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COVID-2019 Alert

The latest information about the 2019 Novel Coronavirus, including vaccine clinics for children ages 5 years old and older.

La información más reciente sobre el nuevo Coronavirus de 2019, incluidas las clínicas de vacunación para niños de 5 años en adelante.

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Dung Nguyen, MD

  • Dung Hoang Nguyen

Specialties

Plastic & Reconstructive Surgery

Work and Education

Professional Education

University of California San Diego School of Medicine, La Jolla, CA, 06/30/2004

Residency

Univ of Southern CA/LAC+USC Medical Center, Los Angeles, CA, 06/23/2007

Univ of Southern CA/LAC+USC Medical Center, Los Angeles, CA, 06/30/2010

Fellowship

Chang Gung Memorial Hospital, Taipei, Taiwan, 07/01/2011

Board Certifications

Plastic & Reconstructive Surgery, American Board of Plastic Surgery

All Publications

Minimizing Postoperative Pain in Autologous Breast Reconstruction With the Omental Fat-Augmented Free Flap. Annals of plastic surgery Deptula, P., Zak, Y., Dua, M., Wapnir, I., Nguyen, D. 2022

Abstract

INTRODUCTION: The omental fat-augmented free flap (O-FAFF) is a recently developed technique for autologous breast reconstruction. Our aim of the study is to evaluate the outcomes of our early case series. We assess the O-FAFF donor site morbidity in terms of postoperative pain, narcotic, and antiemetic use.METHODS: A retrospective analysis of patients undergoing O-FAFF from 2019 to 2021 was performed. Patients were evaluated for demographic data, operative time, hospital course, and complications. Mean pain scores (1-10 scale) and narcotic pain medication use in oral morphine equivalents and doses of antiemetic medications during their hospital course were analyzed. We compared outcomes of our O-FAFF group with those of a control group of patients who underwent breast reconstruction with traditional free abdominal tissue transfer.RESULTS: A total of 14 patients underwent O-FAFF breast reconstruction, representing 23 breasts. Patients had an average age of 48.5 years (2.3 years) and body mass index of 22.6 kg/m2 (1.09 kg/m2). Average follow-up was 232 days (51 days). Average mastectomy weight was 245.6 g (30.2 g) and average O-FAFF weight was 271 g (31.7 g). Average pain scores on postoperative day 1 (POD1), POD2, and POD3 were 3.1 (0.28), 2.8 (0.21), and 2.1 (0.35), respectively. The average narcotic use by patients in oral morphine equivalents on POD1, POD2, and POD3 are 24.3 (5.5), 21.9 (4.6), and 6.2 (2.4), respectively. Total narcotic use during hospital stay was 79.4 mg (11.1 mg). Average pain scores and narcotic use are significantly lower when compared with a previously published cohort of patients who underwent autologous breast reconstruction with free abdominal tissue transfer (P < 0.05). Average antiemetic use was lower in the O-FAFF group compared with the control group: 3.5 versus 4.8 doses (P = 0.6). Hospital length of stay was 3.0 days (0.0 days). No complications were noted (0%). Patients were universally satisfied with their reconstructive outcome (100%).CONCLUSIONS: The O-FAFF is proven to be a viable method of autologous breast reconstruction. Early series of patients undergoing O-FAFF reconstruction suggest a lower donor site morbidity as demonstrated by lower postoperative pain scores and lower consumptions of narcotic pain medications.

View details for DOI 10.1097/SAP.0000000000003084

View details for PubMedID 35180753

Creating a Biological Breast Implant with an Omental Fat-Augmented Free Flap. Plastic and reconstructive surgery Nguyen, D. H., Ma, I. T., Choi, Y. K., Zak, Y., Dua, M. M., Wapnir, I. L. 1800

Abstract

SUMMARY: Women with inadequate myocutaneous or fasciocutaneous soft-tissue donor sites for breast reconstruction after mastectomy are mostly limited to implants. Alternative substitutes are needed for those who do not want-or in whom there are contraindications for-implant-based reconstruction. The authors report a novel technique using an omental fat-augmented free flap to create an autologous breast mound that has comparable shape and projection to a breast implant. Three patients with breast cancer who desired unilateral reconstruction were identified in the period 2019 to 2020. All had insufficient traditional autologous sites and were averse to the use of implants. A nipple-sparing mastectomy was performed, and the omentum was laparoscopically harvested and fat-grafted ex vivo and then encased in acellular dermal matrix for microvascular anastomoses. The body mass indexes of the three patients were 17.6, 25, and 28.3 kg/m2. Each individual's mastectomy specimens and corresponding omentum plus fat-grafting weights were 113.7/228, 271/293, and 270/360 g. No postoperative complications occurred. The reconstructed breast remains soft, with stable breast volume at 6 months and without evidence of fat necrosis. This novel use of fat grafting into an omental flap enveloped in acellular dermal matrix, the omental fat-augmented free flap, provides a viable and successful autologous alternative for patients who are not candidates for traditional autologous breast reconstruction options because of body habitus or personal preference.

View details for DOI 10.1097/PRS.0000000000008963

View details for PubMedID 35103642

Multimodality Approach to Lymphedema Surgery Achieves and Maintains Normal Limb Volumes: A Treatment Algorithm to Optimize Outcomes. Journal of clinical medicine Deptula, P., Zhou, A., Posternak, V., He, H., Nguyen, D. 2022; 11 (3)

Abstract

Surgical treatment of advanced lymphedema is challenging and outcomes are suboptimal. Physiologic procedures including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) improve lymphatic flow but cannot reverse fibrofatty tissue deposition, whereas liposuction removes fibrofatty tissue but cannot prevent disease progression. The adjunctive use of nanofibrillar collagen scaffolds (BioBridgeTM) can promote lymphangiogenesis. We report a treatment algorithm utilizing a multimodality approach to achieve sustained normal limb volumes in patients with stage II-III lymphedema. A retrospective review of late stage II-III lymphedema patients treated with liposuction, physiologic procedures, and BioBridgeTM from 2016 through 2019 was conducted. Treatment outcome in the form of excess volume reduction is reported. Total of 14 patients underwent surgical treatment of late stage II and III lymphedema according to our triple therapy algorithm. Patients had a baseline median volume excess of 29% (19.8, 43.3%). The median volume excess was improved to 0.5% (-4.3, 3.8%) at 14.4 months from the first stage surgery (p < 0.05) and further improved to -1.0% (-3.3, 1.3%) after triple therapy with BB placement at 24.6 months. A triple therapy surgical treatment algorithm can optimize outcomes and achieve sustained normalization of limb volume in late stage II-III lymphedema. The incorporation of nanofibrillar collagen scaffold technology allows for improved and sustained volume reduction.

View details for DOI 10.3390/jcm11030598

View details for PubMedID 35160049

Novel Technique of Breast Reconstruction with Omental Fat-Augmented Free Flap Improves Donor Site Morbidity and Reduces Postoperative Narcotic Use Deptula, P. L., Zak, Y., Dua, M. M., Wapnir, I. L., Nguyen, D. ELSEVIER SCIENCE INC. 2021: S36-S37
Preoperative beta-Lactam Antibiotic Prophylaxis Is Superior to Bacteriostatic Agents in Immediate Breast Reconstruction with Acellular Dermal Matrix Miller, T. J., Remington, A. C., Nguyen, D. H., Gurtner, G. C., Momeni, A. ELSEVIER SCIENCE INC. 2021: S210
Nanofibrillar Collagen Scaffold Enhances Edema Reduction and Formation of New Lymphatic Collectors after Lymphedema Surgery. Plastic and reconstructive surgery Nguyen, D. H., Zhou, A., Posternak, V., Rochlin, D. H. 2021

Abstract

BACKGROUND: Treatment of secondary lymphedema remains challenging, with suboptimal rates of edema reduction following physiologic procedures (i.e., lymphaticovenous anastomosis and vascularized lymph node transfer). The objective of this study was to investigate the long-term effect of a nanofibrillar collagen scaffold on edema reduction in lymphedema patients treated with lymphaticovenous anastomosis or vascularized lymph node transfer.METHODS: A retrospective cohort study was performed, comparing stage 1 to 3 lymphedema patients who underwent lymphaticovenous anastomosis and/or vascularized lymph node transfer with or without delayed implantation of nanofibrillar collagen scaffold (BioBridge) from 2016 to 2019. The primary endpoint was excess volume reduction. Indocyanine green lymphatic mapping was performed to evaluate superficial lymphatic flow.RESULTS: Edema reduction was significantly greater for the BioBridge cohort (12-month follow-up, n = 18) compared to controls (18.2-month follow-up, n = 11) (111.5 34.5 percent versus 70.0 19.0 percent; p = 0.0004). This held true in lymphaticovenous anastomosis and vascularized lymph node transfer subgroup analysis. The average rate of edema reduction increased by 3.5-fold in lymphaticovenous anastomosis and 7.6-fold in vascularized lymph node transfer following BioBridge placement. Eighty-eight percent of patients with concurrent liposuction and BioBridge implantation maintained normal volumes at 13 months postoperatively. Lymphatic mapping following BioBridge placement showed significantly more new lymphatic collectors and decreased dermal backflow. The majority of patients (77.8 percent) achieved and maintained normal limb volume at an average total follow-up of 29 months.CONCLUSION: Nanofibrillar collagen scaffold implantation enhances overall effectiveness of physiologic procedures, even in the presence of liposuction, and is a promising adjunct therapy for treatment of lymphedema.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

View details for DOI 10.1097/PRS.0000000000008590

View details for PubMedID 34705812

Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation: Applications for oncoplastic and massive weight loss surgery. JPRAS open Lipman, K., Graw, G., Nguyen, D. 2021; 29: 123-134

Abstract

Background: Lateral intercostal artery perforator (LICAP) flap for breast volume augmentation provides the benefits of addressing axillary tissue excess and avoiding intramuscular dissection. Previous experience with the LICAP flap in patients with prior breast conservation therapy (BCT) has led to the development of an extended version for massive weight loss (MWL) patients as well.Methods: A retrospective review of all cases of LICAP flaps was performed by a single surgeon. Data were subsequently extracted and analyzed including patient demographics, indication and timing of volume augmentation, complications, and follow-up length.Results: From 2016 to 2020, 12 patients underwent 16 LICAP flaps for volume augmentation. Indications for volume augmentation included deficits from prior oncologic surgery (ten patients) and loss of volume due to MWL (two patients). The average BMI was 29.9 kg/m2. Among the oncologic group, eight patients had delayed reconstruction, while two were immediate. Nine patients underwent radiation prior to volume augmentation. Eight of the 14 patients simultaneously received fat grafting. There were 4 cases of delayed wound healing that improved with local wound care. There were no statistically significant differences in complication rates between the oncologic and MWL groups. The average length of follow-up was 11.4 months.Conclusions: This study supports that the application of the LICAP flap can be effectively broadened from the oncologic population to the MWL population. If needed, extending the flap provides an option to simultaneously address excess axillary and back tissue.

View details for DOI 10.1016/j.jpra.2021.05.005

View details for PubMedID 34195333

Correction to: Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss. Annals of surgical oncology Ju, T., Chandler, J., Momeni, A., Gurtner, G., Tsai, J., Nguyen, D., Wapnir, I. 2021

View details for DOI 10.1245/s10434-021-10553-6

View details for PubMedID 34341890

Two-Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss. Annals of surgical oncology Ju, T., Chandler, J., Momeni, A., Gurtner, G., Tsai, J., Nguyen, D., Wapnir, I. 2021

Abstract

BACKGROUND: Devascularization of the nipple-areola complex (NAC) before nipple-sparing mastectomy (NSM) enhances blood flow to the skin. This study analyzed the effect of the interval between stages in two-stage (2S) operations and compared the ischemic events with those of one-stage (1S) NSM.METHODS: Ischemic complications were defined as partial/reversible (PR) or full-thickness/irreversible (FI) skin necrosis of the NAC or flap. The latter encompassed limited areas of the NAC, resulting in loss of nipple height or areolar circumference without affecting the integrity or appearance of the NAC. Outcomes between the two groups were compared using chi-square and both uni- and multivariate analyses.RESULTS: From 2015 to 2019, 109 breastsunderwent 2S NSM and 103 breasts underwent 1S NSM. Grade 2 or 3 breast ptosis was more common in the 2S group than in the 1S group (60.5% vs 30.5%; p < 0.01). The median time between devascularization and NSM was 30 days (range, 11-415 days). After devascularization, ischemic events occurred in 25.7% of the breasts. Nipple loss occurred in 7.8% of the 1S group and 0% of the 2S group. Both PR and FI NAC ischemic events were observed in 66.7% of the breasts when NSM took place fewer than 20 days (n = 9) after devascularization versus 15% when NSM took place20 days or longer afterward (n = 100). Overall, NAC, flap ischemic complications, or both occurred in 35.9% of the 1S group versus 20.2% of the 2S group (p < 0.05). In the multivariate analysis, the odds ratio of ischemic complications in the 2S versus the 1S group was 0.38 (range, 0.19-0.75).CONCLUSIONS: Fewer ischemic complications and no nipple loss occurred in 2S NSM. Ischemic events are fewer when the interval between devascularization and NSM is 20 days or longer.

