Panel: Injectables and Fillers - Common Complications and Their Management
Moderator: Bruce Cunningham, MD
Miles Graivier, MD
Val S. Lambros, MD FACS
Brian M. Kinney, MD
Objective(s):Discuss the frequency and severity of complications associated with the many new soft tissue fillers. Methods for selecting patients, avoiding and treating unfavorable outcomes will be discussed.
Panel: Presidents Panel: Bringing the Future Into Focus - How Research is Changing Our Practice
Moderator: Richard A. D'Amico, MD
Amy Alderman, MD
Richard Gliklich, MD
Andrea Pusic, MD
Joseph M. Rosen, MD
James M. Stuzin, MD
Objective(s): Plastic Surgery is recognized as a specialty with a rich tradition for innovation and research. These two tenets provide the foundation for advancing modern medical practice and changing patient care. The adoption of evidence-based medicine is increasing physician reliance on quality-data from well designed, clinically relevant studies to make important treatment decisions; however, the need for more and rapid outcomes research is often influenced by complex regulatory, legal, financial considerations.
This panel will explore how:
• Research in plastic surgery translates at the practice level
• Evidence-based medicine impacts the practice of plastic surgery
• Research and innovation in plastic surgery compare to other specialties
• Federal agencies, the legal system, and finances impact the advancement of research leading to clinical practice
• Plastic surgery can maintain its position as a leader in research and innovation
Paper: The Regional Viscoelastic Properties of the SMAS
Andrew P. Trussler, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX
Dan Hatef, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Matt Ruff, BS, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Spencer Brown, phd, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Fritz E. Barton, Jr, MD, Plastic Surgery, UT Southwestern, Dallas, TX
Purpose:
The Superficial Musculoaponeurotic System (SMAS) is a heterogenous supportive lining for facial soft tissue. It has favorable inherent viscoelastic properties which resist deformational forces and provides a platform to surgically correct the effects of aging. The face has a predictable pattern of aging related to regional areas of soft tissue descent tethered by points of fixation. The SMAS likely has similar regional differential properties which contribute to this soft tissue descent. The purpose of this study was to define the regional viscoelastic properties of the SMAS in relation to the aging face and its surgical correction in facelift surgery.
Method:
Fresh cadaver heads were evaluated within 72 hours of death. Cutaneous landmarks were marked prior to dissection and translated onto the hemiface SMAS flap prior to elevation. Regional samples of SMAS were divided into 3 hemiface groupings: lateral, mid cheek and medial. All samples were evaluated ex vivo for bursting strength, stress relaxation and creep with the Instron System tensiometer (Model 5565, Canton, MA). Bursting strength was defined as the force (N) required for tissue rupture, with bursting pressure (psi) calculated using force per tissue unit area. Stress relaxation and creep were respectively defined as the tension (N) created with a constant stretch (mm) over time, and the distance of tissue stretch (mm) with a constant load over time.
Results:
Twelve fresh cadaver hemi-facial specimens were included in the study (N=12). The average age of the cadavers was 55. The SMAS flap had a uniform thickness of 5.2 mm in each region of the face. There were consistent regional differences in the viscoelastic properties of the SMAS. A significant reduction in bursting strength and bursting pressure was seen in a lateral (38.73 N / SD 20.33) to medial (14.56 N / SD 6.56) direction (p<0.0001). Likewise, stress-relaxation and creep had significant regional differences. The lateral SMAS specimens were found to inherently relax to 45 % of their original tension and elongate 15% when subjected to predetermined facelift conditions. Mid cheek and medial SMAS had a significant increase in failure rate, stress relaxation and creep when subjected to similar forces as those placed on the lateral SMAS.
Conclusion
The strength of the SMAS decreases from lateral to medial on the face, which correlates with the pattern of aging. The force required to deform the SMAS varies by region, but once deformed the SMAS responds uniformly. The lateral SMAS in facelift surgery can reliably withstand the load for facial soft tissue repositioning, though increased tension may contribute to early recurrence in facelift surgery.
Paper: The Transconjunctival Midface Lift: A Six Year Experience Working Under the Muscle
Orlando Llorente, MD, Division of Plastic and Reconstructive Surgery, Northwestern Memorial Hospital, Chicago, IL
Julius Few, MD, The Few Institute for Aesthetic Plastic Surgery, Northwestern Memorial Hospital, Chicago, IL; John C. McCallum, BA, Northwestern University, Chicago, IL
Goals/Purpose:Rejuvenation of the midface remains a challenging aesthetic area to attain natural-looking, safe, and long-lasting results. There are numerous subperiosteal approaches that achieve successful rejuvenation. While many of these approaches are very safe and effective in skilled hands, extensive subperiosteal dissection and surgical manipulation can be unforgiving. Our goal was to find an approach that is relatively easy to apply with minimal risk and significant benefit. We feel that the combination of transconjuctival exposure and preservation of the periosteum results in less morbidity. We will present the benefits and limitations of this approach, as it may compare to more traditional approaches.Methods/Technique:A retrospective chart review was conducted of 25 consecutive patients, treated by a single surgeon (JWF) using the transconjuctival submuscular midface lift approach. The surgical technique consists of a combination of subcilliary and preperiosteal dissection under direct vision to release the orbital-malar ligament. The zygomaticofacial retaining ligaments are release via a lateral upper blepharoplasty exposure, which is a nature extension of the lateral retinacular release. The combination of the two exposures allows for varying degrees of release. An extended, insulated needle tip cautery facilitates the dissection, leaving no tissue on the periosteum, minimizing the risk for nerve injury. All patients were treated with either canthoplasty or cantopexy, in addition to lower lid skin pinch excision. All patients were treated over a six year period, 2000 to 2006. Data collected included the following: patient demographic, operative technique, concomitant procedures, and postoperative results. Complications and revisions were reviewed to evaluate the safety and long term efficacy of the procedure. Results/Complications:A retrospective review from 2000 to 2006 identified 25 female and 6 male patients with a minimum of 12 month’s postoperative follow-up. The mean age for the group was 54 years. The median follow-up was 32 months (range 12 to 78 months). No significant complications were recorded over an average of 36 months. The mean operative time for upper blepharoplasty with transconjuctival midface lift (with canthal suspension) was less than 150 minutes. No patient experienced facial nerve injury, prolonged chemosis, prolonged periorbital swelling, hematoma, seroma, ectropion, or lower eyelid malposition. One patient required re-excision of redundant lower eyelid skin, and one patient experienced chemosis that resolved in less than 10 days. Patient satisfaction was 96%. Three patients with extensive preoperative festoons required secondary excision or traditional midface lift, as described by the Paces group, Conclusion:The transconjuctival submuscular midface lift is safe and effective. The technique is readily applicable and more forgiving than the traditional midface lift. There is excellent operative exposure without the need for endoscopic equipment/training, and limited soft tissue dissection which reduces operative morbidity and promotes rapid recovery. Patients with extensive midface redundancy and/or festoons should be treated with more traditional techniques.
Lecture: Safe and Effective Eyelid Rejuvenation
Glenn W. Jelks, MD
Objective(s):Describe the surgical techniques that protect the eye in rejuvenation and identify how the sequence and eyelid coordination of the specific techniques produce predictable results with minimal risks.
Paper: Implications of Postbariatric Status in the Massive Weight Loss Patient
Devin Coon, BA, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
J. Peter Rubin, MD, Division of Plastic Surgery, University of Pittsburgh; Jeffrey Gusenoff, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
Introduction With the rapid increase in US obesity rates, growing numbers of patients are presenting post-massive weight loss (MWL). We sought to characterize demographic and outcome differences between patients who underwent gastric bypass surgery (GBP) and those who lost weight exclusively through diet and exercise (DE).Methods Over six years, 449 patients representing 511 post-MWL body contouring cases were entered into a prospective registry. Entry into the registry was based on body contouring surgery after a loss of >50 pounds. DE patients were matched in a 1:n fashion to 191 GBP patients based on procedures performed (brachioplasty, breast surgery, thigh lift, lower body lift, upper body lift, cosmetic facial surgery and/or panniculectomy). Fixed-effects and conditional logistic regression were used to test for differences between groups. 1:1 matching was then performed by nearest neighbor matching to the most similar GBP patient based on gender, age and BMI. The t-test was used to compare matched patients.ResultsTwenty-nine patients representing 34 cases (6.7%) lost weight exclusively through DE. Overall, DE patients were not significantly different from GBP patients in age, gender, maximum (pre-MWL) BMI or BMI at time of body contouring. DE patients had significantly higher pre-operative hematocrit (39.6 versus 37.6; p = 0.02) and hemoglobin (14.4 versus 12.8; p = 0.05). DE patients tended to have multiple procedures performed in the same case more often (74% versus 61%) and had higher absolute complication rates (50% versus 41%; p=0.3). Infection rates were the only individual complication to reach statistical significance (18% versus 7%; p = 0.03). When matched based on procedures performed, DE patients had a higher but not significant complication rate (OR 1.4; p = 0.38).One-to-one matching resulted in 34 procedure-matched pairs that were not significantly different by age, gender, current BMI, maximum BMI or intraoperative time. DE patients still had more complications (50% versus 38%; p = 0.3), with higher rates of wound dehiscence and infection (18% versus 9% and 27% versus 12% respectively; p = 0.3 and 0.09), a similar rate of hematomas (3%) and a lower rate of seromas (21% versus 29%). Pair-matched DE patients had a higher albumin in the 20 patients with preoperative measurement (3.6 versus 4.0; p = 0.06). Twenty-two patients received a preoperative consultation from a nutritionist regarding protein intake; 7 of 9 DE patients (78%) exceeded the median daily protein intake (60g) while only 6 of 13 GBP patients did (46%; p = 0.15). DE patients also had a lower rate of self-reported history of anemia (20% versus 8%).DiscussionPost-MWL reconstruction is one of the fastest growing areas in plastic surgery. Postbariatric status, which is well correlated with both caloric and nutritional deficits, has motivated much of the emphasis on monitoring and improving nutrition before surgery in this patient population.As might be expected, metabolic assessments and protein intake appeared better in the cohort of patients who lost weight through diet and exercise rather than through bypass surgery. However, this was not borne out in surgical outcomes with non-bypass patients experiencing more complications even after controlling for procedures performed and demographic factors. Definitive conclusions are difficult due to the relatively small proportion of patients who undergo massive weight loss without surgical intervention, but we found no evidence to suggest that postbariatric status adds additional risk beyond that of massive weight loss itself. A comprehensive assessment of nutritional status is an important part of patient selection in this population.
Paper: Benchmarking Outcomes in Plastic Surgery: National Complication Rates for Abdominoplasty and Breast Augmentation
Amy Alderman, MD, MPH, Plastic Surgery, U Michigan, Ann Arbor, MI
E. Dale Collins, MD, Dartmouth Hitchcock Medical Center, Lebanon, NH; James C. Grotting, MD, Grotting Plastic Surgery, Birmingham, AL; Amy Sulkin, MPH, American Society of Plastic Surgeons, Arlington Heights, IL; Peter C. Neligan, MB, Toronto General Hospital, Toronto, ON, Canada; Phillip C. Haeck, MD, Seattle, WA; Karol A. Gutowski, MD, Plastic and Reconstructive Surgery, University of Wisconsin-Madison, Madison, WI
Purpose: Tracking surgical complications in plastic surgery is crucial to ensuring high quality care, patient safety and informed patient choice. Unfortunately, surgical outcomes data are most often generated from a single surgeon or a single center, limiting the generalizability to other healthcare providers and settings. Large databases present another option and allow us to evaluate outcomes in a large cohort of patient. We tested this approach using two national databases that capture both procedural and outcomes data. Two common procedures, breast augmentation and abdominoplasty, were selected to cross validate the data and assess the face validity of the results using this approach.
