Arash Momeni, MD

Abstract

The "Jolie effect" and other media focus on prophylactic treatments have resulted in unilateral breast cancer patients increasingly undergoing contralateral prophylactic mastectomy. Little is known, however, regarding outcomes following therapeutic versus prophylactic mastectomy. In this study, we compared complication rates of unilateral breast cancer patients undergoing contralateral prophylactic mastectomy (BM-TP) to patients undergoing bilateral prophylactic mastectomy (BM-P).The BM-TP and BM-P patients from 2015 to 2019 were identified in Optum Clinformatics DataMart. Six-month outcomes were assessed and included wound complications, infection, hematoma/seroma, breast pain, fat necrosis, flap failure, implant failure/removal, other flap/implant complications, and other complications. Multivariable regression models adjusted for age, residence, insurance, race, and Charlson Comorbidity Index score.Of 9319 women, 7114 (76.3%) underwent BM-TP, and 2205 (23.7%) underwent BM-P. In multivariable analysis, BM-TP had higher odds of overall complications (adjusted odds ratio [aOR], 1.35; P < 0.0001), but no difference was observed among patients who had autologous (P = 0.1448) or no breast reconstruction (P = 0.1530). Higher odds of overall complications persisted even after controlling for radiation therapy (aOR, 1.25; P = 0.0048) and chemotherapy (aOR, 1.28; P = 0.0047), but not after controlling for lymph node surgery (P = 0.7765).The BM-TP (vs BM-P) patients face higher odds of overall complications but without any difference in certain reconstructive modalities or after controlling for lymph node surgery.

View details for DOI 10.1097/SAP.0000000000003648

View details for PubMedID 37553890

Abstract

Impostor phenomenon occurs when high-achieving individuals have persistent self-doubt despite objective measures of competence and success, and has been associated with professional burnout and attenuated career advancement in medical specialties. This study aimed to define the incidence and severity of the impostor phenomenon in academic plastic surgery.A cross-sectional survey containing the Clance Impostor Phenomenon Scale (0-100; higher scores indicating greater severity of impostor phenomenon) was distributed to residents and faculty from 12 academic plastic surgery institutions across the United States. Generalized linear regression was used to assess demographic and academic predictors of impostor scores.From a total of 136 resident and faculty respondents (response rate, 37.5%), the mean impostor score was 64 (SD 14), indicating frequent impostor phenomenon characteristics. On univariate analysis, mean impostor scores varied by gender (Female: 67.3 vs. Male: 62.0; p=0.03) and academic position (Residents: 66.5 vs. Attendings: 61.6; p=0.03), but did not vary by race/ethnicity, post-graduate year of training among residents, or academic rank, years in practice, or fellowship training among faculty (all p>0.05). After multivariable adjustment, female gender was the only factor associated with higher impostor scores among plastic surgery residents and faculty (Estimate 2.3; 95% Confidence Interval 0.03-4.6; p=0.049).The prevalence of the impostor phenomenon may be high among residents and faculty in academic plastic surgery. Impostor characteristics appear to be tied more to intrinsic characteristics, including gender, rather than years in residency or practice. Further research is needed to understand the influence of impostor characteristics on career advancement in plastic surgery.

View details for DOI 10.1097/PRS.0000000000010821

View details for PubMedID 37307036

Abstract

Autologous breast reconstruction yields improved long-term aesthetic results but requires increased resources of practitioners and hospital systems. Innovations in radiographic imaging have been used increasingly to improve the efficiency and success of free-flap harvest. Augmented reality (AR) affords the opportunity to superimpose relevant imaging on a surgeon's native field of view, potentially facilitating dissection of anatomically variable structures. To validate the spatial fidelity of AR projections of deep inferior epigastric perforator flap (DIEP) relevant anatomy, comparisons of 3D models and their virtual renderings were performed by four independent observers. Measured discrepancies between the real and holographic models were evaluated.3D-printed models of DIEP relevant anatomy were fabricated from CTA data from 19 de-identified patients. The corresponding CTA data was similarly formatted for the Microsoft Hololens to generate corresponding projections. Anatomic points were initially measured on 3D models, after which, the corresponding points were measured on the Hololens projections from two separate vantages. Statistical analyses, including Generalized Linear Modeling, were performed to characterize spatial fidelity regarding translation, rotation, and scale of holographic projections.Amongst all participants, the median translational displacement at corresponding points was 9.0 mm, 12.1 mm, and 13.5 mm between the real 3D model and V1, 3D model and V2, and between V1 and V2, respectively.Corresponding points, including topography of perforating vessels for the purposes of breast reconstruction can be identified within millimeters, but there remain multiple independent contributors of error, most notably the participant and location at which the projection is perceived.

View details for DOI 10.1097/PRS.0000000000010592

View details for PubMedID 37092985

Abstract

Microvascular thrombosis with resultant flap loss remains a devastating complication in autologous breast reconstruction. While acetylsalicylic acid (ASA) for prevention of microvascular thrombosis is commonly administered postoperatively, clinical evidence supporting this practice remains insufficient. Here, we investigate the association of postoperative ASA administration with differences in clinical outcomes following microsurgical breast reconstruction.A prospectively maintained database was queried to identify patients who had undergone microsurgical breast reconstruction. Patients were categorized based on whether they had received postoperative ASA for 30d (Group 1) or had not received ASA (Group 2). Patient demographics, reconstructive outcomes, complications, and transfusion requirements were retrieved.One hundred thirty six patients with a mean age of 49.5y and a mean body mass index of 28.5kg/m2 who had undergone a total of 216 microsurgical breast reconstructions were included. No significant differences were noted with regard to patient demographics with the exceptions of increased rates of neoadjuvant chemotherapy and delayed reconstruction in Group 1. There were no significant differences in the rates of postoperative complications including breast hematoma, mastectomy skin flap necrosis, partial flap necrosis, seroma, and deep venous thrombosis between patients who did or did not receive ASA postoperatively. Similarly, no difference was noted regarding postoperative blood transfusion rates (Group 1: 9.9% versus Group 2: 9.1%; P=0.78). Finally, patients in Group 1 had significantly longer hospital stays (Q1=4, median=4.5, Q3=5).Postoperative ASA administration is not associated with improved postoperative clinical outcomes. The use of ASA routinely after autologous breast reconstruction does not appear to be a necessity in practice.

View details for DOI 10.1016/j.jss.2023.02.027

View details for PubMedID 36989833

Abstract

Wound dehiscence, oftentimes a result of the poor tensile strength of early healing wounds, is a significant threat to the postoperative patient, potentially causing life-threatening complications. Vanadate, a protein tyrosine phosphatase inhibitor, has been shown to alter the organization of deposited collagen in healing wounds and significantly improve the tensile strength of incisional wounds in rats. In this study, we sought to explore the effects of locally administered vanadate on tensile strength and collagen organization in both the early and remodeling phases of excisional wound healing in a murine model. Wild-type mice underwent stented excisional wounding on their dorsal skin and were divided equally into three treatment conditions: vanadate injection, saline injection control, and an untreated control. Tensile strength testing, in vivo suction Cutometer analysis, gross wound measurements, and histologic analysis were performed during healing, immediately upon wound closure, and after four weeks of remodeling. We found that vanadate treatment significantly increased the tensile strength of wounds and their stiffness relative to control wounds, both immediately upon healing and into the remodeling phase. Histologic analysis revealed that these biomechanical changes were likely the result of increased collagen deposition and an altered collagen organization composed of thicker and distinctly organized collagen bundles. Given the risk that dehiscence poses to all operative patients, vanadate presents an interesting therapeutic avenue to improve the strength of post-operative wounds and unstable chronic wounds in order to reduce the risk of dehiscence.

View details for DOI 10.1111/wrr.13062

View details for PubMedID 36484112

Abstract

PURPOSE: Composite measures, like textbook outcomes, may be superior to individual metrics when assessing hospital performance and quality of care. This study utilized a Delphi process to define a textbook outcome in DIEP flap breast reconstruction.METHODS: A two-round Delphi survey defined: (1) A textbook outcome, (2) Exclusion criteria for a study population, and (3) Respondent opinion regarding textbook outcomes. An a priori threshold of70% agreement among respondents established consensus among the tested statements.RESULTS: Out of 85 invitees, 48 responded in the first round and 41 in the second. A textbook outcome was defined as one that meets the following within 90 days: (1) No intraoperative complications, (2) Operative duration12h for bilateral and10h for unilateral/stacked reconstruction, (3) No post-surgical complications requiring re-operation, (4) No surgical site infection requiring IV antibiotics, (5) No readmission, (6) No mortality, (7) No systemic complications, and (8) Length of stay<5days. Exclusion criteria for medical and surgical characteristics (e.g., BMI>40, HgbA1c>7) and case-volume cut-offs for providers (21) and institutions (44) were defined. Most agreed that textbook outcomes should be defined for complex plastic surgery procedures (75%) and utilized to gauge hospital performance for microsurgical breast reconstruction (77%).CONCLUSION: This Delphi study identified (1) Key elements of a textbook outcome for DIEP flap breast reconstruction, (2) Exclusion criteria for future studies, and (3) Characterized surgeon opinions regarding the utility of textbook outcomes in serving as quality metric for breast reconstruction care.

View details for DOI 10.1007/s10549-022-06820-z

View details for PubMedID 36441271

View details for Web of Science ID 000867877000011

Abstract

Nipple-sparing mastectomy (NSM) with immediate breast reconstruction is commonly performed. However, nipple areolar complex (NAC) and mastectomy skin necrosis represent significant complications requiring reoperation and revision. Breast MRI, often obtained for oncologic assessment, can visualize the dominant breast and NAC vascular supply. This study describes the surgical technique utilizing breast MRI blood flow information to preserve important NAC blood supply, thereby, reducing ischemic complications.After IRB approval, a prospectively maintained database of all NSM by a single breast surgeon from 2018 to 2020 formed the study group. Preoperative contrast enhanced Breast MRI analysis determined the dominant NAC blood supply. Intraoperatively, the dominant Internal Mammary Artery Perforator (IMP) to the NAC was preserved (IMP-NSM). The IMP-NSM surgical technique preserving the IMP blood flow, evaluation of breast MRI blood flow patterns, surgical findings, and ischemic complications were analyzed.114 NSM were performed in 74 patients (mean age: 49years [range, 22-73years], BMI 25.8kg/m2 [range, 19-41kg/m2]). Breast MRI identified the dominant IMP to the NAC in 92%. IMP preservation was successful in 89% (101/114). Necrosis requiring NAC removal occurred in 0.9% (1/114), and skin necrosis reoperation in 1.8% (2/114). Including all post-operative necrosis occurred in 10.5% (12/114), statistically significantly lower compared to the literature for NSM assessing MRI blood flow data without surgical IMP preservation (necrosis 24.4%, p<0.001) (Bahl et al. in J Am Coll Surg 223(2):279-285, 2016) utilizing Doppler for IMP preservation (necrosis 37%, p<0.001) (Swistel et al. in Plast Reconstr Surg Glob Open 2(8):e198, 2014) and dividing the IMP in all (necrosis 31.4%, p<0.001) (Ahn et al. in Eur J Surg Oncol 44(8):1170-1176, 2018).The IMP-NSM surgical technique preserves the dominant blood supply to the NAC, thereby, decreasing ischemic complications.

View details for DOI 10.1007/s00268-022-06764-x

View details for PubMedID 36207418

Abstract

Evidence-based venous thromboembolism (VTE) prevention among aesthetic patients is lacking. This study seeks to (1) quantify 2005 Caprini scores in primary breast augmentation patients, (2) determine the proportion of patients with potentially modifiable VTE risk factors, and (3) project, using Monte Carlo simulation, the expected distribution of Caprini scores among aesthetic surgery patients who develop VTE.Methods: The observational study (part 1) screened consecutive primary breast augmentation patients for VTE risk using the 2005 Caprini score. Aggregate scores were compiled, and the proportion of patients with potentially modifiable risk factors were identified. Part 2 used Monte Carlo simulation to generate risk score distributions for VTE events predicted to occur among randomly sampled patient cohorts with baseline Caprini risk profiles derived from the part 1 data.Results: One hundred patients had mean age of 35.7 years and mean body mass index of 23.8kg/m2. Median 2005 Caprini score was 3 (range, 2-8), with the majority (96%) having scores of 6. Twenty-eight percent of patients had at least one potentially modifiable risk factor or risk factor potentially benefiting from further investigation. Monte Carlo simulations demonstrated that for a population with 96% Caprini 6 (and 4% Caprini 7), 80% of VTE events would be expected to occur in patients with Caprini scores 6.Conclusions: The majority of breast augmentation patients in this study (96%) have 2005 Caprini scores 6. Twenty-eight percent of patients have potentially modifiable risk factors. The majority of patients with VTE after aesthetic surgery are expected to have lower Caprini risk scores.

View details for DOI 10.1097/GOX.0000000000004573

View details for PubMedID 36246074

Abstract

Microsurgical reconstruction has established itself as a standard procedure in breast reconstruction as it permits creation of a natural and aesthetically appealing breast mound, even after modified radical mastectomy and radiation. In the past few decades numerous new free flap donor-sites have been described that permit an individualized approach to reconstruction, thus, resulting in a high level of patient satisfaction. Paralleling these technical innovations, the focus of microsurgical breast reconstruction has shifted from mere "flap success" to "aesthetic outcome", while also taking into account the respective donor-site morbidity. Here, the authors discuss contemporary developments in the field with a particular focus on surgical techniques and technologies that contribute to increasing the safety of microsurgical breast reconstruction.

View details for DOI 10.1055/a-1858-5214

View details for PubMedID 35785806

Abstract

The challenge following mastectomy is to safely reconstruct breasts of adequate size, shape, symmetry, softness, and sensation ("6S"). Historically, patients have been offered two reconstructive modalities, namely either implant-based or autologous reconstruction. While this binary approach is appropriate for most patients, there remain a subset of patients for whom this simplistic approach is not suitable. For these, hybrid reconstruction, i.e., the combination of an implant with microsurgical tissue transfer, offers the possibility of individualised reconstruction, which avoids some of the limitations of traditional approaches. Hybrid breast reconstruction, thus expands the indications for microsurgical reconstruction and offers the advantages of this reconstructive modality to a larger patient population. In this article, the surgical technique of hybrid breast reconstruction is described, along with a discussion of important parameters related to this reconstructive modality, including plane and timing of implant placement, and the issue of radiotherapy.

View details for DOI 10.1055/a-1808-6779

View details for PubMedID 35732188

Abstract

BACKGROUND: Radiation-induced skin injury is a well-known risk factor for impaired wound healing. Over time, the deleterious effects of radiation on skin produce a fibrotic, hypovascular dermis poorly suited to wound healing. Despite increasing understanding of the underlying pathophysiology, therapeutic options remain elusive. Deferoxamine (DFO), an iron-chelating drug, has been shown in prior murine studies to ameliorate radiation-induced skin injury as well as improve wound healing outcomes in various pathologic conditions when administered transdermally. In this preclinical study, we evaluated the effects of deferoxamine on wound healing outcomes in chronically irradiated murine skin.METHODS: Wild-type mice received 30Gy of irradiation to their dorsal skin and were left to develop chronic fibrosis. Stented excisional wounds were created on their dorsal skin. Wound healing outcomes were compared across 4 experimental conditions: DFO patch treatment, vehicle-only patch treatment, untreated irradiated wound, and untreated nonirradiated wounds. Gross closure rate, wound perfusion, scar elasticity, histology, and nitric oxide assays were compared across the conditions.RESULTS: Relative to vehicle and untreated irradiated wounds, DFO accelerated wound closure and reduced the frequency of healing failure in irradiated wounds. DFO augmented wound perfusion throughout healing and upregulated angiogenesis to levels observed in nonirradiated wounds. Histology revealed DFO increased wound thickness, collagen density, and improved collagen fiber organization to more closely resemble nonirradiated wounds, likely contributing to the observed improved scar elasticity. Lastly, DFO upregulated inducible nitric oxide synthase and increased nitric oxide production in early healing wounds.CONCLUSION: Deferoxamine treatment presents a potential therapeutic avenue through which to target impaired wound healing in patients following radiotherapy.

View details for DOI 10.1186/s12967-022-03479-4

View details for PubMedID 35715816

View details for DOI 10.1097/GOX.0000000000004344

View details for Web of Science ID 000799392200001

Abstract

The effects of recent initiatives to better educate unilateral breast cancer (UBC) patients about contralateral prophylactic mastectomy (CPM) have not been fully examined. The purpose of this study was to update and examine recent annual CPM trends by evaluating 2015-2020 data from a large administrative claims database. We also sought to determine if there were any variations in trends among different age groups and reconstructive modalities.Patients diagnosed with UBC between 2015 and 2019 were identified in Optum Clinformatics DataMart. Patients were then categorized by age group, whether they underwent CPM, whether they underwent breast reconstruction (BR), timing of any BR (immediate or delayed), and type of BR (implant-based or autologous).Of 55,060 patients who were diagnosed with UBC, 2625 (4.8%) underwent CPM. After a slight decline from 2015 to 2016, the CPM rate among UBC patients increased significantly from 3.4% in 2016 to 6.8% in 2019. Although this upward trend remained consistent across all age groups examined, younger UBC patients represented a significantly higher and faster growing percentage of those undergoing CPM. BR rates among those who underwent CPM also increased between 2015 and 2019, with implant-based and immediate BR becoming more heavily favored over autologous and delayed BR.CPM rates continued to rise between 2016 and 2019 and younger women represented a substantially higher and faster growing percentage of UBC patients undergoing CPM than older women. In addition, implant-based and immediate BR are becoming more heavily favored over autologous and delayed BR.

View details for DOI 10.1097/GOX.0000000000004344

View details for PubMedID 35646492

View details for PubMedCentralID PMC9132527

View details for Web of Science ID 000780965900147

Abstract

Treatments for radiation-induced fibrosis range from vitamin E and pentoxifylline systemically to deferoxamine and fat grafting locally. Regarding fat grafting, volume retention hinders its long-term functionality and is affected by two factors: inflammation and necrosis secondary to hypovascularity.We aimed to simultaneously improve fat graft retention and radiation-induced fibrosis by integrating vitamin E and pentoxifylline into fat grafts locally.Forty adult CD-1 nude male mice at 6 weeks of age underwent scalp irradiation and recovered for four weeks to allow for the development of fibrosis. Mice received 200L of donor human fat graft to the scalp. Mice were separated into 4 conditions: no grafting, fat graft without treatment, graft treated with pentoxifylline, and graft treated with vitamin E. Fat graft volume retention was monitored in-vivo using microCT scans at weeks 0, 1, 2, 4, 6, and 8 after grafting. Histological and cytokine analysis of the scalp skin and fat grafts were also performed.Vitamin E (VE) treated grafts had significant improvement in dermal thickness and collagen density of overlying skin compared to all other groups. VE decreased 8-isoprostane and increased CD31 + staining compared to the other grafted groups. Cytokine analysis revealed decreased inflammatory and increased angiogenic markers in both the fat graft and overlying skin of the vitamin E group. Fat graft volume retention was significantly improved in the vitamin E group starting at 1 week post grafting.Radiation-induced fibrosis and fat graft volume retention are both simultaneously improved with local administration of vitamin E.

View details for DOI 10.1093/asj/sjac066

View details for PubMedID 35350074

View details for Web of Science ID 000763583000040

Abstract

BACKGROUND: Breast conservation therapy remains the gold standard for women with localized breast cancer; however, some women may eventually undergo mastectomy with reconstruction. Little is understood regarding the risks of failed breast conservation therapy as they relate to postmastectomy reconstruction and whether this affects outcomes.METHODS: Patients undergoing breast reconstruction were extracted from a merged version of the MarketScan inpatient and outpatient databases from 2007 to 2016. Frequency of lumpectomy and radiation therapy were determined per reconstructive patient. Outcomes included inpatient complications and frequency of revision procedures. Regression models were adjusted for age, obesity, timing of reconstruction, and Elixhauser Comorbidity Index.RESULTS: Six thousand two hundred eighty-eight of 52,826 (11.9 percent) women underwent more than breast mass excisions before mastectomy with reconstruction. Of those, the mean number of excisions per woman was 1.67 0.90. There were 3334 lumpectomy patients (53.0 percent) who completed radiation therapy. The mean number of revisions with breast conservation therapy was 1.5 versus 1.3 in the general cohort. On multivariable analysis, excision of breast mass alone was not associated with increased odds of inpatient complications (OR, 1.07; p = 0.363), nor was radiation therapy (OR, 0.89; p = 0.153). However, radiation therapy with or without excision of breast mass before mastectomy was a significant predictor of more frequent revision operations (p = 0.032). Excision of breast mass alone was not associated with an increased frequency of revision (p = 0.173).CONCLUSIONS: History of radiation therapy in the setting of failed breast conservation therapy resulting in mastectomy with reconstruction was associated with an increased risk for revision. Patients should be counseled accordingly before breast conservation therapy in the event they may eventually undergo mastectomy with reconstruction.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

View details for DOI 10.1097/PRS.0000000000008896

View details for PubMedID 35103635

View details for DOI 10.1016/j.jdcr.2022.08.046

Abstract

Shared decision-making gives patients greater autonomy in their healthcare decisions; however, decisions that result in negative outcomes may lead to decision regret. The complexity of reconstructive options makes post-mastectomy breast reconstruction particularly prone to decision regret. This study's purpose was to explore the relationship between breast reconstruction modalities and degree of postoperative decision regret. Patients who had undergone either implant-based or autologous breast reconstruction with a minimum of 12 months of follow-up were invited to complete the Decision Regret Scale and the BREAST-Q Satisfaction with Breasts module. The impact of reconstructive modality and occurrence of postoperative complications on decision regret and satisfaction with breasts was examined. Sixty-three patients completed the questionnaires-25 patients with implant-based reconstruction and 38 patients with autologous reconstruction. The average Decision Regret score was 84.6 23.6; thirty-one patients experienced no decision regret. The average score for the BREAST-Q module was 81.9 18.8. Neither satisfaction with breasts nor decision regret were impacted by the reconstructive modality. The occurrence of postoperative complications was strongly correlated with lower Decision Regret scores (91.6 vs. 74.6, p=0.004) but was not correlated with lower Satisfaction with Breasts scores (84.6 vs. 78.2, p=0.18). Patients had relatively low levels of decision regret and relatively high levels of satisfaction with breasts, irrespective of reconstructive modality. Having a postoperative complication led to significantly greater levels of decision regret without impacting satisfaction with breasts. Patients may benefit from additional preoperative education on possible complications to mitigate decision regret. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

View details for DOI 10.1007/s00266-021-02660-2

View details for PubMedID 34845512

View details for Web of Science ID 000718303100367

View details for Web of Science ID 000718306700033

View details for Web of Science ID 000718303100399

View details for Web of Science ID 000718303100396

View details for Web of Science ID 000718306700380

Abstract

The iron chelator, deferoxamine (DFO), has been shown to potentially improve dermal radiation-induced fibrosis (RIF) in mice through increased angiogenesis and reduced oxidative damage. This preclinical study evaluated the efficacy of two DFO administration modalities, transdermal delivery and direct injection, as well as temporal treatment strategies in relation to radiation therapy to address collateral soft tissue fibrosis. The dorsum of CD-1 nude mice received 30Gy radiation, and DFO (3mg) was administered daily via patch or injection. Treatment regimens were prophylactic, during acute recovery, post-recovery, or continuously throughout the experiment (n=5 per condition). Measures included ROS-detection, histology, biomechanics and vascularity changes. Compared with irradiated control skin, DFO treatment decreased oxidative damage, dermal thickness and collagen content, and increased skin elasticity and vascularity. Metrics of improvement in irradiated skin were most pronounced with continuous transdermal delivery of DFO. In summary, DFO administration reduces dermal fibrosis induced by radiation. Although both treatment modalities were efficacious, the transdermal delivery showed greater effect than injection for each temporal treatment strategy. Interestingly, the continuous patch group was more similar to normal skin than to irradiated control skin by most measures, highlighting a promising approach to address detrimental collateral soft tissue injury following radiation therapy.

View details for DOI 10.1111/jcmm.16913

View details for PubMedID 34612609

Abstract

In this article, we discuss 4 common free flaps performed in reconstructive surgery: the anterolateral thigh flap, the radial forearm flap, the fibula flap, and the transverse rectus abdominis myocutaneous/deep inferior epigastric perforator flap. Donor and recipient complications for each flap type and strategies on how to prevent and manage such complications are discussed.

View details for DOI 10.1016/j.suc.2021.06.009

View details for PubMedID 34537145

Abstract

OBJECTIVE: Skin fibrosis places an enormous burden on patients and society, but disagreement exists over methods to quantify severity of skin scarring. A suction cutometer measures skin elasticity in-vivo, but it has not been widely adopted due to inconsistency in data produced. We investigated variability of several dimensionless parameters generated by the cutometer to improve their precision and accuracy.APPROACH: Twenty adult human subjects underwent suction cutometer measurement of normal skin and fibrotic scars. Using Mode 1, each subject underwent 5 trials with each trial containing 4 curves. R0/2/5/6/7 and Q1/2/3 data were collected. Analyses were performed on these calculated parameters.RESULTS: R0/2/5/6/7 and Q1/2 parameters from curves 1-4 demonstrated significant differences, while these same parameters were not significantly different when only using curves 2-4. Individual analysis of all parameters between curve 1 and every subsequent curve was statistically significant for R0, R2, R5, R6, R7, Q1, and Q2. No differences were appreciated for parameter Q3. Comparison between normal skin and fibrotic scars were significantly different for parameters R5, Q1, and Q3.INNOVATION: Our study is the first demonstration of accurate comparison between normal skin and fibrotic scars using the dimensionless parameters of a suction cutometer.CONCLUSION: Measured parameters from the first curve of each trial were significantly different from subsequent curves for both normal skin and fibrotic scars. Precision and reproducibility of data from dimensionless parameters can therefore be improved by removing the first curve. R5, Q1, and Q3 parameters differentiated normal skin as more elastic than fibrotic scars.