View details for DOI 10.1245/s10434-021-10456-6

View details for PubMedID 34291379

Preoperative beta-lactam antibiotic prophylaxis is superior to bacteriostatic alternatives in immediate expander-based breast reconstruction. Journal of surgical oncology Miller, T. J., Remington, A. C., Nguyen, D. H., Gurtner, G. C., Momeni, A. 2021

Abstract

BACKGROUND: Staged implant-based breast reconstruction is the most common reconstructive modality following mastectomy. Postoperative implant infections can have a significant impact on adjuvant oncologic care and reconstructive outcome. Here, we investigate the impact of beta-lactam antibiotics (i.e., bactericidal) compared to alternative antibiotic agents on postoperative outcomes for implant-based breast reconstruction.METHODS: A retrospective analysis of patients who underwent immediate sub-pectoral tissue expander placement with an inferior acellular dermal matrix (ADM) sling at a single institution between May 2008 and July 2018 was performed. Patient demographics, comorbidities, and complication rates were retrieved. The impact of antibiotic regimen on postoperative outcomes, including infection rate and reconstructive failure, was investigated.RESULTS: A total of 320 patients with a mean age and BMI of 48.2 years and 25.0kg/m2 , respectively, who underwent 542 immediate breast reconstructions were included in the study. The use of a beta-lactam antibiotic was protective against postoperative infection (odds ratio [OR]=0.467, p=.046), infection requiring operative management (OR=0.313, p=.022), and reconstructive failure (OR=0.365, p=.028). Extended, that is, post-discharge, prophylaxis was not associated with any clinical benefit.CONCLUSION: The use of beta-lactam antibiotics for pre-/peri-operative prophylaxis is superior to alternative antibiotics with a bacteriostatic mechanism of action regarding rates of postoperative infection and reconstructive failure following immediate tissue expander-based breast reconstruction. Extended, that is, post-discharge, prophylaxis does not appear to be indicated, regardless of the antibiotic chosen.

View details for DOI 10.1002/jso.26599

View details for PubMedID 34235740

Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes. Annals of plastic surgery Brazio, P. S., Nguyen, D. H. 2021; 86 (5S Suppl 3): S384S389

Abstract

INTRODUCTION: Outcomes of surgical lymphedema treatment are currently suboptimal. Physiologic procedures including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) reestablish lymphatic flow but cannot correct fibroadipose deposition, whereas liposuction alone cannot prevent disease progression. We propose a treatment algorithm combining liposuction with LVA or VLNT that can achieve normal limb volumes and prevent disease progression in stage II-III lymphedema.METHODS: We performed a retrospective chart review of patients undergoing liposuction and physiologic lymphedema operations at our institution between January 2016 and June 2019. Patients were assigned to treatment groups according to their clinical presentation: physiologic first, followed by no further treatment (physiologic only) or liposuction (physiologic then liposuction); liposuction then physiologic; or simultaneous. Preoperative patient characteristics and sequence of operations were recorded. Compression garment usage was self-reported. Limb volumes were approximated as a truncated cone.RESULTS: Twenty-one patients met the inclusion criteria. The liposuction then physiologic group had significantly higher stage and excess limb volume at baseline, whereas the physiologic first groups had lower excess volume. While the physiologic only group had predominantly stage I disease, the patients who later required liposuction (physiologic then liposuction group) all had stage II disease. All groups achieved 82% to 106% mean excess volume reduction, and volume reduction was maintained for up to 2.4 years. Compression garment class was not reduced, but mean postoperative compression duration decreased from 12.5 to 7.5 h/d (P = 0.003). Ten of 11 patients with history of cellulitis had no further recurrence.CONCLUSION: Lymphedema represents a continuum of fluid and fibroadipose disease. Accurate staging and timely treatment with physiologic procedures and liposuction can normalize limb volume. We propose a treatment algorithm to optimize outcomes. Patients with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize postoperative compression, followed by LVA or VLNT to improve lymphatic drainage. Patients with primarily pitting edema are best treated with physiologic procedures initially, reserving selective liposuction as a second stage. Patients with mixed presentation are best served by single-stage combination procedures.

View details for DOI 10.1097/SAP.0000000000002695

View details for PubMedID 33976067

Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss Ju, T., Momeni, A., Gurtner, G., Nguyen, D., Wapnir, I. SPRINGER. 2021: S214-S215
Staged Approach to Autologous Reconstruction in the Ptotic Breast: A Comparative Study. Annals of plastic surgery Deptula, P. n., Yesantharao, P. n., Wapnir, I. n., Nguyen, D. n. 2021

Abstract

Nipple-sparing mastectomy (NSM) and autologous breast reconstruction are associated with higher patient satisfaction, quality of life, and aesthetic outcome. For patients with naturally ptotic breasts, this ideal reconstructive treatment of NSM and autologous breast reconstruction poses a challenge. We describe our experience in treating patients with ptotic natural breasts using a 2-staged approach: oncoplastic breast reduction in the first stage followed by nipple-sparing mastectomy and immediate autologous reconstruction in a second stage.We reviewed cases of patients with grade III ptosis who underwent a staged reconstruction approach with reduction mammaplasty followed by NSM and immediate reconstruction with an abdominally based free flap (2014-2019). We compared this group of patients to a second group who underwent staging with a technique of nipple-areola complex (NAC) devascularization. A survey was administered to assess for patient satisfaction and aesthetic outcome 1 year after the second stage procedure.Eight patients were identified in our reduction group, and 9 patients were identified in our devascularization group. No cases of total NAC necrosis were noted in either group (0%). Two cases of partial NAC necrosis were noted in the devascularization group (11%), whereas none were observed in the reduction group. All patients were satisfied with final outcome (100%, P = 1.0). Aesthetic scores across all factors were higher in the reduction group. Scores for overall outcome (4.6 vs 3.7, P = 0.04), natural appearance (4.8 vs 3.8, P = 0.01), breast contour (4.8 vs 3.2, P = 0.002), and position of breasts (5.0 vs 3.9, P = 0.03) were significantly higher in the reduction group.Breast ptosis no longer represents a contraindication for patients desiring nipple-sparing mastectomy and immediate autologous reconstruction. This series supports the use of a 2-staged approach with reduction mammaplasty in patients with naturally ptotic breasts. A staged reduction approach may offer fewer NAC complications while also allowing for superior aesthetic outcomes.

View details for DOI 10.1097/SAP.0000000000002725

View details for PubMedID 33470622

Diagnostic and Therapeutic Use of Botox for Breast Reconstruction. Archives of clinical and medical case reports Ma, I. T., Yesantharao, P., Darrach, H. M., Seither, J. G., He, H., Nguyen, D. H. 1800; 5 (5): 759-770

Abstract

Introduction: Breast reconstruction is most commonly performed using implant-based reconstruction. Patients with subpectoral implant placement with or without latissimus dorsi (LD) muscle coverage can experience muscle pain and animation deformity. Due to minimal literature describing the use of botulinum toxin (BTX-A) treatment for these side effects from implant-based reconstruction, we report our outcomes.Methods: A retrospective chart review of breast reconstructive patients for a single surgeon was performed. Patients who underwent BTX-A injection for muscular pain, spasm, or animation deformity were identified and outcomes reviewed. They were also stratified based on radiation treatment and type of muscle flap used.Results: Eleven patients were identified who had a submuscular pectoralis pocket and/or a pedicled latissimus dorsi flap. Nineteen breasts were treated. The average amount of time from the patient's last surgery to BTX-A injection was 11.2 months. 25-100 units were used per injection with an average of 60 units. Non-irradiated patients had signifycantly lower post-injection capsular contracture Baker grades and significantly lower amounts of BTX-A were injected. Patients who had both pectoralis major muscle and LD implant-reconstruction were significantly less likely to have improvement in pain/tightness. Most patients reported improvement or resolution of their pain and/or animation deformities.Conclusion: Implant-based reconstruction using the pectoralis major and/or LD muscles can be plagued with muscular pain, spasm, and animation deformities. The use of BTX-A is a diagnostic and therapeutic modality for these post-breast reconstruction patients with most patients having resolution of symptoms without the need for additional surgery.

View details for DOI 10.26502/acmcr.96550419

View details for PubMedID 34988384

ASO Visual Abstract: Two-Stage Versus One-Stage Nipple-Sparing Mastectomy: Timing of Surgery Prevents Nipple Loss. Annals of surgical oncology Ju, T., Chandler, J., Momeni, A., Gurtner, G., Tsai, J., Nguyen, D., Wapnir, I. 2021

View details for DOI 10.1245/s10434-021-10596-9

View details for PubMedID 34448056

Lymphatic Microsurgical Preventive Healing Approach (LYMPHA) for Lymphedema Prevention after Axillary Lymph Node Dissection-A Single Institution Experience and Feasibility of Technique. Journal of clinical medicine Lipman, K., Luan, A., Stone, K., Wapnir, I., Karin, M., Nguyen, D. 2021; 11 (1)

Abstract

While surgical options exist to treat lymphedema after axillary lymph node dissection (ALND), the lymphatic microsurgical preventive healing approach (LYMPHA) has been introduced as a preventive measure performed during the primary surgery, thus avoiding the morbidity associated with lymphedema. Here, we highlight details of our operative technique and review postoperative outcomes. For our patients, limb measurements and body composition analyses were performed pre- and postoperatively. Intraoperatively, axillary reverse lymphatic mapping was performed with indocyanine green (ICG) and lymphazurin. SPY-PHI imaging was used to visualize the ICG uptake into axillary lymphatics. Cut lymphatics from excised nodes were preserved for lymphaticovenous anastomosis (LVA). At the completion of the microanastomosis, ICG was visualized draining from the lymphatic through the recipient vein. A retrospective review identified nineteen patients who underwent complete or partial mastectomy with ALND and subsequent LYMPHA over 19 months. The number of LVAs performed per patient ranged between 1-4 per axilla. The operating time ranged from 32-95 min. There were no surgical complications, and thus far one patient developed mild lymphedema with an average follow up of 10 months. At the clinic follow up, ICG and SPY angiography were used to confirm intact lymphatic conduits with an uptake of ICG across the axilla. This study supports LYMPHA as a feasible and effective method for lymphedema prevention.

View details for DOI 10.3390/jcm11010092

View details for PubMedID 35011833

Xenogeneic skin transplantation promotes angiogenesis and tissue regeneration through activated Trem2+ macrophages. Science advances Henn, D., Chen, K., Fehlmann, T., Trotsyuk, A. A., Sivaraj, D., Maan, Z. N., Bonham, C. A., Barrera, J. A., Mays, C. J., Greco, A. H., Moortgat Illouz, S. E., Lin, J. Q., Steele, S. R., Foster, D. S., Padmanabhan, J., Momeni, A., Nguyen, D., Wan, D. C., Kneser, U., Januszyk, M., Keller, A., Longaker, M. T., Gurtner, G. C. 2021; 7 (49): eabi4528

Abstract

[Figure: see text].