Methods: Our study population included all cases that underwent a single or combined procedure abdominoplasty or breast augmentation in the TOPS and CosmetAssure databases from July, 2003 to August, 2007. The independent variables included patient age, patient gender, diabetes, nicotine use and facility type. The primary outcomes of interest were the proportion of patients with hematoma, infection or DVT/PE in the two surgical groups.
Results: The TOPS and CosmetAssure databases included 7,310 and 3,350 patients with single procedure abdominoplasty; 13,193 and 7,777 combined procedure abdominoplasty; 30,831 and 14,227 patients with single procedure breast augmentation; and 17,894 and 7,797 combined procedure breast augmentation, respectively. Many of the reported complications were statistically higher in the TOPS compared to the CosmetAssure populations, although many of the differences were not clinically significant. However, both reported complication rates below the published literature. Specifically, in the TOPS and CosmetAssure populations, the complication rates for single procedure abdominoplasty were: 0.9% and 0.5% with hematoma (p = 0.29); 3.5% and 0.7% with infection (p < 0.001); 0.3% and 0.1% with DVT/PE (p = 0.05), respectively. In the TOPS and CosmetAssure populations, the complication rates for primary breast augmentation were: 0.6% and 0.7% with hematoma (p = 0.21); 0.3% and 0.1% with infection (p < 0.001); 0.02% and <0.01% with DVT/PE (p = 0.31), respectively. In addition, combining procedures appeared to increase the risk of postoperative complications, especially with breast augmentation. In particular, combined compared to single procedure breast augmentation in TOPS had significantly higher rates of hematoma, infection and DVT/PE (see Table 1).
Table 1. Breast Augmentation Complications in the TOPS Population, 2003 – 2007
|
Patient Characteristics | Single Procedure (N=30,831)
| Combined Procedure (N=17,894) | P value |
Age (mean, years) | 33.3 | 39.7 | <0.001 |
Female Gender | 99.7% | 99.8% | 0.038 |
Hematoma | 0.6% | 0.8% | 0.009 |
Infection | 0.3% | 1.2% | <0.001 |
DVT/PE | 0.02% | 0.1% | <0.001 |
Hospital Ambulatory Care Office-Based Suite office/other |
16.9% 37.7% 44.2% 1.2% |
23.2% 33.8% 41.2% 1.8% |
<0.001 <0.001 <0.001 <0.001 |
Conclusions: Complication rates for abdominoplasty and breast augmentation were similar in both databases providing a measure of cross validation. The low complication rates reported for abdominoplasty and breast augmentation in the TOPS and CosmetAssure populations support the safety of these procedures when performed by board-certified plastic surgeons. However, surgeons should be aware of the higher complication rates associated with combining breast augmentation with other procedures. These data should be used by individual practitioners for outcomes benchmarking.
Panel: My Aesthetic Breast Practice - What I No Longer Do
Moderator: Elizabeth J. Hall-Findlay, MD
Roberta L. Gartside, MD
Roxanne J. Guy, MD
Ronald E. Iverson, MD
Scott L. Spear, MD
Objective(s): Examine current, proven techniques and understand which techniques have were used in the past and which have stood the test of time.
Panel: Modern Rhytidectomy - What I Now Do Differently and Why
Moderator: James M. Stuzin, MD
Daniel C. Baker, MD
Val S. Lambros, MD FACS
Rod J. Rohrich, MD
Objective(s): Understand how facial rejuvenation experts have evolved their techniques to improve the quality and consistency of their results in facelifting. Patient selection, safety in operative technique, and complications avoidance will be emphasized.
Panel: New! -- Survival Strategies for Tough Economic Times: A Town Hall Meeting
Moderator: Michael McGuire
Plastic surgeons everywhere are feeling the impact of the troubled economy, and there is little consensus about when the tide will turn for the better. Meanwhile, there are some survival strategies that may help ease your pain. Join us for this Town Hall Meeting where you will learn the results of ASPS's recent survey on how the economy is affecting you and your colleagues and hear from a panel of physicians, practice consultants, marketing strategists, and ASPS business partners, who will share their insights on how you can ride out the storm successfully. Their presentations will be brief to leave plenty of time to answer your specific questions.
Paper: Increased EPC Mobilization Improves Diabetic Wound Healing
Robert J. Allen, MD, Plastic Surgery, New York University, New York, NY
Clarence D. Lin, MA, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Phoung D. Nguyen, MD, Plastic Surgery, New York University, New York, NY; Evan S. Garfein, MD, Plastic Surgery, New York University, New York, NY; Stephen Warren, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY
Introduction
The pathogenesis of diabetic wound healing is multifactorial, with major complications resulting from impaired vascular architecture and function. Recent studies have indicated that progenitor cells released from the bone marrow play an integral role in the formation and repair of blood vessels throughout the body. Specifically, endothelial progenitor cells (EPCs) are mobilized from the bone marrow in response to injury, and these progenitor cells migrate through the circulation, home to the site of injury, and incorporate into the wound, where they contribute to vasculogenesis and tissue repair. This physiologic vasculogenic process is impaired in diabetics. For example, our laboratory has confirmed that diabetic animals have fewer circulating EPCs than wild-type animals at baseline and following peripheral ischemia despite having a normal amount of progenitor cells available in their bone marrow. Thus, we hypothesized that restoring EPC mobilization from the bone marrow with the CXCR4 antagonist, AMD3100, would improve diabetic wound healing.
MethodsIn order to test this hypothesis, two 6-mm wounds were made on the dorsum of diabetic mice using a sterile skin punch biopsy. The wounds were stented with a 12-mm O-ring silicone stent to prevent wound contraction and recapitulate healing by secondary intention. Starting on post-operative day 3 and continuing until wound closure, AMD3100 or sterile saline (0.01mg/g) was injected intraperitoneally into the treatment group (n=20) and control group (n=20), respectively. Photogramography was used to compare the percent wound closure between the two groups at days 7, 14, and 21. Circulating endothelial progenitor cell number (Lin-, Sca-1+, ckit+) was compared between the two groups at numerous time points throughout the study period using flow cytometry.
Results
Diabetic mice treated intraperitoneally with AMD3100 showed a significantly improved wound closure rate compared to diabetic mice treated with sterile saline (p < 0.05). At 7, 14, and 21 days post-operatively, mice treated with AMD3100 had wound closures on average of 32.7%, 72.9%, and 90%, respectively; whereas the control mice treated had closures on average of 11.9%, 36.5%, and 66.7%. FACS analysis of peripheral blood revealed that animals treated with AMD3100 also had increased circulating EPCs (Lin-, Sca-1+, ckit+ cells) compared to untreated controls: 3.7±1.0-fold increase at 1 hour, 11.9±1.7-fold increase at day 7, 19.6±1.9-fold increase at day 14. Interestingly, there was a 23.6-fold decrease in circulating EPCs in treated animals at day 21 compared to the controls.
Conclusion
AMD3100-induced EPC mobilization leads to an improved wound healing in diabetic mice by increasing the total number of circulating endothelial progenitor cells. Furthermore, the rate of wound healing is directly proportional to the number of circulating EPCs.
Paper: Patterns and Correlates of Breast Reconstruction among Latinas: Results from a population-based sample of mastectomy-treated breast cancer patients
Amy Alderman, MD, MPH, Plastic Surgery, U Michigan, Ann Arbor, MI
Steven Katz, MD, MPH, Medicine, U Michigan, Ann Arbor, MI
Purpose: There is concern that minority women may have limited access to post-mastectomy breast reconstruction despite federally mandated coverage by the Women’s Health and Cancer Rights Act. Our purpose was to describe the use of breast reconstruction among Latinas and investigate barriers to reconstructive services.
Methods: A sample of women age ≤79 years who were diagnosed with ductal carcinoma in situ and invasive breast carcinoma between 2005 and 2006 was identified from the Surveillance, Epidemiology and End Results (SEER) registry in Los Angeles. Eligible subjects completed a questionnaire at a mean 7.7 months after diagnosis (response rate 71.4%). Chi-square test was used for data analysis.
Results: Of the 1449 respondents, 500 (34.5%) underwent a mastectomy. Receipt of breast reconstruction varied significantly by patient race/ethnicity: 35.9% non-Latina whites, 28.4% blacks, 35.7% English-speaking Latinas, and only 13.2% of Spanish-speaking Latinas received reconstruction (p < 0.001). Compared to the other racial/ethnic groups, Spanish-speaking Latinas were least likely to plan on getting reconstruction in the future (p= 0.009) and were most likely to face significant barriers to reconstructive services. Comparing Spanish-speaking Latinas to non-Latina whites, 15.2% vs. 1.3% didn’t know how to get breast reconstruction (p <0.001), and 13.3% vs. 1.3% didn’t get reconstruction due to financial barriers (p <0.001). Conclusions: Breast reconstruction appears to be under-used in the Spanish-speaking Latina population, as these women face knowledge and financial barriers to surgery. Further work is needed to better educate minority women about their reconstructive options for breast cancer and lessen the financial burden these women face to reconstructive surgery.
Table 1: Receipt of immediate breast reconstruction among breast cancer patients treated with a mastectomy between 2005 and 2006 in the Los Angeles SEER Registry |
| Non-LatinaWhites |
Blacks | English-Speaking Latinas | Spanish-Speaking Latinas |
|
| (N=145) | (N=130) | (N=100) | (N=125) |
|
| % | % | % | % |
|
Received immediate breast reconstruction* | 35.9 | 28.4 | 35.7 | 13.2 |
|
Planning on reconstruction in the future | 34.7 | 25.0 | 30.2 | 23.8 |
|
No future plans for reconstruction | 29.4 | 46.6 | 34.1 | 63.0 |
|
|
|
|
|
|
|
* Pearson chi-square, p < 0.001 |
Paper: Long Term of Survival of Penile Allotransplantation Model in Rat under Cyclosporin-A MonoTherapy
Erhan Sonmez, MD, Plastic Surgery, The Cleveland Clinic, Cleveland, OH
Serdar Nasir, MD, Plastic Surgery, The Cleveland Clinic, Cleveland, OH; Maria Siemionow, MD, PhD, Plastic Surgery, The Cleveland Clinic, Cleveland, OH
Purpose:
Penile
defects may be caused by trauma, cancer surgeries, congenital anomalies and surgical
complications. The treatment options for penile defects include: penile
replantation, reconstruction and transplantation.
In
this study we introduce an experimental model of penile allogenic
transplantation based on neurovascular pedicle.
Methods:
42
adult male LEW (RT1l) and 6 adult male LBN (RT1l+n)
rats weighing 200-300g were used in three experimental groups: Anatomic study
(Group 1, n=6), isotransplantation (Group 2, n=24) and allotransplantation
groups (Group 3, n=12).
In
6 LEW
rats, the vascular anatomy of male rat perineal region was determined by
anatomic dissections. The penile composite flap was created based on the corpus
spongiosum, dorsal penile vein and dorsal penile nerves (Figure 1,2).
In
order to reduce the morbidity and mortality of the recipient rats, instead of
performing amputation of penis of the recipient rat, we have introduced
modification of rerouting it into the scrotum. In 12 LEW
rats, penile composite graft was transplanted as an isotransplant by
microvascular anastomosis of the pedicle of the penis of the donor with the
saphenous vessels of the recipient (Figure 3,4).