View details for DOI 10.1089/wound.2021.0082

View details for PubMedID 34470542

View details for DOI 10.1245/s10434-021-10617-7

View details for PubMedID 34365561

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

View details for PubMedID 34341890

View details for DOI 10.1097/GOX.0000000000003781

View details for Web of Science ID 000695249500008

Abstract

Seroma and infection are among the most common complications after staged prepectoral implant-based reconstruction. Advances in tissue expander technology permit seroma aspiration via an integrated drain port, thus, holding promise for improving clinical outcomes.A prospectively maintained database of patients who had undergone immediate prepectoral breast reconstruction using the Sientra AlloX2 tissue expander was used to determine the rate of postoperative seroma formation, its volume and microbiological spectrum, as well as postoperative complications.49 patients (mean age: 49 years, mean body mass index: 24.5 kg/m2) underwent 79 prepectoral breast reconstructions. Seroma was clinically suspected in 26 reconstructions (32.9%) and was easily aspirated in all cases via the integrated drain port. Importantly, periprosthetic fluid was successfully aspirated in 45 reconstructions (57%) without any clinical evidence for seroma, with aspirated cumulative fluid volumes exceeding 10cm3 in 12 reconstructions. Bacterial cultures from aspirated fluid were positive in six patients (12.2%), of whom two developed clinical signs of infection, at which point targeted antibiotic treatment was initiated.Our study demonstrates that routine office-based aspiration of periprosthetic fluid via the integrated drain port of the AlloX2 tissue expander not only permits successful aspiration of periprosthetic fluid but also allows aspirated fluid to be sent for culture, thus, providing a lead-time advantage for initiation of targeted antibiotic therapy in cases of postoperative surgical site infection. Furthermore, our observations indicate that positive bacterial cultures in the absence of clinical signs of infection do not mandate antibiotic therapy.

View details for DOI 10.1097/GOX.0000000000003781

View details for PubMedID 34667707

View details for PubMedCentralID PMC8517312

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

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

Abstract

OBJECTIVE: Mandibular distraction osteogenesis (MDO) is frequently performed to address airway obstruction in patients with Pierre Robin sequence (PRS), though more recently the technique of orthodontic airway plating (OAP) has gained traction. We aimed to evaluate OAP compared to MDO for airway obstruction in PRS.DESIGN: A systematic literature search across PubMed, Embase, and Google Scholar identified all studies published in English, which involved MDO or any form of OAP as treatments for PRS. All relevant articles were reviewed in detail and reported on, adhering to PRISMA guidelines.MAIN OUTCOME MEASURES: Airway (tracheostomy avoidance, decannulation rate), feeding (full oral feeding tolerance).RESULTS: Literature search identified 970 articles, of which 42 MDO studies and 9 OAP studies met criteria for review. A total of 1159 individuals were treated with MDO, and 322 individuals were treated with OAP. Primary outcomes appear similar for MDO and OAP at face value; however, this must be interpreted with different pretreatment contexts in mind.CONCLUSIONS: Orthodontic airway plating may be considered for airway obstruction in PRS, as some airway-related and feeding-related outcomes appear similar with MDO, per existing evidence in the literature. However, since PRS severity differed between studies, OAP cannot be uniformly considered a replacement for MDO. Further research is required to more comprehensively assess these treatment modalities inclusive of metrics that allow for direct comparison.

View details for DOI 10.1177/10556656211011886

View details for PubMedID 34075816

View details for Web of Science ID 000650046500027

Abstract

BACKGROUND: A promising and useful development of negative-pressure wound therapy (NPWT) is the addition of instillation and dwell time of topical wound solutions (NPWTi-d). Uses of NPWTi-d include acute and traumatic wounds, whereby wound closure may be facilitated via wound cleansing and promotion of granulation tissue formation. This systematic review summarizes publications on NPWTi-d in the treatment of acute and traumatic wounds.METHODS: A systematic review was performed analyzing articles from major clinical databases. Only clinical studies 10 patients reporting on the application of NPWTi-d in acute and traumatic wounds were included.RESULTS: One hundred ninety-two articles were retrieved, of which 10 articles met inclusion criteria. Of those, 2 were lesser-quality randomized controlled trials, comparative studies or prospective cohorts, 2 were retrospective studies, and 6 retrospective cohort studies. In total, included publications reported 109 patients with acute and traumatic wounds treated with NPWTi-d. Data from these studies indicated the potential for reduction in bacterial bioburden through wound cleansing and promotion of granulation tissue formation, thereby facilitating wound closure, reduced length of therapy and hospital time. However, for most publications, different wound causes and subsequently no isolated results for acute and traumatic wounds were reported.CONCLUSION: NPWTi-d has promise to be effective in facilitating wound closure and reducing the time for wound closure. The present systematic review demonstrates a relatively low level of evidence available to objectively support this effect. To underline these positive results, large prospective, randomized controlled trials are necessary to manifest the role of NPWTi-d in the daily clinical routine for this wound category.

View details for DOI 10.1097/PRS.0000000000007610

View details for PubMedID 33347062

Abstract

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View details for DOI 10.1126/sciadv.abi4528

View details for PubMedID 34851663

Abstract

Radiation therapy is effective for cancer treatment but may also result in collateral soft tissue contracture, contour deformities, and non-healing wounds. Autologous fat transfer has been described to improve tissue architecture and function of radiation-induced fibrosis and these effects may be augmented by enrichment with specific adipose-derived stromal cells (ASCs) with enhanced angiogenic potential. CD34+CD146+, CD34+CD146-, or CD34+ unfractionated (UF) human ASCs were isolated by flow cytometry and used to supplement human lipoaspirate placed beneath the scalp of irradiated mice. Volume retention was followed radiographically and fat grafts as well as overlying soft tissue were harvested after eight weeks for histologic and biomechanical analyses. Radiographic evaluation revealed the highest volume retention in fat grafts supplemented with CD34+CD146+ ASCs, and these grafts were also found to have greater histologic integrity than other groups. Irradiated skin overlying CD34+CD146+ ASC-enriched grafts was significantly more vascularized than other treatment groups, had significantly less dermal thickness and collagen deposition, and the greatest improvement in fibrillin staining and return of elasticity. Radiation therapy obliterates vascularity and contributes to scarring and loss of tissue function. ASC-enrichment of fat grafts with CD34+CD146+ ASCs not only enhances fat graft vascularization and retention, but also significantly promotes improvement in overlying radiation-injured soft tissue. This regenerative effect on skin is highly promising for patients with impaired wound healing and deformities following radiotherapy. This article is protected by copyright. All rights reserved.

View details for DOI 10.1002/term.3253

View details for PubMedID 34582109

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

View details for PubMedID 34448056

Abstract

An increase in the number and quality of randomized controlled trials (RCTs) and trends toward higher levels of evidence (LOE) in the plastic surgery literature has been reported; however, there has not been a specific focus on the LOE of presentations at scientific meetings. The purpose of this study was to ascertain trends in the LOE of studies presented at the annual meeting of the American Association of Plastic Surgeons.A hand search was conducted identifying all abstracts of podium presentations from 2009 to 2019. LOE, using American Society of Plastic Surgeons guidelines, were ascribed to each presentation, along with identification of any corresponding journal publications. RCTs were further analyzed using the 12-item Modified Consolidated Standard of Reporting Trials checklist.Four hundred forty-one studies with a median LOE of 3 were included in the study. A non-significant improvement in the mean level of evidence was noted over time (P = 0.09) along with an increase in the number of level 2 studies (P = 0.589) and RCTs (P = 0.717). Level 1 studies were rare (0.91%) and of fair quality (median checklist score 8 out of 12). Seventy-two percent of abstracts resulted in publication, and the mean lag time to publication was 422 days.A favorable trend is observed with respect to the mean LOE as well as the number of level 2 studies and RCTs over time. The importance of research meeting attendance to maintain up-to-date information is noteworthy, given the long lag time from presentation to publication.

View details for DOI 10.1097/GOX.0000000000003588

View details for PubMedID 34046292

View details for PubMedCentralID PMC8143775

Abstract

The accepted "one-size-fits-all" dose strategy for prophylactic enoxaparin may not optimize the medication's risks and benefits after surgical procedures. The authors hypothesized that weight-based administration might improve the pharmacokinetics of prophylactic enoxaparin when compared to fixed-dose administration.The FIxed or Variable Enoxaparin (FIVE) trial was a randomized, double-blind trial that compared the pharmacokinetic and clinical outcomes of patients assigned randomly to postoperative venous thromboembolism prophylaxis using enoxaparin 40 mg twice daily or enoxaparin 0.5 mg/kg twice daily. Patients were randomized after surgery and received the first enoxaparin dose at 8 hours after surgery. Primary hypotheses were (1) weight-based administration is noninferior to a fixed dose for avoiding underanticoagulation (anti-factor Xa <0.2 IU/ml) and (2) weight-based administration is superior to fixed-dose administration for avoiding overanticoagulation (anti-factor Xa >0.4 IU/ml). Secondary endpoints were 90-day venous thromboembolism and bleeding.In total, 295 patients were randomized, with 151 assigned to fixed-dose and 144 to weight-based administration of enoxaparin. For avoidance of underanticoagulation, weight-based administration had a greater effectiveness (79.9 percent versus 76.6 percent); the 3.3 percent (95 percent CI, -7.5 to 12.5 percent) greater effectiveness achieved statistically significant noninferiority relative to the a priori specified -12 percent noninferiority margin (p = 0.004). For avoidance of overanticoagulation, weight-based enoxaparin administration was superior to fixed-dose administration (90.6 percent versus 82.2 percent); the 8.4 percent (95 percent CI, 0.1 to 16.6 percent) greater effectiveness showed significant safety superiority (p = 0.046). Ninety-day venous thromboembolism and major bleeding were not different between fixed-dose and weight-based cohorts (0.66 percent versus 0.69 percent, p = 0.98; 3.3 percent versus 4.2 percent, p = 0.72, respectively).Weight-based administration showed superior pharmacokinetics for avoidance of underanticoagulation and overanticoagulation in postoperative patients receiving prophylactic enoxaparin.Therapeutic, I.

View details for DOI 10.1097/PRS.0000000000007780

View details for PubMedID 33761517

View details for Web of Science ID 000582792300425

View details for Web of Science ID 000582798100415

View details for Web of Science ID 000582798100412

View details for Web of Science ID 000582798100420

View details for DOI 10.1097/GOX.0000000000003112

View details for Web of Science ID 000576727700042

Abstract

Autologous breast reconstruction has been demonstrated to be associated with superior patient-reported outcomes, and hence is regarded as the gold standard reconstructive modality. A common drawback of this procedure, however, is related to a high abdominal scar. Recently, hybrid breast reconstruction (ie, the combination of autologous and implant-based reconstruction) was presented as an approach that would combine the benefits of both reconstructive modalities. In this study, we sought to assess abdominal aesthetic outcomes associated with this approach.Thirty-two blinded reviewers evaluated standardized pre- and postoperative abdominal images of patients following autologous reconstruction with free abdominal flap (Group 1; N = 10), hybrid reconstruction (Group 2; N = 5), and abdominoplasty (Group 3; N = 10). Aesthetic abdominal appearance, including overall result, scar position, skin redundancy, and lateral abdominal contour, was rated on a 5-point Likert scale and a comparative analysis was performed.Hybrid reconstruction was associated with significantly lower abdominal scars compared with Group 1 (P = 0.01), nearing results of patients in Group 3 (P = 0.39). Significantly higher aesthetic ratings were ascribed to Groups 2 and 3 when compared with Group 1 (P < 0.001) with regard to scar positioning (P < 0.001), skin redundancy (P < 0.001), and lateral abdominal contour (P < 0.001). No significant difference in aesthetic ratings was noted between Groups 2 and 3.When applied to the appropriate patient population, hybrid breast reconstruction is a powerful method to achieve reconstructive goals while optimizing abdominal aesthetics. A significantly lower scar position was noted and higher abdominal aesthetic ratings were given following abdominoplasty and hybrid reconstruction compared with conventional abdominal flap-based reconstruction.

View details for DOI 10.1097/GOX.0000000000003112

View details for PubMedID 33133961

View details for PubMedCentralID PMC7544165

Abstract

BACKGROUND: After application of iodinated contrast media (CM), a pronounced deterioration of the microcirculation in skin and myocardium was reported. Clinically, the repeated application of CM, especially, led to an increase of the renal resistance index (RRI). With respect to the transiency of the RRI increase, it is reasonable to assume that the deterioration of blood flow could be due to transient blood stasis caused by reversible morphologic cell alterations due to osmotic discrepancies between CM and human blood. Therefore, the hypothesis was investigated whether CM are able to induce in vivo such blood stasis and cell deformations in the renal vasculature of well-hydrated pigs.METHODS: The in vivo study was performed as a prospective randomized examination to compare the effects of two different CM in 16 pigs (German Landrace). Pigs were randomized to receive either Iodixanol (n = 8), or Iopromide (n = 8). Each animal received 10 injections separated by 5-min intervals via the suprarenal aorta at a rate of 10 mL/s according to the usual procedure during a cardiac catheter examination. Finally, the kidneys were explanted and processed for histology (H & E staining and fibrin staining according to Weigert) as well as for scanning electron microscopy (SEM) with regards to morphologic correlates explaining the changes in the microcirculation.RESULTS: In each of the predefined four categories of vascular diameters, blood stasis were found, but clearly more often after application of Iopromide than after application of Iodixanol (p < 0.001). In addition, Iopromide induced more blood stasis in all of the examined kidney regions compared to Iodixanol (p = 0.0001). There were no obstructive events in the middle cortex following the application of Iodixanol. Except for the region around a puncture channel of a placed-in catheter probe, no fibrin was detected in Weigert's fibrin-stained samples, neither around the histologically assessed thrombi nor in vessels with blood stasis. Complementary SEM analyses revealed in a few cases only a slight generation of fibrin and thrombi and deformations, such as echinocyte and "box-like" deformations.CONCLUSIONS: According to previous in vitro studies, pathological erythrocyte deformations, such as echinocyte and box-like formation of erythrocytes, were observed also in vivo. In addition, blood stasis and/or thrombi could be detected in histological samples from explanted kidneys from young pigs after repeated in vivo administration of CM. In only a few cases, mural platelet aggregates within minimal fibrin meshes occurred only after the application of Iopromide.

View details for DOI 10.3390/life10090167

View details for PubMedID 32867158

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

View details for Web of Science ID 000548418300116

View details for Web of Science ID 000548418300143

Abstract

BACKGROUND: Venous thromboembolism (VTE) is a dreaded complication following microsurgical breast reconstruction. While the high-risk nature of the procedure is well-known, a thorough analysis of modifiable risk factors has not been performed. The purpose of this study is to analyze the association of such factors with the postoperative occurrence of VTE longitudinally.METHODS: Using the Truven MarketScan Database, a retrospective cohort study of women who underwent microsurgical breast reconstruction from 2007-2015 and who developed postoperative VTE within 90 days of reconstruction was performed. Predictor variables included: age, timing of reconstruction, body mass index, history of radiation, history of VTE, Elixhauser comorbidity score, and length of stay (LOS). Univariate analyses were performed, in addition to logistic and zero-inflated Poisson regressions to evaluate predictors of VTE and changes in VTE over the study period, respectively.RESULTS: 12,778 women were identified, of which 167 (1.3%) developed VTE. The majority of VTEs (67.1%) occurred post-discharge with no significant change from 2007-2015. Significant predictors of VTE included Elixhauser score (p<0.01), history of VTE (p<0.03), and LOS (p<0.001). Compared to patients who developed a VTE during the inpatient stay, patients who developed a post-discharge VTE had a lower mean Elixhauser score (p<0.001).CONCLUSIONS: Postoperative VTE continues to be an inadequately addressed problem as evidenced by a stable incidence over the study period. Identification of modifiable risk factors, such as LOS, provide potential avenues for intervention. As the majority of VTEs occur post-discharge, future studies are warranted to investigate the role for an intervention in this period.

View details for DOI 10.1097/PRS.0000000000007051

View details for PubMedID 32453267

View details for Web of Science ID 000538247800137

View details for DOI 10.1093/asj/sjz109

View details for Web of Science ID 000558971600024

Abstract

The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes.A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test.One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62).In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.

View details for DOI 10.1097/SAP.0000000000002227

View details for PubMedID 32000250

Abstract

Pedicled and free flaps are occasionally necessary to reconstruct complex wounds in acute burn patients. Flap coverage has classically been delayed for concern of progressive tissue necrosis and flap failure. We aim to investigate flap complications in primary burn care leveraging national US data.Acute burn patients with known % total body surface area(TBSA) were extracted from the Nationwide/National Inpatient Sample from 2002-2014 based on International Classification of Disease (ICD) Codes 9th edition. Variables included age, gender, race, Elixhauser index, %TBSA, mechanism, inhalation injury, and location of burn. Flap complication was defined by ICD-9 procedure code 86.75, return to OR for flap revision. Multivariable analysis evaluated predictors of flap compromise using stepwise logistic regression with backwards elimination.The weighted sample included 306,924 encounters of which 526 received a flap (0.17%). 7.8% of flap encounters sustained electric injury compared to 2.7% of non-flap encounters (OR 3.76, 95% CI 1.95-7.24, p<0.001). The mean hospital day of flap procedure was 10.1 (SD 10.7) days. Flap complications occurred in 6.4% of cases. The timing of flap coverage was not associated with complications. The only independent predictor of flap complication was electrical injury (OR 40.49, 95% OR 2.98-550.64, p=0.005).Electrical injury was an independent predictor of flap complications compared to other mechanisms. Flap timing was not associated with return to surgery for complications. This suggests that the use of flaps is safe in acute burn care to achieve burn wound closure with an understanding that electrical injuries may warrant particular consideration to avoid failure.

View details for DOI 10.1093/jbcr/iraa096

View details for PubMedID 32582915

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

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

Abstract

Abdominoperineal resection (APR) and pelvic exenteration continue to be common procedures for the treatment of colorectal malignancy. The workhorse flap for reconstruction in these instances has been the vertical rectus abdominis myocutaneous flap. The associated donor site morbidity, however, cannot be ignored. Here, we provide a review of the literature and present the senior author's (A.M.) experience using the pedicled anterolateral thigh (ALT) flap for reconstruction of soft tissue defects following APR and pelvic exenteration.Patients who underwent pelvic/perineal reconstruction with pedicled ALT flaps between 2017 and 2019 were included in the study. Parameters of interest included age, gender, body mass index, comorbidities, history of radiation, extent of ablative surgery, and postoperative complication rate.A total of 23 patients (16 men and 7 women) with a median age and body mass index of 66 years (inter-quartile range [IQR]: 49-71 years) and 24.9kg/m2 (IQR: 24.2-26.7kg/m2) were included in the study, respectively. Thirteen (56.5%) patients presented with rectal cancer, 5 (21.7%) with anal squamous cell carcinoma (SCC), 4 (17.4%) with Crohn's disease, and 1 (4.3%) with Paget's disease. Nineteen patients (82.6%) received neoadjuvant radiation. Nine (39.1%) patients experienced 11 complications (2 major and 9 minor). The most common complication was partial perineal wound dehiscence (N = 6 [26.1%]). Stable soft tissue coverage was achieved in all but one patient.The ALT flap allows for stable soft tissue coverage following APR and pelvic exenteration without being associated with abdominal donor site morbidity. Consideration to its use as a first-line reconstructive option should be given in pelvic/perineal reconstruction.

View details for DOI 10.1097/GOX.0000000000002733

View details for PubMedID 32440406

View details for PubMedCentralID PMC7209827

Abstract

Shared decision-making is a key component of patient-centered care and has been shown to improve patient satisfaction and quality of life. Herein, we study the impact of a standardized patient education class for prospective breast reconstruction patients on clinic efficiency, access to care, and perception on shared decision-making.The number of new patient consultations per clinic, as well as average duration of the first individual clinic encounter, was compared before and after the introduction of a standardized education class given by the senior author to all new breast reconstruction patients. To evaluate patients' perception of shared decision-making, the 9-item Shared Decision-Making Questionnaire (SDM-Q9) and the Satisfaction with Information scale of the BREAST-Q Reconstruction Module were electronically distributed among the patients and compared between the two groups.Introduction of the patient education class was associated with a significant reduction in the duration of new patient encounters compared to historic controls (31.8min vs. 53.5min, p<0.01) along with permitting a 43% increase in new patient visits. No differences in self-perceived patient education and autonomy were seen between class participants and historic controls in the SDM-Q9 scores (p=0.58) and BREAST-Q scores (p=0.14).The introducing a standardized patient education class translated into a significant reduction in the duration of individual new patient encounters, thereby increasing patient access to care, while maintaining high-quality standards of self-perceived patient education and shared decision-making.

View details for DOI 10.1016/j.bjps.2020.02.032

View details for PubMedID 32241738

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

Abstract

The use of systemic prophylactic antibiotics to reduce surgical-site infection in esthetic breast surgery remains controversial, although the majority of surgeons prefer to utilize antibiotics to prevent infection. Nonetheless, postoperative acute and subclinical infection and capsular fibrosis are among the most common complications following implant-based breast reconstruction. After esthetic breast augmentation, up to 2.9% of women develop infection, with an incidence rate of 1.7% for acute infections and 0.8% for late infections. After postmastectomy reconstruction (secondary reconstruction), the rates are even higher. The microorganisms seen in acute infections are Gram-positive, whereas subclinical late infections involving microorganisms are typically Gram-negative and from normal skin flora with low virulence. In primary implantation, a weight-based dosing of cefazolin is adequate, an extra duration of antibiotic cover does not provide further reduction in superficial or periprosthetic infections. Clindamycin and vancomycin are recommended alternative for patients with beta-lactam allergies. The spectrum of microorganism found in late infections varies (Gram-positive and Gram-negative), and the antibiotic prophylaxis (fluoroquinolones) should be extended by vancomycin and according to the antibiogram when replacing implants and in secondary breast reconstruction, to target microorganisms associated with capsular contracture. All preoperative antibiotics should be administered <60 minutes before incision to guarantee high serum levels during surgical procedure.

View details for DOI 10.1097/GOX.0000000000002590

View details for PubMedID 32095400

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

View details for DOI 10.1097/GOX.0000000000002524

View details for Web of Science ID 000512700800009

Abstract

Staged expander-based breast reconstruction represents the most common reconstructive modality in the United States. The introduction of a novel tissue expander with an integrated drain (Sientra AlloX2) holds promise to further improve clinical outcomes.Patients who underwent immediate expander-based pre-pectoral breast reconstruction were identified. Two cohorts were created, that is, patients who underwent placement of a conventional tissue expander [133MX (Allergan)] (Group 1) versus AlloX2 (Sientra) (Group 2). The study endpoint was successful completion of expansion with the objective being to investigate differences in outcome following expander placement.Fifty-eight patients underwent 99 breast reconstructions [Group 1: N = 24 (40 breasts) versus Group 2: N = 34 (59 breast)]. No differences were noted for age (P = 0.586), BMI (P = 0.109), history of radiation (P = 0.377), adjuvant radiotherapy (P = 1.00), and overall complication rate (P = 0.141). A significantly longer time to drain removal was noted in Group 1 (P < 0.001). All patients with postoperative infection in Group 1 required surgical treatment versus successful washout of the peri-prosthetic space via the AlloX2 drain port in 3 of 5 patients in Group 2 (P = 0.196). Furthermore, both cases of seroma in Group 1 required image-guided drainage versus in-office drainage via the AlloX2 drain port in 1 patient in Group 2 (P =0.333).The unique feature of the AlloX2 provides surgeons easy access to the peri-prosthetic space without altering any of the other characteristics of a tissue expander. This resulted in a reduced time to drain removal and facilitated management of postoperative seroma and infection.

View details for DOI 10.1097/GOX.0000000000002524

View details for PubMedID 32537287

View details for PubMedCentralID PMC7288893

Abstract

INTRODUCTION: Bone grafting of alveolar clefts is routinely performed with cancellous bone harvested from the iliac crest. Graft site morbidity is frequently seen, with early postoperative pain being one of the most common complaints. Liposomal bupivacaine (LB) has been demonstrated to provide improvement in postoperative pain for patients undergoing bunionectomy or hemorrhoidectomy, which may translate to patients requiring iliac crest bone graft harvest.METHODS: Thirty-eight patients undergoing iliac crest bone harvest were included in the study. Twenty-one patients underwent open iliac crest bone graft harvest with administration of 0.25% bupivacaine at the hip donor site, while 17 patients received local infiltration of 1.3% liposomal bupivacaine. Patient-reported pain scores, total narcotic use, length of stay, and postoperative steps were monitored.RESULTS: There were no significant differences in age, weight, distribution of clefts, or choice of donor hip between the two groups. There were no significant differences in length of hospitalization stay. However, differences were noted in average postoperative pain scores at five of six time points in the first 24h, total oral morphine equivalents administered (4.75.3 vs. 14.312.0), and steps at postoperative days one to three (p<0.001, for all three days) for patients receiving 1.3% LB versus 0.25% bupivacaine, respectively.CONCLUSION: Reduced pain scores and increased postoperative activity highlight the potential of LB to improve postoperative pain management in children undergoing iliac crest bone harvest for alveolar bone grafting.