View details for DOI 10.1126/sciadv.abi4528

View details for PubMedID 34851663

Lymphatic regeneration after implantation of aligned nanofibrillar collagen scaffolds: Preliminary preclinical and clinical results. Journal of surgical oncology Nguyen, D., Zaitseva, T. S., Zhou, A., Rochlin, D., Sue, G., Deptula, P., Tabada, P., Wan, D., Loening, A., Paukshto, M., Dionyssiou, D. 2021

Abstract

We tested our hypothesis that implantation of aligned nanofibrillar collagen scaffolds (BioBridge) can both prevent and reduce established lymphedema in the rat lymphedema model. Our authors report clinical cases that demonstrate new lymphatic formation guided by BioBridge as seen by near-infrared (NIR) fluoroscopy and magnetic resonance (MR) lymphography.A rat lymphedema model was utilized. A prevention group received implantation of BioBridge immediately after lymphadenectomy. A lymphedema group received implantation of BioBridge with autologous adipose-derived stem cells (ADSC; treatment group) or remained untreated (control group). All subjects were observed for 4 months after lymphadenectomy. The hindlimb change was evaluated using computed tomography-based volumetric analysis. Lymphagiogenesis was assessed by indocyanine green (ICG) lymphography.Animals in the treatment group showed a reduction in affected limb volume. Animals in the prevention group showed no increase in the affected limb volume. ICG fluoroscopy demonstrated lymph flow and formation of lymphatics toward healthy lymphatics.In the rat lymphedema model, implantation of BioBridge at the time of lymph node removal prevents the development of lymphedema. Treatment of established lymphedema with the BioBridge and ADSC reduces lymphedema. New lymphatic vessels are demonstrated by NIR fluoroscopy and MR lymphography. These findings have implications for the treatment of lymphedema in human subjects.

View details for DOI 10.1002/jso.26679

View details for PubMedID 34549427

Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plastic and reconstructive surgery Chang, D. W., Dayan, J. n., Greene, A. K., MacDonald, J. K., Masia, J. n., Mehrara, B. n., Neligan, P. C., Nguyen, D. n. 2021

Abstract

The goal of this consensus conference, sponsored by the American Association of Plastic Surgeons, was to perform a systematic review and meta-analysis of controlled trials to examine both the benefits and risks of surgical treatment and surgical prevention of upper and lower extremity lymphedema.The panel met in Boston for a 3-day, face-to-face meeting in July of 2017. After an exhaustive review of the existing literature, the authors created consensus recommendations using the Grading of Recommendations, Assessment, Development and Evaluation criteria. Important directions for future research were also identified.There is evidence to support that lymphovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C). There is evidence to support that vascular lymph node transplantation can be effective in reducing severity of lymphedema (grade 1B). Currently, there is no consensus on which procedure (lymphovenous bypass versus vascular lymph node transplantation) is more effective (grade 2C). A few studies show that prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B). More studies with longer follow-up are required to confirm this benefit. Debulking procedures such as liposuction are effective in addressing a nonfluid component such as fat involving lymphedema (grade 1C). There is a role for liposuction combined with physiologic procedures although the timing of each procedure is currently unresolved (grade 1C).Many studies seem to support some efficacy of lymphovenous bypass and vascular lymph node transplantation. Many studies show the important role of lymphedema therapy and other procedures such as liposuction and debulking. The management of lymphedema is a challenging field with many promising advances. However, many questions remain unanswered.

View details for DOI 10.1097/PRS.0000000000007783

View details for PubMedID 33761519

Immediate Targeted Nipple-Areolar Complex Re-Innervation: Improving Outcomes in Immediate Autologous Breast Reconstruction Tevlin, R., Wapnir, I., Nguyen, D. ELSEVIER SCIENCE INC. 2020: S226S227
Prophylactic treatment with transdermal deferoxamine mitigates radiation-induced skin fibrosis. Scientific reports Shen, A. H., Borrelli, M. R., Adem, S., Deleon, N. M., Patel, R. A., Mascharak, S., Yen, S. J., Sun, B. Y., Taylor, W. L., Januszyk, M., Nguyen, D. H., Momeni, A., Gurtner, G. C., Longaker, M. T., Wan, D. C. 2020; 10 (1): 12346

Abstract

Radiation therapy can result in pathological fibrosis of healthy soft tissue. The iron chelator deferoxamine (DFO) has been shown to improve skin vascularization when injected into radiated tissue prior to fat grafting. Here, we evaluated whether topical DFO administration using a transdermal drug delivery system prior to and immediately following irradiation (IR) can mitigate the chronic effects of radiation damage to the skin. CD-1 nude immunodeficient mice were split into four experimental groups: (1) IR alone (IR only), (2) DFO treatment for two weeks after recovery from IR (DFO post-IR), (3) DFO prophylaxis with treatment through and post-IR (DFO ppx), or (4) no irradiation or DFO (No IR). Immediately following IR, reactive oxygen species and apoptotic markers were significantly decreased and laser doppler analysis revealed significantly improved skin perfusion in mice receiving prophylactic DFO. Six weeks following IR, mice in the DFO post-IR and DFO ppx groups had improved skin perfusion and increased vascularization. DFO-treated groups also had evidence of reduced dermal thickness and collagen fiber network organization akin to non-irradiated skin. Thus, transdermal delivery of DFO improves tissue perfusion and mitigates chronic radiation-induced skin fibrosis, highlighting a potential role for DFO in the treatment of oncological patients.

View details for DOI 10.1038/s41598-020-69293-4

View details for PubMedID 32704071

Radiation-induced skin fibrosis is reversed by transdermal delivery of deferoxamine Borrelli, M. R., Adem, S., Diaz, N., Mascharak, S., Sen, A., Januszyk, M., Nguyen, D., Momeni, A., Gurtner, G. C., Longaker, M. T., Wan, D. C. WILEY. 2020: S51S52
Pro-Fibrotic CD26-Positive Fibroblasts Are Present in Greater Abundance in Breast Capsule Tissue of Irradiated Breasts AESTHETIC SURGERY JOURNAL Borrelli, M. R., Irizzary, D., Patel, R. A., Dung Nguyen, Momeni, A., Longaker, M. T., Wan, D. C. 2020; 40 (4): 36979

View details for DOI 10.1093/asj/sjz109

View details for Web of Science ID 000558971600024

Surgical Treatment of Lymphedema. JAMA surgery Ogunleye, A. A., Nguyen, D. H., Lee, G. K. 2020

View details for DOI 10.1001/jamasurg.2020.0015

View details for PubMedID 32211838

Use of hyaluronic acid filler for enhancement of nipple projection following breast reconstruction: An easy and effective technique. JPRAS open Sue, G. R., Seither, J. G., Nguyen, D. H. 2020; 23: 1925

Abstract

Background: Breast reconstruction improves the psychological well-being of patients with breast cancer. Patients who complete nipple-areolar reconstruction are even more satisfied with their final reconstructive result. Nipple flattening is a common complication. We hypothesized that injectable soft-tissue filler can be used to augment nipple projection in patients who underwent breast reconstruction.Methods: This is a retrospective study of patients who underwent breast reconstruction and desired an enhanced postoperative nipple projection. The patients underwent a single session of injection with a hyaluronic acid filler as an outpatient. The filler was injected intradermally at the base of the nipple until the desired nipple projection was obtained.Results: Twelve patients and 22 breasts were included in this study. Enhanced nipple projection was observed in all cases, with an average increase of 3.0mm in nipple height (range 2.5-4.5mm). All injected nipples remained soft to the touch. All results were stable at a median of 7.5 months follow-up. No complications were observed.Conclusions: The use of injectable fillers for enhanced nipple projection is a useful adjunct treatment in patients undergoing breast reconstruction. Advantages include the ability to obtain nipple projection in patients who opt to forgo nipple-areola reconstruction with local flaps, to augment reconstructed nipples in patients with thin mastectomy skin flaps especially following implant-based reconstruction, and to improve projection of the native nipple following nipple-sparing mastectomy. Another benefit of this adjunct treatment is that the injection is reversible. Filler injection is a safe and simple solution to the problem of insufficient nipple projection.

View details for DOI 10.1016/j.jpra.2019.10.003

View details for PubMedID 32158901

Assessing the Accuracy of a 3-Dimensional Surface Imaging System in Breast Volume Estimation. Annals of plastic surgery Kwong, J. W., Tijerina, J. D., Choi, S. n., Luan, A. n., Feng, C. L., Nguyen, D. H., Lee, G. K., Nazerali, R. S. 2020

Abstract

Preoperative prediction of breast volume can guide patient expectations and aid surgical planning in breast reconstruction. Here, we evaluate the accuracy of a portable surface imager (Crisalix S.A., Lausanne, Switzerland) in predicting breast volume compared with anthropomorphic estimates and intraoperative specimen weights.Twenty-five patients (41 breasts) undergoing mastectomy were scanned preoperatively with the Crisalix surface imager, and 1 of 3 attending plastic surgeons provided an anthropomorphic volume estimate. Intraoperative mastectomy weights were used as the gold standard. Volume conversions were performed assuming a density of 0.958 g/cm.The Pearson correlation coefficient between imager estimates and intraoperative volumes was 0.812. The corresponding value for anthropomorphic estimates and intraoperative volumes was 0.848. The mean difference between imager and intraoperative volumes was -233.5 cm, whereas the mean difference between anthropomorphic estimates and intraoperative volumes was -102.7 cm. Stratifying by breast volume, both surface imager and anthropomorphic estimates closely matched intraoperative volumes for breast volumes 600 cm and less, but the 2 techniques tended to underestimate true volumes for breasts larger than 600 cm. Stratification by plastic surgeon providing the estimate and breast surgeon performing the mastectomy did not eliminate this underestimation at larger breast volumes.For breast volumes 600 cm and less, the accuracy of the Crisalix surface imager closely matches anthropomorphic estimates given by experienced plastic surgeons and true volumes as measured from intraoperative specimen weights. Surface imaging may potentially be useful as an adjunct in surgical planning and guiding patient expectations for patients with smaller breast sizes.

View details for DOI 10.1097/SAP.0000000000002244

View details for PubMedID 32032116

CD34+CD146+ adipose-derived stromal cells enhance engraftment of transplanted fat. Stem cells translational medicine Borrelli, M. R., Patel, R. A., Blackshear, C. n., Vistnes, S. n., Diaz Deleon, N. M., Adem, S. n., Shen, A. H., Sokol, J. n., Momeni, A. n., Nguyen, D. n., Longaker, M. T., Wan, D. C. 2020

Abstract

Fat grafting is a surgical technique able to reconstruct and regenerate soft tissue. The adipose-derived stromal cells (ASCs) within the stromal vascular fraction are believed to drive these beneficial effects. ASCs are increasingly recognized to be a heterogeneous group, comprised of multiple stem and progenitor subpopulations with distinct functions. We hypothesized the existence of an ASC subpopulation with enhanced angiogenic potential. Human ASCs that were CD34+CD146+, CD34+CD146-, or CD34+ unfractionated (UF) were isolated by flow cytometry for comparison of expression of proangiogenic factors and endothelial tube-forming potential. Next, lipoaspirate was enriched with either CD34+CD146+, CD34+CD146-, CD34+ UF ASCs, or was not enriched, and grafted beneath the scalp skin of immunodeficient CD-1 Nude mice (10000cells/200L/graft). Fat retention was monitored radiographically more than 8weeks and fat grafts were harvested for histological assessment of quality and vascularization. The CD34+CD146+ subpopulation comprised ~30% of ASCs, and exhibited increased expression of vascular endothelial growth factor and angiopoietin-1 compared to CD34+CD146- and CD34+ UF ASCs, and increased expression of fibroblast growth factor-2 compared to CD34+CD146- ASCs. The CD34+CD146+ subpopulation exhibited enhanced induction of tube-formation compared to CD34+CD146- ASCs. Upon transplantation, fat enriched CD34+CD146+ ASCs underwent less resorption and had improved histologic quality and vascularization. We have identified a subpopulation of CD34+ ASCs with enhanced angiogenic effects invitro and invivo, likely mediated by increased expression of potent proangiogenic factors. These findings suggest that enriching lipoaspirate with CD34+CD146+ ASCs may enhance fat graft vascularization and retention in the clinical setting.