Figure 1.
View of the isolated dorsal penile vein (DPV), and dorsal penile nerves
(DPN) on the milimetric scale under operating microscope.
Figure 2.
View of
the isolated corpus spongiosum (CS) on the milimetric scale under
operating microscope. (corpus cavernosum (CC),
preputium(P)).
Figure 3.
View
of
the anastomoses on the milimetric scale under operating microscope.
(saphenous
artery (SA), corpus spongiosum (CS), dorsal penile vein (DPV),
saphenous vein (SV), dorsal penile nerve (DPN), lateral femoral
cutaneous nerve (LFCN)).
In
another 12 LEW rats, penile composite graft was
transferred as a composite graft without vascular anastomosis. In the third
part of the study, penis composite graft was transplanted across MHC barrier
between LBN donors and LEW recipients under
tapered dose of CsA immunotherapy. Graft survival was monitored by daily
observations, somatosensory evoked potentials, histological examination and
microangiography to assess transplant viability.
Figure 4.
Drawing of the design of the transplantation procedure.
Results:
All
vascularized isotransplants and allotransplants survived without signs of acute
or chronic rejection over 200 days (still under observation) whereas all
nonvascularized grafts underwent necrosis at 7 days post-transplant (Figure 5).
Somatosensory evoke potential evaluation tests (SSEP) confirmed that starting at
day 60 post-transplant, stimulation of the glans of the transplanted penis
revealed cortical responses recorded in the somatosensory cortex of the
recipient rat. Microangiographic evaluation of the transplanted penile tissues
with lead oxide gelatin mixture demonstrated well preserved vascular
territories of the transplanted penile allograft at 200 days post-transplant
(Figure 6).
Histological
evaluation confirmed that there were no signs of rejection at post-transplant
day 200. Besides it was observed on the histological slides that the artery of
the urethral bulb, cavernous structures of the corpus spongiosum, the dorsal
penile arteries and the other small arterial branches were filled with the lead
oxide gelatin mixture which was infused via intraarterial route (Figure 7).
Figure 5.
Allotransplant on 200th post-transplant day (rerouted penis to the
scrotum (p), penis allotransplant (pa)).
Figure 6.
Allotransplant filled with intra arterial lead oxide-gelatin mixture (upper),
and microangiographic view (lower). (saphenous
artery (SA), corpus spongiosum (CS), dorsal penile vein (DPV),
saphenous vein (SV), dorsal penile nerve (DPN).
Figure 7.
Histological examination of the penile tissue
allotransplant on the 200th post-transplant day. Note the dorsal
penile arteries (DPA), artery of the urethral bulb (AUB) and cavernous
structures of the corpus spongiosum (arrows)
filled with leadoxide. (x10, H&E staining).(urethra (U),
dorsal penile nerve (DPN)).
Conclusions:
This
study confirmed feasibility of new penile allograft transplantation model. Long
term survival without signs of rejection was achieved on tapered dose of Cyclosporin
A monotherapy. The sensory function of penile transplant was confirmed by
somatosensory evoked potentials. Finally, a new method of neurovascularization
of penile transplant by direct artery-to-corpus spongiosum anastomosis was
introduced.
Lecture: Myths and Realities of Wound Care Products
Elof Eriksson, MD
Objective(s):Critically analyze and discuss the benefits and shortcomings of various types of wound care products.
Paper: Reconstruction of Segmental Femoral Defects with Living Bone Allotransplants Combined with Host-derived Neoangiogenesis: Mechanical, Histologic and Radiographic Analysis
Goetz A. Giessler, MD, Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN
Patricia F. Friedrich, AAS, Department of Orthopedic Surgery, Microvascular Research Laboratory, Mayo Clinic, Rochester, MN; Allen T. Bishop, MD, Department of Orthopedic Surgery, Microvascular Reserach Laboratory, Mayo Clinic, Rochester, MN
Living musculoskeletal allotransplants currently require long-term immunosuppression to maintain viability, impractical due to associated risks for non-life-critical tissue transplantation. We have previously demonstrated an alternative method using implanted host-derived vessels to replace the allogeneic nutrient circulation. These vessels maintain measurable blood flow, generate extensive neoangiogeneic capillaries and form new bone when combined with short-term immunosuppression. In this study, we have used this method to reconstruct large segmental femoral defects.
A segmental femoral defect was created in Dutch-Belted rabbits. Reconstruction was performed using a free vascularized allogeneic femoral diaphyseal transplant from a New Zealand White rabbit. Rigid fixation allowing immediate full weight-bearing was performed. In addition to microvascular repair of the nutrient artery circulation, a pedicled inferior epigastric fascial flap was placed within the medullary canal. Survival time was 16 weeks.
Five groups of 10 Dutch-Belted rabbits each included a pedicled autotransplant control group, and four allotransplant groups which varied in fascial flap patency (patent or ligated) and immunosuppression with 0.08 mg/kg Tacrolimus (+ or -). Healing was quantified by X-ray. Microangiography and Spalteholz bone clearing allowed quantification of neoangiogenesis. Mechanical properties were evaluated using 4-point bending. Quantitative histomorphometry assessed bone remodeling.
X-ray analysis using a grading schema demonstrated an equivalent healing response when autotransplant controls were compared to immunosuppressed allotransplants with patent fascial flaps. The roentgenograms of the latter group demonstrated faster healing as well as the lowest relative ultimate strength and elastic modulus values of all groups. This is an indication of biologic activity, including a greater blood supply and a higher rate of bone remodeling than other animals. It correlated with findings from microangiography (the highest amount of neoangiogenesis among all groups) and histomorphometric analysis of bone turnover. Not surprisingly, the lowest angiogenesis and bone remodeling values were found in the non-immunosuppressed allotransplant femurs with a ligated intramedullary flap.
Surgical angiogenesis from host-derived fascial flaps can provide greater blood flow and improved rates/grading of healing in immunosuppressed allogeneic bone transplants than other groups. Material properties of this group were also less than the other groups. Thus, while the vascularized tissue allotransplants treated with immunosuppression and fascial flap implantation maintained flow and viability at levels higher than other groups, we found this to weaken the transplant more as well. As the demonstrated active bone turnover ultimately replaces the transplant with host-derived cells, this process in the long-term may result in a more stable transplant with minor rejection.
Paper: Occupational Injuries in Plastic Surgery
Mark A. Clayman, MD, Division of Plastic Surgery, Shands Hospital at The University of Florida, Gainesville, FL
Amy McGreane, MSN, ARNP-BC, Division of Plastic & Reconstructive Surgery, University of Florida & Malcom-Randal VA Medical Center, Gainesville, FL; Matthew Steele, MD, Division of Plastic Surgery, Gainsville, FL; Eric S. Clayman, BA, College of Arts and Sciences, Harvard University, Cambridge, MA; Kimberly Wietzke, RN, Division of Plastic & Reconstructive Surgery, University of Florida & The Malcom-Randal VA Medical Center, Gainesville, FL
Background:
Repetitive strain injuries, cumulative trauma disorders, occupational overuse syndrome, or work related upper limb disorders are terms used to describe a loose group of conditions resulting from overuse of a tool/instrument or activities that require repetitive movement. The syndrome affects muscles, tendons, and nerves in the hands, arms, back and neck. The medically accepted condition in which it occurs is when muscles in these areas are kept tense for long periods of time, due to poor posture and/or repetitive motions.
The syndrome is most commonly associated with assembly line and computer workers, but can and does occur in the medical profession. Occupational hazards in our specialty of Plastic and Reconstructive Surgery have previously been overlooked as we treat these problems on a daily basis related to other professions.
The objective of this study was to survey ASPS/PSEF board-certified plastic surgeons about their experiences related to repetitive strain and occupational injuries/hazards throughout their career. The goal is to be proactive during residency and early on in ones practice to prevent/limit potential injuries.
Methods:
5,437 members were surveyed by questionnaire via email about the presence of occupational injuries/hazards in their practice. The results were anonymous. Questions relating to focus of practice (hand, craniofacial, cosmetic, micro. etc), years in practice, diagnosis of medical/musculoskeletal conditions, preexisting or acquired conditions/injuries, operative techniques, use of headlights, loupes, etc, as well as an open answer comment section to extrapolate and strengthen the survey, allowing surgeons to share their experiences.
Results:
5,437 surgeons were sent the survey with 1,843 responding; a response rate of 34%. A number of email addresses were incorrect on the roster and returned, so several surgeons never received the survey. In regards to scope of practice, 68.9% of responders performed hand surgery, 93.4% aesthetic surgery, 52.8% craniofacial, 87.2% reconstructive, and 9.7% other. 94.2% were still practicing when the survey was distributed, with 34% in practice less than 10years, 33.5% for 10-20years, and 31.7% greater than 20 years. 6% were retired. The most common symptomatic complaints were pain, decreased joint motion, swelling, numbness, and tingling. The most common locations: index PIP and thumb MP joints of the dominant hand, non-dominant index DIP, wrist shoulder and elbow of the dominant hand, cervical and lumbar spine. 15.6% were diagnosed with an injury, and 30.7% of those with an injury, underwent surgery or a procedure to treat the injury, with 58.9% claiming the treatment helped/changed the way they practiced. 85.8% of responders were male, 14.4% female (2.4% became pregnant while in practice/residency; 12.7% claimed the pregnancy affected their symptoms). 95% have been stuck by a needle, with 17.2% using double gloves. 9.4% collect disability for injuries occurring while practicing. 4.2% sustained an injury (physical/emotional) caused by a patient.
ConclusionThe appearance of musculoskeletal symptoms among plastic surgeons, even after a short time in practice, suggests that ergonomics should be covered in the educational system to reduce risks to surgeons. Some of the first warning signs noticed, were lower back and cervical spine pain/strains that persisted and didn’t respond to over the counter medications.
Good posture, ergonomics and limiting time in stressful working conditions can help prevent/slow the progress of these disorders. Physical and occupational therapy, stretches, strengthening exercises, yoga and biofeedback training have shown to reduce neck/shoulder muscle tension and can help heal existing or even prevent some disorders.
There were some interesting correlations found, such as injuries related to liposuction. A correlation was found between transferring patients and back problems, between blunt finger dissection and joint arthritis as well as non-dominant digit injuries and blotting while dissecting. The use of headlights, microscopes, lead aprons during fluoroscopy, and loupes also correlated to certain injuries and more detailed associations/findings will be discussed.
Paper: The Dermal Stapler Device: A Faster, More Cost-Effective Method for Incisional Closure as Compared to Standard Dermal Sutures
Esther H. Teo, BS, Plastic Surgery, Weill Medical College Cornell University, New York, NY
Kevin J. Cross, MD, Plastic Surgery, Weill Medical College Cornell University, New York, NY; Shannon L. Wong, MD, Plastic Surgery, Weill Medical College Cornell University, Marshfield, WI; Robert T. Grant, MD, Columbia University, New York, NY; Christine Rohde, MD, New York, NY; Jeffrey A. Ascherman, MD, Plastic Surgery, New York Presbyterian Hospital--Columbia University Campus, New York, NY
Introduction
In
the surgical setting, technique used for wound closure is critical for overall
appearance and integrity of the final scar. Standard plastic closure of surgical wounds involves
placement of multiple layers of dermal sutures, which can be time consuming,
utilize several packets of sutures putting the operator at increased risk of
needlestick injury, increase the risk of inflammation and infection, and have a
variable outcome depending on the skill of each individual surgeon. The INSORB
subcuticular stapler (Incisive Surgical) is FDA-approved for wound closure and
has been shown to have superior cosmetic results in animal models. However, no
randomized controlled studies have been performed in humans. The INSORB
stapler is hypothesized to be a faster alternative to standard closure for
reduced operating room and anesthesia time, improved cost-effectiveness, and
provide a safe, consistent surgical and cosmetic result across users.