View details for DOI 10.1016/j.bjps.2019.09.026

View details for PubMedID 31648962

View details for Web of Science ID 000492740900554

View details for Web of Science ID 000492749600512

View details for Web of Science ID 000492740900421

View details for Web of Science ID 000492749600518

View details for DOI 10.1097/PRS.0000000000005813

View details for PubMedID 31348380

View details for DOI 10.1111/tbj.13299

View details for Web of Science ID 000474305600005

Abstract

Abdominoperineal resection (APR) carries a high risk of morbidity. Preoperative risk assessment can help with patient counseling, minimize adverse outcomes, and guide surgeons in their choice of reconstruction. This study examined the impact of sarcopenia (low lean muscle mass) on postoperative complications after APR.One hundred seventy-eight patients who underwent APR between May 2000 and July 2017 were retrospectively analyzed. Sarcopenia was identified on preoperative computed tomography scans using the Hounsfield Unit Average Calculation. Two cohorts were compared (group 1: primary perineal closure; group 2: flap-based perineal reconstruction). Multivariable analysis evaluated predictors of complications.Sarcopenia was an independent risk factor for postoperative surgical site infection in patients undergoing APR (odds ratio [OR] = 2.9, P = 0.04). The risk for sarcopenic patients who underwent flap-based perineal reconstruction was even higher (OR = 8.9, P < 0.01). Male sex was also found to be a risk factor for infection (OR = 3.5, P < 0.01). Perineal flap-based reconstruction was a risk factor for delayed wound healing (OR = 3.2, P < 0.01).Sarcopenia was an independent risk factor for infection in patients undergoing APR. This risk was even greater in patients undergoing flap-based perineal reconstruction. Sarcopenia can be identified on preoperative imaging and inform surgeons on risk stratification and surgical plan.

View details for DOI 10.1097/GOX.0000000000002343

View details for PubMedID 31942365

View details for PubMedCentralID PMC6952152

View details for DOI 10.1097/GOX.0000000000002343

View details for Web of Science ID 000482308900041

View details for DOI 10.1097/PRS.0000000000005962

View details for PubMedID 31206490

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

View details for DOI 10.12659/MSM.914665

View details for Web of Science ID 000468035000003

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

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

View details for DOI 10.1097/GOX.0000000000002185

View details for Web of Science ID 000468097200028

View details for DOI 10.1097/PRS.0000000000005483

View details for Web of Science ID 000474582600052

Abstract

Venous thromboembolism is an important patient safety in plastic surgery, and multiple clinical trials in the past 10 years have provided increased understanding of the risks and benefits of venous thromboembolism prevention strategies. This paper provides an exhaustive discussion of the rationale behind and methodology for an in progress randomized double-blind clinical trial in plastic surgery inpatients, in which the 2 study arms are enoxaparin 40mg twice daily and enoxaparin 0.5mg/kg twice daily. The trial's primary aims are to: (1) demonstrate whether enoxaparin 0.5mg/kg twice daily is superior to enoxaparin 40mg twice daily for the pharmacokinetic endpoint of overanticoagulation (anti-Factor Xa > 0.4 IU/mL) and (2) demonstrate whether enoxaparin 0.5mg/kg twice daily is not inferior to enoxaparin 40mg twice daily for the pharmacokinetic endpoint of underanticoagulation (anti-Factor Xa < 0.2 IU/mL). The results of this trial will provide Level I evidence to help guide plastic surgeon's choice of postoperative prophylactic anticoagulation.

View details for DOI 10.1097/GOX.0000000000002185

View details for PubMedID 31321183

View details for PubMedCentralID PMC6554177

Abstract

Harvest of the deep inferior epigastric vessels for microsurgical breast reconstruction can be complicated by an intricate and lengthy subfascial dissection. Although multiple preoperative imaging modalities exist to help visualize the vascular anatomy and assist in perforator selection, few can help clearly define the intramuscular course of these vessels. The authors introduce their early experience with 3D-printed anatomical modeling (to-scale) of the infraumbilical course of the deep inferior epigastric subfascial vascular tree to better assist in executing the intramuscular dissection.

View details for DOI 10.1097/GOX.0000000000002222

View details for PubMedID 31321193

View details for PubMedCentralID PMC6554155

View details for DOI 10.1097/GOX.0000000000002222

View details for Web of Science ID 000468097200038

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

Abstract

The two common reconstructive modalities following mastectomy include implant-based reconstruction and autologous reconstruction. While the majority of patients can be successfully treated with either one of these approaches, a subset of patients will benefit from a third reconstructive approach which combines implant-based and autologous reconstruction, i.e., hybrid reconstruction. Here, the authors discuss indications, surgical technique, results and additional reconstructive considerations of combining free abdominal tissue transfer with simultaneous implant placement. A reconstructive algorithm is presented.

View details for DOI 10.21037/gs.2018.11.01

View details for PubMedID 30842932

View details for PubMedCentralID PMC6378255

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

Abstract

Post-mastectomy autologous reconstruction with abdominal tissue has evolved over the past 4 decades and is a common reconstructive modality today. To gain more insight into this evolution, we performed an analysis of the 100 most commonly cited articles focusing on autologous breast reconstruction with transverse rectus abdominis musculocutaneous (TRAM) or deep inferior epigastric perforator (DIEP) flaps. A review of the ISI Web of Knowledge database was performed. Only peer-reviewed articles in English were included for analysis. Articles were ranked by their total citations as well as citation density (citations divided by years since publication). The 100 most cited articles were analyzed by their bibliographic parameters. The 100 most cited articles were published in 12 journals. The highest ranked plastic surgery journal published almost 2/3 of the articles. All articles were published within 23 years and marked the "rising age" of autologous breast reconstruction with TRAM and DIEP flaps. The focus of clinical research changed over this time period and ranged from innovations in surgical technique to analysis of clinical outcomes, comparative analyses with other reconstructive modalities, timing of reconstruction, and preoperative diagnostic workup, as well as cost-effectiveness analyses. This literature review illustrates the dramatic change that has occurred subsequent to introduction of abdominal flaps for breast reconstruction. While the use of abdominal flaps has become widely accepted for breast reconstruction, many questions remain unanswered, thus highlighting the need for ongoing clinical investigation.

View details for PubMedID 31079136

Abstract

Radiotherapy (RT) has become an indispensable part of oncologic treatment protocols for a range of malignancies. However, a serious adverse effect of RT is radiodermatitis; almost 95% of patients develop moderate to severe skin reactions following radiation treatment. In the acute setting, these can be erythema, desquamation, ulceration, and pain. Chronically, soft tissue atrophy, alopecia, and stiffness can be noted. Radiodermatitis can delay oncologic treatment protocols and significantly impair quality of life. There is currently a paucity of effective treatment options and prevention strategies for radiodermatitis. Importantly, recent preclinical and clinical studies have suggested that fat grafting may be of therapeutic benefit, reversing detrimental changes to soft tissue following RT. This review outlines the damaging effects of RT on the skin and soft tissue as well as discusses available treatment options for radiodermatitis. Emerging strategies to mitigate detrimental, chronic radiation-induced changes are also presented.

View details for DOI 10.1097/SAP.0000000000002098

View details for PubMedID 31513068

View details for DOI 10.1097/PRS.0000000000005962

View details for PubMedID 31461052

Abstract

Despite the growing spotlight on value-based care and patient safety, little is known about the influence of patient-, reconstruction-, and facility-level factors on safety events following breast reconstruction. The purpose of this study is to characterize postoperative complications in light of hospital-level risk factors.Using the National Inpatient Sample, all patients who underwent free flap and prosthetic breast reconstruction from 2012 to 2014 were identified. Predictor variables included patient demographic and clinical characteristics, type and timing of reconstruction, annual hospital reconstructive volume, hospital bed size, hospital setting (rural vs. urban), and length of stay. Patient safety indicators (PSIs) were based on the Agency for Healthcare Research and Quality's designation of preventable hospital complications: venous thromboembolism, bleeding, wound complications, pneumonia, and sepsis. Logistic models were used to analyze outcomes.The sample included 103,301 women, of which 27,695 (26.8%) underwent free flap reconstruction. 3.6% of patients experienced1 PSI, most commonly wound PSI (4.9% and 2.5% for free flap and prosthetic reconstruction, respectively). Significant predictors of PSIs included rural setting (p<0.01) and Elixhauser score4 (p<0.01) for the free flap group, and delayed reconstruction (p<0.01) for the prosthetic group. Annual reconstructive facility volume was not associated with increased odds of PSIs in either prosthetic or free flap reconstruction (p>0.05).PSIs were associated with rural hospitals and greater comorbidities for patients undergoing reconstruction with free flaps. Annual reconstructive facility volume was not associated with adverse inpatient outcomes with either method of reconstruction.

View details for DOI 10.1007/s10549-019-05361-2

View details for PubMedID 31338643

View details for DOI 10.1097/PRS.0000000000005813

View details for PubMedID 31188301

Abstract

The benefits of breast reconstruction via free tissue transfer with simultaneous implant placement, that is, hybrid breast reconstruction, in select patients are well-known. Challenges exist, however, and are related to proper implant selection as well as postoperative mastectomy skin necrosis. Here, the authors present an approach that increases reconstructive precision while minimizing postoperative mastectomy skin necrosis. A retrospective analysis of patients who underwent immediate prepectoral tissue expander placement (stage 1) followed by delayed-immediate hybrid breast reconstruction (stage 2) was performed. Parameters of interest included patient demographics, postoperative complications, and revision rates. A total of 31 patients with a mean age of 48.7years (range, 30-67years) and a mean BMI of 26.3kg/m2 (range, 21.0-35.3kg/m2 ) who underwent bilateral breast reconstruction were included. Of the 62 free abdominal flaps, 45 (72.6%) and 17 (27.4%) were MS-TRAM and DIEP flaps, respectively. The most common implant volume was 240cc (range, 140-445cc). Following stage 1, minor and major complications were observed in nine (29%) and one (3.2%) patients, respectively. No major complications were noted after stage 2. Of note, no patient developed mastectomy skin necrosis or requested a change in implant size following stage 2. Delayed-immediate hybrid breast reconstruction improves the ability to more precisely match patient expectations related to breast size and is associated with a reduction in the rate of mastectomy skin necrosis following the critical second stage of reconstruction.

View details for DOI 10.1111/tbj.13356

View details for PubMedID 31155835

View details for PubMedID 30592350

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

Abstract

Implant-based breast reconstruction is the most common reconstructive modality in the United States. Significant advances in surgical technique and technology have resulted in improvement of clinical outcomes. A recent innovation has been the introduction of a tissue expander with an integral drain that permits access to the periprosthetic space. A new use for this drain port is presented in patients with postoperative surgical-site infection.Patients who underwent staged implant-based breast reconstruction with the Sientra AlloX2 tissue expander and experienced postoperative infection that warranted inpatient management with intravenous antibiotics were included in the study. The integral drain port was used in these patients to perform washout of the periprosthetic space at the bedside. The ability to salvage the tissue expander in the setting of infection without the need for surgical revision in the operating room was determined.Of 31 patients who underwent a total of 52 staged breast reconstructions with the Sientra AlloX2 tissue expander, 3 patients (8.7%) with a mean age of 50.3 years (range, 34-76 years) and mean body mass index of 23.3kg/m2 (range, 22.3-24.1kg/m2) met inclusion criteria. Salvage of the device with successful progression through expansion and eventual expander-implant exchange was achieved in 2 patients. One patient failed the salvage attempt and required removal of the device.Using the integral drain port of the AlloX2 tissue expander has the potential for device salvage in a subset of patients with surgical-site infection without the need for surgical revision.

View details for PubMedID 30656121

View details for DOI 10.1097/PRS.0000000000004885

View details for Web of Science ID 000448330200080

Abstract

Breast numbness is a recognized problem following mastectomy and subsequent reconstruction. Contemporary literature acknowledges the positive role of breast neurotization, but it is characterized by a variety of technical approaches and substantial heterogeneity with respect to the degree of recovered sensibility that remains suboptimal in comparison with other sensory nerve reconstructions. This study's purpose was to provide an anatomical basis for observed inconsistencies and therein provide a principle that can be used to develop a technical approach that will optimize sensory recovery.Anatomical dissections on 6 fresh cadavers, that is, 12 hemi-abdominal flaps and 12 hemi-chest dissections, were performed. The technical aspects of harvesting the abdominal flap with a nerve target, that is, inclusion of a sensory nerve branch only, recipient nerves in the chest, and the applications of allograft for acquired nerve gap reconstruction were investigated.Abdominal flaps that include sensory-only intercostal nerve 10-12 segments and identification of recipient chest wall intercostal nerves 2-4 could be consistently performed. The dissection and extraction of the donor sensory nerve target allowed preservation of the motor rectus innervation. The acquired nerve gap was easily bridged by an interposing allograft, allowing free arch of rotation for flap inset, suitable for either single or dual neurotization.We provide a likely anatomical explanation for suboptimal sensory recovery after deep inferior epigastric perforator (DIEP) flap breast neurotization, as mixed intercostal autograft is prohibitive to maximal sensory recovery. Breast neurotization with allograft that bridges sensory donor intercostal nerves to sensory recipient intercostal nerves should anatomically optimize restoration of breast sensibility.

View details for DOI 10.1097/GOX.0000000000001985

View details for PubMedID 30881792

View details for PubMedCentralID PMC6414125

Abstract

The ideal timing of soft-tissue coverage for open lower extremity fractures remains controversial. Using U.S. national data, this study aims to characterize secular trends and regional variation in the timing of soft-tissue coverage.Using discharge data from the Nationwide Inpatient Sample (2002 to 2011), the authors identified 888 encounters admitted from the emergency department with isolated open lower extremity fractures treated with pedicled or free tissue transfer. Soft-tissue coverage timing was assessed by patient factors, hospital characteristics, and fracture patterns. Statistical significance and secular trends were analyzed with generalized linear models.The mean day of soft-tissue reconstruction was at 6.64 days. Over the 10-year period, the day of reconstruction increased significantly (from 6.12 days in 2002 to 12.50 days in 2011; coefficient, 0.09; 95 percent CI, 0.05 to 0.12; p < 0.001). Demographic and facility factors did not significantly impact timing. Elixhauser comorbidity scores greater than 2 were associated with later coverage (10.13 days versus 6.29 days; p = 0.001) along with multisite fractures (8.35 days; p = 0.022) and external fixators (8.78 days; p < 0.001). The U.S. Census division showed significant variation in timing ranging from 0.94 days (East North Central) to 9.84 days (Pacific).A progressive delay in the timing of soft-tissue reconstruction was noted and may be attributed to negative-pressure wound therapy. The timing of soft-tissue coverage varied by region after adjusting for patient and hospital factors. Additional studies are needed to understand the impact of delayed soft-tissue coverage on patient outcomes and health services utilization.

View details for DOI 10.1097/PRS.0000000000004885

View details for PubMedID 30511989

View details for DOI 10.1097/GOX.0000000000001985

View details for Web of Science ID 000453901600020

Abstract

Significant advances in our understanding of human obesity, endocrinology, and metabolism have been made possible by murine comparative models, in which anatomically analogous fat depots are utilized; however, current research has questioned how truly analogous these depots are. In this study, we assess the validity of the analogy from the perspective of cellular architecture. Whole tissue mounting, confocal microscopy, and image reconstruction software were employed to characterize the three-dimensional structure of the inguinal fat pad in mice, gluteofemoral fat in humans, and subcutaneous adipose tissue of the human abdominal wall. Abdominal and gluteofemoral adipose tissue specimens from 12 human patients and bilateral inguinal fat pads from 12 mice were stained for adipocytes, blood vessels, and a putative marker for adipose-derived multipotent progenitor cells, CD34. Samples were whole-mounted and imaged with laser scanning confocal microscopy. Expectedly, human adipocytes were larger and demonstrated greater size heterogeneity. Mouse fat displayed significantly higher vascular density compared to human fat when normalized to adipocyte count. There was no significant difference in the concentration of CD34+ stromal cells from either species. However, the mean distance between CD34+ stromal cells and blood vessels was significantly greater in human fat. Finally, mouse inguinal fat contained larger numbers of brown adipocytes than did human gluteofemoral or human abdominal fat. Overall, the basic architecture of human adipose tissue differs significantly from that of mice. Insofar as human gluteofemoral fat differs from human abdominal adipose tissue, it was closer to mouse inguinal fat, being its comparative developmental analogue. These differences likely confer variance in functional properties between the two sources, and thus must be considered when designing murine models of human disease.

View details for PubMedID 30215305

Abstract

BACKGROUND: Postoperative complication following ventral hernia repair (VHR) is a major clinical and financial burden. Preoperative risk assessment is necessary to minimize adverse outcomes following VHR. This study examines the ability of an independent parameter to predict postoperative morbidity following VHR.METHODS: A retrospective analysis of 58 patients who underwent VHR by component separation between January 2009 and December 2013 was performed. Preoperative abdominal CT scans were analyzed to assess sarcopenia. Sarcopenia was determined using the Hounsfield unit average calculation (HUAC), a measure of psoas muscle size and density. Sarcopenia was defined as an HUAC score of less than 19.6HU calculated using receiver operating characteristic (ROC) analysis and the Youden index. Multivariate analysis was performed to analyze the association of sarcopenia and postoperative complications.RESULTS: Preoperative sarcopenia was associated with an increased risk for postoperative complications (odds ratio [OR]=5.3; p=0.04). Preexisting gastrointestinal conditions such as ulcerative colitis or colon cancer were associated with an increased risk for postoperative complications (OR=5.7; p=0.05). A significantly higher rate of hernia recurrence (33.3% vs. 10.8% [p=0.04]) and renal failure (19% vs. 2.7% [p=0.03]) was noted in patients with sarcopenia when compared to patients without sarcopenia.CONCLUSIONS: Sarcopenia is an independent risk factor for postoperative complications in patients who underwent VHR. Assessment of sarcopenia using the HUAC score provides an opportunity for the adjustment of perioperative care plans to minimize postoperative complication rates.

View details for PubMedID 30173713

Abstract

The National Institutes of Health, American Medical Association, and US National Library of Medicine recommend that educational material for patients be written at a sixth-grade reading level. The purpose of this study is to assess the complexity of hand surgery information on academic plastic and orthopedic surgery websites.An online search was performed for all hand surgery patient education materials provided by institutions with plastic and orthopedic surgery training programs. Readability analyses were conducted using the Flesch-Kincaid Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Index, Gunning Fog Score, Automated Readability Index, and Coleman-Liau Index. A 2-tailed z test was used to compare means.Seventy-six institutions with both plastic and orthopedic surgery training programs were identified; 42 had educational material available online. The average readability for all hand-related information was at the 11.92 grade reading level. Information regarding de Quervain tenosynovitis had the highest grade level for all plastic surgery procedures (13.45). Hand arthritis had the highest grade level for all orthopedic surgery procedures (12.82). Ganglion cysts had the lowest grade level for both plastic and orthopedic surgery (10.15 and 11.01, respectively; P = .12). Carpal tunnel release was the most commonly described procedure overall. There were no differences in text complexity among geographic regions.Online patient resources for common hand ailments are too complex for the average patient to understand. Efforts should be made to provide materials at the recommended sixth-grade reading level to improve patient education and improve the physician-patient relationship.

View details for DOI 10.1177/1558944717725384

View details for PubMedID 28825342

View details for PubMedCentralID PMC6109909

Abstract

INTRODUCTION: The use of arteriovenous (AV) loops in microsurgical lower extremity reconstruction is a controversial topic. The objective of the present study was to assess the impact of AV loops on complication rates following microsurgical reconstruction of posttraumatic lower extremity defects.PATIENTS AND METHODS: Patients who underwent free flap coverage of posttraumatic defects in combination with an AV loop (Group 1) were identified and matched for age, body mass index (BMI), tobacco use, defect location, and flap type with patients who underwent reconstruction without vein grafts (Group 2). Outcomes of interest included complication rate and flap loss rate.RESULTS: Groups 1 and 2 consisted of 10 patients each with a mean age of 51 years (range, 21-79 years) and 47.3 years (range, 22-69 years), respectively (P=0.596). No differences were noted regarding flap loss (P=1.0), intraoperative (P=0.474) or postoperative complication rate [surgical site infection (P=1.0), bleeding (P=1.0), delayed wound healing (P=0.23), dehiscence (P=0.58), and osseous non-union (P=1.0)]. Only one flap loss was noted in Group 1. The only differences were increased operative time (P=0.03) and increased length of stay (P=0.009) in Group 1.CONCLUSION: Our results suggest that utilization of vein grafts with creation of AV loops followed by single-stage division and free flap transfer for reconstruction of posttraumatic lower extremity defects achieve reconstructive outcomes similar to those obtained in patients in whom no vein grafts are necessary.

View details for PubMedID 28657669

Abstract

The most common donor-site for autologous breast reconstruction is the abdomen. Over the past several decades technical advances have resulted in the development of flaps that have been associated with a progressive decrease in abdominal wall morbidity. However, controversy exists related to the differences between muscle-sparing (MS)-TRAM and deep inferior epigastric perforator (DIEP) flaps. Hence, the question which approach should be considered standard of care remains unanswered. To address this question the current literature and published evidence was critically reviewed and discussed by an expert panel at the 39th Annual Meeting of the German-speaking Society for Micro surgery of the Peripheral Nerves and Vessels (DAM). Based on this discussion a consensus statement was developed that incorporates contemporary data regarding postoperative complication rate, donor site morbidity, as well as expert opinion regarding technical details in autologous breast reconstruction with free TRAM and DIEP flaps.

View details for PubMedID 30130834

View details for PubMedID 30296810

Abstract

BACKGROUND: Autologous breast reconstruction is considered by many to be the gold standard reconstructive modality following mastectomy. Despite the advantages of autologous reconstruction, however, surgeons have been cautious in recommending this approach to patients who desire to become pregnant postoperatively because of concerns related to abdominal wall morbidity. While intuitive, this approach does not appear to be based on robust data. Hence, the authors examined the clinical outcome in patients who became pregnant following autologous breast reconstruction.METHODS: Patients who underwent autologous breast reconstruction with free abdominal flaps that required an incision in the anterior rectus sheath were identified. Of them, patients who became pregnant post reconstruction were included for subsequent analysis. Of particular interest were any peripartal and postpartal complications that could be attributed to the preceding abdominal flap harvest. Additionally, a systematic review of the literature was performed.RESULTS: We identified five patients who met inclusion criteria. All five patients underwent bilateral breast reconstruction with free muscle-sparing transverse rectus abdominis musculocutaneous (MS-TRAM) flaps. None of the patients had any preexisting abdominal wall morbidity. All five patients proceeded to full-term pregnancy and successfully delivered newborns, four of which were delivered by normal vaginal delivery and one by cesarean section. No abdominal wall complications were noted during pregnancy, delivery, or postpartum.CONCLUSION: Contemporary data do not support the notion that breast reconstruction with free abdominal flaps is contraindicated in the setting of desired or planned pregnancy.

View details for PubMedID 29970346

Abstract

Scientific publications are the cornerstone of scholarly activities. The importance of appropriately assigned authorship cannot be overstated. Hence, we felt it prudent to examine the perception of plastic surgery trainees regarding authorship. We hypothesized that plastic surgery trainees would not be in compliance with International Committee of Medical Journal Editors guidelines when determining what constitutes an authorship justifying contribution.An online survey describing 4 distinct scenarios was distributed to plastic surgery trainees at 2 academic institutions using the Qualtrics research software (Provo, UT). Additional parameters queried included level of training and number of publications. Linear regression models were used to test correlation between responses and level of training and number of publications.Thirty-three of 48 trainees responded (response rate, 68.8%). All respondents had previously authored publications, with the majority (54.5%) having at least 10 publications. Although none of the scenarios presented justified authorship based on international guidelines, 33.3% of respondents believed that authorship was warranted in at least 3 of the 4 presented scenarios. Linear regression comparing for demographic variables to number of perceived authorship scenarios found a mild-moderate positive correlation with level of training (R = 0.34, P = 0.05) and number of publications (R = 0.32, P = 0.07).Plastic surgery trainees do not seem to be familiar with guidelines regarding authorship justifying contributions. It is important to raise awareness regarding criteria that warrant authorship and to educate our residents and fellows in matters of appropriate scholarly conduct because nothing short of the credibility of our scientific endeavors is otherwise in question.