View details for DOI 10.1002/sctm.19-0195

View details for PubMedID 32543083

Immediate targeted nipple-areolar complex re-innervation: Improving outcomes in immediate autologous breast reconstruction. Journal of plastic, reconstructive & aesthetic surgery : JPRAS Tevlin, R. n., Brazio, P. n., Tran, N. n., Nguyen, D. n. 2020

Abstract

Breast reconstruction often renders the chest skin and nipple areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves during mastectomy and using them to reinnervate the NAC following mastectomy and immediate autologous tissue reconstruction. The technique involves preservation of the lateral intercostal nerves during mastectomy, dissection of the lateral intercostal nerves to length, coaptation of the intercostal nerves to a nerve graft which is then tunneled through the free flap and the distal nerve graft is then coapted to the nerve stumps at the base of the NAC. We performed a retrospective analysis of 14 breasts, which underwent nipple reinnervation during immediate autologous breast reconstruction. Mean age was 49 years (range: 32-61 years). Sensory outcomes, as tested with Semmes-Weinstein monofilaments, were compared to a cohort of breasts that underwent nipple sparing mastectomy without neurotization. Compared to control patients, there was no statistically significant difference (p=0.0969) in sensation between pre-operative and post-operative nipple sensation at final follow-up. This proof-of-concept study suggests that immediate re-innervation of the NAC in the setting of immediate breast reconstruction enhances recovery of the NAC sensation.

View details for DOI 10.1016/j.bjps.2020.11.021

View details for PubMedID 33341386

The utility of three-dimensional models in complex microsurgical reconstruction. Archives of plastic surgery Ogunleye, A. A., Deptula, P. L., Inchauste, S. M., Zelones, J. T., Walters, S. n., Gifford, K. n., LeCastillo, C. n., Napel, S. n., Fleischmann, D. n., Nguyen, D. H. 2020; 47 (5): 42834

Abstract

Three-dimensional (3D) model printing improves visualization of anatomical structures in space compared to two-dimensional (2D) data and creates an exact model of the surgical site that can be used for reference during surgery. There is limited evidence on the effects of using 3D models in microsurgical reconstruction on improving clinical outcomes.A retrospective review of patients undergoing reconstructive breast microsurgery procedures from 2017 to 2019 who received computed tomography angiography (CTA) scans only or with 3D models for preoperative surgical planning were performed. Preoperative decision-making to undergo a deep inferior epigastric perforator (DIEP) versus muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap, as well as whether the decision changed during flap harvest and postoperative complications were tracked based on the preoperative imaging used. In addition, we describe three example cases showing direct application of 3D mold as an accurate model to guide intraoperative dissection in complex microsurgical reconstruction.Fifty-eight abdominal-based breast free-flaps performed using conventional CTA were compared with a matched cohort of 58 breast free-flaps performed with 3D model print. There was no flap loss in either group. There was a significant reduction in flap harvest time with use of 3D model (CTA vs. 3D, 117.714.2 minutes vs. 109.811.6 minutes; P=0.001). In addition, there was no change in preoperative decision on type of flap harvested in all cases in 3D print group (0%), compared with 24.1% change in conventional CTA group.Use of 3D print model improves accuracy of preoperative planning and reduces flap harvest time with similar postoperative complications in complex microsurgical reconstruction.

View details for DOI 10.5999/aps.2020.00829

View details for PubMedID 32971594

Blossom smart expander technology for tissue expander-based breast reconstruction facilitates shorter duration to full expansion: A pilot study. Archives of plastic surgery Choi, Y. K., Rochlin, D. H., Nguyen, D. H. 2020; 47 (5): 41927

Abstract

This study evaluated the Blossom system, an innovative self-filling, rate-controlled, pressure-responsive saline tissue expander (TE) system. We investigated the feasibility of utilizing this technology to facilitate implant-based and combined flap with implant-based breast reconstruction in comparison to conventional tissue expansion.In this prospective, single-center, single-surgeon pilot study, participants underwent either implant-based breast reconstruction or a combination of autologous flap and implantbased breast reconstruction. Outcome measures included time to full expansion, complications, total expansion volume, and pain scores.Fourteen patients (TEs; n=22), were included in this study. The mean time to full expansion was 13.4 days (standard error of the mean [SEM], 1.3 days) in the combination group and 11.7 days (SEM, 1.4 days) in the implant group (P=0.78). The overall major complication rate was 4.5% (n=1). No statistically significant differences were found in the complication rate between the combination group and the implant group. The maximum patient-reported pain scores during the expansion process were low, but were significantly higher in the combination group (mean, 2.000.09) than in the implant group (mean, 0.290.25; P=0.005).The reported average duration for conventional subcutaneous TE expansion is 79.4 days, but this pilot study using the Blossom system achieved an average expansion duration of less than 14 days in both groups. The Blossom system may accommodate single-stage breast reconstruction. The overall complication rate of this study was 4.5%, which is promising compared to the reported complication rates of two-stage breast reconstruction with TEs (20%-45%).

View details for DOI 10.5999/aps.2020.00535

View details for PubMedID 32971593

Immediate Targeted Nipple-Areolar Complex Reinnervation: Improving Outcomes in Gender-affirming Mastectomy. Plastic and reconstructive surgery. Global open Rochlin, D. H., Brazio, P. n., Wapnir, I. n., Nguyen, D. n. 2020; 8 (3): e2719

Abstract

Female-to-male mastectomy often renders the chest skin and nipple-areolar complex (NAC) insensate. We propose a new technique of preserving the intercostal nerves and using them to reinnervate the NAC after mastectomy.We performed a prospective analysis of transmasculine patients who underwent female-to-male mastectomy. The technique involves dissecting out the lateral intercostal nerves to length and performing a neurorrhaphy to nerve stumps at the base of the NAC. Sensory outcomes, as assessed with Semmes-Weinstein monofilaments, were compared to a cohort of patients who underwent mastectomy without neurotization.Ten patients with a mean age of 17.5 years (range: 16-19 years) underwent mastectomy. The final follow-up was a mean of 15.4 4.3 months for the treated group and 40.7 12.9 months for the control group. Compared to control patients, treated patients had significant improvement in sensation at the nipple (P 0.0002), areola (P = 0.0001), and peripheral breast skin (P = 0.0001). For treated patients, there was no statistically significant difference in sensation between preoperative and postoperative sensation in all tested areas at final follow-up.This proof of concept study suggests that immediate reinnervation of the NAC after mastectomy enhances recovery of NAC sensation in patients undergoing female-to-male mastectomy and may be further generalized to women undergoing postmastectomy breast reconstruction.

View details for DOI 10.1097/GOX.0000000000002719

View details for PubMedID 32537367

View details for PubMedCentralID PMC7253256

Delivery of Human Stromal Vascular Fraction Cells on Nanofibrillar Scaffolds for Treatment of Peripheral Arterial Disease. Frontiers in bioengineering and biotechnology Hu, C. n., Zaitseva, T. S., Alcazar, C. n., Tabada, P. n., Sawamura, S. n., Yang, G. n., Borrelli, M. R., Wan, D. C., Nguyen, D. H., Paukshto, M. V., Huang, N. F. 2020; 8: 689

Abstract

Cell therapy for treatment of peripheral arterial disease (PAD) is a promising approach but is limited by poor cell survival when cells are delivered using saline. The objective of this study was to examine the feasibility of aligned nanofibrillar scaffolds as a vehicle for the delivery of human stromal vascular fraction (SVF), and then to assess the efficacy of the cell-seeded scaffolds in a murine model of PAD. Flow cytometric analysis was performed to characterize the phenotype of SVF cells from freshly isolated lipoaspirate, as well as after attachment onto aligned nanofibrillar scaffolds. Flow cytometry results demonstrated that the SVF consisted of 33.1 9.6% CD45+ cells, a small fraction of CD45-/CD31+ (4.5 3.1%) and 45.4 20.0% of CD45-/CD31-/CD34+ cells. Although the subpopulations of SVF did not change significantly after attachment to the aligned nanofibrillar scaffolds, protein secretion of vascular endothelial growth factor (VEGF) significantly increased by six-fold, compared to SVF cultured in suspension. Importantly, when SVF-seeded scaffolds were transplanted into immunodeficient mice with induced hindlimb ischemia, the cell-seeded scaffolds induced a significant higher mean perfusion ratio after 14 days, compared to cells delivered using saline. Together, these results show that aligned nanofibrillar scaffolds promoted cellular attachment, enhanced the secretion of VEGF from attached SVF cells, and their implantation with attached SVF cells stimulated blood perfusion recovery. These findings have important therapeutic implications for the treatment of PAD using SVF.

View details for DOI 10.3389/fbioe.2020.00689

View details for PubMedID 32766213

View details for PubMedCentralID PMC7380169

Global Health Microsurgery Training With Cell Phones. Annals of plastic surgery Inchauste, S. M., Deptula, P. L., Zelones, J. T., Nazerali, R. S., Nguyen, D. H., Lee, G. K. 2020; 84 (5S Suppl 4): S273S277

Abstract

Lack of surgical care for trauma, burns, congenital anomalies, and other surgical diseases is a growing portion of global disability and death accounting for 30% of the global disease burden. Global surgical and anesthesia care aim to achieve excellence and equality of clinical care through leadership, innovation, teaching, research, and advocacy. Stanford University Division of Plastic Surgery faculty partnered with ReSurge International to teach reconstructive microsurgery in low- and middle-income countries.Global surgery teaching and training are challenged by limited resources. Surgical loupes and operating microscopes used to perform complex microsurgery magnify the surgical field are very expensive. Our goal was to identify low-cost alternatives to teach and practice microsurgery suturing.Use cell phone camera with zoom capacity to teach and practice microsurgery suturing.Cell phones with zoom feature are widely available even in low- and middle-income countries. A cell phone was placed on a stand over a microsurgery practice station. The camera was used to zoom and focus on the suturing station to mimic a surgical field with loupes or microscope magnification. Nine attending surgeons and 7 residents practiced microsurgery with microsurgical instruments and 9-0 nylon suture under the magnification of a cell phone camera. The Stanford Microsurgery and Resident Training Scale was used to track their progress. A feedback survey was given to the participants to identify the usefulness of the cell phone setup for microsurgery suture practice.Global surgery teaching and training face many challenges especially limited resources. Identifying low-cost alternative is crucial. Cell phone camera with zoom is a low-cost alternative to loupes or operating microscope for microsurgical teaching and training.

View details for DOI 10.1097/SAP.0000000000002403

View details for PubMedID 32294075

Cryopreserved human skin allografts promote angiogenesis and dermal regeneration in a murine model. International wound journal Henn, D. n., Chen, K. n., Maan, Z. N., Greco, A. H., Moortgat Illouz, S. E., Bonham, C. A., Barrera, J. A., Trotsyuk, A. A., Padmanabhan, J. n., Momeni, A. n., Wan, D. C., Nguyen, D. n., Januszyk, M. n., Gurtner, G. C. 2020

Abstract

Cryopreserved human skin allografts (CHSAs) are used for the coverage of major burns when donor sites for autografts are insufficiently available and have clinically shown beneficial effects on chronic non-healing wounds. However, the biologic mechanisms behind the regenerative properties of CHSA remain elusive. Furthermore, the impact of cryopreservation on the immunogenicity of CHSA has not been thoroughly investigated and raised concerns with regard to their clinical application. To investigate the importance and fate of living cells, we compared cryopreserved CHSA with human acellular dermal matrix (ADM) grafts in which living cells had been removed by chemical processing. Both grafts were subcutaneously implanted into C57BL/6 mice and explanted after 1, 3, 7, and 28days (n = 5 per group). A sham surgery where no graft was implanted served as a control. Transmission electron microscopy (TEM) and flow cytometry were used to characterise the ultrastructure and cells within CHSA before implantation. Immunofluorescent staining of tissue sections was used to determine the immune reaction against the implanted grafts, the rate of apoptotic cells, and vascularisation as well as collagen content of the overlaying murine dermis. Digital quantification of collagen fibre alignment on tissue sections was used to quantify the degree of fibrosis within the murine dermis. A substantial population of live human cells with intact organelles was identified in CHSA prior to implantation. Subcutaneous pockets with implanted xenografts or ADMs healed without clinically apparent rejection and with a similar cellular immune response. CHSA implantation largely preserved the cellularity of the overlying murine dermis, whereas ADM was associated with a significantly higher rate of cellular apoptosis, identified by cleaved caspase-3 staining, and a stronger dendritic cell infiltration of the murine dermis. CHSA was found to induce a local angiogenic response, leading to significantly more vascularisation of the murine dermis compared with ADM and sham surgery on day 7. By day 28, aggregate collagen-1 content within the murine dermis was greater following CHSA implantation compared with ADM. Collagen fibre alignment of the murine dermis, correlating with the degree of fibrosis, was significantly greater in the ADM group, whereas CHSA maintained the characteristic basket weave pattern of the native murine dermis. Our data indicate that CHSAs promote angiogenesis and collagen-1 production without eliciting a significant fibrotic response in a xenograft model. These findings may provide insight into the beneficial effects clinically observed after treatment of chronic wounds and burns with CHSA.