Methods
This is a prospective,
randomized, blinded, IRB-approved study that allows for the unique ability to
compare the standard and experimental intervention in the same patient. Patients undergoing bilateral breast
reconstruction with tissue expanders, age 18 or older, were eligible for
inclusion in this study. After
expander placement, one breast incision was randomly assigned to closure using
the INSORB dermal stapler and the contralateral incision was closed in standard
fashion with dermal sutures. A subcuticular suture layer was placed in both
groups. Intraoperative parameters
documented include length of incision, number of sutures placed/staples
deployed, number of suture packets/staplers used, and time for incision
closure. Wounds were objectively
assessed by a blinded observer at ensuing follow-up visits using the Vancouver
Scar Scale (VSS), which combines scar vascularity, pigmentation, pliability,
and height ratings into a total score of 0-13.
Results
Intraoperative data was
collected on 10 patients, 20 incisions.
The average length of suture-closed incisions and INSORB-closed
incisions were 13.95 cm and 13.65 cm, respectively (p-value = 0.795). An average of 20.6 sutures or 16 staples
were placed per incision (1.48 sutures/cm incision, 1.21 staples/cm incision,
p=0.996). Each closure required a
median of 2.5 packages of sutures or 1 stapler, which deploys 25 dermal staples
per device. This is an estimated
cost of $11.95/closure using sutures and $45/closure using the INSORB. Mean closure time was 15 minutes for
sutures and 3.8 minutes for dermal staples (p=<0.001). With a per hour
operating room cost of approximately $2,000 at our institution, overall savings
with the device is greater than $300/case. At follow-up visit an average of 22.1 days post-operatively,
VSS rating was 2.86 for the suture side and 4.14 for the staple side
(p=0.022). The largest difference
was scar height (suture=0.29, staples=1.14, p=0.045), demonstrating effective
wound eversion on the INSORB side in the early post-operative period. No
significant difference was found for scar vascularity, pigmentation, or
pliability. Though data collection
is ongoing, in the patients who have data available from several follow-up
visits, VSS scores trended towards equality between the INSORB and dermal
suture sides. This suggests
settling of wound eversion as healing matured.
Conclusion
There was no significant
difference between length of incisions, number of sutures or staples used in
total, and number of sutures or staples used per cm of incision. One INSORB dermal stapler or 2.5 suture
packages were used per closure, for a cost increase of $33.05/closure using the
INSORB. However, use of the dermal
stapler reduced incisional closure time by 11.2 minutes/closure (47.4
seconds/cm incision) and thus afforded great savings in overall operative
costs. VSS rating was initially
1.28 points higher for the INSORB, reflecting wound eversion, a beneficial
characteristic in wound closure.
The VSS at subsequent visits trended towards a comparable result for the
INSORB closure as compared to standard suture closure.
The INSORB stapler is
significantly faster than standard suture closure techniques, allowing for a
more cost effective, safer, and equivalent cosmetic result. Our study offers compelling evidence
towards the beneficial properties of this emerging technology for surgical
wound closure.
Panel: You’ve Cut a Nerve - Now What?
Moderator: Michael W. Neumeister, MD
Donald H. Lalonde, MD
Susan E. Mackinnon, MD
Nicholas B. Vedder, MD
Objective(s): Address the management of nerve injuries that occur during procedures performed by plastic surgeons. The identification, management, and sequelae will be discussed and treatment plans formulated.
Paper: Hydrogen Sulfide Significantly Mitigates Ischemia Reperfusion Injury
Sunil P. Singh, BA, School of Medicine, New York University, New York, NY
Daniel C. Rafii, BA, Pediatric Hematology/Oncology, Weill Cornell Medical College, New York, NY; David C. Lyden, MD, PhD, Pediatric Hematology/Oncology, Weill Cornell Medical College, New York, NY; Jason A. Spector, MD, Division of Plastic Surgery, Weill Cornell Medical College, New York, NY
Hydrogen Sulfide
Significantly Mitigates Ischemia Reperfusion Injury
Sunil P. Singh, BA, Daniel C. Rafii,
BA, David C. Lyden, MD, PhD, Jason A. Spector, MD
Background:
Despite the ubiquity of microvascular free tissue
transfer, a major limitation and source of morbidity in these procedures is
related to reperfusion injury of the transferred tissue. Longer periods of
ischemia may result in significant reperfusion injury ultimately leading to
partial flap loss or flap failure. Hydrogen sulfide, though traditionally
considered a toxic species, has recently been recognized as an important
endogenous signaling molecule with potential as a cytoprotectant.
Our unique approach to improving flap tolerance to ischemia induces a
“suspended animation” like state within the flap tissue by exposure to Hydrogen
Sulfide. This compound is thought to bind to cytochrome
c oxidase and reversibly interrupt the process of
oxidative phosphorylation. Because muscle and
intestine are known to be among the most sensitive flap tissues to
ischemia/reperfusion injury, we chose to establish the validity of our
hypothesis using these tissue types.
Methods: Our study assessed the ability of H2S to
mitigate ischemia reperfusion in 2 different tissue types; intestine and
muscle. Ten 8 week old wildtype (C57/b6) male mice were exposed to either a
mixture of H2S (150ppm) balanced with room air for 30 minutes (6
animals) or room air alone for 30 minutes (6 animals). After H2S or room air (control)
exposure, intestinal blood supply was occluded for 15 minutes, 2 hours or 4
hours and finally all groups were allowed to reperfuse
for 3 hours. Intestinal tissue was then harvested. Paraffin sections were stained with Hematoxylin and Eosin (H&E) and TUNEL assay
antibody. Additionally, twelve 8 week
old wildtype (C57/b6) male mice were exposed to
either a mixture of H2S (150ppm) balanced with room air for 30
minutes (6 animals) or room air alone for 30 minutes (6 animals). Hind limb ischemia was induced by tourniquet
applied above the greater trochanter for a period of
3 hours followed by 3 hours reperfusion.
The contralateral leg served as a
control. Gastrocnemius
and soleus muscles were harvested bilaterally. Frozen sections were stained with H&E and
TUNEL assay antibody.
H&E sections were examined for breakdown of villus architecture (intestine) and breakdown of muscular
architecture (vacuole formation, edema, fiber separation). Quantitative analysis of apoptosis for both
intestine and muscle tissue was performed with a TUNEL Assay as an average of
TUNEL positive nuclei per high powered field across five fields per slide (Fig 1-2).
Statistical significance was determined by ANOVA single factor with Tukey-Kramer post-hoc pair testing. All experiments were performed in triplicate.
Results:
Intestinal tissue treated with H2S demonstrated a
significant reduction in the number of apoptotic cells versus control. This cytoprotective effect was noted after 15 minutes and 2
hours of ischemia (92%, 91% reduction in the number of apoptotic cells versus
untreated controls, respectively). After 4 hours of ischemia, the protective
effect was less evident (38% reduction) (Fig 1). H&E staining of intestinal
sections from H2S treated animals showed a preservation of
intestinal villous architecture versus controls. As in the TUNEL staining, this
difference was most evident after 2 hours of ischemia. Muscle tissue also showed significant
reduction in apoptosis versus controls with a preservation of muscular
architecture and significantly reduced number of apoptotic cells (93%) in
treated ischemic groups versus ischemic controls (Fig 2). There were no significant differences in numbers
of apoptotic cells between non-ischemic muscle treated
with H2S versus control.
Conclusion: This
study demonstrated a significant protective effect through gaseous hydrogen
sulfide exposure to intestinal and muscle tissue against ischemia reperfusion
injury. These data suggest that hydrogen
sulfide exposure mitigates ischemia-reperfusion injury without direct cellular
toxicity in our target range, giving this molecule significant therapeutic
potential as a cytoprotectant in free tissue transfer
and other conditions associated with ischemic conditions.
Figure 1:
Figure 2:
Paper: Immunotolerance Induction for Composite Tissue Transplantation by donor presensitization with Recipient's Bone Marrow
Mikael Hivelin, MD, Plastic Surgery, Cleveland Clinic, Cleveland, OH
Serdar Nasir, MD, Plastic Surgery, Cleveland Clinic, Cleveland; Aleksandra Klimczak, PhD, Plastic Surgery, Cleveland Clinic, Cleveland, OH; Lukasz Krokowicz, MD, Plastic Surgery, Cleveland Clinic, Cleveland, OH; Maria Siemionow, MD, PhD, DSc, Plastic Surgery, Cleveland Clinic, Cleveland, OH
Introduction: New protocols are needed for tolerance induction in composite tissue allograft (CTA). It is well documented that bone marrow transplantation induces donor–specific immune-tolerance through mixed macrochimerism, which is the existence of two genetically disparate cell populations in the same organism.Donor sensitization with the recipient bone marrow before transplantation is a new approach to induce immunotolerance. We demonstrated the effect of donor sensitization on the immune response to vascularized skin allografts.
Methods: Twenty transplantations were performed in 4 experimental groups of 5 animals each. Allograft transplants were performed between Presensitized ACI donors and Lewis recipients. The ACI (RT1a) donor rats were presentisized with Lewis (RT1l) bone marrow (80x 106 cells) injected intraosseously and these donors received αβ-TCR and cyclosporine (CSA) treatment therapy before the cells transplantation. Bone marrow cells were isolated from tibia and femoral bones by flushing technique, cell viability was determined by tryptan blue staining, and the cells where then stained with PKH to allow their late tracing. At either 24 hours or 72 hours after sensitization, the vascularized skin allografts (VSA) were transplanted to Lewis (RT1 I) recipients. In Group I and II no immunosuppressive treatment was given after transplantation, whereas group III and IV received αβ TCR and CSA protocol for 7 days. Assessment included flap viability, flow cytometry for donor specific chimerism, skin biopsies for histological evaluation, hematoxylin eosin staining for the grading of rejection (0 to 3) and immunohistochemistry.
Result: In the control groups (group I, II) VSA were acutely rejected within 2 to 6 days post transplant. The mean survival of VSA was 82 days in Group III and 73 days in group IV, with longest survival of 115 days. Donor specific chimerism in peripheral blood was estimated by presence of T and B cells. Total chimerism levels for Group III at day 7, 21, 35 and 63 were 4.93%, 1.75%, 2.46%, 1.45% respectively and Group IV 3.6%, 2.37%, 1.87%, and 0.48% respectively.
Conclusions: Donor presensitization with bone morrow cells of recipient origin modifies the recipient’s responsiveness and extends survival of vascularized skin allografts under short-term protocol of αβ-TCR and cyclosporine (CSA) therapy. This new approach to induce immunotolerance, could be promising for composite tissue allotransplantations in reconstructive surgery as well as for solid organ transplantations.