View details for DOI 10.1097/SAP.0000000000001396

View details for Web of Science ID 000432679800014

View details for PubMedID 29489531

View details for PubMedID 29483056

Abstract

BACKGROUND: Low anti-factor Xa level, indicative of inadequate enoxaparin dosing, has a significant association with 90-day venous thromboembolism events. The authors examined the pharmacodynamics of enoxaparin 40 mg twice daily and its correlation with anti-factor Xa level, postoperative venous thromboembolism, and bleeding.METHODS: Adult patients were admitted after plastic and reconstructive surgery and received enoxaparin 40 mg twice daily. Peak anti-factor Xa levels, which quantify enoxaparin's antithrombotic effect, were drawn, with a goal level of 0.2 to 0.4 IU/ml. Ninety-day symptomatic venous thromboembolism and clinically relevant bleeding were identified.RESULTS: The authors enrolled 118 patients who received enoxaparin 40 mg twice daily. Of these patients, 9.6 percent had low peak anti-factor Xa levels (<0.2 IU/ml), 62.6 percent had in-range peak anti-factor Xa levels (0.2 to 0.4 IU/ml), and 27.8 percent had high anti-factor Xa levels (>0.4 IU/ml). With enoxaparin 40 mg twice daily, 90.4 percent of patients received at least adequate prophylaxis. Patient weight predicted the rapidity of enoxaparin metabolism. Zero acute 90-day venous thromboembolism occurred. Eight patients (6.8 percent) had clinically relevant 90-day bleeding: clinical consequences ranged from cessation of enoxaparin prophylaxis to transfusion to operative hematoma evacuation.CONCLUSIONS: When enoxaparin 40 mg twice daily is provided, 90 percent of patients receive at least adequate venous thromboembolism prophylaxis (anti-factor Xa level >0.2 IU/ml). However, 27 percent of the overall population is overtreated (anti-factor Xa level >0.4 IU/ml). These pharmacodynamics data likely explain the low rate of 90-day acute venous thromboembolism (0 percent) and the high rate of clinically relevant bleeding (6.8 percent) observed. Future studies are needed to better optimize the risks and benefits of enoxaparin prophylaxis in plastic and reconstructive surgery patients.CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

View details for PubMedID 29608533

Abstract

INTRODUCTION: Venous thromboembolism (VTE) is a life or limb threatening complication that occurs in plastic surgery patients. At present, the optimal dose of enoxaparin that balances the risk of VTE and the risk of medication related adverse drug events, specifically bleeding, remains unknown.METHODS: This study compared pharmacodynamic and clinical outcomes, including 90-day VTE and 90-day clinically relevant bleeding, between two prospectively performed clinical trials whose sole difference was post-operative anticoagulation strategy. Patients in Trial #1 received enoxaparin 40mg once daily for the duration of inpatient stay, and patients in Trial #2 received enoxaparin 40mg twice daily for the duration of inpatient stay. The study also examined the potential impact of a weight-based twice daily prophylaxis strategy to achieve in range anti-Factor Xa levels.RESULTS: The study compared 94 patients who received once daily enoxaparin to 118 patients who received twice daily enoxaparin. Twice daily enoxaparin was associated with a significant decrease in 90-day acute VTE (0% vs. 5.3%, p=0.012) and a non-significant increase in 90-day clinically relevant bleeding (6.8% vs. 3.2%, p=0.25). Twice daily enoxaparin at 0.4-0.5mg/kg may allow an increased proportion of patients to avoid both inadequate anticoagulation and over-anticoagulation, based on anti-Factor Xa levels.CONCLUSION: Twice daily enoxaparin is superior to once daily enoxaparin for 90-day acute VTE risk reduction. Twice daily enoxaparin may increase clinically relevant bleeding, although observed differences in this study were not significant. Weight based twice daily enoxaparin dosing may optimize the risks and benefits of prophylactic anticoagulation after plastic & reconstructive surgery.

View details for PubMedID 29649055

Abstract

Studies evaluating fat grafting in mice have frequently used micro-computed tomography (micro-CT) as an accurate radiographic tool to measure longitudinal volume retention without killing the animal. Over the past decade, however, microultrasonography has emerged as an equally powerful preclinical imaging tool. Given their respective strengths in 3-dimensional reconstruction, there is no study to our knowledge that directly compares micro-CT with microultrasound in volumetric analysis. In this study, we compared the performance of micro-CT with microultrasound in the evaluation of adipose tissue graft volume in a murine model. Fifteen immunodeficient mice were given 200 L of adipose tissue grafts. In vivo volumetric analysis of the grafts by micro-CT and microultrasound was conducted at discrete time points up to postoperative day 105. Three mice were killed at multiple time points, and explanted grafts were reimaged by CT and ultrasound, as mentioned previously. Analysis revealed that in vivo graft volumes measured by micro-CT do not differ significantly from those of microultrasound. Furthermore, both micro-CT and microultrasound were capable of accurately measuring fat grafts as in vivo volumes closely correlated with explanted volumes. Finally, ultrasound was found to yield improved soft tissue contrast compared with micro-CT. Therefore, either modality may be used, depending on experimental needs.

View details for DOI 10.1097/SAP.0000000000001183

View details for Web of Science ID 000425352000021

View details for PubMedID 28678028

View details for PubMedCentralID PMC5752634

Abstract

Breast reconstruction is one of the most common procedures performed by plastic surgeons and is achieved through various choices in both technology and method. Cost-effectiveness analyses are increasingly important in assessing differences in value between treatment options, which is relevant in a world of confined resources. A thorough evaluation of the cost-effectiveness literature can assist surgeons and health systems evaluate high-value care models.A systematic review of PubMed, Web of Science, and the Cost-Effectiveness Analysis Registry was conducted. Two reviewers independently evaluated all publications up until August 17, 2017.After removal of duplicates, 1996 records were screened, from which 53 studies underwent full text review. All the 13 studies included for final analysis mention an incremental cost-effectiveness ratio. Five studies evaluated the cost-effectiveness of technologies including acellular dermal matrix (ADM) in staged prosthetic reconstruction, ADM in direct-to-implant (DTI) reconstruction, preoperative computed tomography angiography in autologous reconstruction, indocyanine green dye angiography in evaluating anastomotic patency, and abdominal mesh reinforcement in abdominal tissue transfer. The remaining eight studies evaluated the cost-effectiveness of different reconstruction methods. Cost-effective strategies included free vs. pedicled abdominal tissue transfer, DTI vs. staged prosthetic reconstruction, and fascia-sparing variants of free abdominal tissue transfer.Current evidence demonstrates multiple cost-effective technologies and methods in accomplishing successful breast reconstruction. Plastic surgeons should be well informed of such economic models when engaging payers and policymakers in discussions regarding high-value breast reconstruction.

View details for PubMedID 29196176

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

Abstract

Renevia is a hyaluronin-gelatin crosslinked matrix scaffold that has been studied as an alternative to adipose transfer in soft tissue reconstruction. It is designed to emulate the native extracellular matrix environment by supporting stromal vascular fraction (SVF) cell attachment, survival, and proliferation, thus promoting cell-based volume restoration. However, the concentration of incorporated cells for a clinically relevant result has yet to be determined.Five experimental groups of seven CD-1 nude immunodeficient mice were given 250 L grafts of the following composition: 1 million human SVF cells per mL of Renevia scaffold, 6 million human SVF cells per mL scaffold, 12 million human SVF cells per mL scaffold, Renevia scaffold-alone or human adipose tissue-alone. Volumetric analysis was conducted at discrete time points over 16 weeks using 3-dimensional ultrasound, after which time the grafts were explanted for histologic analysis.At the conclusion of the study at week 16, the Renevia scaffold group incorporating the highest concentration of human SVF cells (12 million cells per mL scaffold) had significantly greater volume retention compared with the 2 lower concentrations, scaffold-alone and fat-alone groups. Histology of the 12 million scaffold group revealed abundant adipocyte formation within the scaffold, exceeding that observed in the 6 million, 1 million, and scaffold-alone groups. The 12 million group also demonstrated significantly increased vascularity per CD31 staining.Stromal vascular fraction cells coupled with Renevia hydrogel scaffold can enhance soft tissue volume reconstruction. In this study, we observed the greatest effect with 12 million cells per mL. From the perspective of volume retention, incorporation of higher concentrations of SVF cells with Renevia may be an alternative to conventional adipose tissue grafting.

View details for PubMedID 28671889

View details for PubMedCentralID PMC5677558

View details for PubMedID 28953749

Abstract

Craniofacial distraction osteogenesis (DO) is a common treatment modality today. Despite its numerous advantages, however, concerns have been expressed regarding the use of DO in the irradiated setting.A systematic review was performed to identify all published reports of patients who underwent DO of the irradiated craniofacial skeleton. The following parameters were of particular interest: postoperative complications, specifically, insufficient bone formation, fracture, and hardware exposure (intraoral and cutaneous), as well as the need for additional bone grafting.The initial search retrieved a total of 183 articles of which 20 articles (38 patients) met predetermined inclusion criteria. The most common site of distraction was the mandible (76.3%). The median radiation dose was 50.7 Gy (range, 30-70 Gy). Bone defects ranged from 30 to 80mm (median, 42.5mm). Complications were encountered in 19 patients (50%), with insufficient bone formation being most common (9 patients; 23%). The overall incidence of complications was not significantly associated with radiation dosage (P=0.79). The remaining procedural and demographic variables also failed to meet statistical significance when compared against the overall complication rate (P=0.27-0.97).The complication rate associated with craniofacial DO of the irradiated skeleton does not appear to be substantially higher than what is reported for DO in the nonirradiated setting. As such, patients should be offered this treatment modality, particularly in light of the fact, that it offers the option to decrease patient morbidity as well as treatment complexity.

View details for PubMedID 28665865

Abstract

Due to the abundance and biocompatibility of fat, lipotransfer has become an attractive method for treating soft tissue deficits. However, it is limited by unpredictable graft survival and retention. Currently, little is known about the viscoelastic properties of fat after various injection methods. Here, we assess the effects of cannula diameter, length, and shape on the viscoelastic properties, structure, and retention of fat.Human lipoaspirate was harvested using suction-assisted liposuction and prepared for grafting. A syringe pump was used to inject fat at a controlled flow rate through cannulas of varying gauge, length, and shape. Processed samples were tested in triplicate on an oscillatory rheometer to measure their viscoelastic properties. Fat grafts from each group were placed into the scalps of immunocompromised mice. After 8 weeks, graft retention was measured using micro-CT and grafts were explanted for histological analysis.Lipoaspirate injected through narrower, longer, and bent cannulas exhibited more shear thinning with diminished quality. The storage modulus (G') of fat processed with 18-gauge cannulas was significantly lower than when processed with 14-gauge or larger cannulas, which also corresponded with inferior in vivo histological structure. Similarly, the longer cannula group had a significantly lower G' than the shorter cannula, and was associated with decreased graft retention.Discrete modifications in the methods used for fat placement can have a significant impact on immediate graft integrity, and ultimately on graft survival and quality. Respecting these biomechanical influences during the placement phase of lipotransfer may allow surgeons to optimize outcomes.

View details for DOI 10.1097/PRS.0000000000003578

View details for PubMedID 28574947

Abstract

Wound healing remains a global issue of disability, cost, and health. Addition of cells from the stromal vascular fraction (SVF) of adipose tissue has been shown to increase the rate of full thickness wound closure. This study aimed to investigate the angiogenic mechanisms of CD248+ SVF cells in the context of full thickness excisional wounds. Single cell transcriptional analysis was used to identify and cluster angiogenic gene-expressing cells, which was then correlated with surface marker expression. SVF cells isolated from human lipoaspirate were FACS sorted based on the presence of CD248. Cells were analyzed for angiogenic gene expression and ability to promote microvascular tubule formation in vitro. Following this, 6mm full thickness dermal wounds were created on the dorsa of immunocompromised mice and then treated with CD248+, CD248-, or unsorted SVF cells delivered in a pullalan-collagen hydrogel or the hydrogel alone. Wounds were measured every other day photometrically until closure. Wounds were also evaluated histologically at 7 and 14 days post-wounding and when fully healed to assess for reepithelialization and development of neovasculature. Wounds treated with CD248+ cells healed significantly faster than other treatment groups, and at 7 days, had quantitatively more reepithelialization. Concurrently, immunohistochemistry of CD31 revealed a much higher presence of vascularity in the CD248+ SVF cells treated group at the time of healing and at 14 days post-op, consistent with a pro-angiogenic effect of CD248+ cells in vivo. Therefore, using CD248+ pro-angiogenic cells obtained from SVF presents a viable strategy in wound healing by promoting increased vessel growth in the wound.

View details for DOI 10.1111/wrr.12542

View details for PubMedID 28464475

Abstract

Patient education is essential in enhancing the physician-patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites.An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P<0.05.Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P<0.001, P=0.04).The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.

View details for DOI 10.1097/SCS.0000000000003435

View details for Web of Science ID 000400649800043

View details for PubMedID 28468160

Abstract

Soft tissue reconstruction to restore volume to damaged or deficient tissue beneath the skin remains a challenging endeavor. Current techniques are centered around autologous fat transfer, or the use of synthetic substitutes, however, a great deal of scientific inquiry has been made into both the molecular mechanisms involved in, and limitations of, de novo adipogenesis, that is, the formation of new adipose tissue from precursor cells. To best comprehend these mechanisms, an understanding of defined markers for adipogenic differentiation, and knowledge of both commercially available and primary cell lines that enable in vitro and in vivo studies is necessary. We review the growth factors, proteins, cytokines, drugs, and molecular pathways that have shown promise in enhancing adipogenesis and vasculogenesis, in addition to the multitude of scaffolds that act as delivery vehicles to support these processes. While progress continues on these fronts, equally important is how researchers are optimizing clinically employed strategies such as autologous fat transfer through cell-based intervention, and the potential to augment this approach through isolation of preferentially adipogenic or angiogenic precursor subpopulations, which exists on the horizon. This review will highlight the novel molecular and synthetic modifications currently being studied for inducing adipose tissue regeneration on a cellular level, which will expand our arsenal of techniques for approaching soft tissue reconstruction.

View details for DOI 10.1089/ten.TEB.2016.0455

View details for PubMedID 28372485

View details for DOI 10.1097/PRS.0000000000003156

View details for Web of Science ID 000398956600066

Abstract

Evidence-based plastic surgery guidelines support the effectiveness of once-daily enoxaparin prophylaxis. Despite prophylaxis, one in 25 highest risk patients has a venous thromboembolism event. The authors examined the pharmacodynamics of standard enoxaparin doses in plastic surgery patients to examine whether patient-level factors predict enoxaparin metabolism, whether inadequate enoxaparin dose predicts downstream venous thromboembolism events, and whether a pharmacist-driven dose-adjustment protocol was effective.The authors recruited adult plastic surgery patients who received postoperative enoxaparin at 40 mg/day. Steady-state peak anti-factor Xa levels, a marker of enoxaparin effectiveness and safety, were determined. Patients with out-of-range anti-factor Xa levels had real-time dose adjustment based on a written protocol. Patients were followed for 90-day venous thromboembolism events.Ninety-four patients were recruited, and 44 percent had in-range peak anti-factor Xa levels in response to standard enoxaparin dosing. Patient-level factors including extent of surgical injury and gross weight were independent predictors of enoxaparin metabolism. Patients with low anti-factor Xa levels were significantly more likely to have 90-day venous thromboembolism (10.2 percent versus 0 percent; p = 0.041). Real-time dose adjustment allowed a significantly increased proportion of patients to have in-range levels (67.1 percent versus 44.3 percent; p = 0.002).Based on pharmacodynamic data, the majority of plastic surgery patients receive inadequate enoxaparin prophylaxis using fixed dosing. Patient-level factors can predict how patients will metabolize enoxaparin, and patients who receive inadequate enoxaparin prophylaxis are significantly more likely to have downstream venous thromboembolism events. Individualization of enoxaparin prophylaxis may minimize perioperative venous thromboembolism risk and further improve patient safety after plastic and reconstructive surgery procedures.Therapeutic, II.

View details for DOI 10.1097/PRS.0000000000003159

View details for Web of Science ID 000398956600067

View details for PubMedID 28350685

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

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

Abstract

More than 250,000 women will be diagnosed with invasive breast cancer in the United States in 2017 alone. A large number of these patients will undergo mastectomy and will be candidates for immediate breast reconstruction. The most common reconstructive options are either implant-based or autologous tissue reconstruction, with the latter having been reported to have higher rates of long-term patient satisfaction, lower cost, and less postoperative pain. A subset of patients, however, may not be ideal candidates for autologous microsurgical reconstruction, for example, due to inadequate abdominal tissues, yet they may desire this reconstructive modality. This is particularly challenging in patients requiring bilateral reconstructions. In this article, the authors discuss the various reconstructive modalities that can be considered in patients who desire bilateral breast reconstruction, are not ideal candidates for autologous reconstruction, yet do not wish to rely solely on implant-based modalities.

View details for DOI 10.1055/s-0037-1599074

View details for PubMedID 28235213

Abstract

Patient education is essential in enhancing the physician-patient therapeutic alliance, patient satisfaction, and clinical outcomes. The American Medical Association and National Institute of Health recommend that information be written at a 6th-grade reading level, but online resources often exceed patient literacy. The purpose of this study is to assess readability of online material for facial plastics procedures presented on academic plastic surgery and otolaryngology websites.An Internet search was performed of all academic institutions that had both plastic surgery and otolaryngology training programs who offered patient information on facial plastic surgery procedures. National society websites for both plastic surgery and otolaryngology were also analyzed. All procedural information was compiled and readability analyses were performed. A 2-tailed Z-test was used to compare scores, and statistical significance was set at P<0.05.Sixty-three programs were identified; 42 had educational material. The overall average readability for all information was at a 10th-grade reading level. The national plastic surgery website had a significantly higher word count and number of syllables per word compared to the national otolaryngology website (P<0.001, P=0.04).The complexity of written resources represents an obstacle to online patient education and efforts to improve readability could benefit patients seeking medical information online. Current online education materials are a potential hindrance to patient education, satisfaction, and decision making. Healthcare institutions should consider writing new materials with simpler language that would be accessible to patients.

View details for DOI 10.1097/SCS.0000000000003435

View details for PubMedID 28106697

Abstract

Composite upper extremity defects involving muscle-tendon units are amongst the most formidable reconstructive challenges and mandate functional restoration in addition to stable soft-tissue coverage. Here, the authors present a case of a composite defect involving the extensor muscle-tendon units of the forearm resulting from surgical resection of a recurrent Merkel cell cancer. Functional restoration was achieved via multiple tendon transfers followed by soft tissue coverage with a free anterolateral thigh (ALT) flap. No donor- or recipient-site complications were encountered and complete flap survival was noted. Following a 6-week period of immobilization, physical therapy and range of motion exercises were initiated. Excellent functional outcome and high patient satisfaction were noted at 8 weeks postoperatively. In summary, simultaneous tendon transfers and microsurgical tissue transfer may provide a potentially superior approach for upper extremity reconstruction in complex composite defects.

View details for DOI 10.1002/micr.30096

View details for Web of Science ID 000393458400012

View details for PubMedID 27580418

Abstract

The internal mammary vessels are the most common recipient vessels in free flap breast reconstruction. The literature on internal mammary vascular anatomy is limited by small sample sizes, cadaveric studies, or intraoperative changes. The purpose of this study is to analyze internal mammary anatomy using computed tomographic angiography. A retrospective review of 110 consecutive computed tomographic angiography studies of female patients was performed. Measurements of vessel caliber, distance of internal mammary vessels to sternum, location of internal mammary vein bifurcation, intercostal space height, and chest width were analyzed. Patient demographics and comorbidities were reviewed. The right internal mammary artery and vein were larger than the left in all intercostal spaces (p=0.02 and p<0.001, respectively). A significant correlation was found between both skeletal chest width and body mass index with internal mammary vessel caliber at the third intercostal space (p0.02). The internal mammary vein bifurcated at the third intercostal space bilaterally, 4.3 and 1.2mm caudal to the third rib on the right and left sides, respectively. The third intercostal space was <1.5cm in 25% of patients. Understanding the anatomy, bifurcation, and caliber of internal mammary vessels can aid preoperative planning of autologous, free flap breast reconstruction. On average, the internal mammary vein bifurcates at the third intercostal space; patients with larger chest widths and body mass index had larger caliber internal mammary vessels, and 25% of patients had third intercostal space <1.5cm and, thus, may not be suitable candidates for rib-sparing techniques.

View details for DOI 10.1016/j.bjps.2016.07.005

View details for PubMedID 27475336

Abstract

Rhinoplasty is perhaps the most complex cosmetic surgery procedure performed today. It is characterized by an intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal appearance but also resolution of preexisting airway symptoms. The prerequisite for successful execution of this challenging procedure is a thorough understanding of nasal anatomy and physiology. Hence, a thorough preoperative evaluation is at least as important and the surgical skill in performing the operation. Establishing an accurate diagnosis through a comprehensive nasal analysis is obligatory. As to the surgical approach, much has been written about the advantages and disadvantages of closed vs open rhinoplasty. The more commonly chosen open approach has numerous advantages, including improved visualization without distortion, thus, enabling precise diagnosis and correction of deformities. While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, the authors have noted a total of 10 essential components to form the foundation for successful technical execution of rhinoplasty. These include: (1) septoturbinotomy; (2) opening the nose; (3) humpectomy/spreader flaps; (4) tip-plasty; (5) supratip-plasty; (6) columellar strut; (7) dorsal augmentation; (8) nasal base reduction; (9) osteotomies; and (10) rim grafts. Postoperative, a variety of problems, such as edema, may be successfully addressed without surgical intervention. Diligent postoperative management is critical in ensuring a positive patient experience. Finally, a comprehensive understanding of possible postoperative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity is mandatory prior to offering rhinoplasty to patients.

View details for DOI 10.1093/asj/sjw093

View details for PubMedID 27651480

Abstract

Despite substantial advances in the management of craniofacial trauma, numerous clinical questions remain. These are increasingly being answered using systematic reviews (SRs). However, caution is warranted as their validity and role in influencing clinical practice has been called into question.A PubMed search was performed in October 2014 to identify SRs published up to and including September 2014 in 35 scientific journals. Two authors independently reviewed the literature and extracted data from included studies. Discrepancies were resolved by consensus. Assessment of multiple systematic reviews (AMSTAR) was used to determine the quality of SRs.The initial search retrieved 3080 articles of which 3051 articles were excluded after screening title and abstract. After full-text review of the remaining 29 articles, 3 additional articles were excluded, thus, leaving 26 SRs for final analysis. Regression analysis demonstrated that the overall number of published SRs increased significantly throughout the period analyzed (P = 0.022). The median AMSTAR score of all SRs was 4.5, consistent with a "poor-to-fair" quality. The interobserver agreement was high, as evidenced by a mean of 0.91. Although there appeared to be a trend toward an increase in AMSTAR score by year over the period analyzed, this failed to reach statistical significance in terms of median (P = 0.36) or absolute (P = 0.26) counts.A tremendous opportunity exists for improvements in the quality of SRs focusing on craniofacial trauma. In addition to familiarizing authors with quality criteria for SRs, adoption of strict reporting criteria by scientific journals may result in long-term improvements in the quality of reporting.

View details for DOI 10.1097/SAP.0000000000000633

View details for PubMedID 26418794

Abstract

The deleterious effects of radiotherapy, including hypovascularity and hypocellularity, have made distraction of irradiated bones challenging. Animal studies, however, have demonstrated adjunctive measures such as the administration of deferoxamine to significantly improve bone regeneration across irradiated distraction gaps. In this report, the authors demonstrate, for the first time, enhanced bone formation following deferoxamine application in a patient following distraction of a previously irradiated maxilla. Computed tomography imaging of the pterygomaxillary buttress on the side of administration revealed significantly increased bone area and density relative to the contralateral buttress. This is the first presentation of clinical deferoxamine use to promote bone formation following irradiated bone distraction and highlights the promise for this adjunctive measure to make outcomes after distraction of irradiated bone more reliable.

View details for DOI 10.1097/SCS.0000000000002633

View details for Web of Science ID 000378088800052

View details for PubMedID 27171947

View details for PubMedCentralID PMC4902756

Abstract

A common postoperative observation after microsurgical ear replantation has been venous congestion necessitating alternate modes of decongestion, frequently in conjunction with blood transfusion. A comprehensive literature search was performed to assess the relationship between mode of vascular reconstruction and postoperative outcome as well as postoperative transfusion requirement after microsurgical ear replantation.The search was limited to cases of microsurgical ear replantation following complete amputation. Only articles published in English and indexed in PubMed were included.The initial search retrieved 285 articles, which was narrowed down to 40 articles reporting on 60 cases that matched the aforementioned criteria. Reconstruction of the arterial and venous limb (Group 1) was performed in 63.3% of patients and artery-only anastomosis (Group 2) was performed in 31.7%. Among measurable outcomes, only the duration of surgery was significantly different between groups (2.6 hours longer in Group 1 than Group 2; P=0.0042).In light of contemporary data demonstrating successful artery-only ear replantation, replantation should not be abandoned when unable to establish venous outflow microsurgically. 2015 Wiley Periodicals, Inc. Microsurgery 36:345-350, 2016.

