surgery involving body-attachable vascular mapping sheets. However, it was not possible to obtain clear separate images of arteries and veins. In this study, we tried to visualize subcutaneous arteries that cross the midline of the abdomen, since these arteries are known to be important for obtaining large perfusion areas in transverse abdominal flaps. METHODS: Four patients scheduled to undergo breast reconstruction with abdominal flaps were examined. Photoacoustic tomography was performed preoperatively. The tentative arteries and veins were traced according to the S-factor, an approximate hemoglobin oxygen saturation parameter calculated using 2 laser excitation wavelengths (756 and 797 nm). Intraoperatively, arterial-phase indocyanine green (ICG) angiography was performed after abdominal flap elevation. Images of vessels speculated to be arteries by preoperative photoacoustic tomography were merged with those of intraoperative ICG angiography and analyzed in an 8 × 4-cm2 area below the umbilical region. RESULTS: The S-factor was used to visualize the midline-crossing subcutaneous arteries in all 4 patients. A matching analysis compared preoperative tentative arteries according to photoacoustic tomography with ICG angiography results in the 8 × 4-cm2 area below the umbilical region and indicated a 71.3-82.1% match (average: 76.9% match). CONCLUSIONS: This study demonstrates that the S-factor, a noninvasive, label-free imaging modality, can be used to successfully visualize subcutaneous arteries. This information can aid in selecting perforators for abdominal flap surgery.

Abstract Surgical intervention for alveolar bone formation is important in patients with alveolar cleft; however, the treatment methods and materials are still controversial. A precise evaluation method for postoperative bone formation is important for comparing outcomes and establishing the best treatment protocol. The purpose of this study is to establish a new method of evaluating surgical outcomes for patients with alveolar cleft. Computed tomography datasets from 20 patients who underwent secondary alveolar bone grafting were obtained before and 1 year after surgery. Six anatomical landmarks were used to superimpose the preoperative and mirrored preoperative volume and postoperative volume data. The cleft region was segmented by subtracting the preoperative from mirrored preoperative volume data, and the failed osteogenesis region was segmented by subtracting the postoperative volume data from the cleft region; subsequently, the bone formation ratio was calculated. Two observers performed this method using a free software 3D slicer and the average evaluation times were 12.7 and 13.2 min for observers 1 and 2, respectively. Method reliability was determined by evaluating intraclass correlation coefficients. The intra‐observer intraclass correlation coefficients were 0.97 and 0.96 for observers 1 and 2, respectively. The inter‐observer intraclass correlation coefficient was 0.97. Our method is practical for assessing bone formation after treatment, which does not require specific knowledge or software and can be used by ordinary physicians.

PURPOSE: Chronic pain following breast surgery is a concern for breast cancer survivors; however, few studies have investigated the localization of persistent postoperative pain. We conducted this study to identify the location of pain following breast reconstruction. METHODS: A total of 213 Japanese women undergoing mastectomy only or breast reconstruction with a tissue expander/implant (TE/Imp) or a deep inferior epigastric perforator (DIEP) flap were enrolled in the study. Questionnaires related to pain location were sent to patients at the end of postoperative year (POY) 1 and POY 5. Multiple comparisons of the types of operation and cross-tabulation were made between the two time points. RESULTS: Surveys were completed by 107 of the women. Severe pain in the upper medial breast was significantly more common in POY 1 after DIEP reconstruction than after mastectomy only (P = 0.01), whereas abdominal pain was worse in POY 5 after DIEP reconstruction than after mastectomy only (P = 0.04). Pain in the medial arm and axilla had resolved better after TE/Imp (P = 0.03) and DIEP reconstruction (P = 0.01) than after mastectomy only by POY 5, but the difference between TE/Imp and DIEP reconstruction was not significant. CONCLUSIONS: These results show that localization of prolonged postoperative pain following breast reconstruction differs depending on the surgical strategy.

Local flaps from the upper lip and cheeks have been the first choice for two-thirds to total resection of the lower lip. However, these local flap techniques involve many clinical problems, including small a mouth, drooling, scarring, and hypesthesia. The improvement of free anterolateral thigh (ALT) flap transfer can solve these problems with expansion of the application of free flaps for lower lip reconstruction. The patient in this case was a 56-year-old man with squamous cell carcinoma of the lower lip (cT3N1M0). Subtotal lower lip resection preserving both corners of the mouth with bilateral neck dissection was performed. Simultaneously, a sensory ALT flap was elevated with an 8 × 6 cm skin island and a lateral femoral cutaneous nerve. The lateral and medial sides of the fascia lata were processed into 1-cm-wide strings, which were tunneled through the orbicularis oris muscle of the upper lip and sutured to the orbicularis oris muscle at the mucosal side of the philtrum. The lateral femoral cutaneous nerve and right mental nerve were sutured. At 3 months, a second surgery was performed to replace the ALT flap on the white labial side with a clavicle full-thickness skin graft. This surgery achieved four important factors: opening and closing of the mouth, sensory function of the lower lip, cosmetic appearance, and minimization of donor-site damage. We believe the worldwide improvement of microsurgery techniques enables lower lip reconstruction using the sensory ALT flap to be selected as the first choice for two-thirds to total lower lip defects.