Paper: A New Method for Heel Reconstruction: Chimeric Vastus Lateralis Muscle Flap with Thinned Innervated Skin Island
Fabio Busnardo, MD, PhD, University of Sao Paulo - Brazil, São Paulo, Brazil
Marcelo Olivan, MD, University of Sao Paulo - Brazil, São Paulo, Brazil; Jose Carlos Faria, MD, PhD, University of Sao Paulo - Brazil, São Paulo, Brazil; Marcus Castro Ferreira, MD, Plastic Surgery, Sao Paulo University, Sao Paulo, Brazil
Reconstruction of the weight-bearing heel area still represents a difficult problem for the plastic surgeon. A new technique for weight-bearing heel reconstruction with chimeric flap with stable and sensate skin is presented. Six patients with full thickness defects of the heel area were seen: in five, the defects were created by oncological resection of acral melanomas with immediate reconstruction and in one the defect was traumatic and reconstruction was secondary. The chimeric flaps were dissected from the lateral circumflex femoral system and were composed by a muscular cuff of the vastus lateralis muscle and a perforator based innervated skin island. The skin island was thinned through microdissection preserving vascular and neural structures. The muscular cuff was used for contour restoration. The thinned cutaneous tissue was adjusted over the muscle. After the flap was positioned, microvascular anastomoses to the posterior tibial vessels were done and neurorraphy of the sensitive nerve of the flap with the calcaneous branch of the posterior tibial nerve was performed. All flaps healed uneventfully. After one year postoperatively no ulcerations were observed. In five patients there was recovery of protective sensation. The two point discrimination test on the flap area showed a mean value of 12 mm. The proposed technique is a combination of traditional methods used for heel reconstruction. In comparison with other cases operated in our clinic, it seems that this method can offer a potential for a more stable reconstruction of the weight-bearing area with the advantage of also being a sensate flap. Thinning of the flap may have contributed for better stability of the flap, avoiding the shearing forces often seen in conventional miocutaneous flaps.
Panel: Gaspare Tagliacozzi - Was He Wrong?
Moderator: Paul S. Cederna, MD
Charles E. Butler, MD
Joseph J. Disa, MD
William M. Kuzon, Jr, MD, PhD
Michael R. Zenn, MD
Objective(s): Analyze a series of controversial wounds and contrast opinions regarding appropriate reconstructive or microsurgical management.
Panel: Chest Wall Reconstruction - Tumors, Trauma, and Infection
Moderator: Geoffrey L. Robb, MD
Grant W. Carlson, MD
Craig H. Johnson, MD
L. Scott Levin, MD, FACS
David H. Song, MD
Understand that often misunderstood and underdiagnosed sternal non-union and chronic instability are now treatable with new technology using an orthoplastic approach and review the history of rigid sternal fixation with various different techniques and devices, appreciating current emphasis on patient selection. Assess differing management algorithms of acute versus subacute and chronic sternal infections and discuss different approaches available for reconstruction of the chest wall following tumor resections.
Panel: Revising the Unsatisfactory Breast Augmentation
Moderator: Jack Fisher, MD
Laurie A. Casas, MD
Sharon Y. Giese, MD
Roxanne J. Guy, MD
Dennis C. Hammond, MD
Objective(s): Identify patients at risk for developing problems. Select appropriate procedures based on mechanism of failure and identify patients who need minor revisions versus total redo.
Paper: The BREAST-Q: Development of a New Patient-Reported Outcome Measure for Breast Surgery
Andrea L. Pusic, MD, MHS, Plastic and Reconstructive Surgery, Plastic & Reconstructive Surgery, New York, NY
Stefan J. Cano, PhD, Neurological Outcome Measures Unit, Institute of Neurology, University College London, London, United Kingdom; Nancy Y. Van Laeken, MD, Plastic Surgery, University of British Columbia, Vancouver, BC, Canada; Peter A. Lennox, MD, Plastic Surgery, University of British Columbia, Vancouver, BC, Canada; Amy Alderman, MD, MPH, Plastic Surgery, U Michigan, Ann Arbor, MI; Joseph J. Disa, MD, New York, NY; Babak J. Mehrara, MD, New York, NY; Colleen McCarthy, MD, Department of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; Amie M. Scott, BSc, Department of Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY; Stefan J. Cano, PhD, Neurological Oucome Measures Unit, University College London, London, United Kingdom; Anne F. Klassen, DPhil, CanChild, McMaster University, Hamilton, ON, Canada; Peter G. Cordeiro, MD, Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
BACKGROUND: The overriding goal of breast surgery is to satisfy the patient regarding her own assessment of the results of surgery. While many questionnaires have been used in cosmetic and reconstructive breast surgery, few have undergone adequate development and validation. The objective of this study was therefore, to rigorously develop a new questionnaire that could be used to measure satisfaction and quality of life following breast surgery and be easily incorporated into clinical practice. METHODS: This measure was developed with strict adherence to internationally accepted guidelines. In Phase I, the conceptual model and item list were developed from patient interviews (n=48) and focus groups (n=12). The preliminary questionnaire was pilot tested with cognitive debriefing interviews (n=47) and further modified. Field-testing was preformed at 5 centers in the US and Canada (total n=1950, test-retest n=491, response rate 72%). Item response theory (Rasch) analysis was used for item reduction and scale development.RESULTS: A conceptual model for the impact of breast surgery was developed with scales that examine: (1) psychosocial well-being, (2) physical well-being, (3) sexual well-being, (4) satisfaction with breasts, (5) satisfaction with overall outcome and (6) satisfaction with care. The process of item generation led to a separate module for each surgery type: 1) breast augmentation, 2) reconstruction, and 3) reduction. In the item reduction analysis, 48% of field-test items were eliminated. All preoperative items are repeated in the postoperative questionnaires. Cronbach’s alphas for the scales (3 modules with 6 scales) ranged from 0.87 to 0.98. Test-retest reliability, as measured by intraclass correlation coefficients, ranged from 0.85 to 0.98. CONCLUSIONS: This new patient-reported outcome measure, the BREAST-Q ©, will provide essential information about the impact and effectiveness of breast surgery from the patients' perspective. It has a procedure-specific, modular structure and addresses multiple aspects of the patient's experience. It will support multi-center prospective studies and facilitate an evidence-based approach to the management of breast surgery patients.
Paper: An Analysis of Reconstructive Frequency and Post-Reconstructive Survival Using the Surveillance, Epidemiology, and End Results (SEER) Program
Shailesh Agarwal, BS, Pritzker School of Medicine, University of Chicago, Chicago, IL
Sean Pitroda, BS, University of Chicago; Jayant Agarwal, MD, University of Utah
INTRODUCTION: The option to undergo breast reconstruction following mastectomy significantly impacts patients’ breast cancer treatment choices. Previous studies using the Surveillance, Epidemiology, and End Results (SEER) program suggest that sociodemographic factors including patient age, race, and geographic location influence the utilization of postmastectomy breast reconstruction in the United States. Notably, Alderman et al (2003) have shown that African American, Hispanic, and Asian women are significantly less likely to undergo reconstruction when compared with Caucasian women. Although studies have shown a post-mastectomy local recurrence rate ranging from five to thirty percent, few studies have investigated survival rates following breast reconstruction. In this study, we use the SEER database to investigate post-reconstructive survival rates between 1998 and 2002 based on race.METHODS: Data from the Surveillance, Epidemiology, and End Results (SEER) Program was used for this study. The designated study period was from 1998 to 2002 using the SEER 17 November 2006 database. Patient selection criteria were all females diagnosed with intraductal carcinoma (ICD-O-3 8500), lobular carcinoma (ICD-O-3 8520), infiltrating ductal carcinoma (ICD-O-3 8521), intraductal and lobular carcinoma (ICD-O-3 8522), Paget disease (ICD-O-3 8540), Paget disease and infiltrating duct carcinoma (ICD-O-3 8541), or Paget disease and intraductal carcinoma (ICD-O-3 8543) and treated with mastectomy (primary site surgery codes 30-80). The primary outcome measures were the frequency of reconstruction in African American and Caucasian patients. Secondary outcomes of interest were the post-reconstructive survival rates determined by Kaplan-Meier method with cause of death attributed to all causes, non-neoplastic causes, any malignant cancer, or breast cancer in Caucasian and African American women. RESULTS: A total of 75,895 mastectomy cases were found, of which 68,475 had a known reconstructive status. A total of 11,068 patients were reconstructed (16.2%). Of the 57,267 mastectomy cases in Caucasian women with known reconstructive outcome, 9,711 were reconstructed (17.0%). Of the 5,243 mastectomy cases in African American women with known reconstructive outcome, 813 were reconstructed (15.5%). The observed post-reconstructive 5-year survival in all patients was 89.9%; the observed 5-year post-reconstructive survival rate in African American patients and Caucasian patients were 81.5% and 90.6% respectively. When censoring out all malignancy-related deaths, the 5-year post-reconstructive cause-specific survival rate was 99.0% overall, and African American and Caucasian 5-year post-reconstructive survival rates were 99.3% and 99.0% respectively. However, when censoring out all non-malignancy-related deaths, 5-year post-reconstructive cause-specific survival was 91.3% overall; survival rates in African Americans and Caucasians were 82.6% and 92.0% respectively. Lastly when defining death only from breast cancer, the 5-year post-reconstructive cause-specific survival was 91.9% overall; survival rates in African Americans and Caucasians were 83.9% and 93.1% respectively.DISCUSSION: In this study we show that the percentages of post-mastectomy African American and Caucasian women undergoing reconstruction are similar. We also report that Caucasian women have a higher post-reconstructive survival rate than African American women when counting deaths from all cause, any malignant tumor, or breast cancer only. However, African American and Caucasian women have a similar post-reconstructive survival rate when counting deaths only from non-neoplastic causes. Logistic regression analysis will be performed to determine whether these differences are significant. This study is limited to the four-year time-frame from 1998-2002 and does not account for differences in tumor stage upon presentation between Caucasian and African American women. Additionally, this study is specific to the institutions included in the SEER database and relies on cause of death coding from the SEER database. Substantial future research into post-reconstructive survival rates is warranted.
Paper: Pocket Conversion Made Easy: A Simple Technique Using Alloderm® to Convert Subglandular Breast Implants to the Dual Plane Position
Mehrdad Mark Mofid, MD, Department of Surgery, Division of Plastic Surgery, University of California San Diego, San Diego, CA
Navin K. Singh, MD, Baltimore, MD
BackgroundThe advantages of dual plane, partially submuscular breast implants are well documented. These advantages include decreased rates of capsular contracture, improved upper pole fullness, decreased palpability and visibility of implants and improved breast aesthetics in cases where the soft tissue envelope is inadequate to support subglandular implants. Standard conversion techniques to dual-plane positioning utilize marionette sutures and internal capsulorrhaphy sutures from the lower edge of the pectoralis major muscle to the anterior capsule or breast fascia within the subglandular plane. These techniques are limited by high rates of post-operative implant malposition and technical limitations that make combined mastopexy procedures difficult to perform. We describe a simple technique familiar to most plastic surgeons accustomed to placing tissue expanders for use in breast reconstruction using Alloderm® as a sling beneath the pectoralis major muscle to the chest wall.MethodsWe retrospectively studied 25 women who underwent breast augmentation revision from subglandular to the dual plane position by performing a 9-year retrospective review from 1999-2007 of two surgeons’ experience. We identified 10 women for whom Alloderm®, sutured from the lower edge of the pectoralis major muscle to the chest wall was used to create a composite pectoralis-Alloderm® pocket for partial-submuscular transfer of implants, and identified 15 matched case-controls who underwent pocket conversion using standard capsulorrhaphy and marionette suture techniques. Dependent variables analyzed included post-op capsular contracture, pain, infection, and requirement of revision. Statistical analyses were performed using STATA Software (College Station, TX). Data analyzed included patient age, size and type of implants, duration from previous surgery, palpability, capsular contracture, seroma, implant pocket-displacement, pain, IMF discrepancy, need for mastopexy, OR time, and duration of follow up. Fisher’s Exact Test was used for comparisons of contingency tables. T-test was used to compare mean OR times. ResultsThe average patient age was 42 (29-56) years, the average implant size was 323 cc (range 200 cc - 500 cc) and 74% of pocket-change patients also sought a size-change. For the size change, 61% sought an increase and 39% sought a decrease in size. Indications for seeking revision were palpability (48%), capsular contracture (70%), and rupture (26%), which were not related to silicone or saline implants (Fisher’s Exact test, p=0.4). The principal outcome variable of at least one complication was 73.3% without Alloderm® resulting in a 40% need for revision surgery vs. 0% with Alloderm® (Fisher’s Exact test, p<0.05). There were no seromas and only 1 superficial infection in the non-Alloderm® group.Conclusions The standard techniques available for conversion of subglandular breast implants to the dual-position plane using capsulorrhaphy and marionette sutures are limited by a high complication rate for the reliable positioning of implants into a stable dual-plane pocket during implant exchange. A commonly utilized technique in reconstructive breast surgery using Alloderm® is described to reliably convert subglandular implants to the dual plane position.