View details for DOI 10.1002/micr.22411

View details for Web of Science ID 000377114900013

View details for PubMedID 25847853

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

Abstract

Reconstruction of soft tissue defects has traditionally relied on the use of grafts and flaps, which may be associated with variable resorption and/or significant donor site morbidity. Cell-based strategies employing adipose-derived stromal cells (ASCs), found within the stromal vascular fraction (SVF) of adipose tissue, may offer an alternative strategy for soft tissue reconstruction. In this study, we investigated the potential of a bone morphogenetic protein receptor type 1A (BMPR1A)(+) subpopulation of ASCs to enhance de novo adipogenesis.Human lipoaspirate was enzymatically digested to isolate SVF and magnetic-activated cell separation was utilized to obtain BMPR1A(+) and BMPR1A(-) cells. These cells, along with unenriched cells, were expanded in culture and evaluated for adipogenic gene expression and in vitro adipocyte formation. Cells from each group were also labeled with a green fluorescent protein (GFP) lentivirus and transplanted into the inguinal fat pads, an adipogenic niche, of immunocompromised mice to determine their potential for de novo adipogenesis. Confocal microscopy along with staining of lipid droplets and vasculature was performed to evaluate the formation of mature adipocytes by transplanted cells.In comparison to BMPR1A(-) and unenriched ASCs, BMPR1A(+) cells demonstrated significantly enhanced adipogenesis when cultured in an adipogenic differentiation medium, as evidenced by increased staining with Oil Red O and increased expression of peroxisome proliferator-activating receptor gamma (PPAR-) and fatty acid-binding protein 4 (FABP4). BMPR1A(+) cells also formed significantly more adipocytes in vivo, as demonstrated by quantification of GFP+ adipocytes. Minimal formation of mature adipocytes was appreciated by BMPR1A(-) cells.BMPR1A(+) ASCs show an enhanced ability for adipogenesis in vitro, as shown by gene expression and histological staining. Furthermore, within an adipogenic niche, BMPR1A(+) cells possessed an increased capacity to generate de novo fat compared to BMPR1A(-) and unenriched cells. This suggests utility for the BMPR1A(+) subpopulation in cell-based strategies for soft tissue reconstruction.

View details for DOI 10.1089/ten.tea.2015.0278

View details for PubMedID 26585335

Abstract

Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

View details for DOI 10.1016/j.bjps.2015.08.032

View details for Web of Science ID 000367236800007

Abstract

Immediate expander-implant breast reconstruction (EIBR) with external beam radiation therapy (XRT) is pursued by many breast cancer patients; however, there is still a lack of consensus on the expected clinical outcomes. We performed a critical analysis of postoperative outcomes in EIBR patients with XRT exposure through a retrospective review from January 2007 to December 2013. Patients were stratified into three groups: exposure to preoperative XRT (XRT-pre), postoperative XRT (XRT-post), or no XRT (control). A subset of XRT patients with bilateral EIBR was assessed using a matched-pair analysis with the patients serving as their own controls. A total of 76 patients were included in the study. Major complications were observed in 6 of 8, 26 of 38, and 14 of 30 patients in the XRT-pre, XRT-post, and control groups, respectively, and were not statistically different (p > 0.05). EIBR failure rates were 13.3% in the control group compared to 50.0% in the XRT-pre group (p = 0.044) and 26.3% in the XRT-post group (p > 0.05). In the matched-pair analysis, 16 of 26 irradiated breasts developed complications compared to only 7 of 26 contralateral non-irradiated breasts (p = 0.043). In conclusion, we detected a significantly increased risk of complications in patients with pre-mastectomy radiotherapy. Patients with this history of XRT should strongly consider autologous reconstruction instead of EIBR to avoid the high risk of developing complications and subsequently losing their implant. Increased complications in irradiated breasts when compared to the contralateral non-irradiated breasts in bilateral EIBR patients confirmed the detrimental role of XRT in the setting of EIBR.

View details for DOI 10.1016/j.bjps.2015.08.032

View details for PubMedID 26453182

Abstract

Patients with peripheral nerve injuries, especially severe injury, often face poor nerve regeneration and incomplete functional recovery, even after surgical nerve repair. This review summarizes treatment options of peripheral nerve injuries with current techniques and concepts and reviews developments in research and clinical application of these therapies.

View details for DOI 10.1155/2016/4175293

View details for PubMedID 26904282

View details for PubMedCentralID PMC4745297

View details for DOI 10.1097/SAP.0000000000000596

View details for PubMedID 26207557

Abstract

The use of Hirudo medicinalis in clinical practice has increased in recent years. The primary indication in plastic surgery has traditionally been venous congestion. However, other reported clinical applications were in varicose veins, thrombophlebitis, and osteoarthritis. In this review, we summarize recent data elucidating the role that medicinal leeches play in the field of plastic surgery.

View details for DOI 10.1007/s10354-015-0382-5

View details for PubMedID 26297126

Abstract

Adipose-derived stromal cells represent a relatively abundant source of multipotent cells, with many potential applications in regenerative medicine. The present study sought to demonstrate the use of RNA sequencing in identifying differentially expressed transcripts, particularly long noncoding RNAs, associated with adipogenic differentiation to gain a clearer picture of the mechanisms responsible for directing adipose-derived stromal cell fate toward the adipogenic lineage.Human adipose-derived stromal cells were cultured in adipogenic differentiation media, and RNA was harvested at days 0, 1, 3, 5, and 7. Directional RNA sequencing libraries were prepared and sequenced. Paired-end reads were mapped to the human genome reference sequence hg19. Transcriptome assembly was performed and significantly differentially expressed transcripts were identified. Gene ontology term analysis was then performed to identify coding and noncoding transcripts of interest. Differential expression was verified by quantitative real-time polymerase chain reaction.Of 2868 significantly differentially expressed transcripts identified, 207 were noncoding. Enriched gene ontology terms among up-regulated coding transcripts notably reflected differentiation toward the adipogenic lineage. Enriched gene ontology terms among down-regulated coding transcripts reflected growth arrest. Guilt-by-association analysis revealed noncoding RNA candidates with potential roles in the process of adipogenic differentiation.The precise mechanisms that guide lineage-specific differentiation in multipotent cells are not yet fully understood. Defining long noncoding RNAs associated with adipogenic differentiation allows for potential manipulation of regulatory pathways in novel ways. The authors present RNA sequencing as a powerful tool for expanding the understanding of adipose-derived stromal cells and developing novel applications within regenerative medicine.

View details for DOI 10.1097/PRS.0000000000001582

View details for PubMedID 26090763

Abstract

Systemic sclerosis (SSc) is a rare connective tissue disease associated with significant digital vasculopathy. Peripheral sympathectomy is frequently offered late in the disease process after severe digital ischemia has already occurred with patients being symptomatic for numerous years. The purpose of the present study was to analyze the results of peripheral sympathectomy in patients with a confirmed diagnosis of SSc.A retrospective analysis of 17 patients (26 hands) who underwent peripheral sympathectomy between January 2003 and September 2013 was performed. Data regarding patient demographics, clinical features, and postoperative outcomes were retrieved. Of note, preoperative pain was present in all patients with a mean duration of 9.6 years prior to peripheral sympathectomy.Pain improvement/resolution was seen in 24 hands (92.3%). Digital ulcers healed in all patients with only two patients (two hands; 7.7%) requiring surgical intervention for ulcer recurrence 6 months and 4.5 years later. Minor complications were seen in seven hands (26.9%); including infection, wound opening, and stitch abscess, but none required surgical intervention. Seven of eight patients queried would have preferred surgical treatment at an earlier point in the disease process.Peripheral sympathectomy is a well-tolerated procedure in patients with SSc and is associated with predictable pain relief and ulcer healing in the majority of patients. In light of these findings it seems prudent to offer surgical treatment not as a last resort but rather earlier in the disease process to decrease the duration that patients suffer pain. 2015 Wiley Periodicals, Inc. Microsurgery, 2015.

View details for DOI 10.1002/micr.22379

View details for PubMedID 25585522

Abstract

Cutaneous wound repair in adult mammals typically does not regenerate original dermal architecture. Skin that has undergone repair following injury is not identical to intact uninjured skin. This disparity may be caused by differences in the mechanisms that regulate postnatal cutaneous wound repair compared to embryonic skin development and thus we seek a deeper understanding of the role that Wnt signaling plays in the mechanisms of skin repair in both fetal and adult wounds. The influence of secreted Wnt signaling proteins in tissue homeostasis has galvanized efforts to identify small molecules that target Wnt-mediated cellular responses. Wnt signaling is activated by wounding and participates in every subsequent stage of the healing process from the control of inflammation and programmed cell death, to the mobilization of stem cell reservoirs within the wound site. Endogenous Wnt signaling augmentation represents an attractive option to aid in the restoration of cutaneous wounds, as the complex mechanisms of the Wnt pathway have been increasingly investigated over the years. In this review, we summarize recent data elucidating the roles that Wnt signaling plays in cutaneous wound healing process.

View details for DOI 10.1080/15476278.2015.1086052

View details for PubMedID 26309090

View details for PubMedCentralID PMC4879891

Abstract

Nanotechnology represents a major frontier with potential to significantly advance the field of bone tissue engineering. Current limitations in regenerative strategies include impaired cellular proliferation and differentiation, insufficient mechanical strength of scaffolds, and inadequate production of extrinsic factors necessary for efficient osteogenesis. Here we review several major areas of research in nanotechnology with potential implications in bone regeneration: 1) nanoparticle-based methods for delivery of bioactive molecules, growth factors, and genetic material, 2) nanoparticle-mediated cell labeling and targeting, and 3) nano-based scaffold construction and modification to enhance physicochemical interactions, biocompatibility, mechanical stability, and cellular attachment/survival. As these technologies continue to evolve, ultimate translation to the clinical environment may allow for improved therapeutic outcomes in patients with large bone deficits and osteodegenerative diseases.Traditionally, the reconstruction of bony defects has relied on the use of bone grafts. With advances in nanotechnology, there has been significant development of synthetic biomaterials. In this article, the authors provided a comprehensive review on current research in nanoparticle-based therapies for bone tissue engineering, which should be useful reading for clinicians as well as researchers in this field.

View details for DOI 10.1016/j.nano.2015.02.013

View details for Web of Science ID 000363967100022

View details for PubMedID 25791811

View details for PubMedCentralID PMC4476906

Abstract

Cell-assisted lipotransfer has shown much promise as a technique for improving fat graft take. However, the concentration of stromal vascular fraction cells required to optimally enhance fat graft retention remains unknown.Human lipoaspirate was processed for both fat transfer and harvest of stromal vascular fraction cells. Cells were then mixed back with fat at varying concentrations ranging from 10,000 to 10 million cells per 200 l of fat. Fat graft volume retention was assessed by means of computed tomographic scanning over 8 weeks, and then fat grafts were explanted and compared histologically for overall architecture and vascularity.Maximum fat graft retention was seen at a concentration of 10,000 cells per 200 l of fat. The addition of higher number of cells negatively impacted fat graft retention, with supplementation of 10 million cells producing the lowest final volumes, lower than fat alone. Interestingly, fat grafts supplemented with 10,000 cells showed significantly increased vascularity and decreased inflammation, whereas fat grafts supplemented with 10 million cells showed significant lipodegeneration compared with fat alone: The authors' study demonstrates dose dependence in the number of stromal vascular fraction cells that can be added to a fat graft to enhance retention. Although cell-assisted lipotransfer may help promote graft survival, this effect may need to be balanced with the increased metabolic load of added cells that may compete with adipocytes for nutrients during the postgraft period.

View details for DOI 10.1097/PRS.0000000000001367

View details for Web of Science ID 000357096300002

View details for PubMedID 25829158

View details for PubMedCentralID PMC4483157

Abstract

Pyoderma gangrenosum (PG) is a rare skin disorder of unknown etiology that is believed to be part of the spectrum of neutrophilic dermatoses. Although 25% to 50% of cases are idiopathic, PG is associated with systemic disease in up to 70% of patients, most notably inflammatory bowel disease, rheumatoid arthritis, and paraproteinemia. Although a multitude of PG cases after breast reduction have been reported, only recently has an association of PG with breast reconstruction been acknowledged. In the present article, the case of postsurgical PG (PSPG) after autologous breast reconstruction is presented along with a review of the literature. The importance of early diagnosis and initiation of appropriate treatment is discussed. The authors discuss the possibility that the increased number of breast reconstructions being performed may increase the incidence of PSPG cases seen by plastic surgeons. As such, it is critical to remove PSPG from the list of "exotic" diseases and place it higher on the list of differential diagnoses as delays in treatment can result in debilitating complications with substantial patient morbidity.

View details for DOI 10.1097/SAP.0b013e318296b7ae

View details for Web of Science ID 000349678900005

View details for PubMedID 24557050

Abstract

Although the level of evidence is an important parameter during critical appraisal, the quality of reporting is similarly relevant. It is surprising that no objective analysis of the quality of reporting of the most common group of studies (ie, evidence level 4) has been performed to date.A hand search was conducted including all issues of Plastic and Reconstructive Surgery, British Journal of Plastic Surgery, Journal of Plastic Reconstructive and Aesthetic Surgery, Annals of Plastic Surgery, and Microsurgery for the years 1992, 2002, and 2012. All evidence level 4 studies with a focus on microsurgical reconstruction were included in the study. To assess the quality of reporting, a modification of an established quality assessment scale for retrospective clinical studies was used. This instrument generates a total possible score of 32, with a score of lower than 11, 12 to 21, and 22 to 32 representing poor, fair, and good quality of reporting, respectively.A total of 223 studies were included in the final analysis. An increase in the number of published case series was noted (46, 73, and 104 in 1992, 2002, and 2012, respectively). Similarly, an increase in the median number of patients was seen over time (8 [range, 2-165], 11 [range, 2-660], and 16 [range, 2-819] patients in 1992, 2002, and 2012, respectively) (P = 0.03). Most of the studies were conducted in Asia (38.1%) and North America (30.5%) and predominantly focused on head and neck (30.5%) as well as lower extremity reconstruction (21.5%). Although the quality of reporting was poor in 1992 and 2002 (median score, 10 [range, 3-19] in both years), an improvement to a fair quality of reporting was noted in 2012 (median score, 13 [range, 4-24]) (P = 0.0001).The trend to publish an increasing number of case series with a focus on microsurgical reconstruction is paralleled by an improvement in the quality of reporting. Although a favorable trend is seen, increased efforts are indicated to further improve the quality of case series in microsurgery.

View details for PubMedID 25710552

Abstract

Systematic reviews frequently form the basis for clinical decision making and guideline development. Yet, the quality of systematic reviews has been variable, thus raising concerns about the validity of their conclusions. In the current study, a quality analysis of systematic reviews was performed, addressing microsurgical head and neck reconstruction.A PubMed search was performed to identify all systematic reviews published up to and including December 2012 in 12 surgical journals. Two authors independently reviewed the literature and extracted data from the included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 1020 articles. After screening titles and abstracts, 987 articles were excluded. Full-text review of the remaining 33 articles resulted in further exclusion of 18 articles, leaving 15 systematic reviews for final analysis. A marked increase in the number of published systematic reviews over time was noted (P = 0.07). The median AMSTAR score was 5, thus reflecting a "fair" quality. No evidence for improvement in methodological quality over time was noted.The trend to publish more systematic reviews in microsurgical head and neck reconstruction is encouraging. However, efforts are indicated to improve the methodological quality of systematic reviews. Familiarity with criteria of methodological quality is critical to ensure future improvements in the quality of systematic reviews conducted in microsurgery.

View details for DOI 10.1097/SCS.0000000000001248

View details for Web of Science ID 000347954400083

Abstract

Cloud-based applications including Box, Dropbox, Google Drive, Evernote, Notability, and Zotero are available for smartphones, tablets, and laptops and have revolutionized the manner in which medical students and surgeons read and utilize plastic surgery literature. Here we provide an overview of the use of Cloud computing in practice and propose an algorithm for organizing the vast amount of plastic surgery literature. Given the incredible amount of data being produced in plastic surgery and other surgical subspecialties, it is prudent for plastic surgeons to lead the process of providing solutions for the efficient organization and effective integration of the ever-increasing data into clinical practice.

View details for PubMedID 26576208

Abstract

Systematic reviews frequently form the basis for clinical decision making and guideline development. Yet, the quality of systematic reviews has been variable, thus raising concerns about the validity of their conclusions. In the current study, a quality analysis of systematic reviews was performed, addressing microsurgical head and neck reconstruction.A PubMed search was performed to identify all systematic reviews published up to and including December 2012 in 12 surgical journals. Two authors independently reviewed the literature and extracted data from the included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 1020 articles. After screening titles and abstracts, 987 articles were excluded. Full-text review of the remaining 33 articles resulted in further exclusion of 18 articles, leaving 15 systematic reviews for final analysis. A marked increase in the number of published systematic reviews over time was noted (P = 0.07). The median AMSTAR score was 5, thus reflecting a "fair" quality. No evidence for improvement in methodological quality over time was noted.The trend to publish more systematic reviews in microsurgical head and neck reconstruction is encouraging. However, efforts are indicated to improve the methodological quality of systematic reviews. Familiarity with criteria of methodological quality is critical to ensure future improvements in the quality of systematic reviews conducted in microsurgery.

View details for DOI 10.1097/SCS.0000000000001248

View details for PubMedID 25478976

Abstract

We developed an experimental rat model to explore the possibility of enhancing the healing of critical-size bone defects. The aim of this study was to demonstrate the feasibility of this concept by achieving high local BMP-2 expression via a transduced muscle flap that would facilitate bony union while minimizing systemic sequelae.The transduction potential of the adenoviral vector encoding for BMP-2 was tested in different cell lines in vitro. In vivo experiments consisted of harvesting a pedicled quadriceps femoris muscle flap with subsequent creation of a critical-size defect in the left femur in Sprague-Dawley rats. Next, the pedicled muscle flap was perfused with high titers of Ad.BMP-2 and Ad.GFP virus, respectively. Twelve animals were divided into three groups comparing the effects of Ad.BMP-2 transduction to Ad.GFP and placebo. Bone healing was monitored radiologically with subsequent histological analysis post-mortem.The feasibility of this concept was demonstrated by successful transduction in vitro and in vivo as evidenced by a marked increase of BMP-2 expression. The three examined groups only showed minor difference regarding bone regeneration; however, one complete bridging of the defect was observed in the Ad.BMP-2 group. No evidence of systemic viral contamination was noted.A marked increase of local BMP-2 expression (without untoward systemic sequelae) was detected. However, bone healing was not found to be significantly enhanced, possibly due to the small sample size of the study.

View details for DOI 10.1186/s13018-015-0196-6

View details for PubMedID 25924919

View details for PubMedCentralID PMC4424495

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

Abstract

Aesthetic surgery is an integral component of plastic surgery. Despite its importance, adequate training in aesthetic surgery is met with challenges. Although the educational benefit of resident clinics has been demonstrated, such clinics are rarely found outside the United States. The objective of the present study was to assess safety and patient satisfaction associated with aesthetic surgery procedures performed by plastic surgery residents at a German academic medical center.The study had 2 components, namely, a retrospective chart review and an administration of a patient satisfaction survey. Only patients who underwent a surgical intervention by a plastic surgery resident between 2003 and 2011 were included in the study. Parameters of interest included age, sex, procedure performed, number of procedures, revenue (in &OV0556;), length of follow-up, revision rate, and postoperative complication rate. Patient satisfaction was assessed by the client satisfaction questionnaire-8.A total of 273 aesthetic procedures were performed in 206 patients with an increase in recent years. The median follow-up period was 49.5 months. The most frequently performed procedures were liposuction (n = 59), breast augmentation (n = 53), and upper eyelid blepharoplasty (n = 31). One hundred ninety-two (90.3%) patients had an uneventful postoperative course. The client satisfaction questionnaire-8 questionnaire was completed by 110 patients (response rate, 50.2%). The median value of 28 indicates a high degree of patient satisfaction. An association between occurrence of major complications and patient satisfaction was seen.Aesthetic surgery performed by plastic surgery residents under supervision by attending physicians is safe and provides for high levels of patient satisfaction postoperatively. Offering these services may be able to bridge the gap between providing high-quality aesthetic surgery training while yet recruiting an increasing number of patients who may appreciate the lower fees associated with these services.

View details for DOI 10.1097/SAP.0b013e31828d7090

View details for Web of Science ID 000345160000016

View details for PubMedID 23759970

Abstract

Ear amputation is a devastating injury characterized by a conspicuous deformity that is not easily concealed and can result in tremendous psychological trauma in addition to the physical insult. While numerous different approaches have been proposed, microvascular replantation is widely considered to deliver the best esthetic outcome. In this article, the authors report a case in which an unconventional perfusion pattern (i.e., arterialization of the venous system) was chosen, as intraoperative anatomic conditions precluded conventional vascular reconstruction. A 25-year-old male patient sustained a human bite resulting in subtotal amputation of his left ear. In the setting of an adequate arterial donor vessel, that is, branch of the posterior auricular artery, and a single suitable recipient vein (0.4 mm), the decision was made to perform an end-to-end arterio-venous anastomosis without the use of vein grafts. Medicinal leeches were applied postoperatively to provide for venous drainage. The ear survived and the patient was discharged after 14 days. To the best of our knowledge, this is first case of a subtotal ear amputation that was successfully replanted by arterialization of the venous system without the use of vein grafts and with preservation of the superficial temporal vessels.

View details for DOI 10.1002/micr.22308

View details for Web of Science ID 000343761700012

View details for PubMedID 25116223

View details for DOI 10.1097/PRS.0000000000000470

View details for Web of Science ID 000349460300018

View details for PubMedID 25158729

Abstract

Fat grafting has become increasingly popular for the correction of soft tissue deficits at many sites throughout the body. Long-term outcomes, however, depend on delivery of fat in the least traumatic fashion to optimize viability of the transplanted tissue. In this study, we compare the biologic properties of fat following injection using two methods.Lipoaspiration samples were obtained from five female donors and cellular viability, proliferation, and lipolysis were evaluated following injection using either a modified Coleman technique or an automated, low shear device. Comparisons were made to minimally processed, uninjected fat. Volume retention was also measured over twelve weeks following injection of fat under the scalp of immunodeficient mice using either the modified Coleman technique or the Adipose Tissue Injector. Finally, fat grafts were analyzed histologically.Fat viability and cellular proliferation were both significantly greater with the Adipose Tissue Injector relative to injection with the modified Coleman technique. In contrast, significantly less lipolysis was noted using the automated device. In vivo fat volume retention was significantly greater than with the modified Coleman technique at 4, 6, 8, and 12 week time points. This corresponded with significantly greater histological scores for healthy fat and lower scores for injury following injection with the device.Biological properties of injected tissues reflect how disruptive and harmful techniques for placement of fat may be, and our in vitro and in vivo data both support the use of the automated, low shear devices compared to the modified Coleman technique.

View details for DOI 10.1097/PRS.0000000000000290

View details for PubMedID 24622574

View details for DOI 10.1097/SAP.0b013e31828f6303

View details for Web of Science ID 000338342000026

View details for PubMedID 24918741

Abstract

Although fat grafting can address many soft-tissue deficits, results remain inconsistent. In this study, the authors compared physical properties of fat following injection using an automated, low-shear device or the modified Coleman technique.Lipoaspirate was obtained from nine patients and processed for injection using either a modified Coleman technique or an automated, low-shear device. Fat was passed through a 2-mm cannula and compared with minimally processed fat. A rheometer was used to measure the storage modulus and shear rate at which tissues began to lose their solid-like properties. Viscosity was also measured, and gross properties of treatment groups were evaluated qualitatively with a glass slide test.Fat injected through an automated, low-shear device closely matched physical properties of minimally processed fat. The storage modulus (G') of fat for the device group was greater than for the modified Coleman group, and the onset of breakdown was delayed. Similarly, viscosity measurement of fat from the automated device closely matched minimally processed fat and was greater than that of othe modified Coleman group.The physical properties of lipoaspirate processed using an automated, low-shear device with a 2-mm cannula preserved the intactness of fat more than the modified Coleman technique. The authors' rheologic data demonstrate less damage using an automated device compared with the modified Coleman technique and potentially support its use for improved fat graft integrity.

View details for DOI 10.1097/PRS.0000000000000289

View details for PubMedID 25028817

Abstract

Staged expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are the most common modes of breast reconstruction (BR) in the United States. Whether the mode of breast reconstruction has an impact on patient quality of life (QoL) and satisfaction remains a question. A retrospective study was conducted identifying a population of 119 patients who underwent unilateral immediate BR. Only patients who were eligible for either EIBR or MAFBR based on preoperative characteristics were included in the study. The following parameters were retrieved: demographics, mode of reconstruction, cancer, recovery, QoL, and patient satisfaction. The latter two parameters were determined using the BREAST-Q BR module questionnaire. Two-way analysis of variance with mode of reconstruction and occurrence of complication as independent variables was used to determine the effect on patient satisfaction and QoL. The association between mode of reconstruction and patient response with each item of the QoL and satisfaction survey domains was analyzed. The overall response rate was 62.2%. Non-respondents and respondents did not significantly differ in demographics, surgery type, cancer staging, adjuvant therapy, and complication rate. Age and BMI were significantly higher in MAFBR, while level of education was higher in EIBR. MAFBR had higher scores in psychosocial and sexual wellbeing, satisfaction with outcome, breast, information, and plastic surgeon when compared with patients who underwent EIBR. For patients eligible for both MAFBR and EIBR, MAFBR is associated with higher levels of satisfaction and QoL. Comprehensive pre-operative information of pros and cons of both modes of BR is crucial for patients to make a well-informed decision, thus, resulting in higher levels of satisfaction.

View details for DOI 10.1007/s10549-014-2981-z

View details for Web of Science ID 000338219300012

Abstract

Fat grafting has become increasingly popular for the correction of soft tissue deficits at many sites throughout the body. Long-term outcomes, however, depend on delivery of fat in the least traumatic fashion to optimize viability of the transplanted tissue. In this study, we compare the biologic properties of fat following injection using two methods.Lipoaspiration samples were obtained from five female donors and cellular viability, proliferation, and lipolysis were evaluated following injection using either a modified Coleman technique or an automated, low shear device. Comparisons were made to minimally processed, uninjected fat. Volume retention was also measured over twelve weeks following injection of fat under the scalp of immunodeficient mice using either the modified Coleman technique or the Adipose Tissue Injector. Finally, fat grafts were analyzed histologically.Fat viability and cellular proliferation were both significantly greater with the Adipose Tissue Injector relative to injection with the modified Coleman technique. In contrast, significantly less lipolysis was noted using the automated device. In vivo fat volume retention was significantly greater than with the modified Coleman technique at 4, 6, 8, and 12 week time points. This corresponded with significantly greater histological scores for healthy fat and lower scores for injury following injection with the device.Biological properties of injected tissues reflect how disruptive and harmful techniques for placement of fat may be, and our in vitro and in vivo data both support the use of the automated, low shear devices compared to the modified Coleman technique.