View details for DOI 10.1111/iwj.13349

View details for PubMedID 32227459

The antifibrotic adipose-derived stromal cell: Grafted fat enriched with CD74+ adipose-derived stromal cells reduces chronic radiation-induced skin fibrosis. Stem cells translational medicine Borrelli, M. R., Patel, R. A., Adem, S. n., Diaz Deleon, N. M., Shen, A. H., Sokol, J. n., Yen, S. n., Chang, E. Y., Nazerali, R. n., Nguyen, D. n., Momeni, A. n., Wang, K. C., Longaker, M. T., Wan, D. C. 2020

Abstract

Fat grafting can reduce radiation-induced fibrosis. Improved outcomes are found when fat grafts are enriched with adipose-derived stromal cells (ASCs), implicating ASCs as key drivers of soft tissue regeneration. We have identified a subpopulation of ASCs positive for CD74 with enhanced antifibrotic effects. Compared to CD74- and unsorted (US) ASCs, CD74+ ASCs have increased expression of hepatocyte growth factor, fibroblast growth factor 2, and transforming growth factor 3 (TGF-3) and decreased levels of TGF-1. Dermal fibroblasts incubated with conditioned media from CD74+ ASCs produced less collagen upon stimulation, compared to fibroblasts incubated with media from CD74- or US ASCs. Upon transplantation, fat grafts enriched with CD74+ ASCs reduced the stiffness, dermal thickness, and collagen content of overlying skin, and decreased the relative proportions of more fibrotic dermal fibroblasts. Improvements in several extracellular matrix components were also appreciated on immunofluorescent staining. Together these findings indicate CD74+ ASCs have antifibrotic qualities and may play an important role in future strategies to address fibrotic remodeling following radiation-induced fibrosis.

View details for DOI 10.1002/sctm.19-0317

View details for PubMedID 32563212

Fat Grafting Rescues Radiation-Induced Joint Contracture. Stem cells (Dayton, Ohio) Borrelli, M. R., Diaz Deleon, N. M., Adem, S., Patel, R. A., Mascharak, S., Shen, A. H., Irizarry, D., Nguyen, D., Momeni, A., Longaker, M. T., Wan, D. C. 2019

Abstract

The aim of this study was to explore the therapeutic effects of fat grafting on radiation-induced hind limb contracture. Radiation therapy (RT) is used to palliate and/or cure a range of malignancies but causes inevitable and progressive fibrosis of surrounding soft tissue. Pathological fibrosis may lead to painful contractures which limit movement and negatively impact quality of life. Fat grafting is able to reduce and/or reverse radiation-induced soft tissue fibrosis. We explored whether fat grafting could improve extensibility in irradiated and contracted hind limbs of mice. Right hind limbs of female 60-day-old CD-1 nude mice were irradiated. Chronic skin fibrosis and limb contracture developed. After 4weeks, irradiated hind limbs were then injected with (a) fat enriched with stromal vascular cells (SVCs); (b) fat only; (c) saline; or (d) nothing (n = 10/group). Limb extension was measured at baseline and every 2weeks for 12weeks. Hind limb skin then underwent histological analysis and biomechanical strength testing. Irradiation significantly reduced limb extension but was progressively rescued by fat grafting. Fat grafting also reduced skin stiffness and reversed the radiation-induced histological changes in the skin. The greatest benefits were found in mice injected with fat enriched with SVCs. Hind limb radiation induces contracture in our mouse model which can be improved with fat grafting. Enriching fat with SVCs enhances these beneficial effects. These results underscore an attractive approach to address challenging soft tissue fibrosis in patients following RT.

View details for DOI 10.1002/stem.3115

View details for PubMedID 31793745

Identifying risk factors for postoperative major complications in staged implant-based breast reconstruction with AlloDerm BREAST JOURNAL Remington, A. C., Gurtner, G. C., Wan, D. C., Nguyen, D., Momeni, A. 2019; 25 (4): 597603

View details for DOI 10.1111/tbj.13299

View details for Web of Science ID 000474305600005

Successful treatment of lymphedema in a vasculopath and neuropathic patient. Journal of surgical oncology Inchauste, S., Zelones, J., Rochlin, D., Nguyen, D. H. 2019

Abstract

This is a case report of a 68-year-old male with stage III right lower extremity lymphedema following right inguinal lymph node dissection and adjuvant chemoradiotherapy for Hodgkin's lymphoma. He developed peripheral neuropathy and radiation-induced right femoral artery thrombosis, treated with saphenous vein graft. He underwent three vascularized lymph node transfers (VLNTs) to the upper medial thigh, posterior calf, and ankle with placement of nanofibrillar collagen scaffolds. Three months after surgery, he had volume reduction, less neuropathic pain, and improved ambulation.

View details for DOI 10.1002/jso.25590

View details for PubMedID 31228351

The role of adjunct nanofibrillar collagen scaffold implantation in the surgical management of secondary lymphedema: Review of the literature and summary of initial pilot studies. Journal of surgical oncology Rochlin, D. H., Inchauste, S., Zelones, J., Nguyen, D. H. 2019

Abstract

Secondary lymphedema is a worldwide affliction that exacts a significant public health burden. This review examines the etiology, presentation, and management of secondary lymphedema. In addition, emerging adjunctive strategies are explored, specifically evidence from animal and pilot human studies regarding implantation of a collagen nanofibrillar scaffold (BioBridge; Fibralign Corporation, Union City, CA) in promoting lymphangiogenesis, preventing and treating lymphedema, and enhancing outcomes with lymphaticovenous anastomosis and vascularized lymph node transfer.

View details for DOI 10.1002/jso.25576

View details for PubMedID 31209884

Breast Reconstruction with Free Abdominal Flaps Is Associated with Persistent Lower Extremity Venous Stasis PLASTIC AND RECONSTRUCTIVE SURGERY Momeni, A., Sorice, S. C., Li, A. Y., Nguyen, D. H., Pannucci, C. 2019; 143 (6): 1144E1150E
Postoperative analgesia after microsurgical breast reconstruction using liposomal bupivacaine (Exparel). The breast journal Momeni, A., Ramesh, N. K., Wan, D., Nguyen, D., Sorice, S. C. 2019

Abstract

Conventional opioid-based regimen for postoperative analgesia after autologous breast reconstruction can be associated with significant side effects. The purpose of this study was to assess the efficacy of an intraoperatively administered transversus abdominis plane (TAP) block with liposomal bupivacaine on postoperative narcotic use in patients undergoing microsurgical breast reconstruction with free abdominal flaps. Patients treated between December 2016 and June 2017 were included in the study. Parameters of interest were patient-reported pain score, total narcotic use (in oral morphine equivalent [OME]) during the hospitalization, length of stay (LOS), and the need for patient-controlled analgesia (PCA). Eighty-two free abdominal flaps were transferred in 46 patients with a mean age of 47.6years and a mean body mass index (BMI) of 28.1kg/m2 . The average LOS was 3.5days (range, 3-5). Postoperatively, 42 patients (91.3%) did not require patient-controlled analgesia (PCA). The mean time to first narcotic use after arrival on the nursing unit was 6hours (range, 0-19hours). The mean total postoperative OME use was 123.2mg (range, 0-285mg). However, analysis of OME use excluding the four patients requiring PCA revealed a mean OME use of 90.3mg (range, 0-167.5mg). Liposomal bupivacaine provides for reliable, safe, and long-acting postoperative analgesia and contributes to a reduction in postoperative narcotic intake. The use of liposomal bupivacaine shows great promise in improving the standard of care in postoperative analgesia in microsurgical breast reconstruction.

View details for DOI 10.1111/tbj.13349

View details for PubMedID 31131501

Identifying risk factors for postoperative major complications in staged implant-based breast reconstruction with AlloDerm. The breast journal Remington, A. C., Gurtner, G. C., Wan, D. C., Nguyen, D., Momeni, A. 2019

Abstract

Acellular dermal matrices (ADM) have reportedly been associated with postoperative complications following breast reconstruction. The purpose of this study was to identify risk factors predictive of major postoperative complications after staged implant-based breast reconstruction with ADM. A retrospective study of all patients who underwent implant-based breast reconstruction with AlloDerm between 2013 and 2017 was conducted. Demographic information, procedural data, and postoperative complications were retrieved. The main objective was to analyze patient and procedural factors associated with the occurrence of major complications, including postoperative readmission and loss of reconstruction. A total of 166 patients (288 breasts) were included. Major complications were noted in 19.9%. The overall rate of infection and mastectomy skin necrosis was 16.9% and 6.6%, respectively. Readmission occurred in 16.3% and loss of reconstruction occurred in 8.4% of patients. Risk factors for major complications included body mass index (BMI) >27.0 kg/m2 (OR 2.46; p = 0.041), higher tissue expander volume (p = 0.049), history of chemotherapy (OR 2.20; p = 0.047) and radiotherapy (OR 2.22; p = 0.040). Loss of reconstruction was associated with a BMI >27.0 kg/m2 (OR 4.00; p = 0.012), tobacco use (OR 6.64, p = 0.006), and higher tissue expander volume (p = 0.035). Similarly, readmission was associated with higher tissue expander volume (p = 0.042). In conclusion, a variety of factors were identified to be associated with major complications, including higher BMI, increased tissue expander volume, as well as history of chemotherapy and radiation. This information is valuable for pre-operative counseling and for future comparative studies between different ADM types.

View details for PubMedID 31087378

Acellular Dermal Matrix Reduces Myofibroblast Presence in the Breast Capsule. Plastic and reconstructive surgery. Global open Tevlin, R., Borrelli, M. R., Irizarry, D., Nguyen, D., Wan, D. C., Momeni, A. 2019; 7 (5): e2213

Abstract

Background: Capsular contracture remains a common complication after implant-based breast reconstruction. Previous work has suggested that the use of acellular dermal matrix (ADM) reduces the rate of capsular contracture, though little is understood about the underlying mechanism. As myofibroblasts are believed to be the key cells implicated in contracture formation, we hypothesized that ADM would result in a reduction in periprosthetic myofibroblast concentration.Methods: Five patients who underwent immediate prepectoral tissue expander placement with anterior ADM coverage and an inferior cuff were included. At the second stage, tissue samples were obtained of both ADM and capsule from each reconstructed breast. Samples were then prepared for hematoxylin and eosin staining and immunohistochemistry for myofibroblast identification (alpha smooth muscle actin and vimentin positive and desmin negative) and analysis. Experimental values are presented as mean SD unless otherwise stated. Statistical significance was determined using unpaired t test.Results: Successful incorporation of ADM was noted in all cases. A significant reduction in myofibroblast concentration was noted in the ADM versus the capsule (P = 0.0018). This was paralleled by significantly thicker periprosthetic capsule formation overlying the formerly raw pectoralis major muscle, that is, not covered by ADM (P < 0.0001).Conclusions: In the presence of ADM, there are significantly fewer myofibroblasts in breast capsules and thinner capsules on histology. Given the central role of myofibroblasts in the development of clinically significant capsular contracture, this study unmasks a possible mechanism for the protective effect of ADM with respect to capsular contracture development.