Paper: Correction Of Synmastia Using The Neo-subpectoral Pocket: Technical Refinements For Difficult Cases
Joseph Dayan, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC
Scott L. Spear, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC; David P. Bogue, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC; Mark Clemens, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC; Steven A. Teitelbaum, MD, Santa Monica, CA; G. Patrick Maxwell, MD, Nashville, TN
Introduction:
Synmastia correction
following subpectoral breast augmentation can be a difficult problem. Numerous
techniques have been reported with varied results including capsulorrhaphy,
delayed revision, and adjustable implants. Each of these options has drawbacks
in terms of reliability, technical difficulty, and convenience for the patient.
Instead
of repairing an already deformed pocket, an ideal solution would be to create a
new pocket in a different site. The neo-subpectoral technique is described
whereby a new pocket is dissected between the pectoralis major muscle and the
anterior surface of the implant capsule. Thus, the benefits of a subpectoral
position are maintained while a precise pocket dissection may be performed in a
new site. The purpose of this study is to evaluate the effectiveness of this
technique along with the use of adjuncts such as acellular dermis.
Method:
The creation of a
neo-subpectoral pocket involves a precise pocket dissection just deep to the
pectoralis muscle but superficial to the anterior surface of the capsule. For
patients who had multiple prior treatment failures, a sheet of acellular dermis
was used to bolster the repair. The technical details of this procedure are
described. All patients with synmastia were evaluated since this technique was
first used at Georgetown University Hospital in November 2005.
Results:
Ten patients
underwent synmastia correction using the neo-subpectoral technique. Three of
these patients presented to us with recurrent synmastia after previously failed
attempts at correction using capsulorrhaphy. Acellular dermis was used as an
adjunct in three patients. There was no recurrence of synmastia to date in
this study. Follow-up ranged from 1.5 to 27 months with a mean follow-up of
11.5 months. There was one hematoma that required evacuation.
Conclusion:
The neo-subpectoral
technique is an effective method for the correction of synmastia and many types
of implant malposition in a single stage. Acelluar dermis may also be used
successfully as an adjunct to the neo-subpectoral technique in difficult
revisions. This procedure is technically straightforward with stable results
on long-term follow-up.
Paper: Changes in Breast Shape after Cosmetic Surgery – A Photometric Study of 147 Patients
Eric Swanson, MD, Swanson Center, Leawood, KS
PURPOSE: Evaluation of changes in breast shape after
surgery, specifically upper pole fullness, breast projection, and “bottoming
out,” has been made difficult by the fact that there is no definition of these
entities and no standardized system for measurements and comparison. The
author proposes a means of evaluating breast shape before and after surgery,
and compares 5 cosmetic breast procedures – augmentation, mastopexy,
augmentation/mastopexy, reduction, and reduction + implants. The
inverted-T technique is compared to the vertical technique. The clinical
data and outcome analysis are reported separately.
METHODS: The prospective study group includes 112
female patients undergoing primary mastopexy (< 300 g per side),
augmentation/mastopexy, or breast reduction (> 300 g per side) during a
5-year period, 2002-2007 and primary breast augmentation during a six-month
period, October, 2006, to March, 2007. Patients who were unavailable for
follow-up photographs at least 3 months after surgery or who underwent another
breast operation were excluded. The retrospective study group includes 35
patients treated with primary mastopexy, mastopexy/augmentation, or breast
reduction during 1996-2002, with the same inclusion criteria. All
procedures in prospective group were performed using the vertical technique
with a medially-based pedicle. All patients in the retrospective group
were treated using the inverted-T, inferior pedicle technique.
The Canfield Mirror (Canfield Scientific Inc., Fairfield, N .J.) 7.17 software is used to match the size and orientation of the
photographs. A horizontal plane is drawn at the level of maximum
postoperative breast projection (MPBP) (fig. 1). A vertical line is
dropped at the level of the sternal notch. The distance from the vertical
meridian to the leading edge of the breast along the plane of MPBP is called
the “breast projection” (BP). The distance between this plane and the
level of the sternal notch is bisected and another horizontal reference line is
created. The distance to the leading edge of the upper breast mound along
this line is called “upper pole projection” (UPP). Other measured
parameters include the lower pole level (LPL), nipple level, upper pole area
(UPA), lower pole area (LPA), breast parencymal ratio (UPA/LPA), and breast
mound elevation (BME). On frontal images, the distance from the lowest
point on the breast to the MPBP plane is halved and the breast width at this
level is called the “lower pole width”(LPW). The ratio of the lower pole width
to the lower pole length is the “lower pole ratio,” (LPR), a measure of the
boxiness of the lower pole. Areolar diameters are measured.
Patient photographs depict patients with the most average
(lowest z scores) measurements. (figs. 1-4). Illustrations were created using a
software program that allows breast shapes to be drawn according to the actual
means for each of these 6 breast measurements. (figs. 5-8)
RESULTS: Breast augmentation, augmentation/mastopexy
(vertical and inverted-T), and vertical mastopexy (but not inverted-T) provided
increased breast projection (fig. 9) and upper pole projection (p <
0.01) (fig. 10). Vertical reductions increased upper pole
projection (p < 0.01), but inverted-T reductions did not.
Neither reduction technique significantly increased breast projection.
The lower pole ratio (LPR) was significantly lower (more hemispheric, less
boxy) for vertical procedures than for inverted-T procedures (p <
0.01).
CONCLUSIONS:This measurement system can be used to
standardize measurements and compare results. The vertical technique
outperforms the inverted-T technique in key parameters of breast shape – upper
pole projection, breast projection, and lower pole ratio.
Fig.
1. 33 year-old. Inverted-T mastopexy. 4.7 mos.
Fig.
2. 36 year-old. Vertical mastopexy. 4.0 mos.
Fig.
3: 37 year-old. Inverted-T, inferior pedicle breast reduction. 22 mos.
Fig. 4:
28 year-old. Vertical breast reduction. 6 mos.
Fig. 5.
Inverted-T mastopexy. Lower pole is elliptical.
Fig. 6.
Vertical mastopexy. Lower pole is semicircular.
Fig. 7.
Inverted-T breast reduction. Lower pole is elliptical.
Fig. 8.
Vertical breast reduction. Lower pole is semicircular.
Fig. 9.
Breast projection.
Fig. 10.
Upper pole projection.
Panel: Fresh Faces, Real Cases
Moderator: Adam D. Lowenstein, MD FACS
Carolyn De La Cruz, MD
Gary A. Tuma, MD
Dennis C. Hammond, MD
Foad Nahai, MD
Loren S. Schechter, MD, FACS
Kent V. Hasen, MD
Michael S. Wong, MD
Raymond M. Dunn, MD
Gregory R. D. Evans, MD
Felmont F. Eaves, III, MD
Objective(s):Review selected common complications presented by young plastic surgeons with interactive discussion of prevention, management, and outcomes with Senior Discussants and audience. Patient Safety, medicolegal, and ethical issues will be discussed.
Panel: Beauty for Life
Moderator: Richard A. D'Amico, MD
Mark L. Jewell, MD
Julius Few, MD
Roxanne J. Guy, MD
Alan H. Gold, MD
Renato Saltz, MD
Objective(s):Discuss present day issues for cosmetic medicine and the Plastic Surgeon.
Panel: Should We Inject Fat into the Breast?
Moderator: Foad Nahai, MD
Louis P. Bucky, MD, FACS
Sydney R. Coleman, MD
William P. Adams, MD
Nora Hansen, MD
Objective(s):Discuss and analyze the medical and legal risks and benefits of fat injections into the breast. Patient safety will be emphasized, including appropriate patient selection and the prevention and management of complications.
Panel: ASPS/ASPSN Patient Safety Panel: Deep Vein Thrombosis and Pulmonary Embolism - The Latest Thinking on an Enduring Problem
Moderator: V. Leroy Young, MD
Morey A. Blinder, MD
Rod J. Rohrich, MD
Marilyn Cassetta, BScN, RN
Objective(s): Report up-to-date information on how to screen patients for DVT/PE risk and the prevention of DVT/PE.
Paper: Facial transplantation for plexiform neurofibroma
laurent A. Lantieri, MD, Plastic surgery department, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France
jean-Paul Meningaud, MD, PhD, Plastic Surgery, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France; Philippe Grimbert, MD, PhD, Department of nephrology, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France; Frank Bellivier, MD, PhD, Psychiatry, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France; jean Pascal Le faucheur, MD, PhD, Physiology, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France; Nicolas Ortonne, MD, PhD, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France; Philippe Lang, MD, PhD, Nephrology, Hopital Henri Mondor (APHP) Paris XII University, Créteil, France; Pierre Wolkenstein, MD, PhD, Dermatology, Hopital Henri Mondor (APHP) Paris XII University, Creteil, France
The authors
present the results of a facial Composite Tissue Allotransplantation with 12
months follow up on a a 29 yo patient with plexiform neurofibroma. The patient
was operated by several plastic surgeons with no success (over 35 operations).
We decided to go to this process after several anatomical and technical
studies. These studies completed with ethical and immunological reviews by
several expert committees resulted in an IRB approval in October 2005. Several
expert committees directed by the French national agencies made the necessity
of several modifications. The patient was on waiting list since August 2006. He
was carefully reviewed by psychologist and psychiatrist and give inform
consent.
The surgery
took place on Sunday 21 January 2007. The excision of all neurofibroma resulted
in extreme blood loss. The excision included all soft tissue under
zygomatic arch on both side down to the neck and laterally to the ears. Facial
nerve was dissected at its origin in the stylo mastoid foramen. The lower
branches of the facial nerve were sacrificed as going into the tumour. The
harvest of the face was done by another team in another hospital of the great Paris area on a brain dead donor. The face was harvested on beating heart before the
other organs. End to end anastomosis was performed on external carotid and
thyrolingofacial trunk on one side which allowed complete revascularisation of
the entire flap. We then performed nerve anastomosis beginning on left facial
nerve end to side on facial trunk followed by both sub orbitaries nerves along
with mucosa closure and finishing with end to end anastomosis on facial nerve
on right side. At last vascular anastomosis was done on both vein and arteries
on right side..
For the
donor: the French law is based on “supposed consent”. In this case we ask
specific consent of the family for harvesting the face. The restoration of the
body was done by doing first a mold of the face with alginate. A solid mask was
done during the harvest and could be put on the defect so that the other team
could harvest other organ after total repair of the face.