View details for DOI 10.1097/PRS.0000000000000290

View details for Web of Science ID 000338116400042

Abstract

Although fat grafting can address many soft-tissue deficits, results remain inconsistent. In this study, the authors compared physical properties of fat following injection using an automated, low-shear device or the modified Coleman technique.Lipoaspirate was obtained from nine patients and processed for injection using either a modified Coleman technique or an automated, low-shear device. Fat was passed through a 2-mm cannula and compared with minimally processed fat. A rheometer was used to measure the storage modulus and shear rate at which tissues began to lose their solid-like properties. Viscosity was also measured, and gross properties of treatment groups were evaluated qualitatively with a glass slide test.Fat injected through an automated, low-shear device closely matched physical properties of minimally processed fat. The storage modulus (G') of fat for the device group was greater than for the modified Coleman group, and the onset of breakdown was delayed. Similarly, viscosity measurement of fat from the automated device closely matched minimally processed fat and was greater than that of othe modified Coleman group.The physical properties of lipoaspirate processed using an automated, low-shear device with a 2-mm cannula preserved the intactness of fat more than the modified Coleman technique. The authors' rheologic data demonstrate less damage using an automated device compared with the modified Coleman technique and potentially support its use for improved fat graft integrity.

View details for DOI 10.1097/PRS.0000000000000289

View details for Web of Science ID 000338116400043

View details for PubMedCentralID PMC4101917

Abstract

Expander-implant breast reconstruction (EIBR) and microsurgical abdominal flap breast reconstruction (MAFBR) are currently the two most frequent breast reconstruction techniques performed in the United States. The aim of this study was to compare outcomes between EIBR and MAFBR in order to help future breast cancer patients to be more knowledgeable and better informed in choosing their optimal reconstruction option.Medical records of 795 patients who underwent breast reconstruction at Stanford Hospital from 2007 to 2011 were reviewed. We found 254 patients to be candidates for both MAFBR and EIBR preoperatively and included them in the study. Patients demographics, postoperative clinic visits, length of hospital stay, postoperative complications, and follow-up time were compared. Logistic regression analysis was used to determine risk factors for major complications.MAFBR patients had 8.7 clinic visits postoperatively, while 14.6 visits were needed for EIBR patients. Length of hospital stay was 4.81.32days for MAFBR and 2.10.9days for EIBR. Complication occurred in 21.3% of MAFBR versus 37.4% for EIBR patients. Follow-up duration was 24.717.2months for EIBR and 30.118.5months for MAFBR. On multivariate analysis, EIBR and a body mass index of 30kg/m(2) were the only significant predictors of major complication.For patients eligible for both options, MAFBR has a lower incidence of major complications and fewer postoperative visits, but it has a longer initial hospital stay compared to EIBR. Patients should be informed of not only short-term but also long-term possible risks and benefits in order to make an informed decision.

View details for DOI 10.1245/s10434-014-3521-0

View details for PubMedID 24558063

Abstract

Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n = 5, 56%), mastectomy flap necrosis (n = 5, 56%), cellulitis (n = 4, 44%), seroma (n = 3, 33%), hematoma (n = 1, 11%), and chronic pain (n = 1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.

View details for DOI 10.1097/SAP.0000000000000167

View details for PubMedID 24740024

Abstract

Although mantle radiation (ie, extended field radiation) represented the standard of care in the past for Hodgkin disease, contemporary treatment of lymphoma consists of a multimodal approach with chemotherapy. Patients who were exposed to mantle radiation have a higher risk of breast cancer and are more susceptible to postoperative complications after breast reconstruction due to radiation. In this study, we present postoperative outcomes in patients with a history of mantle radiation who underwent mastectomy and breast reconstruction.All patients at Stanford University Medical Center between January 2006 and December 2012 with a history of Hodgkin lymphoma treated with mantle radiation who received breast reconstruction were identified. A retrospective chart review was conducted analyzing patient demographics, history of Hodgkin treatment, type of reconstruction, follow-up, and complications. Complications were further classified into medical complications, donor-site complications, and recipient-site complications.Sixteen patients with a history of Hodgkin disease and mantle radiation received breast reconstruction. The average age of the patients at their mastectomy was 46 (33-60) years, with the average age at the time of their mantle radiation of 20.5 (10-33) years with an average interval of radiation to breast cancer treatment of 24.8 (16-38) years. There were five unilateral and 11 bilateral reconstructions. All patients had immediate reconstruction with tissue expanders (14 patients) or autologous tissue (one muscle-sparing transverse rectus abdominis myocutaneous and one transverse upper gracilis flap). Eleven (69%) patients had postoperative complications. In the patients who had tissue expander reconstruction, there was an overall complication rate of 64%, which included capsular contracture (n = 5, 56%), mastectomy flap necrosis (n = 5, 56%), cellulitis (n = 4, 44%), seroma (n = 3, 33%), hematoma (n = 1, 11%), and chronic pain (n = 1, 11%). Three (two unilateral and one bilateral) tissue expander infections required removal of the expander and delayed reconstruction with a latissimus dorsi flap, whereas one patient with chronic pain and capsular contracture required a muscle-sparing transverse rectus abdominis myocutaneous for a unilateral implant failure.Although the risk of complications associated with preoperative radiation is well documented, physicians and patients should be cognizant of the increased risk of complications after mantle radiation as it represents a unique modality of radiation exposure.

View details for DOI 10.1097/SAP.0000000000000167

View details for PubMedID 24740024

Abstract

Trapeziometacarpal, or thumb carpometacarpal (CMC), arthritis is a common problem with a variety of treatment options. Although widely used, the Eaton radiographic staging system for CMC arthritis is of questionable clinical utility, as disease severity does not predictably correlate with symptoms or treatment recommendations. A possible reason for this is that the classification itself may not be reliable, but the literature on this has not, to our knowledge, been systematically reviewed.We therefore performed a systematic review to determine the intra- and interobserver reliability of the Eaton staging system.We systematically reviewed English-language studies published between 1973 and 2013 to assess the degree of intra- and interobserver reliability of the Eaton classification for determining the stage of trapeziometacarpal joint arthritis and pantrapezial arthritis based on plain radiographic imaging. Search engines included: PubMed, Scopus(), and CINAHL. Four studies, which included a total of 163 patients, met our inclusion criteria and were evaluated. The level of evidence of the studies included in this analysis was determined using the Oxford Centre for Evidence Based Medicine Levels of Evidence Classification by two independent observers.A limited number of studies have been performed to assess intra- and interobserver reliability of the Eaton classification system. The four studies included were determined to be Level 3b. These studies collectively indicate that the Eaton classification demonstrates poor to fair interobserver reliability (kappa values: 0.11-0.56) and fair to moderate intraobserver reliability (kappa values: 0.54-0.657).Review of the literature demonstrates that radiographs assist in the assessment of CMC joint disease, but there is not a reliable system for classification of disease severity. Currently, diagnosis and treatment of thumb CMC arthritis are based on the surgeon's qualitative assessment combining history, physical examination, and radiographic evaluation. Inconsistent agreement using the current common radiographic classification system suggests a need for better radiographic tools to quantify disease severity.

View details for DOI 10.1007/s11999-013-3208-z

View details for PubMedID 23917991

View details for DOI 10.1097/01.prs.0000445829.40020.04

View details for PubMedID 24675339

View details for DOI 10.1097/01.prs.0000444979.14443.08

View details for PubMedID 25942261

View details for DOI 10.1097/01.prs.0000444994.28797.34

View details for PubMedID 25942275

Abstract

As complexity of care of hospitalized patients has increased, the need for communication and collaboration among members of the team caring for the patient has become increasingly important. This often takes the form of a nurse's need to contact a patient's physician to discuss some aspect of care and modify treatment plans. Errors in communication delay care and can pose risk to patients. This report describes the successful implementation of a standardized team-based paging system at an academic center. Results showed a substantial improvement in nurses' perceptions of knowing how to contact the correct physician when discussion of the patient's care is needed. This improvement was found across multiple medical and surgical specialties and was particularly effective for services with the greatest communication problems.

View details for PubMedID 24716330

View details for DOI 10.1002/micr.22194

View details for Web of Science ID 000331394700001

View details for PubMedID 24123172

View details for Web of Science ID 000329763900029

View details for PubMedID 24440075

Abstract

It is safe to say that in situ decompression of the ulnar nerve in cubital tunnel syndrome has been demonstrated to achieve equivalent functional results when compared with more elaborate techniques, such as decompression with nerve transposition. The evolution toward procedures associated with less patient morbidity is reflected by the introduction of endoscopic techniques for the treatment of cubital tunnel syndrome. The authors have incorporated the endoscopic approach as proposed by Hoffmann and Siemionow into their practice and have obtained favorable results. Although the skin incision can frequently be kept to a minimum (<2 cm), superior visualization associated with this approach allows for in situ decompression of the ulnar nerve along a distance of up to 30 cm. Despite the extent of decompression performed, operative morbidity is minimal, with return to full duty being the rule even in manual laborers within 10 to 14 days postoperatively.

View details for DOI 10.1016/j.hc1.2013.08.021

View details for Web of Science ID 000329087000009

View details for PubMedID 24286743

Abstract

ABSTRACT: The treatment of facial palsy is a complex and challenging area of plastic surgery. Two distinct anatomical regions and functions are the focus of interest when managing facial palsy: (1) reanimation of the eyelids and (2) reconstruction of the smile. This review will focus on the treatment of ocular manifestations of facial palsy. The principles of eyelid rehabilitation will be presented along with a discussion of surgical and nonsurgical treatment options.

View details for DOI 10.1097/SAP.0b013e318264fcba

View details for Web of Science ID 000338013700025

Abstract

Background. Three educational models for plastic surgery training exist in the United States, the integrated, combined, and independent model. The present study is a comparative analysis of aesthetic surgery training, to assess whether one model is particularly suitable to provide for high-quality training in aesthetic surgery. Methods. An 18-item online survey was developed to assess residents' perceptions regarding the quality of training in aesthetic surgery in the US. The survey had three distinct sections: demographic information, current state of aesthetic surgery training, and residents' perception regarding the quality of aesthetic surgery training. Results. A total of 86 senior plastic surgery residents completed the survey. Twenty-three, 24, and 39 residents were in integrated, combined, and independent residency programs, respectively. No statistically significant differences were seen with respect to number of aesthetic surgery procedures performed, additional training received in minimal-invasive cosmetic procedures, median level of confidence with index cosmetic surgery procedures, or perceived quality of aesthetic surgery training. Facial aesthetic procedures were felt to be the most challenging procedures. Exposure to minimally invasive aesthetic procedures was limited. Conclusion. While the educational experience in aesthetic surgery appears to be similar, weaknesses still exist with respect to training in minimally invasive/nonsurgical aesthetic procedures.

View details for DOI 10.1155/2014/281923

View details for PubMedID 25225615

View details for DOI 10.1097/PRS.0b013e31829fe0f7

View details for Web of Science ID 000329796500020

Abstract

A multitude of different approaches have been proposed for achieving optimal aesthetic results after nipple reconstruction. In contrast, however, only a few studies focus on the morbidity associated with this procedure, particularly after implant-based breast reconstruction.Using a cross-sectional study design all patients who underwent implant-based breast reconstruction with subsequent nipple reconstruction between 2000 and 2010 at Stanford University Medical Center were identified. The aim of the study was to analyze the impact of the following parameters on the occurrence of postoperative complications: age, final implant volume, time interval from placement of final implant to nipple reconstruction, and history of radiotherapy.A total of 139 patients with a mean age of 47.5 years (range, 29 to 75 years) underwent 189 nipple reconstructions. The overall complication rate was 13.2 percent (N = 25 nipple reconstructions). No association was observed between age (p = 0.43) or implant volume (p = 0.47) and the occurrence of complications. A trend towards higher complication rates in patients in whom the time interval between final implant placement and nipple reconstruction was greater than 8.5 months was seen (p = 0.07). Radiotherapy was the only parameter that was associated with a statistically significant increase in postoperative complication rate (51.7 percent vs. 6.25 percent; p < 0.00001).While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy, the presence of an irradiated field converts it to a high-risk one with a significant increase in postoperative complication rate. Patients with a history of radiotherapy should be informed about their risk profile and as a result may choose autologous reconstruction instead.IV.

View details for PubMedID 24072956

Abstract

Increasing awareness of the importance of evidence-based medicine is demonstrated not only by an increasing number of articles addressing it but also by a specialty-wide evidence-based medicine initiative. The authors critically analyzed the quality of reporting of randomized controlled trials published in this Journal over a 21-year period (1990 to 2010).A hand search was conducted, including all issues of Plastic and Reconstructive Surgery from January of 1990 to December of 2010. All randomized controlled trials published during this time period were identified with the Cochrane decision tree for identification of randomized controlled trials. To assess the quality of reporting, a modification of the checklist of the Consolidated Standard of Reporting Trials Statement was used.Of 7121 original articles published from 1990 to 2010 in the Journal, 159 (2.23 percent) met the Cochrane criteria. A significant increase in the absolute number of randomized controlled trials was seen over the study period (p < 0.0001). The median quality of these trials from 1990 to 2010 was "fair," with a trend toward improved quality of reporting over time (p = 0.127).A favorable trend is seen with respect to an increased number of published randomized controlled trials in Plastic and Reconstructive Surgery. Adherence to standard reporting guidelines is recommended, however, to further improve the quality of reporting. Consideration may be given to providing information regarding the quality of reporting in addition to the "level of evidence pyramid," thus facilitating critical appraisal.

View details for DOI 10.1097/PRS.0b013e31829fe0f7

View details for PubMedID 24076714

Abstract

BACKGROUND: The major focus of research when addressing nipple reconstruction has been on developing new techniques to provide for long-lasting nipple projection. Rarely, has the outcome of nipple reconstruction as it relates to postoperative morbidity, particularly after implant-based breast reconstruction, been analyzed. METHODS: A "matched-pair" study was designed to specifically answer the question whether a history of radiotherapy predisposes to a higher complication rate after nipple reconstruction in patients after implant-based breast reconstruction. Only patients with a history of unilateral radiotherapy who underwent bilateral mastectomy and implant-based breast reconstruction followed by bilateral nipple reconstruction were included in the study. RESULTS: A total of 17 patients (i.e. 34 nipple reconstructions) were identified who met inclusion criteria. The mean age of the study population was 43.5 years (range, 23-69). Complications were seen after a total of 8 nipple reconstructions (23.5 percent). Of these, 7complications were seen on the irradiated side (41.2 percent) (p=0.03). CONCLUSION: While nipple reconstruction is a safe procedure after implant-based breast reconstruction in patients without a history of radiotherapy the presence of an irradiated field converts it to a procedure with a significant increase in postoperative complication rate.

View details for DOI 10.1016/j.bjps.2013.04.052

View details for PubMedID 23664573

Abstract

The importance of providing high-quality exposure and training in aesthetic and reconstructive surgery during residency has come to the forefront of plastic surgery education. Adequate training in aesthetic surgery, however, has traditionally been challenging. The authors were interested in how these challenges were met abroad.A 17-item online survey was developed to assess the quality of training in aesthetic surgery in Germany. The survey had 3 distinct sections: demographic information, current state of aesthetic surgery training, and residents' opinions about the perceived quality of aesthetic surgery training. Only responses of senior residents were included in the final analysis.A total of 112 residents responded (30% response rate), of which 88 were senior plastic surgery residents. Ninety percent (n = 79) reported that a resident aesthetic surgery clinic was not part of their training experience. Eighty-eight percent (n = 77) reported that they did not have a dedicated aesthetic surgery rotation during their residency training. According to 69.3% (n = 61), no didactic training in aesthetic surgery was provided. Fifty-six percent (n = 49) of senior plastic surgery residents had performed only a maximum of 10 aesthetic surgery procedures at the time of the survey. Although only 43.2% of senior residents claimed to be interested in a predominantly aesthetic surgery practice, 90.9% (n = 80) felt that they require further training in aesthetic surgery (ie, fellowship).Deficiencies exist with respect to aesthetic surgery training among senior plastic surgery residents in Germany. Structural improvements in residency training with formal exposure and teaching in aesthetic surgery are warranted. The German Society of Plastic, Reconstructive and Aesthetic Surgeons is actively addressing deficiencies identified with the goal of improving the quality of training.

View details for DOI 10.1097/SAP.0b013e3182468346

View details for Web of Science ID 000319068200023

View details for PubMedID 22868325

View details for PubMedID 23676523

Abstract

Systematic reviews constitute the top of the "level-of-evidence pyramid." Despite their strengths, they have been found to be of varying quality, thus raising concerns about their validity and role in influencing clinical practice. In the present study, a quality analysis of systematic reviews with a focus on hand surgery was performed.A PubMed search was performed to identify all systematic reviews published up to and including December of 2011 in eight surgical journals. Two authors independently reviewed the literature and extracted data from included reviews. Discrepancies were resolved by consensus. Quality assessment was performed using AMSTAR.The initial search retrieved 687 articles. After screening titles and abstracts, 635 articles were excluded. Full-text review of the remaining 52 articles resulted in further exclusion of 10 articles, leaving 42 systematic reviews for final analysis. A significant increase in the number of published systematic reviews over time was noted (p = 0.04), with the majority of systematic reviews being published in The Journal of Hand Surgery (n = 19) and Plastic and Reconstructive Surgery (n = 12). Although a significant improvement in the quality of systematic reviews was noted over time (p = 0.01), a median AMSTAR score of 7 indicated the bulk of reviews to be of fair to good quality.The trend to publish more systematic reviews in hand surgery is paralleled by an increase in the quality of systematic reviews. Nonetheless, increased efforts are indicated to further improve the quality of systematic reviews in hand surgery.

View details for DOI 10.1097/PRS.0b013e3182818d24

View details for Web of Science ID 000317282800062

View details for PubMedID 23542254

Abstract

Penile burns are devastating injuries and are frequently associated with significant functional and psychological sequelae. The goals of penile reconstruction after burn injury include: 1) skin coverage, 2) preservation of penile length, sensation and erectile function, 3) esthetic integrity, and 4) permissive for penile growth in the pediatric patient. A multitude of different techniques have been proposed, including skin grafts, local, regional, and free flaps, each of which fail to address all goals of reconstruction. We introduce the foreskin advancement flap that, when available, successfully addresses these key challenges and as such provides for an ideal reconstruction.

View details for DOI 10.1016/j.bjps.2012.08.026

View details for Web of Science ID 000316738100033

View details for PubMedID 22981384

Abstract

BACKGROUND: Evaluation of quality of life (QOL) measures is increasingly being valued as an essential parameter to determine treatment results after head and neck reconstruction. The present study was designed to evaluate the effect of microsurgical reconstruction on patient-reported QOL. METHODS: Patients undergoing microsurgical reconstruction after radical oncosurgical ablation of head and neck malignancies from March 2007 to March 2010 were included in the study. To assess health-related QOL, the following questionnaires were sent to patients who met inclusion criteria: European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30 [Version 3.0]) and Head and Neck Cancer Quality of Life Questionnaire (QLQ-H and N35). RESULTS: A total of 60 patients underwent microsurgical reconstruction of postablative head and neck defects during the study period. Twenty-one patients were successfully contacted, all of which completed the surveys. Satisfactory global QOL scores were achieved. Advanced age correlated with greater impairment for the ability to taste and smell (P = 0.05). Radiotherapy seemed to be associated with "sticky saliva"; although this was not statistically significant (P = 0.06). Recurrent disease at the time of surgical ablation and microsurgical reconstruction did not seem to have any appreciable impact on QOL. Finally, patients who developed postoperative complications had lower levels of "cognitive functioning" (P = 0.04), problems with "insomnia" (P = 0.04) and "social contact" (P = 0.03), and more commonly "felt ill" (P = 0.03). CONCLUSIONS: Improved global QOL scores were observed after microsurgical reconstruction of various head and neck defects when compared to reported pretreatment scores. Of the parameters analyzed, it seems that postoperative complications have the most profound effect on items assessed with the EORTC QLQ-C30 and H and N35 surveys. Our findings provide further scientific evidence that patients with head and neck malignancy benefit from surgical intervention with respect to postoperative QOL.

View details for DOI 10.1097/SAP.0b013e31827737a5

View details for Web of Science ID 000316603400020

Abstract

BACKGROUND: Evaluation of quality of life (QOL) measures is increasingly being valued as an essential parameter to determine treatment results after head and neck reconstruction. The present study was designed to evaluate the effect of microsurgical reconstruction on patient-reported QOL. METHODS: Patients undergoing microsurgical reconstruction after radical oncosurgical ablation of head and neck malignancies from March 2007 to March 2010 were included in the study. To assess health-related QOL, the following questionnaires were sent to patients who met inclusion criteria: European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30 [Version 3.0]) and Head and Neck Cancer Quality of Life Questionnaire (QLQ-H and N35). RESULTS: A total of 60 patients underwent microsurgical reconstruction of postablative head and neck defects during the study period. Twenty-one patients were successfully contacted, all of which completed the surveys. Satisfactory global QOL scores were achieved. Advanced age correlated with greater impairment for the ability to taste and smell (P = 0.05). Radiotherapy seemed to be associated with "sticky saliva"; although this was not statistically significant (P = 0.06). Recurrent disease at the time of surgical ablation and microsurgical reconstruction did not seem to have any appreciable impact on QOL. Finally, patients who developed postoperative complications had lower levels of "cognitive functioning" (P = 0.04), problems with "insomnia" (P = 0.04) and "social contact" (P = 0.03), and more commonly "felt ill" (P = 0.03). CONCLUSIONS: Improved global QOL scores were observed after microsurgical reconstruction of various head and neck defects when compared to reported pretreatment scores. Of the parameters analyzed, it seems that postoperative complications have the most profound effect on items assessed with the EORTC QLQ-C30 and H and N35 surveys. Our findings provide further scientific evidence that patients with head and neck malignancy benefit from surgical intervention with respect to postoperative QOL.

View details for DOI 10.1097/SAP.0b013e31827737a5

View details for PubMedID 23486123

Abstract

The increasing incidence of breast cancer is paralleled by an increasing demand for post-mastectomy breast reconstruction. At the time of breast reconstruction routine submission of mastectomy scars has been considered appropriate clinical practice to ensure that no residual cancer exists. However, this practice has been challenged by some and has become the topic of controversy. In a retrospective analysis we wished to assess whether routine submission of mastectomy scars altered treatment.Utilizing the Stanford Translational Research Integrated Database Environment (STRIDE) all patients who underwent implant-based breast reconstruction with routine histological analysis of mastectomy scars were identified. The following parameters were retrieved and analyzed: age, cancer histology, cancer stage (according to the American Joint Committee on Cancer staging system), receptor status (estrogen receptor [ER], progesterone receptor [PR], Her2neu), time interval between mastectomy and reconstruction, and scar histology.A total of 442 patients with a mean age of 45.9 years (range, 22-73 years) were included in the study. Mastectomy with subsequent reconstruction was performed for in-situ disease and invasive cancer in 83 and 359 patients, respectively. A total of 619 clinically unremarkable mastectomy scars were sent for histological analysis, with the most common finding being unremarkable scar tissue (i.e. collagen fibers). Of note, no specimen revealed the presence of carcinoma.According to published reports routine histological examination of mastectomy scars may detect early local recurrence. However, we were not able to detect this benefit in our patient population. As such, particularly in the current health-care climate the cost-effectiveness of this practice deserves further attention. A more selective use of histological analysis of mastectomy scars in patients with tumors that display poor prognostic indicators may be a more reasonable utilization of resources.

View details for DOI 10.1016/j.bjps.2012.09.013

View details for Web of Science ID 000313620600012

View details for PubMedID 23044349

View details for PubMedCentralID PMC3545080

Abstract

The treatment of facial palsy is a complex and challenging area of plastic surgery. Microsurgical innovation has introduced the modern age of dynamic reconstruction for facial palsy. This review will focus on microsurgical reconstruction for smile restoration in patients with long-standing facial palsy. The most common donor muscles and nerves will be presented. The advantages and disadvantages of single-stage versus multi-stage reconstruction will be discussed. Contemporary trends will be highlighted and the authors' preferred practice outlined.

View details for DOI 10.1002/micr.22042

View details for PubMedID 22976539

Abstract

ABSTRACT: The treatment of facial palsy is a complex and challenging area of plastic surgery. Two distinct anatomical regions and functions are the focus of interest when managing facial palsy: (1) reanimation of the eyelids and (2) reconstruction of the smile. This review will focus on the treatment of ocular manifestations of facial palsy. The principles of eyelid rehabilitation will be presented along with a discussion of surgical and nonsurgical treatment options.