View details for DOI 10.1097/GOX.0000000000002213

View details for PubMedID 31333946

Pro-Fibrotic CD26-Positive Fibroblasts are Present in Greater Abundance in Breast Capsule Tissue of Irradiated Breasts. Aesthetic surgery journal Borrelli, M. R., Irizzary, D., Patel, R. A., Nguyen, D., Momeni, A., Longaker, M. T., Wan, D. C. 2019

Abstract

BACKGROUND: Breast capsular contracture is a major problem following implant-based breast reconstruction, particularly in the setting of radiation therapy. Recent work has identified a fibrogenic fibroblast subpopulation characterized by CD26 surface marker expression.OBJECTIVE: This work aimed to investigate the role of CD26-positive fibroblasts in the formation of breast implant capsules following radiation therapy.METHODS: Breast capsule specimens were obtained from irradiated and non-irradiated breasts of 10 patients following bilateral mastectomy and unilateral irradiation at the time of expander-implant exchange, under institutional review board approval. Specimens were processed for Hematoxylin and Eosin staining, as well as for immunohistochemistry and fluorescence activated cell sorting (FACS) for CD26-positive fibroblasts. Expression of fibrotic genes and production of collagen was compared between CD26-positive, CD26-negative, and unsorted fibroblasts.RESULTS: Capsule specimens from irradiated breast tissue were thicker and had greater CD26-postive cells on immunofluorescence imaging and on FACS analysis, than did capsule specimens from the non-irradiated breast. Compared to CD26-negative fibroblasts, CD26-positive fibroblasts produced more collagen and had increased expression of the profibrotic genes IL8, TGF-beta1, COL1A1, and TIMP4.CONCLUSIONS: CD26-positive fibroblasts were found in a significantly greater abundance in capsules of irradiated compared to non-irradiated breasts and demonstrated greater fibrotic potential. This fibrogenic fibroblast subpopulation may play an important role in the development of capsular contracture following irradiation, and its targeted depletion or moderation may represent a potential therapeutic option.

View details for PubMedID 30972420

Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model PLASTIC AND RECONSTRUCTIVE SURGERY Chung, N. N., Ransom, R. C., Blackshear, C. P., Irizarry, D. M., Yen, D., Momeni, A., Lee, G. K., Nguyen, D. H., Longaker, M. T., Wan, D. C. 2019; 143 (4): 106775
Breast Reconstruction with Free Abdominal Flaps is associated with Persistent Lower Extremity Venous Stasis. Plastic and reconstructive surgery Momeni, A., Sorice, S. C., Li, A. Y., Nguyen, D. H., Pannucci, C. 2019

Abstract

BACKGROUND: Previous work has demonstrated the occurrence of lower extremity venous stasis in the early postoperative period after breast reconstruction with free abdominal flaps. The purpose of this study was to ascertain whether venous stasis persisted through the day of discharge (DOD), thus, potentially exposing patients to an elevated risk of venous thromboembolism (VTE) post-discharge.METHODS: Patients who underwent breast reconstruction with free abdominal flaps were prospectively enrolled and underwent Duplex ultrasound of the common femoral vein (CFV) at the following time points: Preoperatively, POD 1, and DOD. Parameters of interest included CFV diameter, area, and maximum flow velocity (MFV).RESULTS: Thirty patients with a mean age of 50.3 years (range, 29 - 70) underwent breast reconstruction with 52 free abdominal flaps. A significant increase in CFV diameter (19.1%; p < 0.01) and area (46.8%; p < 0.01) correlated with a significant reduction in MFV (-10.9%; p = 0.03) between baseline and POD1. These changes persisted through the DOD (CFV diameter [17.8%; p < 0.01], area [46 %; p < 0.01], MFV (-11.3%; p = 0.01)]. Venous parameters were not influenced by uni- vs. bilateral flap harvest (p = 0.48).CONCLUSION: Postoperative lower extremity venous stasis following autologous breast reconstruction with free abdominal flaps seems to persist through the day of discharge. This finding may explain why patients remain at risk for VTE post-discharge. While our findings are at odds with current VTE prophylaxis recommendations, additional studies are indicated to examine whether these findings translate into VTE events.

View details for PubMedID 30907811

Correction of complete thoracic duct obstruction with lymphovenous bypass: A case report MICROSURGERY Miller, T. J., Gilstrap, J. N., Maeda, K., Rockson, S., Nguyen, D. H. 2019; 39 (3): 25558

View details for DOI 10.1002/micr.30339

View details for Web of Science ID 000462628500009

Fat Chance: The Rejuvenation of Irradiated Skin PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Borrelli, M. R., Patel, R. A., Sokol, J., Dung Nguyen, Momeni, A., Longaker, M. T., Wan, D. C. 2019; 7 (2): e2092

Abstract

Radiotherapy (RT) helps cure and palliate thousands of patients with a range of malignant diseases. A major drawback, however, is the collateral damage done to tissues surrounding the tumor in the radiation field. The skin and subcutaneous tissue are among the most severely affected regions. Immediately following RT, the skin may be inflamed, hyperemic, and can form ulcers. With time, the dermis becomes progressively indurated. These acute and chronic changes cause substantial patient morbidity, yet there are few effective treatment modalities able to reduce radiodermatitis. Fat grafting is increasingly recognized as a tool able to reverse the fibrotic skin changes and rejuvenate the irradiated skin. This review outlines the current progress toward describing and understanding the cellular and molecular effects of fat grafting in irradiated skin. Identification of the key factors involved in the pathophysiology of fibrosis following RT will inform therapeutic interventions to enhance its beneficial effects.

View details for PubMedID 30881833

Fat Grafting into Younger Recipients Improves Volume Retention in an Animal Model. Plastic and reconstructive surgery Chung, N. N., Ransom, R. C., Blackshear, C. P., Irizarry, D. M., Yen, D., Momeni, A., Lee, G. K., Nguyen, D. H., Longaker, M. T., Wan, D. C. 2019

Abstract

BACKGROUND: Soft tissue deficits associated with various craniofacial anomalies can be addressed by fat grafting, although outcomes remain unpredictable. Furthermore, consensus does not exist for timing of these procedures. While some advocate approaching soft tissue reconstruction after the underlying skeletal foundation has been corrected, other studies have suggested earlier grafting may exploit a younger recipient niche that is more conducive for fat graft survival. As there is a dearth of research investigating effects of recipient age on fat graft volume retention, this study compared the effectiveness of fat grafting in younger versus older animals through a longitudinal, in vivo analysis.METHODS: Human lipoaspirate from three healthy female donors was grafted subcutaneously over the calvarium of immunocompromised mice. Volume retention over 8 weeks was evaluated using micro-computed tomography in three experimental ages - 3-weeks old, 6-months old, and 1-year old. Histology was performed on explanted grafts to evaluate graft health and vascularity. Recipient site vascularity was also evaluated by confocal microscopy.RESULTS: Greatest retention of fat graft volume was noted in the youngest group compared to both older groups (*p < 0.05) at 6 and 8 weeks following grafting. Histological and immunohistochemical analyses revealed that improved retention in younger groups was associated with greater fat graft integrity and more robust vascularization.CONCLUSION: Our study provides evidence that grafting fat into a younger recipient site correlates with improved volume retention over time, suggesting that beginning soft tissue reconstruction with fat grafting in patients at an earlier age may be preferable to late correction.

View details for PubMedID 30730498

A Matched-Pair Analysis of Prepectoral with Subpectoral Breast Reconstruction: Is There a Difference in Postoperative Complication Rate? Plastic and reconstructive surgery Momeni, A. n., Remington, A. C., Wan, D. C., Nguyen, D. n., Gurtner, G. C. 2019; 144 (4): 8017

Abstract

The development of acellular dermal matrices has revolutionized implant-based breast reconstruction. The most recent development has been the introduction of prepectoral breast reconstruction. However, concerns have been expressed related to the quality of soft-tissue coverage and infectious complications. Thus, the authors felt it prudent to perform a matched-pair analysis of clinical outcomes following prepectoral and subpectoral tissue expander placement.A retrospective study of patients who underwent immediate breast reconstruction by means of prepectoral (group 1) and dual-plane subpectoral (group 2) tissue expander placement was performed. Patients in each group were matched for age, body mass index, history of radiotherapy, and type of acellular dermal matrix. Of note, patients in group 1 received perioperative antibiotic prophylaxis for less than 24 hours, whereas patients in group 2 received antibiotic prophylaxis for at least 1 week.A total of 80 patients (138 breast reconstructions) were included in the study (group 1, n = 40; group 2, n = 40). No difference in total postoperative complication rate (p = 0.356) and mastectomy skin necrosis rate (p = 1.0) was noted. Observed differences in major complications (p = 0.06), major infection (p = 0.09), and loss of reconstruction (p = 0.09) were not found to be significant.Immediate prepectoral tissue expander insertion with anterior acellular dermal matrix coverage and less than 24 hours of antibiotic prophylaxis is safe and compares favorably to subpectoral tissue expander placement with an inferior acellular dermal matrix sling and a prolonged course of antibiotics.Therapeutic, III.

View details for DOI 10.1097/PRS.0000000000006008

View details for PubMedID 31568276

Preoperative Computed Tomography Angiography in Autologous Breast Reconstruction-Incidence and Impact of Incidentalomas PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN Tevlin, R., Borrelli, M. R., Dung Nguyen, Momeni, A. 2018; 6 (12): e2019

Abstract

Incidentalomas are lesions found coincidentally during examination, imaging, or surgical procedures. Preoperative computed tomography angiography (CTA) before abdominal flap harvest for breast reconstruction can lead to identification of incidentalomas leading to the need for further investigations. The aim of this study was to examine the prevalence of incidental findings on preoperative CTA and to determine their impact on management.A retrospective chart review was performed at a single tertiary institution. CTA reports were analyzed for the presence of incidental findings and details of follow-up were studied. Logistic regression was used to identify factors associated with incidental findings.One hundred eighteen patients with a mean age of 49 years were included in the study. The majority of patients underwent bilateral reconstruction (65%, n = 77) in the immediate setting (70%, n = 83). Fifty-six percentage had an incidental finding on CTA, with hepatic (20%), renal (14%), and osseous (11%) abnormalities being most common. Additional imaging including ultrasound, CT, and magnetic resonance imaging were recommended in 19 cases (16%). Additional consultations were sought for 3 patients before reconstruction (with suspicion of bone metastases, an intraabdominal mass, and suspicion of colonic malignancy, respectively). No significant surgical delay secondary to CT findings was noted.Incidentalomas following preoperative CTA of the abdomen/pelvis are common (56%). However, unlike previous reports, we did not observe a change in reconstructive plan following incidentaloma discovery. We recommend that all patients are counseled pre-CTA regarding the possibilities of incidentaloma detection and need for additional imaging.

View details for PubMedID 30656111

Correction of complete thoracic duct obstruction with lymphovenous bypass: A case report. Microsurgery Miller, T. J., Gilstrap, J. N., Maeda, K., Rockson, S., Nguyen, D. H. 2018

Abstract

Thoracic duct injury can be a devastating injury with disruption of lymphatic flow leading to potentially chylothorax and/or severe lymphedema. Standard treatment modalities include thoracic duct ligation or embolization for chylothorax, but treatment options to date are few for resultant lymphedema. In this case report, we describe lymphaticovenous bypass of the thoracic duct to the jugular venous system in a 21-year-old male with secondary lymphedema after iatrogenic thoracic duct injury. The patient experienced improvement of lymphedema symptoms including decreased weight and limb girth as well as normalization of serum markers indicating improved lymphatic delivery to the venous system. Lymphangiogram at 3 months post op demonstrated patency of the lymphaticovenous anastomoses. At 6-month follow-up, the patient had returned to his preoperative level of activity and showed continued improvement of his lymphedema symptoms. Lymphovenous bypass of the thoracic duct may be an effective technique to treat secondary lymphedema from thoracic duct obstruction, though further studies are required to determine long-term efficacy.