For the
immunosuppression we used a protocol with anti lymphocyte serum for 10
days started at the time of anastomosis, Tacrolimus MMF and Steroids as in other
CTA or kidney transplants. The biopsies at day 28 showed a moderate
infiltration of lymphocyte grade 1 which necessitated corticosteroid therapy.
The concomitant moderate inflammation then quickly resolved. The biopsies at
day 42 did not show any more lymphocyte infiltration at the level of mucous
membranes. At day 60 the patient sustained antiviral-resistant cytomegalovirus
(CMV) , leading to ganciclovir but not to cidofovir resistance and we
identified a new DNA polymerase mutation, this was associated with acuted rejection
which was resolutive after CMV infection treatment. Biopsies since that episode do not show
any sign of rejection.
Active movement started to
appear at 6 months and the patient required locale anesthesia at four month
From a
psychological point of view the patient saw his new face 10 days after the
intervention and seems to perfectly accept the new aspect. His general state is
excellent. He is able to carry alone not only the routine activites of dayly
living (gestures, dress, toilet & food) but can go to departement store and
has started a new job. He and comes every month for routine examination and
still follow active therapy for improvement of facial movement.
Conclusion
Face transplant has move from
ethical debate to surgical reality. However, as in other organ transplant this
procedure carries high risks and needs longtime follow-up to evaluate the risks
and benefits of such procedure even if our first data shows that, beside the
feasibility, functional and psychological results go behind our initial
expectation.
Paper: Outcome Analysis and Quantification of Structural Compensatory Changes in the Contralateral Mandible (CM) after Unilateral Mandibular Distraction Osteogenesis (UMDO)
Alero Fregene, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Mehreen Kakwan, BS, Plastic Surgery, University of Michigan, Ann Arbor, MI; Daniel A. Schwarz, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI; Krikor Arman, BA, Plastic Surgery, University of Michigan, Ann Arbor, MI; Ameen Jamali, BS, Plastic Surgery, University of Michigan, Ann Arbor, MI; Steven R. Buchman, MD, Plastic Surgery, F7859 Mott Children's Hospital, Ann Arbor, MI
Purpose:
The full physiologic impact of UMDO on the CM remains uncertain. The aim of this study was to determine the degree of structural change in the CM after UMDO utilizing metrics of bone mineralization. Our hypothesis was that the biomechanical stimulus of UMDO would cause a compensatory increase bone volume and bone mineral density in the CM. Our goal is to better understand the risks and benefits of UMDO to the CM.
Methods:
Unilateral osteotomies were created behind the third molar after external fixators were placed on male Sprague Dawley rat mandibles. The UMDO group (n=26) was distracted to 5.1mm after 4days latency at 0.3mm Q12hrs. The 2mm fracture group (n=12) was distracted to create a 2mm defect eight hours after surgery. The reduced fracture group (n=10) was left undisturbed. (The two fracture groups were included as controls.) Animals were euthanized after 28days consolidation. Unoperated controls (UC, n = 18) and the CM of all surgical groups underwent ex-vivo Micro-CT scanning. Three independent reviewers measured Bone Mineral Density (BMD), Bone Volume Fraction (BVF) and Volumetric Bone Mineral Density (vBMD = BMD/BVF), utilizing Microview version 2.2. and validated region of interest templates. Statistical analyses were considered significant if p≤0.05.
Results:
We found significantly higher BMD and BVF in the CM of all groups when compared to UC's. However, we also found significantly lower vBMD in the CM of all groups when compared to UC's. There were no statistically significant differences of this effect when the CM's of the surgical groups were compared to each other.
Conclusions:
Quantitative outcome analysis of CM’s demonstrated a statistically significant increase in BMD and BVF in the CM's when compared to the UC group indicating an overall increase in the amount of mineralized bone. However, further analysis utilizing vBMD, an algorithm calculated in our lab to determine bony structural properties, demonstrated findings consistent with an overall lower quality of the involved bone. These changes are uniform across all surgical groups, indicating that the osteotomy, rather than the distraction , may be the agent triggering the observed structural changes. These exciting findings have prompted further research focused on determining if the observed changes in bone mineral density are due to loco-regional alterations in dynamic loading or to humeral responses to injury And to determine the clinical implications for the care of the CM after surgery or trauma.
Paper: Secondary Reconstruction of Bone Defects of the Head and Neck with the Angular Scapular Free Flap
Jose R. Castello, MD, PhD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Lawrence Garro, MD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Introduction: Secondary reconstruction of bone defects in the head and
neck area poses a great challenge for the plastic surgeon, and is usually more
difficult than primary reconstruction. Maxillary and mandibular defects are
frequently associated with soft tissue and intraoral defects, requiring
composite three dimensional reconstructions. Scar contracture due to previous
surgery and irradiation must also be addressed. Selection of recipient vessels
may also be limited for the same reasons.
The ideal reconstruction for this type of defects must include a flap with a
very long pedicle containing well vascularized bone and soft tissue which can be
placed in divergent positions, allowing rigid fixation and osseointegration, and
which can be performed in a single stage procedure. The angular scapular bone
flap, based on the angular branch of the thoracodorsal artery, fulfills these
premises, allowing composite reconstructions of defects of the maxilla, palate
and mandible with a single long vascular pedicle (12-14 cm.).
Flaps based on the subscapular artery are not very popular in primary head and
neck reconstruction where a 2-team approach is recommended. However, secondary
reconstructions do not demand extensive resections but a more versatile and
conscientious flap design, for which a one-team approach may be more practical.
Methods: Fifteen patients with bone defects secondary to previous
surgery of the head and neck area, in whom primary reconstruction was not
performed or had failed, underwent reconstruction with the angular scapular free
flap. This series included one total reconstruction of the palate, 3 pre-maxillary
defects, one alveolar bone defect, 2 patients with defects of the floor of the
orbit, and 3 segmental mandibular defects. Twelve of them required two or more
different tissues and where reconstructed using a composite flap based on the
thoracodorsal pedicle. Results: All flaps were successfully transferred and rigidly fixated.
There were no flap failures and no complications at the donor site or the
scapula. There was no need to use vascular grafts or secondary flaps. Bone
consolidation was obtained in all the cases and 6 patients were successfully
osseointegrated with dental implants.Conclusions: The angular branch of the thoracodorsal artery allows
harvesting of the tip of the scapula and up to 10 cm. of the lateral border of
the scapula. There is no need to include the circumflex scapular artery to
obtain a well vascularized bone segment. Although anatomic variations have been
reported, in all of our cases the angular branch arose just proximal or distal
to the bifurcation of the thoracodorsal branch into the serratus anterior and
latissimus dorsi branches (fig. 1). Skin, subcutaneous tissue, muscle or fascia,
based on branches of the thoracodorsal, serratus anterior or teres major
branches may be associated when needed.
The triangular shape of the tip of the scapula is especially well suited for
reconstruction of small pre-maxillary, palate and alveolar bone defects, where
bulkiness must be avoided (fig. 2). This flap allows placing the skin island and
the bone in divergent positions, facilitating rigid fixation. Segmental defects
of the mandible, especially those comprising the angle of the mandible, are also
well suited for this flap. The external margin of the scapular bone has a
sufficient cross section to allow osseointegration.
When compared with the circumflex scapular flap, the donor scar of this flap is
located inferiorly and female patients can easily conceal it in the bra strap
(fig. 3). The pedicle is longer than the circumflex scapular pedicle.
Fig. 1: Angular scapular free flap combined with muscle and skin from the
latissimus dorsi (upper left and right), with skin based on a perforator from
the latissimus dorsi artery (lower left) or alone (lower right). S= segment of
scapular bone, AB= angular branch of the thoracodorsal artery, LDB= latissimus
dorsi branch of the thoracodorsal artery, =
thoracodorsal artery.
Fig. 2: A. Pre-maxilla reconstruction. B. Total palate reconstruction.
Fig. 3. Donor scar.
Paper: A Reliable Frozen Section Technique for Basal Cell Carcinoma of the Head and Neck
Wisam Menesi, MD, Plastic Surgery, University of Manitoba, Winnipeg, MB, Canada
Thomas Hayakawa, MD, Plastic Surgery, University of Manitoba, Winnipeg, MB, Canada; Edward W. Buchel, MD, Plastic Surgery, Health Science Center, Winnipeg, MB, Canada
PURPOSE: Mohs surgery is considered the gold standard for achieving maximal tissue preservation during the excision of basal cell carcinoma in the head and neck. We evaluate the effectiveness of a surgeon directed frozen section technique that appears to offer an alternative to Mohs surgery.
MTHODS: The technique is as follows; a 1mm margin is marked beyond the visible and palpable limits of the tumor, and additional 1 mm margin is marked beyond this; the resulting margin is divided up into labeled units that will fit on a standard frozen section mounting block. With the pathologist present, the surgeon mounts each labeled unit with its surgical margin facing the cutting surface of the block. We reviewed 57 consecutive BCC’s excised over a 5 year period (2002-2006) using this technique.
RESULTS: Fifty seven BCC’s were treated. Two were recurrent tumors following radiation. Mean follow-up was 3 years. Tumors ranged in size from 0.5 x 0.4 cm to 4 x 4 cm. mean operating time was 01:47 hr including the reconstruction. Histological subtypes were recorded in 21 tumors; (3) Superficial, (9) Nodular, (7) Morpheaform, (1) Sebaceous variant, (1) Sclerosing. There was a single recurrence (1.7%) identified at 13 months which was treated with minor re-excision.
CONCLUSION: Frozen section control in BCC has been notoriously frustrating and likely inaccurate due to the traditional methods of evaluating margins. Typically one or two transverse sections through the specimen are examined thus excluding the majority of the margins from evaluation. With this technique the entire circumferential margin is evaluated. It may offer a reasonable, simpler, and quicker alternative to Mohs.
Paper: Lasting Outcome of the Surgical Treatment of Migraine Headaches – a Four Year Follow-up
Thomas Muehlberger, MD, FRCS, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany
Wolfgang Brittner, MD; Alexandra Buschmann, MD, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany; Nidal Toman, MD, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin
Background Migraine is an abnormal response to normal sensory input. Altered processing of afferent signals in the brainstem accounts for many of the temporal features of migraine. Peripheral and central sensitization of the meningeal perivascular-trigeminal nociceptors and the trigeminal nucleus caudalis, respectively, induce the neuronal hyper-excitability and concomitant neurogenic inflammation. The ophthalmic division of the trigeminal nerve represents the principal sensory pathway to the trigeminal nucleus. The surgical decompression of pertinent extracranial sensory nerves through transpalpebral resection of the corrugator muscles is thought to inhibit the instigating step of a domino-effect leading to migraine headaches.
Material and methods Botulinum toxin injections into the corrugators (25 IU each) were performed in 167 patients 8 weeks preceeding the operation as a prognostic indicator. 96 patients ( sex ratio 81 female/ 15 male, age range 21-67) with a pre-established baseline of migraine attack frequency and intensity had the corrugator muscles resected preserving the supratrochlear and supraorbital nerves. According to the severity of migraine symptoms, the patients were graded in group I-IV. The postoperative follow-up period was 4 years (range 48 – 56 months). Alterations in attack frequency, pain intensity and dosage of medication were considered relevant parameters. The Migraine Specific Questionnaire (MSQ) and SF-36 were used preoperatively and twice postoperatively after one and four years.