View details for DOI 10.1097/SAP.0b013e318264fcba

View details for PubMedID 23241787

Abstract

Obesity is not only a causative factor for premature mortality, it has also been demonstrated to be associated with an increased postoperative complication rate. As such, it has traditionally been considered a relative contraindication to autologous breast reconstruction. The purpose of this study was to assess whether this recommendation is justified.A retrospective study was conducted analyzing the effect of obesity on complication rate after microsurgical autologous breast reconstruction using abdominal tissue. Patients undergoing breast reconstruction between November 2006 and February 2011 were included. In contrast to prior studies, only patients meeting criteria to undergo bariatric surgery were included in the study, thus, representing a particularly high-risk subset of patients (Group 1: BMI greater 40 kg/m(2); Group 2: BMI greater 35 kg/m(2) with co-morbidities).A total of 42 breast reconstructions were performed in 28 patients who met inclusion criteria. Surgical complications were seen in a total of 9 patients (p = 1.00). All complications were successfully managed conservatively and did not prolong hospitalization. No differences were seen among study groups with respect to donor-site (p = 0.57) and recipient-site complications (p = 1.00). Of note, no partial or total flap loss was seen in this study.Obesity is associated with a relatively high risk of minor complications postoperatively. However, complications can typically be managed non-operatively and on an outpatient basis with fairly minimal patient morbidity. We believe that obesity should not be considered a relative contraindication to autologous microsurgical breast reconstruction. Patients should, however, be informed preoperatively about their higher risk of postoperative complications.

View details for DOI 10.1016/j.bjps.2011.10.005

View details for Web of Science ID 000301982000012

View details for PubMedID 22024538

Abstract

The complexity of modern head and neck reconstruction is paralleled by consumption of large amounts of resources provided by both treating physicians as well as the institution, that is, hospital. In times of increasing economic constraints, analysis of the financial value of providing these services seems prudent. A retrospective analysis of medical and billing records of patients who underwent immediate microsurgical reconstruction of postablative head and neck defects from 2007 to 2010 at Stanford University Medical Center was performed. Financial data related to the treatment of 60 patients were analyzed. Total reimbursement for plastic surgery services was $319,609, representing a collection rate of 18.4%. Total hospital charges were $31,038,846.10. Actual reimbursement was $9,109,776.55, which represents a collection rate of 29.3%. Analysis of hospital revenue revealed a net profit of $1,512,136.46, which represents a mean net revenue of $25,202.27 per case. Microsurgical reconstruction secures substantial revenue for the institution. Innovative reimbursement models need to be implemented to attract skilled microsurgeons, who represent the backbone of these services.

View details for DOI 10.1097/SAP.0b013e31823d2dec

View details for Web of Science ID 000301800600017

View details for PubMedID 22421488

Abstract

Soft tissue reconstruction with a temporoparietal fascial flap (TPFF).Defect coverage with thin, pliable, and well-vascularized tissue. A bilayered TPFF provides a gliding surface in tendon reconstruction. Further options include TPFF harvest with overlying skin or subjacent bone for composite tissue reconstruction or the application as a sensate local fascial flap. Maximum defect dimensions: 1714cm.Absolute: prior injury to the flap or flap pedicle, temporal arteritis, Moyamoya syndrome, defects with volume deficit. Relative: alopecia along the planned incision.Pedicle location is outlined using Doppler ultrasound. Injection of the incision line with diluted epinephrine solution. Skin incision with subsequent visualization of the temporoparietal fascia and supplying vessels. Skin flaps are raised carefully paying special attention to the hair follicles (CAVE: postoperative alopecia). Primary closure of the donor site. Defect coverage with pedicled or free TPFF with subsequent full or split-thickness skin grafting. Dressing: Bolster or V.A.C.Immobilization/elevation in the setting of extremity reconstruction. Removal of bolster dressing or V.A.C. on postoperative day5. Dangling protocol instituted on postoperative day7. Removal of sutures/staples at the donor site on postoperative day5-7 and at the recipient site on postoperative day12-14.The TPFF was utilized for soft tissue reconstruction in 8patients. A pedicled TPFF was used in 2patients. Mean time to healing was 16.3days. Mean follow-up was 13.4months. Successful reconstructive results with satisfactory functional and aesthetic appearance were obtained in all patients. Complications were encountered in 3patients and included alopecia at the donor site and iatrogenic injury to the frontal branch of the facial nerve. Vascular compromise was observed in the early postoperative period in a third patient. However, operative revision resulted in successful flap salvage.

View details for DOI 10.1007/s00064-011-0097-8

View details for Web of Science ID 000300780700004

View details for PubMedID 22190272

Abstract

The introduction of radiotherapy (XRT) has resulted in increased survival of patients diagnosed with head and neck malignancies. However, the potentially deleterious impact of radiotherapy on reconstructive efforts continues to be the subject of intense debate. The present study was designed to evaluate the effects of preoperative XRT on complication rates in patients undergoing microsurgical reconstruction of head and neck defects after oncosurgical resection.A retrospective cohort study was conducted of all patients who underwent immediate microsurgical reconstruction of post-ablative defects over a 3-year period. Study subjects were divided into two groups: (1) those who did not receive XRT and (2) those who received preoperative XRT. Clinical variables examined and analysed included age, gender, co-morbid conditions, tobacco history, the presence of recurrent disease and ischaemia time. Outcomes of interest included length of intensive care unit (ICU) and hospital stay and postoperative complications. Complications were further classified as flap-related as well as 'medical'.A total of 60 patients were included in this study (group 1: 26 patients; group 2: 34 patients). Results were similar between the study groups with the exception of a higher rate of flap-related complications in patients undergoing XRT. Overall, 19 patients (31.7%) experienced flap-related complications, with 12% of the patients being in group 1 (N=3) versus 47% of patients being in group 2 (N=16) (p=0.003).Our data suggest that preoperative radiotherapy is associated with a significant increase in postoperative flap-related complications. However, these did not result in a prolonged hospital stay, reflecting the fact that the majority of flap-related complications can be managed on an outpatient basis. Although microsurgical reconstruction is frequently successful, patients with a history of XRT should be informed preoperatively about their increased risk of complications.

View details for DOI 10.1016/j.bjps.2011.06.043

View details for Web of Science ID 000296579400015

View details for PubMedID 21783448

Abstract

Radical surgical resection remains the single-most important treatment in the curative multimodal therapy of soft tissue sarcomas. Refinements in surgical techniques have resulted in the development of function preserving approaches increasingly avoiding limb amputation.The records of all patients (n = 34) who underwent microsurgical soft tissue coverage subsequent to primary resection of soft tissue sarcoma of the upper or lower limb from 1999 to 2009 are reviewed regarding postoperative complications, time until start of adjuvant radiation and functional outcome (Toronto Extremity Salvage Score, TESS).Thirty-four patients (range: 21-86 years) received a total of 35 free flaps. Complete tumor resection was obtained in 33 patients, one patient required re-excision ultimately resulting in tumor-free margin status (R0 resection). Major complications were encountered in four cases including one patient with complete flap loss requiring an additional free flap and three patients with partial flap loss requiring split-thickness skin graft procedures. Minor complications were observed in three patients (9%). Extremity salvage could be achieved in 33 patients with adequate postoperative ambulation (TESS 84 18) and adequate use of the upper extremity (TESS 80 22). One patient underwent amputation. Mean time until start of adjuvant radiotherapy was 37 days (range 24-56 days).A synergetic center-based interdisciplinary approach is crucial in therapeutical management of soft tissue sarcomas with the aim of R0 resection status and limb preservation. Plastic surgery contributes by offering microsurgical reconstruction using free tissue transfer, thus broadening surgical possibilities. This increases the chance of both adequate oncosurgical resection and limb preservation.

View details for DOI 10.1002/micr.20895

View details for Web of Science ID 000295214400003

View details for PubMedID 21630335

Abstract

Prior to the advent of a multidisciplinary approach to the treatment of soft-tissue sarcomas, surgical treatment consisted of extremity amputation. Advances in treatment modalities such as radiotherapy allowed more limited resections with similar survival rates. As local control is the primary objective in the management of these neoplasms, distally located tumours pose a particular reconstructive challenge. Limb preservation is now possible due to the availability of microsurgical techniques. A retrospective analysis was conducted assessing the suitability of the free anterolateral thigh (ALT) flap for distal-extremity reconstruction after wide local excision of sarcomas. Nine patients were included in the study with a median follow-up period of 36 months. In all patients, tumours were located at or distal to the elbow and knee, respectively. All flaps survived. In one patient, the ALT donor site was addressed with a split-thickness skin graft after wound dehiscence was observed postoperatively after initial primary closure. The free ALT perforator flap is an ideal flap for the reconstruction of distal-extremity defects after sarcoma resection as it allows coverage of large skin defects with minimal donor-site morbidity. Its thinness addresses the shallow defects typically encountered in the distal extremity and thus avoids the bulkiness encountered after reconstruction with musculocutaneous flaps.

View details for DOI 10.1016/j.bjps.2010.08.005

View details for Web of Science ID 000289284800021

View details for PubMedID 20829135

Abstract

The diagnosis of soft-tissue sarcomas of the limbs is often delayed, sometimes markedly so, even though prompt and appropriate treatment improves survival and lowers the amputation rate.On the basis of a selective literature review and consideration of the relevant guidelines, we developed an algorithm that can serve as a guide to the diagnosis of soft-tissue tumors in general and to the treatment of soft-tissue sarcomas of the limbs.Surgical resection accompanied by multimodal therapy is the only treatment strategy for soft-tissue sarcoma that provides a chance of cure. Particularly when the tumor is located in the distal part of a limb, plastic-reconstructive surgical techniques often enable adequate local control, along with limb salvage and preservation of function. The role of adjuvant or neo-adjuvant radiotherapy and/or chemotherapy is currently debated. The overall survival rate at 5 years is 87% for low-grade sarcomas and 62% for high-grade sarcomas.Any solid mass of the limbs that has been present for more than four weeks requires diagnostic evaluation. Excisional biopsy is suitable only for epifascial lesions measuring less than 5 cm in diameter. All other lesions should be imaged with MRI and then diagnosed with an incisional biopsy. Patients with soft tissue sarcomas must be treated in an interdisciplinary collaboration so that they can undergo multimodal treatment. The proposed algorithm should help avoid delays in diagnosis and optimize treatment strategies.

View details for DOI 10.3238/arztebl.2011.0032

View details for Web of Science ID 000288600900002

View details for PubMedID 21286000

Abstract

The increasing importance of evidence-based medicine (EBM) is the result of an increasing demand for a rational decision-making process in healthcare. It has been demonstrated that 15-40% of decisions made in healthcare do not have a solid scientific basis. This is particularly problematic in times of limited financial resources, when reimbursement increasingly depends on how "evidence-based" a particular treatment is. Application of EBM principles in plastic surgery is therefore no longer an option. This, however, requires a basic understanding of the existing levels of evidence. In the present article, principles of EBM will be presented. The importance of randomized controlled trials and systematic reviews for plastic surgery will be highlighted along with a discussion of the quality of the plastic surgical literature based on results of recent systematic analyses. The plastic surgical community has appreciated the need for higher quality clinical studies. Improvement of the quality of reporting is, however, critical.

View details for DOI 10.1055/s-0030-1263129

View details for Web of Science ID 000286686100008

View details for PubMedID 20814855

Abstract

Microsurgical autologous breast reconstruction has evolved significantly over the last three decades. The muscle-sparing transverse rectus abdominis musculocutaneous (TRAM), deep inferior epigastric artery perforator, and superficial inferior epigastric artery flaps have been developed to minimize abdominal donor-site morbidity. Assuming that harvest of the superficial inferior epigastric artery flap has the same impact on abdominal wall morbidity as performing an abdominoplasty, the authors designed a matched-pair analysis comparing patients' abdominal wall strength after muscle-sparing TRAM flap reconstruction with that after abdominoplasty.A total of 104 patients were included in the study. Fifty-two TRAM flap patients were matched with 52 abdominoplasty patients for age and body mass index. Outcome measures included postoperative complications, particularly hernia and abdominal bulge formation. Two surveys were used to assess patient satisfaction as well as the impact of the procedure on everyday life.Both study groups were similar with regard to age, body mass index, past medical history, and postoperative complication rate, including hernia and abdominal bulge formation. Results were similar between the study groups, with the exception of a higher rate of satisfaction with the appearance of the abdominal scar among TRAM flap patients (p=0.03) as well a lower likelihood of TRAM flap patients to engaging in sporting activities postoperatively (p=0.01).In the present study, the muscle-sparing TRAM flap did not result in a higher rate of postoperative complications related to abdominal wall morbidity. Differences observed regarding the postoperative level of activity are unlikely to be related to the surgical insult to the abdominal wall.

View details for DOI 10.1097/PRS.0b013e3181ef904b

View details for Web of Science ID 000283844700005

View details for PubMedID 21042101

Abstract

Introduction of vacuum-assisted closure (VAC) system into clinical practice has revolutionized wound care. Despite its multiple advantages, however, the VAC is only rarely used in the setting of microsurgical reconstruction. Concerns have been the inability to clinically monitor the flap as well the possibility of flap compression by the device. The authors put their postoperative treatment concept of applying the VAC to free flaps to the test by reviewing their experience with this concept in patients undergoing microsurgical reconstruction of posttraumatic lower-extremity soft tissue defects. Twenty-six patients (22 male, 4 female) were included in this study. Use of the implantable Doppler probe allowed for postoperative flap monitoring. Two flap failures were observed, both in patients with peripheral vascular disease. In conclusion, using the VAC device in the setting of microsurgical reconstruction is safe and allows for increased patient comfort.

View details for DOI 10.1055/s-0030-1267378

View details for Web of Science ID 000283452100007

View details for PubMedID 20922656

Abstract

As the final step in breast reconstruction, nipple reconstruction is considered a minor surgical procedure. However, despite the multitude of techniques and postoperative dressings proposed, none have proven to resist the tendency of the reconstructed nipple to gradually flatten over time. A prospective randomized controlled trial was conducted assessing the value of using the Asteame Nipple Guard compared to standard gauze dressing in maintaining nipple projection postoperatively. A total of 30 nipple reconstructions in 22 patients were included in the study with randomisation of 15 nipples to each study arm. Nipple projection was measured at various time points postoperatively with calculation of the percent changes in nipple projection. The mean decrease in long-term nipple projection at 6 months in the experimental group was 46.6% vs. 71.8% in the control group (p<0.05). In conclusion, the Nipple Guard helps in maintaining nipple projection postoperatively.

View details for DOI 10.1016/j.bjps.2009.10.006

View details for Web of Science ID 000281655500003

View details for PubMedID 19897430

Abstract

The deep inferior epigastric perforator (DIEP) flap is gaining popularity for autologous breast reconstruction as it reportedly reduces abdominal donor site morbidity when compared with the transverse rectus abdominis musculocutaneous (TRAM) flap. Disadvantages include greater technical difficulties during flap harvest and a greater incidence of vascular compromise. A well-known and feared complication is venous congestion which requires immediate intervention. We present a novel salvage technique in a case of total flap venous congestion in the setting of absent drainage via the deep inferior epigastric vein (DIEV). Utilizing the superficial venous system via the superficial inferior epigastric vein (SIEV) and using the DIEV as a venous interposition graft resulted in successful salvage of the DIEP flap.

View details for DOI 10.1002/micr.20774

View details for Web of Science ID 000282253300004

View details for PubMedID 20878727

Abstract

Management of flexor tendon injuries is one of the most demanding tasks in hand surgery. Despite substantial improvements in surgical technique and postoperative rehabilitation protocols, functional outcomes may still be somewhat unreliable. In the present article, the authors present complications encountered after flexor tendon repair and provide their preferred methods of prevention and treatment.

View details for DOI 10.1016/j.hcl.2009.11.004

View details for Web of Science ID 000278887200004

View details for PubMedID 20494744

Abstract

One of the most demanding areas in plastic surgery is reconstruction of the smile in the setting of facial palsy. A multitude of surgical techniques and approaches have been proposed with variable success rates. The most frequently applied treatment algorithm is a two-stage approach with placement of a cross-facial nerve graft (CFNG) initially and subsequent free functional muscle transfer. As this approach has several limitations, the authors have performed single-stage reconstructions utilising the motor nerve to the masseter as the donor nerve. Four patients underwent this single-stage reconstruction for facial palsy between July 2007 and May 2008. In all patients free functional transfer of the gracilis muscle was performed using the motor nerve to the masseter as the donor nerve. Outcome measures were functional result as well as patient satisfaction. The intraoperative as well as postoperative course was uneventful in all patients. In only one patient we encountered a small area of delayed wound healing which was amenable to conservative treatment. In all patients voluntary contraction of the gracilis muscle was visible after a mean period of 2.5 months. All patients displayed a high level of satisfaction with the functional result. Utilising the motor nerve to the masseter muscle as a donor nerve allows single-stage microsurgical reconstruction of the smile in the setting of facial palsy with reproducible results.

View details for DOI 10.1055/s-0030-1249030

View details for Web of Science ID 000276307900004

View details for PubMedID 20217642

Abstract

: Stable internal screw/plating systems for hand fractures have evolved during the last 20 years. The improved versatility leads to the increased use of these materials in open fractures, with the benefit of early mobilization. The aim of this retrospective study is to discern whether the broadening of the indications for these implants is accompanied by increased complication rates.: Data from 365 patients treated during the last 10 years at our department for metacarpal or phalangeal fractures with stable internal fixation by screw or plate were gathered and analyzed.: Uneventful bony consolidation was observed in 91.2% (n = 333). The functional results were excellent to acceptable in 85.2%, whereas in 14.8% (n = 54), the result was unsatisfactory, the latter group presenting with concominant soft tissue injury. There was no statistically significant difference in infection and nonunion rates when comparing open and closed fractures.: These results confirm that most patients with open metacarpal and phalangeal fractures can be treated by stable internal fixation.

View details for DOI 10.1097/TA.0b013e3181bb8ea0

View details for Web of Science ID 000275491200027

View details for PubMedID 20220420

View details for DOI 10.1177/1753193409349957

View details for Web of Science ID 000274390300009

Abstract

Enchondromas are common in the hand but less frequent in the distal phalanges. Epidermal cysts are rare in the hand but when they occur can be difficult to differentiate from enchondromas both clinically and radiologically. Our review of seven distal phalangeal bone lesions treated over 7 years included four enchondromas and three epidermal cysts. The patients with epidermal cysts all had a history of previous penetrating trauma 5-8 years earlier. One patient with an enchondroma had a history of a penetrating injury. Patients presenting with distal phalangeal lesions and a history of previous penetrating injury appear more likely to have an epidermal cyst than an enchondroma. This is important as there may be a higher recurrence rate following curettage and bone grafting.

View details for DOI 10.1177/1753193409349957

View details for PubMedID 19828567

View details for Web of Science ID 000274430700015

View details for PubMedID 20151354

Abstract

Financial and other competing interests have recently received increasing attention. In particular clinical research in plastic surgery attracts for-profit organizations, thus, explaining the increasing number of financial sponsorships. However, research articles often lack sufficient description of study design as well as disclosure of the source of funding. Furthermore, debate exists whether industry funding influences research findings and is leading to pro-industry results. A hand search was conducted identifying all randomized controlled (RCT) and controlled clinical trials (CCT) in 4 plastic surgery journals (Plastic and Reconstructive Surgery, British Journal of Plastic Surgery, Annals of Plastic Surgery, and Aesthetic Plastic Surgery) between 1990 and 2005. Subsequently, the influence of financial support on study outcome was analyzed. A total of 10,476 original articles were analyzed, resulting in the identification of 346 clinical trials which meet the Cochrane criteria for RCTs and CCTs. One hundred eighty-three trials and 163 studies were found to be RCTs and CCTs, respectively. Hereof, only 70 trials (20.2%) reported on grant support. Of these, 42 trials (60%) were supported by the industry. Depending on the topic addressed marked differences were detected regarding grant support. Studies with a focus on reconstructive plastic surgery were supported by the industry and by public institutions in almost equal shares (18 trials vs. 15 trials), whereas aesthetic surgical topics were predominantly funded by the industry (13 trials vs. 6 trials). Industry-funded trials reported more often statistically significant differences between treatment arms (28 trials vs. 16 trials). Authors' conclusions were found to be positively associated with financial competing interests. However, trial funding is rarely declared in the plastic surgery literature. Thus, the quality of reporting needs to be improved to be able to investigate these relationships in greater detail and draw more representative conclusions.

View details for DOI 10.1097/SAP.0b013e3181951917

View details for Web of Science ID 000272316400019

View details for PubMedID 19887933

Abstract

Abdominoplasty is one of the most popular body-contouring procedures. However, it is associated with a significant number of complications, the most common being seroma and wound-healing problems. In this study, we analysed postoperative complications following abdominoplasty and evaluated the presence of statistically significant correlations between pre-existing risk factors and postoperative complications.We carried out a retrospective chart review of all patients who underwent abdominoplasty from June 1994 to April 2004 at our institution. Patient demographics, risk factors (smoking, previous abdominal surgery, obesity, and male gender) and complications (minor and major) were noted from the patient's medical record.In all, 139 patients were included in the study (126 female and 13 male), with a mean age of 42.8 years at the time of surgery. Minor and major complications were seen in 40 (28.8%) and 16 patients (11.5%), respectively. Smoking and previous abdominal surgery were not associated with a significantly increased complication rate. However, patients without previous surgery displayed a significantly increased complication rate (43.2% vs. 22.1% for minor and 25% vs. 5.3% for major complications; p<0.05). Obesity (BMI >30 kg/m(2)) was associated with a significant increase in major complications (20.8% vs. 9.7%; p<0.05). Male gender was predisposed to increased minor and major complications; however, this was not statistically significant.Despite its popularity, abdominoplasty is still associated with a significant rate of complications. In particular, obese patients and those with no previous history of abdominal surgery seem to be at risk for complications. The role of male gender needs to be evaluated further.

View details for DOI 10.1016/j.bjps.2008.03.043

View details for Web of Science ID 000272523800004

View details for PubMedID 18692451

View details for DOI 10.1097/PRS.0b013e3181b03a79

View details for Web of Science ID 000269485200055

View details for PubMedID 19730342

Abstract

Although a myriad of original articles is published annually in plastic surgical journals assessment of the level of evidence-based medicine has rarely been conducted. A hand search was conducted identifying randomized controlled (RCTs) and controlled clinical trials in 3 plastic surgical journals from 1990 to 2005. The quality of reporting was assessed and additional parameters investigated including report of statistical significance, type of institution, and country affiliation of the first author. Nine thousand four hundred twenty-eight original articles were analyzed of which 172 and 139 articles met the inclusion criteria for RCTs and controlled clinical trials, respectively. Fifty-nine RCTs reported on successful double-blinding with only 20 RCTs reporting the allocation concealment appropriately. Description of participant drop-outs was detected in 64 RCTs and a statistically significant result was reported in 118 RCTs. The annual publication of controlled trials has increased over the last 16 years, with the majority of controlled trials being from North-America and Europe. Execution and publication of controlled trials has increased in the plastic surgical literature. However, the quality of reporting deserves improvement.

View details for DOI 10.1097/SAP.0b013e31818015ff

View details for Web of Science ID 000263640800018

View details for PubMedID 19240528

Abstract

The gracilis muscle flap is certainly among the most versatile sources of vascularized tissue available for microsurgical reconstruction. However, the aesthetic appearance of the resultant scar has frequently been a source of dissatisfaction. Various minimal invasive techniques have been proposed, all of which aim to reduce scar formation. Drawbacks of endoscopic techniques, however, include a steep learning curve as well the need for special technical equipment. A semi-open approach without endoscopic assistance is presented, characterized by a short transverse incision in the groin area without a counterincision distally. This technique was performed in six patients (mean age, 48.8 years). Mean incision length was 8.8 cm, and average muscle harvesting time was 49 minutes. We suggest the semi-open approach to the gracilis muscle flap because it does not require special instruments and training and is characterized by easy performance and a short incision in the inconspicuous groin area with resultant better cosmesis.

View details for DOI 10.1055/s-0028-1104560

View details for Web of Science ID 000262164000010

View details for PubMedID 19048464

Abstract

Patients with soft tissue sarcomas are initially treated in community hospitals and in the private practice setting in the majority of cases. Thus, this disease entity is initially treated by surgeons with limited experience and expertise regarding the complex and demanding therapeutic regimen necessary to address this distinct group of malignancies.A retrospective analysis was conducted with a particular focus on factors affecting patient outcome, oncosurgical intervention, and plastic surgical reconstruction.A total of 75 patients were included in the study. Only 66% of all patients presented with a primary tumor. The remaining 34% presented with either local recurrence or distant metastasis. The oncosurgical procedure most commonly performed was wide excision (69%). However, amputation was unavoidable in 7% of cases. Single-step reconstruction included primary closure (19%), skin grafting (19%), local fascio- or myocutaneous flap transfer (31%), as well as free flap transfer (31%). 17 patients (20%) have deceased due to their underlying disease. Yet another 10% are alive with evidence of residual tumor. Kaplan-Meier analysis displayed significant differences in overall survival rate depending on disease stage upon initial presentation.Based on our data favorable oncological outcomes with satisfactory functional results and limb preservation are achievable if oncological principles for resection are respected and reconstruction is performed according to plastic surgical principles.

View details for DOI 10.1007/s00402-008-0576-z

View details for Web of Science ID 000260765800008

View details for PubMedID 18210141

Abstract

Abdominoplasty has become one of the most frequently performed procedures for improving body contour. Numerous reports exist focusing on postoperative complications with even more studies suggesting technical modifications to decrease their occurrence. However, the impact of complications on patient satisfaction has not been sufficiently addressed to date. A retrospective analysis was performed investigating the occurrence of complications following abdominoplasty and their effect on patient satisfaction. Patient satisfaction was assessed by means of the client satisfaction questionnaire-8. From June 1994 to April 2004 a total of 139 patients underwent an abdominoplasty. Minor and major complications were encountered in 40 (28.8%) and 16 (11.5%) patients, respectively. The median client satisfaction questionnaire-8 score among those patients with and without complications was 29. Thus, it seems that postoperative complications after abdominoplasty do not negatively affect patient satisfaction.