View details for PubMedID 29974499

Deepithelialized Skin Reduction Preserves Skin and Nipple Perfusion in Immediate Reconstruction of Large and Ptotic Breasts ANNALS OF PLASTIC SURGERY Rochlin, D. H., Nguyen, D. H. 2018; 81 (1): 22-27
Deepithelialized Skin Reduction Preserves Skin and Nipple Perfusion in Immediate Reconstruction of Large and Ptotic Breasts. Annals of plastic surgery Rochlin, D. H., Nguyen, D. H. 2018

Abstract

BACKGROUND: Women with large and/or ptotic breasts are often not considered candidates for nipple-sparing mastectomy (NSM) and/or immediate breast reconstruction given difficulties avoiding ischemic complications and achieving a favorable aesthetic result. We report a novel technique involving deepithelialized skin reduction to simultaneously reduce the skin envelope and preserve perfusion to the skin and nipple in immediate breast reconstruction for women that fit this high-risk anatomic profile.METHODS: We reviewed cases of NSM and skin-sparing mastectomy (SSM) with immediate implant-based and free autologous reconstruction by a single plastic surgeon from 2013 to 2017. All patients had at least size C cup breasts (>500 g) and/or grade 3 ptosis. Select patients undergoing NSM had devascularization of the nipple-areolar complex (NAC) 1 to 2 months before surgery to promote adaptive circulatory change. After mastectomy, skin reductions were performed via Wise, periareolar, or circumareolar reduction patterns, with infolding of a deepithelialized inferior and periareolar skin flap over a tissue expander or free flap. In NSM, the nipple was advanced superiorly and redirected through a keyhole of deepithelialized skin flap.RESULTS: Patients had an average age of 43.6 years and body mass index of 27.7. A total of 33 breasts in 19 patients (14 bilateral, 5 unilateral) underwent deepithelialized skin reduction. There were 14 NSM and 19 SSM. Reconstructions consisted of 13 tissue expanders exchanged to implants and 20 abdominally-based free flaps. Four patients underwent devascularization of the NAC before NSM. Six (18%) breasts had partial thickness flap loss that healed by delayed primary (n = 1) or secondary (n = 5) intention. Four nipples, all in patients without prior NAC devascularization, had ischemic complications (2 epidermolysis, 12.5%; 2 partial necrosis, 12.5%), which all healed by secondary intention with the exception of 1 case of NAC removal.CONCLUSIONS: Skin reduction with deepithelialization and tissue infolding preserves dermal plexus perfusion and promotes nipple and skin flap survival in immediate implant-based and autologous breast reconstruction after SSM and NSM. This technique can be combined with NAC devascularization to further promote nipple perfusion. Overall, this method offers an acceptable complication rate and the potential to expand the reconstructive options available to women with large and/or ptotic breasts.

View details for PubMedID 29746276

Deferoxamine Preconditioning of Irradiated Tissue Improves Perfusion and Fat Graft Retention PLASTIC AND RECONSTRUCTIVE SURGERY Flacco, J., Chung, N., Blackshear, C. P., Irizarry, D., Momeni, A., Lee, G. K., Dung Nguyen, Gurtner, G. C., Longaker, M. T., Wan, D. C. 2018; 141 (3): 65565

Abstract

Radiation therapy is a mainstay in the treatment of many malignancies, but collateral damage to surrounding tissue, with resultant hypovascularity, fibrosis, and atrophy, can be difficult to reconstruct. Fat grafting has been shown to improve the quality of irradiated skin, but volume retention of the graft is significantly decreased. Deferoxamine is a U.S. Food and Drug Administration-approved iron-chelating medication for acute iron intoxication and chronic iron overload that has also been shown to increase angiogenesis. The present study evaluates the effects of deferoxamine treatment on irradiated skin and subsequent fat graft volume retention.Mice underwent irradiation to the scalp followed by treatment with deferoxamine or saline and perfusion and were analyzed using laser Doppler analysis. Human fat grafts were then placed beneath the scalp and retention was also followed up to 8 weeks radiographically. Finally, histologic evaluation of overlying skin was performed to evaluate the effects of deferoxamine preconditioning.Treatment with deferoxamine resulted in significantly increased perfusion, as demonstrated by laser Doppler analysis and CD31 immunofluorescent staining (p < 0.05). Increased dermal thickness and collagen content secondary to irradiation, however, were not affected by deferoxamine (p > 0.05). Importantly, fat graft volume retention was significantly increased when the irradiated recipient site was preconditioned with deferoxamine (p < 0.05).The authors' results demonstrated increased perfusion with deferoxamine treatment, which was also associated with improved fat graft volume retention. Preconditioning with deferoxamine may thus enhance fat graft outcomes for soft-tissue reconstruction following radiation therapy.

View details for PubMedID 29135894

View details for PubMedCentralID PMC5826842

Successful management of persistent lower extremity lymphedema with suction-assisted lipectomy GYNECOLOGIC ONCOLOGY REPORTS Micha, J. P., Nguyen, D. H., Goldstein, B. H. 2018; 23: 1315

Abstract

Lower-extremity lymphedema is a significant complication attributed to gynecologic cancer surgery, potentially effectuating severe edema and discernible pain.We report on a patient who developed persistent, lower-extremity lymphedema following her treatment for cervix cancer. Despite repeated efforts to manage the lymphedema with conventional measures, the patient's condition had not markedly improved. Thereafter, she underwent a suction-assisted lipectomy that effectively resolved her symptoms.Since lymphedema often remains disabling and incurable following traditional therapy, suction-assisted lipectomy should be considered as an alternative when endeavoring to optimally manage this complication.

View details for PubMedID 29322088

Fat Graft Retention Decreases with Recipient Age Montenegro, C. F., Flacco, J., Chung, N. N., Irizarry, D. M., Brett, E. A., Blackshear, C. P., Nguyen, D., Longaker, M. T., Wan, D. C. ELSEVIER SCIENCE INC. 2017: E144E145
Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction: Is There a True Reduction in Postoperative Narcotic Use? Annals of plastic surgery Hunter, C., Shakir, A., Momeni, A., Luan, A., Steffel, L., Horn, J., Nguyen, D., Lee, G. K. 2017; 78 (3): 254-259

Abstract

The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

View details for DOI 10.1097/SAP.0000000000000873

View details for PubMedID 28118232

Transversus Abdominis Plane Block and Free Flap Abdominal Tissue Breast Reconstruction Is There a True Reduction in Postoperative Narcotic Use? ANNALS OF PLASTIC SURGERY Hunter, C., Shakir, A., Momeni, A., Luan, A., Steffel, L., Horn, J., Dung Nguyen, D., Lee, G. K. 2017; 78 (3): 254-259

Abstract

The use of the transversus abdominis plane (TAP) block is increasing in abdominally based autologous tissue breast reconstruction as a method to provide postoperative donor site analgesia. The purpose of this study was to evaluate the efficacy of the TAP block in the immediate postoperative period.A retrospective analysis of all patients who underwent autologous microsurgical breast reconstruction over a 2-year period (2013-2015) was conducted. Only patients with an abdominal donor site were included. Patients were grouped based on the presence or absence of TAP blocks. Primary endpoints included patient-reported pain score, daily and total narcotic use during the hospitalization, antiemetic use, as well as complications.We identified 40 patients that had undergone abdominal-based free flap breast reconstruction and TAP block catheter placement for postoperative analgesia that met inclusion criteria. This group was then compared with a matched cohort of 40 patients without TAP blocks. There were no complications associated with using the TAP catheters. There was no statistically significant difference in postoperative pain scores, daily or total narcotic use during the hospitalization, or antiemetic use between the 2 groups. Although not statistically significant, linear regression analysis identified trends of improved donor site analgesia in select groups, such as unilateral immediate reconstructions, body mass index greater than 30 kg/m, and those without abdominal mesh placed at the time of donor site closure in the TAP block group.Constant delivery of local anesthetic through the TAP block appears to be safe; however, it did not reduce narcotic requirements or postoperative pain scores in patients undergoing abdominal-based free flap breast reconstruction.

View details for DOI 10.1097/SAP.0000000000000873

View details for Web of Science ID 000394386700004

Protecting Nipple Perfusion by Devascularization and Surgical Delay in Patients at Risk for Ischemic Complications During Nipple-Sparing Mastectomies ANNALS OF SURGICAL ONCOLOGY Bertoni, D. M., Dung Nguyen, D., Rochlin, D., Hernandez-Boussard, T., Meyer, S., Choy, N., Gurtner, G. C., Wapnir, I. L. 2016; 23 (8): 2665-2672

Abstract

Indications for nipple-sparing mastectomy (NSM) are expanding; however, high-risk patients have more ischemic complications. Surgical devascularization of the nipple-areolar complex (NAC) prior to NSM can reduce complications. This study reports perfusion patterns and complications in high-risk patients undergoing 2-stage NSM.Surgical devascularization of the NAC was performed 3-6weeks prior to NSM in 28 women. Risk factors included ptosis, obesity, smoking, prior breast surgery, and radiation. Using indocyanine green (ICG)-based fluorescence and an infrared camera, blood inflow was visualized intraoperatively. NAC perfusion patterns were classified as: V1, underlying breast; V2, surrounding skin; V3=V1+V2, or V4, capillary fill following devascularization. Ischemic complications were analyzed.Baseline perfusion for 54 breasts was 35% V1, 32% V2, and 33% V3. Increasing ptosis was associated with V1 pattern: 86% for grade 3, 31% for grade 2, and 18% for grade 1. Postdevascularization epidermolysis was observed in 63% of V1 baseline, 41% of V2, and 22% of V3 (P=.042) and after NSM in 26% for V1, 7% for V2, and 6% for V3 (P=.131). Ptosis was significantly associated with epidermolysis postdevascularization (P=.002) and NSM (P=.002). Smoking and BMI 30 were related to increased ischemic complications. Two or more risk factors were associated with postdevascularization ischemic changes (P=.026), but were not significant after NSM. Nipple loss was not observed, but 2 patients underwent partial areolar resection.Adaptive circulatory changes after devascularization allow tissues to tolerate the additional ischemic challenge of mastectomy. Our findings support extending 2-staged operations to high-risk women previously considered unsuitable for NSM.

View details for DOI 10.1245/s10434-016-5201-8

View details for PubMedID 27038458

Breast Augmentation and Breast Reconstruction Demonstrate Equivalent Aesthetic Outcomes. Plastic and reconstructive surgery. Global open Rochlin, D. H., Davis, C. R., Nguyen, D. H. 2016; 4 (7)

Abstract

There is a perception that cosmetic breast surgery has more favorable aesthetic outcomes than reconstructive breast surgery. We tested this hypothesis by comparing aesthetic outcomes after breast augmentation and reconstruction.Postoperative images of 10 patients (cosmetic, n = 4; reconstructive, n = 6; mean follow-up, 27 months) were presented anonymously to participants who were blinded to clinical details. Participants were asked if they believed cosmetic or reconstructive surgery had been performed. Aesthetic outcome measures were quantified: (1) natural appearance, (2) size, (3) contour, (4) symmetry, (5) position of breasts, (6) position of nipples, (7) scars (1 = poor and 4 = excellent). Images were ranked from 1 (most aesthetic) to 10 (least aesthetic). Analyses included two-tailed t tests, Mann-Whitney U tests, and (2) tests.One thousand eighty-five images were quantified from 110 surveys (99% response rate). The accuracy of identifying cosmetic or reconstructive surgery was 55% and 59%, respectively (P = 0.18). Significantly more of the top 3 aesthetic cases were reconstructive (51% vs 49%; P = 0.03). Despite this, cases perceived to be reconstructive were ranked significantly lower (5.9 vs 5.0; P < 0.0001). Mean aesthetic outcomes were equivalent regardless of surgery for 5 categories (P > 0.05), with the exception of breast position that improved after reconstruction (2.9 vs 2.7; P = 0.009) and scars that were more favorable after augmentation (2.9 vs 3.1; P < 0.0001). Age and nipple position (R (2) = 0.04; P = 0.03) was the only association between a demographic factor and aesthetic outcome.Aesthetic outcomes after cosmetic and reconstructive breast surgery are broadly equivalent, though preconceptions influence aesthetic opinion. Plastic surgeons' mutually inclusive-reconstructive and aesthetic skill set maximizes aesthetic outcomes.

View details for DOI 10.1097/GOX.0000000000000824

View details for PubMedID 27536490

View details for PubMedCentralID PMC4977139

Use of Indocyanine Green-SPY Angiography for Tracking Lymphatic Recovery After Lymphaticovenous Anastomosis. Annals of plastic surgery Shih, H. B., Shakir, A., Nguyen, D. H. 2016; 76: S232-7

Abstract

Lymphaticovenous anastomosis (LVA) is a surgical treatment option for patients with early stage lymphedema. To date, no ideal imaging modality exists for tracking patency of the LVA postoperatively. We hypothesize that laser angiography utilizing indocyanine green (ICG) via the SPY system (Lifecell Corp.) would be a useful methodology for assessing the patency of the LVA and lymphatic recovery postoperatively.A prospective trial was performed on patients with stage II lymphedema who underwent LVA from 2013 to 2014 by a single surgeon. All candidates underwent preoperative and postoperative lymphatic mapping using ICG-SPY angiography. Postoperative analyses were performed at 1 month and at 9 months after surgery and assessed for patency at the site of the LVAs and for changes in lymphatic pattern.Five patients underwent LVA, 3 for upper extremity and 2 for lower extremity stage II lymphedema. The number of LVAs per extremity was 1 to 3 (total, 11). One month postoperative ICG-SPY angiography demonstrated flow through 9 of 11 anastomoses. Evaluation at 9 months postoperative showed improvement in lymphatic drainage.Indocyanine green-SPY angiography may be used to objectively evaluate the surgical outcome of LVA.