INTRODUCTION: Surgical options for post-mastectomy breast reconstruction (PMBR) have increased and become more diverse. These options may cause difficulty and stress for patients in making the best choice, and this also increases the likelihood of postoperative regret over a particular decision. To solve this issue, implementation of shared decision-making (SDM) using a decision aid (DA) has become of increasing interest. We have created the first prototype DA in Japan. The aim of the current field study was to assess the usability of this DA in promoting effective SDM and avoiding regret over a decision to undergo reconstructive surgery. METHODS: A total of 25 consecutive patients who underwent BR were enrolled in the study, including 13 with SDM using the decision aid (DA + group) and 12 who received standard information (DA- group) before their choice of surgery. The Decision Regret Scale (DRS) were completed after PMBR, whereas SDM Questionnaire (SDM-Q-9) was completed before PMBR. Descriptive and summary statistics were compared to identify differences between the two groups to assess the usability of the DA. RESULTS: The DA + group had significantly higher mean total scores on the SDM-Q-9 (90.2 ± 5.3 vs. 84.1 ± 3.5, P = 0.0034) and DRS (90.3 ± 3.8 vs. 84.3 ± 6.7, P = 0.023), compared to those in the DA- group. CONCLUSION: Use of the DA may cause patients to have a higher level of perceived SDM and less regret, which suggests that the DA helps to facilitate smooth and effective implementation of SDM. We conclude that this type of decision-making approach should be recommended for choice of surgery for PMBR.

INTRODUCTION: There is widespread recognition of the importance of assessment of patient satisfaction and well-being after breast reconstruction. However, few studies of fat grafting performed simultaneously with implant-based breast reconstruction (IBBR) have accounted for confounding factors, such as patient background and information bias. The aim of this study was to examine patient satisfaction and well-being using multivariate analysis of BREAST-Q scores in patients treated with IBBR combined with fat grafting. METHODS: Seventy-one consecutive patients who underwent IBBR with silicone breast implants were enrolled for a prospective cohort study. Among these patients, 56 responded to the BREAST-Q questionnaire, including 24 who underwent fat grafting at the same time as IBBR (FAT+ group) and 32 who underwent IBBR alone (FAT- group). The BREAST-Q questionnaire was completed 1 year after surgery. Statistical analysis was performed using descriptive and summary statistics to identify differences between the 2 groups. RESULTS: Logistic regression analysis showed that the FAT+ group was significantly more likely than the FAT- group to have satisfaction with breasts (P = 0.0201) and satisfaction with outcome (P = 0.0364). CONCLUSIONS: Multivariate analysis with consideration of confounding factors indicated that addition of fat grafting to IBBR improves outcomes of breast reconstruction. These results suggest that a minor surgical procedure of fat grafting can improve patient satisfaction and outcomes after breast reconstruction.

The medical imaging projection system (MIPS) is a real-time surgical navigation device using indocyanine green (ICG) emission signals and active projection mapping. The difference between the object and the projected image is within 1 mm, and the time lag is within 0.1 seconds. We herein report the application of the MIPS to vascularized lymph-node transplantation (VLNT) surgery for lower extremity lymphedema to detect inguinal lymph nodes and perform color-coded navigation surgery for lymph-node resection. A left superficial inguinal lymph node was planned to be used as a donor for VLNT to the right lower leg in a 73-year-old woman with lower extremity lymphedema. Under general anesthesia, multiple intradermal injections of 0.1 ml of ICG were administered around the left inguinal donor site. The MIPS showed a clear linear projection image from a lateral injected point connecting to a lateral superficial inguinal lymph node. The left superficial circumflex iliac artery and vein were dissected for vascularized VLNT. Intraoperative real-time MIPS navigation continuously guided the transection plane colored by ICG fluorescence signals without shifting the visual focus from the surgical field. This is the first report of the intraoperative use of ICG projection mapping for VLNT donor-site surgery. The MIPS was able to visualize functional lymph nodes to facilitate minimally invasive donor-site surgery.