View details for DOI 10.1097/SAP.0b013e318174f973

View details for Web of Science ID 000262026000003

View details for PubMedID 19131709

Abstract

Reconstruction of extensive distal phalangeal defects with exposure of tendon, bone, or joint can be particularly a difficult problem. For assessment of the value of the reverse homodigital island flap patients with distal phalangeal avulsion and crush injuries who were treated from January 2005 to April 2006 were analysed retrospectively. Main outcome measurements included flap survival rate, sensory restoration, occurrence of cold intolerance, length of occupational disability, and joint mobility. Eleven patients were included in the study. Only one patient suffered from venous congestion with partial flap necrosis, requiring debridement with subsequent skin grafting. The minimum follow-up was 6 months. The static 2-point discrimination had a mean value of 9 mm. None of our patients complained of cold intolerance or residual joint contracture. All patients returned to full occupational activity within an average time period of 4.5 weeks. In conclusion, the reverse homodigital island flap is an excellent option for 1-stage reconstruction of distal phalangeal defects.

View details for DOI 10.1016/j.injury.2008.02.015

View details for Web of Science ID 000262072900020

View details for PubMedID 18573493

View details for DOI 10.1016/j.jtcvs.2007.11.066

View details for Web of Science ID 000259327500037

View details for PubMedID 18805291

Abstract

Although a myriad of original articles is published annually in plastic surgical journals, assessment of the level of evidence-based medicine has rarely been conducted. A hand search was conducted identifying randomized controlled trials (RCTs) and controlled clinical trials in 3 plastic surgical journals from 1990-2005. The quality of reporting was assessed and additional parameters investigated including report of statistical significance, type of institution, and country affiliation of the first author. Of the 9428 original articles that were analyzed, 172 and 139 articles met the inclusion criteria for RCTs and controlled clinical trials, respectively. Fifty-nine RCTs reported on successful double-blinding with only 20 RCTs reporting the allocation concealment appropriately. Description of participant drop-outs was detected in 64 RCTs and a statistically significant result was reported in 118 RCTs. The annual publication of controlled trials has increased over the last 16 years, with the majority of controlled trials being from North-America and Europe. Execution and publication of controlled trials has increased in the plastic surgical literature. However, the quality of reporting deserves improvement.

View details for DOI 10.1097/SAP.0b013e31815f39dc

View details for Web of Science ID 000257942200020

View details for PubMedID 18650619

Abstract

A multitude of studies has been published focusing on different technical aspects of abdominoplasty. However, rarely has attention been drawn to skin closure techniques and its implications on postoperative scar length and complication rate. A retrospective analysis was conducted comparing a new comprehensive approach to skin closure with conventional techniques. Patients in each study group were matched for race, body mass index, gender, medical history, and smoking habits. We focused on postoperative scar length and rate of wound healing problems. Forty-six patients were included in each study group. Patients in whom wound closure was achieved via the technique presented here displayed a mean scar length of 33.68 cm (vs. 49.92 cm) and wound healing problems in 8.7% (vs. 23.9%). A marked reduction of scar length and postoperative wound healing problems is achievable with application of the technique presented in this article.

View details for DOI 10.1097/SAP.0b013e31812f6df0

View details for Web of Science ID 000254501600002

View details for PubMedID 18362556

View details for DOI 10.1097/01.prs.0000305388.11263.24

View details for Web of Science ID 000207666900020

View details for PubMedID 18349613

Abstract

A multitude of local flaps has been suggested for lower extremity reconstruction. However, the gold standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction of defects requiring bone and soft tissue in complex 3-dimensional relationships. Composite bone and soft-tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular flap, the "latissimus/bone flap," and the thoracodorsal artery perforator-scapular osteocutaneous flap.Patient outcome following reconstruction of lower extremity defects with composite free flaps from the thoracodorsal system were analyzed. Here, we demonstrate the execution of technical refinements on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise reduction of donor-site morbidity.

View details for DOI 10.1097/SAP.0b013e3180dc9a77

View details for Web of Science ID 000254501600011

View details for PubMedID 18362565

Abstract

Aesthetic surgery is one pillar of plastic surgery. Thus, not surprisingly, journals exist that focus predominantly on advances within this subspecialty. However, rarely has the process of systematic reviewing that identified randomized controlled trials (RCTs) and controlled clinical trials (CCTs) been conducted within this subspecialty. All original articles published in Aesthetic Plastic Surgery were analyzed to identify all RCTs and CCTs. The proportion of RCTs and CCTs in all original articles was determined, and the quality of reporting was assessed on the basis of established quality items. Additional parameters were investigated including reporting of statistically significant differences, type of institution, and country affiliation of the first author. Of the 1,048 original articles analyzed, 11 (1%) and 24 (2.3%) articles met the inclusion criteria for RCTs and CCTs, respectively. Only two studies were single blinded, whereas only one study reported on successful double blinding and appropriate allocation concealment. Notably, these trials were RCTs. Participant dropout was reported in one study. Statistically significant differences were reported in 18 trials, 6 of which were RCTs. The annual publication of RCTs has increased over the past 5 years. North America and Europe contributed a total of 28 controlled trials (80%). Controlled trials are being conducted in aesthetic surgery at a strikingly low rate. However, a recent increase in published RCTs reflects the recognition that performing outcome studies is pivotal in moving practice toward a foundation based on assessment by outcome. The quality of reporting, however, needs improvement.

View details for DOI 10.1007/s00266-007-9075-9

View details for Web of Science ID 000253680200027

View details for PubMedID 18058165

Abstract

Introduction of the Vacuum-Assisted Closure (V.A.C.) system has revolutionized the approach to a multitude of clinical settings. Yet, its use precludes adequate clinical monitoring of skin-grafted free flaps, thus, making a reliable monitoring system essential if broad clinical application is aspired. In a clinical study, the usefulness of the combination of the V.A.C. and implantable Doppler probe was critically evaluated in patients with microsurgical lower extremity reconstruction. We retrospectively analyzed the usefulness of the implantable Doppler probe in five consecutive patients treated in our department from January to July 2007. Inclusion criteria were lower extremity reconstruction by means of skin-grafted free tissue transfers with subsequent application of the V.A.C. device. Five consecutive patients (four males, one female) with a mean age of 37.8 years (range, 8-58 years) matched the criteria mentioned above. Of note, the two pediatric patients (8-year-old male and 12-year-old female) suffered from significant posttraumatic stress disorder necessitating concomitant psychological care by the Department of Psychiatry. All flaps healed uneventfully displaying no signs of vascular compromise. Interpretation of the Doppler signal was simple and well received by the nursing staff. The combination of V.A.C. and the implantable Doppler probe enhances patient comfort due to a reduction of the number of dressing changes while still allowing continuous free flap monitoring. Interpretation of the signal transmitted by the probe is simple and potentially reduces misinterpretations due to different levels of experience.

View details for DOI 10.1002/micr.20512

View details for Web of Science ID 000259624400005

View details for PubMedID 18623161

Abstract

Although many technical descriptions of nipple reconstruction exist in the medical literature, insufficient evidence-based data are present about the outcome. This study aimed to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) in the plastic surgical literature addressing nipple reconstruction, and to elucidate whether a hand search was superior to an extensive database search in retrieving all pertinent studies. The hand search included analysis of all "original articles" published in four of the leading plastic surgery journals from January 1990 to December 2005, with subsequent identification of RCTs and CCTs. Additionally, a computerized search was conducted including the following databases: PubMed, Web of Science, and Evidence-Based Medicine Reviews. From a total of 10,476 published original articles in four plastic surgery journals over a 16-year period, only one RCT was identified that addressed nipple reconstruction. The database search, however, retrieved two trials: the RCT identified by hand search and one CCT. The impact of nipple reconstruction is well described in the literature. However, it is astonishing that the plastic surgical literature lacks evidence-based trials addressing this issue. Clearly, more evidence-based trials are necessary to ensure that recommendations for a particular technique are based on solid scientific data.

View details for DOI 10.1007/s00266-007-9039-0

View details for Web of Science ID 000252159800004

View details for PubMedID 17943342

Abstract

Survival of ex vivo constructed tissues after transplantation is limited by insufficient oxygen and nutrient supply. Therefore, strategies aiming at the improvement of neovascularization of engineered tissues are a key issue. A method to enhance graft vascularization is to establish a primitive vascular plexus within the graft before transplantation by the use of cellular-based concepts. To explore the utility of endothelial progenitor cells (EPCs) for the ex vivo vascularization of tissue engineered grafts, we analyzed the in vitro angiogenic properties of this cell type in two different angiogenesis models: the 3-dimensional spheroid sprouting assay and the 2-dimensional matrigel assay. In both assays, EPCs were able to form tubelike structures, resembling early capillaries. This process was significantly enhanced by the addition of angiogenic growth factors. Direct comparison between EPCs and mature endothelial cells, represented by human umbilical vein endothelial cells (HUVECs), revealed that both cell types displayed an almost identical angiogenic potential. Other functional in vitro parameters such as angiogenic growth factor induced cell proliferation and cell survival were investigated as well, revealing a significantly decreased level of apoptosis of EPCs in relation to HUVECs under serum-deprived conditions. The observed survival advantage of EPCs along with the observation that EPCs perform very well in the above mentioned in vitro angiogenesis assays, make them an ideal autologous cell source for vascularization of ex vivo generated tissues. The attractiveness of this cell type for tissue engineering applications is strengthened further by the fact that these cells can be easily isolated from the peripheral blood of patients, thereby eliminating donor site morbidity.

View details for DOI 10.1089/ten.2006.0369

View details for Web of Science ID 000248035500003

View details for PubMedID 17550338

Abstract

The concentration of metabolites of neurohormones in cerebrospinal fluid (CSF) is an index of turnover of substances in brain parenchyma. The raised intracranial pressure in hydrocephalic children may cause alteration in the metabolism of neurohormones. Serotonin and its metabolite 5-HIAA have been studied extensively in CSF of patients with neuropsychiatric diseases. Hence we studied the neurohormones serotonin and its end product 5-hydroxy indole acetic acid (5-HIAA) in CSF of hydrocephalus infants before and after ventriculoperitoneal (VP) shunt. Ventricular CSF samples form 50 hydrocephalic infants were obtained serially at the time of shunt insertion, and then on day 8 and day 30 postoperatively by direct puncture from shunt chamber using 26G needles. Control CSF samples were taken from otherwise healthy children operated under spinal anesthesia. The samples were analyzed for serotonin and 5-HIAA by spectrofluorophotometric method. At the time of shunt insertion, serotonin was significantly decreased (P<0.05) while 5-HIAA was significantly increased (P<0.001) in hydrocephalic infants. On day 8 and day 30 values of serotonin and 5-HIAA approached the baseline values. In patients who developed VP shunt blockade there was again a rise in levels of 5-HIAA. However, no correlation could be established between the levels of serotonin, 5-HIAA and the duration of hydrocephalus and the type of hydrocephalus. Our study shows increased 5-HIAA concentration in CSF indicating increased turnover of serotonin to its metabolite due to pressure changes in hydrocephalus. Long-term follow-up is required to assess if they could be of prognostic significance as regards to long term attainment of brain functions in hydrocephalic children.

View details for DOI 10.1007/s00383-006-1689-5

View details for Web of Science ID 000246757500011

View details for PubMedID 17380338

Abstract

Despite efforts of plastic surgeons in recent years to discover new alternatives, the techniques currently used for restoration of soft tissue defects still have disadvantages. The gold standard for soft tissue reconstruction remains autologous pedicled/free tissue transfer. This technique often results in high rates of operative morbidity and donor site deformity. Results obtained by autologous fat tissue transfer usually are disappointing because of a high graft resorption rate with unpredictable outcomes. Different tissue engineering approaches have been used in the past to generate adipose tissue. However, long-term results in terms of volume persistence have been disappointing.In this study, different concentrations of undifferentiated human preadipocytes in fibrin were injected into athymic nude mice (n = 8). Mice that had fibrin injection without cells served as control subjects (n = 8). The specimens were explanted after 1, 2, 6, and 9 months, with subsequent qualitative and quantitative analysis of adipose tissue formation by histologic and image analysis.Within the first 4 weeks after initial volume reduction of the implants, the volume and shape of the implants with preadipocytes remained stable. The implants without cells were completely resorbed within 3 weeks. Histologic analysis demonstrated generation of stable adipose tissue with no signs of an inflammatory response or evidence of tissue necrosis in the implants containing preadipocytes. The best results were obtained after implantation of 30 million preadipocytes. Adipose tissue formation was not observed in the control group.The findings demonstrate that long-term stable adipose tissue can be engineered in vivo by simple injection of human preadipocytes using fibrin as a carrier material. After further investigation, this approach may represent an alternative to the techniques currently used for soft tissue restoration.

View details for DOI 10.1007/s00266-006-0221-6

View details for Web of Science ID 000246220300013

View details for PubMedID 17380359

Abstract

The volume-persistent survival of transplanted adipose tissue in vivo relies on early vascularization, due to an otherwise early induction of apoptosis of the centrally located cells. Thus, one way to enable the early formation of a capillary network resulting in a sufficient perfusion of the transplanted construct might be the co-transplantation of autologous preadipocytes with endothelial cells. To investigate preadipocyte-endothelial cell interaction, three-dimensional proliferation- and angiogenesis assays were performed in vitro. Proliferation rates of co-cultured endothelial cells and preadipocytes suspended in a fibrin matrix were elucidated by Alamarblue assays. The spheroid angiogenesis model was applied for analyzing the effects of vascular endothelial cell growth factor (VEGF) and basic fibroblast growth factor (bFGF) (produced by preadipocytes) as well as the impact of cell-cell interaction between preadipocytes and endothelial cells and fibrin matrix on endothelial cell migration. Preadipocytes proliferated in fibrin glue, whereas endothelial cells underwent apoptosis. By co-culturing, both cell types demonstrated an increased proliferation rate. Preadipocytes provoked migration of endothelial cells. Blocking bFGF and/or VEGF led to a significant decrease of migration. Changes in fibrin structure were followed by migration of single cells instead of sprouting. An appropriate fibrin matrix as well as already differentiated endothelial cells are necessary for preadipocytes to develop their angiogenic activity via bFGF and VEGF.

View details for DOI 10.1080/13645700600935398

View details for Web of Science ID 000247724200002

View details for PubMedID 17573618

Abstract

The successful substitution or augmentation of soft tissues by implantation of three dimensional cell constructs, consisting of human preadipocytes and fibrin glue as a carrier matrix, requires a rapid and homogeneous vascularization of the whole implant in order to provide a sufficient blood supply of centrally situated cells. Previous investigations have shown that under in vivo conditions primary human preadipocytes induce vascularization of fibrin matrices by secretion of several growth factors, such as VEGF and bFGF. The current study investigates whether vascularization of implants can be improved by transplantation of preadipocytes following transfection with a VEGF-vector. Transfection was performed by electroporation with an pCMX-GFP and pCMX-VEGF165 vector. Transfection efficiency (GFP expression) and VEGF expression were determined in vitro by FACS analysis and VEGF immunoassay, respectively. In vivo investigations to determine the vascularization of the implants were performed on the cylinder chorioallantoic membrane (CAM). Four million VEGF transfected cells were transferred within a fibrin matrix onto the CAM on the 7(th) day of incubation and after 8 days the vascularization of the implant was histologically examined and evaluated by means of a computer-assisted image analysis program. Transfection of preadipocytes with the GFP vector by electroporation yielded transfection efficiencies between 12% and 41% of surviving cells. Results of the VEGF immunoassay demonstrated that VEGF expression was significantly higher following transfection. Investigations on the CAM outlined a significantly higher rate of vascularization in the transfected vs. control population. Our investigations demonstrate that primary human preadipocytes can be successfully transfected by electroporation with a VEGF vector. The enhanced VEGF expression on transfected cells results in an increase of vascularization of the cell constructs on the CAM.

View details for DOI 10.1080/13645700701384116

View details for Web of Science ID 000247724200004

View details for PubMedID 17573620

Abstract

Bureau-Barrire syndrome (BBS) describes a rare destructive process affecting skin and bone resulting from an acquired unilateral or bilateral polyneuropathy. Clinically, it is characterized by a triad of symptoms, namely, acral ulcerations, polyneuropathy, and bone lesions. To date, the development of Marjolin's ulcer in the course of BBS has not been described to the authors' knowledge.

View details for PubMedID 16928676

Abstract

Successful augmentation of soft tissues by transplantation of preadipocytes within a matrix requires the formation of a new capillary network with connection to the host vessel system. Particularly, cells located centrally within the transplanted cell-matrix-construct represent a population with a blood supply questionable for survival. We demonstrated that under in vivo conditions preadipocytes possess the ability to induce and support the vascularization of the implant presumably by expression of several growth factors, such as VEGF (vascular endothelial growth factor) and bFGF (basic fibroblast growth factor). Fertilized White-Leghorn eggs were incubated under standardized conditions. Opening was performed at day three of incubation and preadipocytes with and without recombinant growth factors were transferred into a fibrin matrix and subsequently placed on the Chorioallantoic Membrane (CAM), respectively. Eight days later, the implanted constructs were explanted, histologically processed and vascularization evaluated by means of a computer-assisted image analysis program. Matrices containing preadipocytes displayed a significantly higher density of vascularization, whereas in the control group (fibrin without preadipocytes) no vessel ingrowth was observed. Daily application of recombinant growth factors added to the medium did not positively influence vascularization of the implant. Our investigations demonstrate that preadipocytes possess a strong angiogenic potential to induce and support neovascularization of 3D-fibrin matrices under in vivo conditions. Addition of recombinant growth factors did not result in any stimulatory effect. Neither did the application of fibrin alone demonstrate an angiogenic potential with regard to induction of vascularization.

View details for DOI 10.1080/14017450600761620

View details for Web of Science ID 000240435100009

View details for PubMedID 16966139

Abstract

The free fibular flap has been used extensively in facial and extremity long bone reconstruction but has not been presented as a tool for reconstruction following composite hand injuries, in particular for reconstruction of the ulnar border of the hand. We present a case of the use of this flap for reconstruction of such a complex composite hand injury.

View details for PubMedID 16621209

View details for DOI 10.1016/j.jhsb.2006.02.003

View details for Web of Science ID 000238295000013

Abstract

During the last decades, numerous surgical techniques have been described for breast augmentation. In addition to the very popular inframammary and the periareolar approaches, the transaxillary technique provides an elegant means of conducting a safe and accurate implant placement without producing visible scars on the breast mound. Due to a questionable lack of intraoperative visualisation with resultant higher complication rates,we conducted a retrospective analysis comparing the endoscopy-assisted transaxillary approach with the inframammary technique. A retrospective analysis was conducted comparing the endoscopy-assisted transaxillary approach with the more commonly chosen inframammary aditus. Patients undergoing breast augmentation from 1997 to 2005 were analysed retrospectively. The analysis was conducted in patients undergoing this procedure for aesthetic reasons only. Underlying breast pathology as well as previously performed breast surgery were among the exclusion criteria. The Client Satisfaction Questionnaire (CSQ-8) was applied for assessment of patient satisfaction. From 1997 to 2005, 96 patients underwent breast augmentation at our institution. Implant volumes ranged from 150 to 400 ml.62.5% preferred the transaxillary technique vs. 37.5% who chose the inframammary route. Complication rates were low in both patient subsets, the statistics revealing no differences. Assessment of patient satisfaction displayed high levels of satisfaction in both groups without any significant differences. The endoscopy-assisted transaxillary breast augmentation is a safe technique which generates high levels of patient satisfaction. Predictable results can be achieved by this approach which is preferred by the majority of patients when offered.

View details for DOI 10.1055/s-2006-924252

View details for Web of Science ID 000242047800003

View details for PubMedID 16883498

Abstract

High-energy trauma resulting in a composite defect of the lower extremity confronts the microvascular surgeon with more difficulties than do free flap reconstruction elsewhere in the body, since the choice of distant recipient vessels is particularly difficult. Combining principles of perforator flap surgery with those of composite tissue transfer, we designed a thoracodorsal artery perforator flap with a vascularized bone segment from the scapula for reconstruction of a composite lower extremity defect in a patient following a paragliding accident. This is the first report on the application of a composite thoracodorsal artery perforator flap with vascularized scapula in lower extremity reconstruction. Among its multiple advantages, such as preservation of latissimus dorsi function, it is a good tool for one-stage reconstruction of traumatic composite lower extremity defects because its low donor site morbidity and long vascular pedicle enables anastomosis placement outside the zone of injury.

View details for DOI 10.1002/micr.20279

View details for Web of Science ID 000241801500005

View details for PubMedID 17001635

Abstract

During the last decades breast augmentation has gained worldwide acceptance. In addition to the inframammary and periareolar approach for augmentation mammaplasty, the transaxillary route provides an elegant means of retaining the integrity of the breast mound by avoiding visible scars. Due to concerns as to the safety of this technique we analysed 47 patients who underwent endoscopy-assisted transaxillary submuscular augmentation mammaplasty in our department from 1999 to 2004. The inclusion criteria were aesthetic breast augmentation due to breast hypoplasia. Patients with a history of breast cancer, other malignancies, or previously performed mastectomy were excluded. Procedures for tuberous breast deformity as well as concomitantly performed mastopexy were also excluded. No complications were observed impairing final outcome or requiring early operative intervention, such as infection or haematoma. This technique is suitable for patients who prefer a hidden incision at a distant site, and provides predictability of aesthetic outcome and is safe.

View details for DOI 10.1016/j.bjps.2006.01.031

View details for Web of Science ID 000241412700011

View details for PubMedID 16996432

Abstract

Since its introduction, augmentation mammaplasty has gained widespread popularity, as demonstrated by the fact that an estimated 2 million women in the United States have received implants. During recent decades, several surgical approaches have evolved in terms of implant placement or site of access to the surgical plane. Debate has existed concerning the questionable superiority of a particular technique for achievement of optimal results. Thus, the inframammary approach, an established and widely accepted technique for breast augmentation, and endoscopically assisted transaxillary breast augmentation were retrospectively compared in terms of safety and aesthetic outcome, as measured, respectively, by the rate of postoperative complications and patient satisfaction.This study analyzed 78 patients undergoing augmentation mammaplasty between 1997 and 2004. Only patients seeking primary augmentation mammaplasty solely for aesthetic reasons were included in the study. Previously performed breast surgery and simultaneously conducted ipsilateral mastopexy were among the exclusion criteria. Patient satisfaction was assessed using the client satisfaction questionnaire (CSQ-8) because of its easy applicability.The complication rate was low in both patient subsets, thus confirming the safety of the transaxillary approach, as compared with the more common submammary technique. However, a higher level of satisfaction was detected in the former patient group, indicating a more favorable aesthetic outcome with the transaxillary augmentation mammaplasty.Endoscopically assisted transaxillary augmentation mammaplasty is a safe method with predictable results associated with a high level of patient satisfaction. If applied in the setting of appropriate indications, it is an excellent tool for use with patients who prefer to have an incision at a distant site.

View details for DOI 10.1007/s00266-005-0095-z

View details for Web of Science ID 000234298300022

View details for PubMedID 16237580

Abstract

Cultivated epithelial autografts as multilayered thin sheets represent common standard in clinically applied tissue engineering substitutes, outnumbering all experimental alternatives. However, the unsatisfying short and long term results concerning mechanical stability and scarring demand for alternatives. Our group investigated cultivation and transplantation of cultured autologous keratinocytes as a single cell suspension in a fibrin sealant matrix in athymic mice in combination with allogenic skin grafting. We observed reliable wound reepithialization after a cultivation period of only 2 weeks. Additionally, we could allocate successful combination of a keratinocyte fibrin sealant suspension and acellular dermis in an attempt to regenerate full thickness skin defects in a pig animal model. The potential clinical implication of subconfluently cultured keratinocytes is enhanced by the possibility of co-transplantation with decellularized dermis.

View details for Web of Science ID 000230564700006

View details for PubMedID 15985977

Abstract

Modification with proteases and cholesterylesterase transforms LDL to a moiety that resembles lipoproteins isolated from atherosclerotic lesions and possesses atherogenic properties. To identify changes in monocyte-derived foam cells laden with enzymatically modified LDL (E-LDL), we compared patterns of the most abundant transcripts in these cells after incubation with LDL or E-LDL.Serial analyses of gene expression (SAGE) libraries were constructed from human monocytes after treatment with LDL or E-LDL. Several tags were differentially expressed in LDL-treated versus E-LDL-treated cells, whereby marked selective induction by E-LDL of cathepsin H was conspicuous. We show that cathepsin H is expressed in atherosclerotic lesions in colocalization with E-LDL. Furthermore, we demonstrate that LDL modified with cathepsin H and cholesterylesterase can confer onto LDL the capacity to induce macrophage foam cell formation and to induce cathepsin H.Cathepsin H could contribute to the transformation of LDL to an atherogenic moiety; the process might involve a self-sustaining amplifying circle.

View details for DOI 10.1161/01.ATV.0000063615.21233.BF

View details for Web of Science ID 000182165100021

View details for PubMedID 12615673