View details for DOI 10.1097/SAP.0000000000000766

View details for PubMedID 27070461

Double-Chamber Tissue Expanders Optimize Lower Pole Expansion in Immediate Breast Reconstruction Requiring Adjuvant Radiation Therapy ANNALS OF PLASTIC SURGERY Fischer, L., Dung Nguyen 2016; 76: S171S174

Abstract

Tissue expander-based reconstruction in the irradiated breast has been associated with significant complications, including infection, skin breakdown and implant extrusion, and poor aesthetic outcome. These complications may be attributed to inadequate lower pole expansion causing increased pressure on the suture line. Achieving and maintaining adequate lower pole expansion in the reconstructed breast requiring adjuvant radiation therapy may reduce the pressure/strain on the suture line and preserve the natural appearance of the breast. We describe the effective use of a double-chamber tissue expander to control lower pole expansion in immediate breast reconstruction requiring adjuvant radiation therapy.We performed a retrospective chart review of patients who underwent postoperative radiation therapy after immediate breast reconstruction using Sientra's double-chamber tissue expander, performed by a single plastic surgeon from 2012 to 2014.A total of 22 patients met our inclusion criteria. Seventeen patients had bilateral, and 5 patients had unilateral reconstruction (n = 39 total breasts). All patients were over expanded by 20% on the side affected by cancer before the start of radiation, which started by the sixth postoperative week. There was no expansion during radiation therapy. Two patients had further expansion after radiation therapy was completed. The tissue expanders were exchanged for shaped silicone gel implants 3 to 4 months after completion of radiation. A total of 2 complications occurred in 2 patients (9.0%) and 2 breasts (5.1%). These included an infection in one patient and a tissue expander leak in another. No patient developed Baker grade 3 or 4 capsular contracture, seroma, or device malposition. Good lower pole contour and projection was maintained in all breasts at 9 to 12 months of follow-up.The double-chamber tissue expander is effective in controlling shape, contour, and position of the breast following immediate tissue expander reconstruction requiring adjuvant radiation therapy, with decreased complication rates compared to standard expanders. These results suggest that double-chamber tissue expanders may be the preferred expander option in patients requiring adjuvant radiation therapy. Prospective clinical studies are needed to better evaluate the advantages of this reconstructive approach.

View details for DOI 10.1097/SAP.0000000000000768

View details for Web of Science ID 000375061200007

View details for PubMedID 26954736

Quantity of lymph nodes correlates with improvement in lymphatic drainage in treatment of hind limb lymphedema with lymph node flap transfer in rats. Microsurgery Nguyen, D. H., Chou, P., Hsieh, Y., Momeni, A., Fang, Y. D., Patel, K. M., Yang, C., Cheng, M. 2016; 36 (3): 239-245

Abstract

This study was conducted to investigate the correlation between the number of vascularized lymph nodes (LN) transferred and resolution of hind limb lymphedema in a rat model.Unilateral hind limb lymphedema was created in 18 male Sprague-Dawley rats following inguinal and popliteal LN resection and radiation. A para-aortic LN flap based on the celiac artery was subsequently transferred to the affected groin. The three study groups consisted of Group A (no LN transfer), Group B (transfer of a single vascularized LN), and Group C (transfer of three vascularized LNs). Volumetric analysis of bilateral hind limbs was performed using micro-CT imaging at 1, 2, and 3 months postoperatively. Lymphatic drainage was assessed with Tc(99) lymphoscintigraphy preoperatively and at 3 months postoperatively.A statistically significant volume reduction was seen in Groups B and C compared to Group A at all time points. Volume reduction of Group A vs.Group B at 1 month (8.6%2.0% vs. 2.7%2.6%, P<0.05), 2 months (9.3%2.2% vs. -4.3%2.7%, P<0.05), and 3 months (7.6%3.3% vs. -8.9%5.2%, P<0.05). Volume reduction of Group A vs. Group C at 1 month (8.6%2.0% vs. -6.6%3.1%, P<0.05), 2 months (9.3%2.2% vs. -10.2%4.6%, P<0.05), and 3 months (7.6%3.3% vs. -9.1%3.1%, P<0.05). Of note, comparison of Groups B and C demonstrated greater volume reduction in Group C at 1 (P<0.02) and 2 (P=0.07) months postoperatively.LN flap transfer is an effective procedure for the treatment of lymphedema. The number of vascularized LNs transferred correlates positively with the degree of volume reduction. 2015 Wiley Periodicals, Inc. Microsurgery 36:239-245, 2016.

View details for DOI 10.1002/micr.22388

View details for PubMedID 25715830

Using intraoperative laser angiography to safeguard nipple perfusion in nipple-sparing mastectomies. Gland surgery Dua, M. M., Bertoni, D. M., Nguyen, D., Meyer, S., Gurtner, G. C., Wapnir, I. L. 2015; 4 (6): 497-505

Abstract

The superior aesthetic outcomes of nipple-sparing mastectomies (NSM) explain their increased use and rising popularity. Fortunately, cancer recurrences involving the nipple-areolar complex (NAC) have been reassuringly low in the range of 1%. Technical considerations and challenges of this procedure are centered on nipple ischemia and necrosis. Patient selection, reconstructive strategies and incision placement have lowered ischemic complications. In this context, rates of full NAC necrosis are 3% or less. The emergence of noninvasive tissue angiography provides surgeons with a practical tool to assess real-time breast skin and NAC perfusion. Herein, we review our classification system of NAC perfusion patterns defined as V1 (from subjacent breast), V2 (surrounding skin), and V3 (combination of V1 + V2). Additionally, we describe the benefits of a first stage operation to devascularize the NAC as a means of improving blood flow to the NAC in preparation for NSM, helping extend the use of NSM to more women. Intraoperative evaluation of skin perfusion allows surgeons to detect ischemia and modify the operative approach to optimize outcomes.

View details for DOI 10.3978/j.issn.2227-684X.2015.04.15

View details for PubMedID 26645004

Motion Analysis for Microsurgical Training: Objective Measures of Dexterity, Economy of Movement, and Ability. Plastic and reconstructive surgery McGoldrick, R. B., Davis, C. R., Paro, J., Hui, K., Nguyen, D., Lee, G. K. 2015; 136 (2): 231e-40e

Abstract

Evaluation of skill acquisition in microsurgery has traditionally relied on subjective opinions of senior faculty, but is shifting toward early competency-based training using validated models. No objective measures of dexterity, economy of movement, and ability exist. The authors propose a novel video instrument motion analysis scoring system to objectively measure motion.Video of expert microsurgeons was analyzed and used to develop a resident motion analysis scoring system based on a mathematical model. Motion analysis scores were compared to blinded, global rating scores of the same videos using the Stanford Microsurgery and Resident Training scale.Eighty-five microsurgical anastomoses from 16 residents ranging from postgraduate years 1 through 6 were analyzed. Composite motion analysis scores for each segmented video correlated positively to arterial anastomotic experience (rho, +0.77; p < 0.001). Stanford Microsurgery and Resident Training scale interrater reliability was consistent between expert assessors, and mean composite motion analysis overall performance and Stanford scores were well matched for each level of experience. Composite motion analysis scores correlated significantly with combined Stanford Microsurgery and Resident Training [instrument handling (rho, +0.66; p < 0.01), efficiency (rho, +0.59; p < 0.01), suture handling (rho, +0.83; p < 0.001), operative flow (rho, +0.67; p < 0.001), and overall performance (rho, +89; p < 0.001)] motion components of the scale.Instrument motion analysis provides a novel, reliable, and consistent objective assessment for microsurgical trainees. It has an associated cost, but is timely, repeatable, and senior physician independent, and exposes patients to zero risk.

View details for DOI 10.1097/PRS.0000000000001469

View details for PubMedID 26218398

Nipple Perfusion Is Preserved by Staged Devascularization in High-Risk Nipple-Sparing Mastectomies Bertoni, D. M., Nguyen, D., Rochlin, D., Choy, N., Gurtner, G., Wapnir, I. SPRINGER. 2015: 3536
Using intraoperative laser angiography to safeguard perfusion in nipple-sparing mastectomies. Gland Surgery Journal Dua, M., Bertoni, D., Nguyen, D. H., Meyer, S., Gurtner, G., Wapnir, I. 2015

Abstract

This study was conducted to investigate the correlation between the number of vascularized lymph nodes (LN) transferred and resolution of hind limb lymphedema in a rat model.Unilateral hind limb lymphedema was created in 18 male Sprague-Dawley rats following inguinal and popliteal LN resection and radiation. A para-aortic LN flap based on the celiac artery was subsequently transferred to the affected groin. The three study groups consisted of Group A (no LN transfer), Group B (transfer of a single vascularized LN), and Group C (transfer of three vascularized LNs). Volumetric analysis of bilateral hind limbs was performed using micro-CT imaging at 1, 2, and 3 months postoperatively. Lymphatic drainage was assessed with Tc(99) lymphoscintigraphy preoperatively and at 3 months postoperatively.A statistically significant volume reduction was seen in Groups B and C compared to Group A at all time points. Volume reduction of Group A vs.Group B at 1 month (8.6%2.0% vs. 2.7%2.6%, P<0.05), 2 months (9.3%2.2% vs. -4.3%2.7%, P<0.05), and 3 months (7.6%3.3% vs. -8.9%5.2%, P<0.05). Volume reduction of Group A vs. Group C at 1 month (8.6%2.0% vs. -6.6%3.1%, P<0.05), 2 months (9.3%2.2% vs. -10.2%4.6%, P<0.05), and 3 months (7.6%3.3% vs. -9.1%3.1%, P<0.05). Of note, comparison of Groups B and C demonstrated greater volume reduction in Group C at 1 (P<0.02) and 2 (P=0.07) months postoperatively.LN flap transfer is an effective procedure for the treatment of lymphedema. The number of vascularized LNs transferred correlates positively with the degree of volume reduction. 2015 Wiley Periodicals, Inc. Microsurgery 36:239-245, 2016.

View details for DOI 10.1002/micr.22388

Quantity of lymph nodes correlates with improvement in lymphatic drainage in treatment of hind limb lymphedema with lymph node flap transfer in rats Microsurgery Nguyen, D. H., Chou, P. Y., Hsieh, Y. H., Momeni, A., Fang, Y. D., Patel, K. M., Yang, C. Y., Ko, Y. S., Cheng, M. H. 2015: 23945

Abstract

This study was aimed to establish a consistent lower limb lymphedema animal model for further investigation of the mechanism and treatment of lymphedema.Lymphedema in the lower extremity was created by removing unilateral inguinal lymph nodes followed by 20, 30, and 40 Gy (groups IA, IB, and IC, respectively) radiation or by removing both inguinal lymph nodes and popliteal lymph nodes followed by 20 Gy (group II) radiation in Sprague-Dawley rats (350-400g). Tc(99) lymphoscintigraphy was used to monitor lymphatic flow patterns. Volume differentiation was assessed by microcomputed tomography and defined as the percentage change of the lesioned limb compared to the healthy limb.At 4 weeks postoperatively, 0% in group IA (n = 3), 37.5% in group IB (n = 16), and 50% in group IC (n = 26) developed lymphedema in the lower limb with total mortality and morbidity rate of 0%, 56.3%, and 50%, respectively. As a result of the high morbidity and mortality rates, 20 Gy was selected, and the success rate for development of lymphedema in the lower limb in group II was 81.5% (n = 27). The mean volume differentiation of the lymphedematous limb compared to the health limb was 7.76% 1.94% in group II, which was statistically significant compared to group I (P < 0.01).Removal of both inguinal and popliteal lymph nodes followed by radiation of 20 Gy can successfully develop lymphedema in the lower limb with minimal morbidity in 4 months.

View details for DOI 10.1097/GOX.0000000000000064

View details for PubMedID 25289315

View details for PubMedCentralID PMC4174147

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