Results 106 of 167 patients who had botulinum toxin injected, responded with a symptomatic improvement of more than 50%. Corrugator resection was performed in 98 of these 106 patients, additional decompression of the major occipital nerve was performed as a second procedure in 12 patients. The 4 year follow-up period was recorded in 96 patients. Complete, continuing remission was reported by 21 % (n=20). 71% (n=68) reported a significant improvement of migraine intensity and frequency. This group included patients (n=49) whose migraine had been replaced by less severe non-migrainous headache without neurological or gastroenterological symptoms. 8 patients (8%) experienced unsatisfactory results. The questionnaire findings improved significantly following the operation (p<0.018 MSQ, p<0.023 SF-36) and showed no significant alterations between one and four years. Regression linkage analysis found the presence of allodynia (p<0.038) to be a significant prognostic indicator of the success rate. The long-term symptomatic improvement after surgical decompression was identical with the grade of symptomatic alterations previously induced by chemodenervation. In contrast to previous reports, age and severity of migraine symptoms were no significant prognostic indicators in this study.
Conclusion 92 % of patients in this study had lasting, unchanged, postoperative results with marked symptomatic improvement. Allodynia, the clinical correlate of central brainstem sensitization, was a significant prognostic parameter, indicating the pivotal role of the trigeminal system in migraine. Interestingly, four years following the operation, most patients reported not the cessation of pain, but rather the disappearance of the previously frightening awareness of a pending migraine attack as their most important benefit. The surgical treatment of migraine headaches yielded positive results in 88 out of the initial group of 167 patients (53%) who received botulinum toxin, which highlights the crucial importance of the selection process to identify the eligible patients for this therapeutic option.
Paper: Outcome Analysis of Our First 75 Spring Assisted Surgeries for Scaphocephaly
Christina Plikaitis, MD, Plastic Surgery, Wake Forest University, Winston Salem, NC
Claire Sanger, DO, Plastic Surgery, Wake Forest University, Winston-Salem, NC; Steven Glazier, MD, Neurosurgery, Wake Forest University, Winston-Salem, NC; Louis C. Argenta, MD, Plastic Surgery, Wake Forest University, Winston Salem, NC; Lisa R. David, MD, Plastic Surgery, Wake Forest University School of Medicine, Winston Salem, NC
Background: Since the beginning of the modern craniofacial era, the treatment of craniofacial deformities has come full circle. Initial minimally invasive surgeries such as the strip craniectomy had poor long-term results, and more aggressive operations with higher morbidity were developed that achieved superior durability. Recent trends in craniofacial surgery focus on developing less invasive techniques that achieve lasting results. Spring assisted surgery, first introduced by Claes Lauritzen in 1998, has demonstrated promising outcomes for the treatment of craniosynostosis. The purpose of this study was to assess the clinical outcome of this treatment modality in our first 75 cases, in comparison to both historical controls and patients treated during the same time interval, with standard cranial expansion techniques. Additionally, cost analysis of the two treatment protocols was performed. Materials and Methods: Children, between the age of three and six months, diagnosed and undergoing treatment for scaphocephaly were considered for this IRB approved study requiring parental consent for enrollment. Seventy-five children, 20 females and 55 males, have completed this study protocol to date. All study patients underwent cranial surgery with removal of a 1.5 cm strip of midline calvarium including the sagittal suture followed by the insertion of two 1.2 mm thick stainless steel omega shaped expanders (springs). Each spring exerted a mean force of 8 Newtons at initial placement. All patients had preoperative and postoperative skull films to measure cranial expansion and cephalic index. Spring removal was performed once complete reossification of the calvarial defect had occurred based upon clinical exam. Clinical outcome assessment included analysis of changes in cephalometric measurements and 3 dimensional laser shape and were compared to control patients treated for scaphocephaly using cranial expansion techniques during the same time interval as well as historic controls. Additionally, perioperative variables including OR time, OR blood loss, transfusion requirements, ICU stay, hospital stay, and hospital costs were compared between the two groups. Results: All of the study patients successfully underwent spring assisted surgery without significant complications. All children are reassessed on an annual basis with a mean follow up time of 46 months. Four children underwent a secondary surgery for skin infection (1), spring malposition (1), and scars (2). No secondary surgeries for relapse were required. The mean age at the initial operation for the spring cranioplasty group was 5.7 months and 9.8 months for the cranial expansion group. Perioperative variables were significantly different between treatment groups. No transfusions were required for any spring cases. The mean operative time was 30 minutes for spring placement. The mean hospital stay for the initial procedure was 22 hours. The second outpatient operative procedure to remove the springs was done at a mean age of 8.5 months, without any perioperative sequela. The mean operative time for the second procedure was 19 minutes with a mean hospital stay of 13 hours. Comparison of the cranial expansion technique with the two spring procedures combined still demonstrated a significant difference in blood loss, transfusion requirements and OR time.
Serial follow-up skull films showed a mean maximal spring expansion of 7.1 cm. The mean cephalic index preoperatively was 64.3 and postoperatively was 75.1, which compares favorably to published normal age matched historical controls treated with cranial expansion techniques. Additionally there was no significant difference between the postoperative cephalic index in patients treated with cranial expansion versus spring assisted surgery. Conclusion: This data supports that spring assisted surgery is a safe and effective, minimally invasive treatment for scaphocephaly. It combines the low morbidity and operative time of a strip craniectomy with cranial expansion techniques using an implanted spring to gradually distract the skull, acheiving an improved head shape. Our results indicate the potential for significant reduction in blood loss, operative time, ICU admission, hospital stay, and treatment costs compared to traditional cranial expansion. Our 7 years of experience with more than 75 children has shown spring assisted surgery is able to effectively correct cranial shape abnormalities including frontal bossing, and maintain cephalic index. Long term 3D scanning analysis demonstrates these outcomes are maintained over time.
Paper: Repair of Medial Orbital Wall Fracture Using a Retrocaruncular Approach: A Clinical and Anatomic Study
David Cho, MD, Department of Plastic Surgery, Loma Linda University, Redlands, CA
Steven Kempton, BS, Department of Plastic Surgery, Loma Linda University, Loma Linda, CA; Mark Martin, MD, DMD, Department of Plastic Surgery, Loma Linda University, Redlands, CA
Introduction: Fractures to the medial orbital wall can result in significant patient morbidity. Surgical approaches in the past have focused on transcutaneous approaches with a current trend towards the development of transconjunctival incisions and the use of endoscopic-assisted methods. Different authors have suggested different variations of the medial transconjunctival approach, however an in depth anatomic comparison has not been presented.
Objective: 1) To compare the anatomic basis for three different medial transconjunctival approaches to the medial orbit. 2) To review the clinical outcomes of medial orbital wall fracture repair with a retrocaruncular approach.
Methods: An anatomic and clinical study was conducted. 1) In 30 fresh cadaver orbits, the classic transcaruncular approach was compared with the precaruncular and a retrocaruncular approach under magnified dissection. 2) A retrospective analysis was conducted on a series of 15 consecutive patients that underwent primary repair of medial orbital wall fractures using a retrocaruncular approach over the past 2 years. A retrocaruncular medial transconjunctival incision was used in all patients without endoscopic assistance. Titanium implants were shaped by hand based on the angular measurements between the medial wall and floor of the orbit on the CT scan of the uninjured side. Post operative CT scans were obtained for all patients. Angular relationships between the medial wall and floor of the orbit were determined on hemi-coronal CT scans in a blinded fashion. Within-patient comparisons were performed by three experienced clinicians based on axial and coronal views and ratings assigned based on a Likert scale.
Results: 1) Anatomic dissections showed the all three approaches provided excellent exposure of the entire medial orbital wall. The classic transcaruncular and also the precaruncular approaches demonstrated two negative attributes: a) both resulted in exposure of the upper and lower tarsi when incisions greater than 1mm were used, b) both required a transition from the preseptal plane to the postseptal plane when combined with inferior fornix incisions. None of the approaches resulted in damage to the medial rectus, inferior oblique muscles or the lacrimal system. 2) A clinical study of 15 patients showed all reconstructions were possible without endoscopic assistance. On follow-up there were no functional or cosmetic sequelae relating to the conjunctival incision. Post-operative C.T. scans showed anatomic orbital reconstruction in all patients. Angular relationships between the medial and inferior walls of the reconstructed orbits were within five degrees of the uninjured orbit in all cases. All reconstructions were judged as excellent by the clinicians.
Conclusion: A variety of approaches to medial orbital wall fractures have been described in recent years. Medial orbital wall fractures can be successfully repaired using transconjunctival incisions with minimal morbidity and without using endoscopes or indirect trans-sinus approaches. The retrocaruncular approach surpasses the transcaruncular and precaruncular methods due to its conservation of intricate medial canthal anatomy, its decreased risk of postoperative lid complications, and its ability to be directly carried to the inferior conjunctival fornix when repairing the orbital floor in combined fractures. This study provides an anatomic basis and clinical support for the use of the new retrocaruncular incision as the preferred approach to the fractured medial orbit.
Paper: Co-Culture with Craniosynostotic Dural Cells Facilitates BMP4-Mediated Osteogenic Induction of Murine Myoblast Cells
Gary E. DeCesare, MD, Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA
Emily Lensie, BS, Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA; Darren Smith, MD, Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA; Mark Mooney, PhD, Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA; Joseph E. Losee, MD, Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA; Gregory Cooper, PhD, Pediatric Plastic Surgery, Children's Hospital of Pittsburgh, Pittsburgh, PA
Background: The dura mater has been causally implicated in the premature fusion of calvarial sutures, termed craniosynostosis (CS). In order to better understand the capacity of the dura to influence osteogenic differentiation, the effects of co-culture were examined with dura mater cells derived from either CS or wild-type (WT) rabbits on BMP4-induced osteogenic differentiation of a murine myoblast cell line (C2C12). Methods:C2C12 cells were stimulated with medium containing BMP4 (0ng/ml, 10ng/ml, or 50ng/ml) in culture alone or in co-culture with dural cells isolated from a unique New Zealand White rabbit model of congenital nonsyndromic CS or from wild-type control rabbits. After 3 days, the C2C12 cells were analyzed for osteogenic induction via alkaline phosphatase (ALP) staining and a quantitative ALP assay. The quantitative ALP assay was performed with nine CS samples and three WT control sample. Effects of co-culture on normalized ALP activity were assessed using independent sample t-tests for each BMP dose. Results:Co-culture with dural cells derived from rabbits with CS significantly increased the normalized ALP activity of C2C12 cells by roughly two-fold at the 10ng/ml (p<0.05) and three-fold at the 50ng/ml dose (p<0.05) of BMP4 in all CS samples. The effects of co-culture with WT dural cells at any BMP4 dose tested on ALP activity showed no statistical significance.Conclusions:Results suggest that soluble factors expressed by CS dural-derived cells, but not by WT dural-derived cells, can enhance BMP4’s osteogenic effects on C2C12 cells. These results, obtained in a unique pathological CS model, support the assertion that the increased bone formation in CS may result from signals expressed by the dura mater. Future studies will focus on elucidating the molecular mediators responsible for the observed osteogenic effect of craniosynostotic dura mater.
Paper: Correction of Frontoethmoidal Encephaloceles: HULA Repair
James P. Bradley, MD, Plastic Surgery, UCLA, Los Angeles, CA
Anand R. Kumar, MD, Plastic Surgery, National Naval Medical Center, Bethedsa, MD; Dax Guenther, MD, Plastic Surgery, UCLA, Los Angeles, CA; Eric Helling, MD, LTC, Plastic Surgery, Tripler Army Medical Center, Honolulu, HI; Thomas G. Crabtree, MD, Tripler Army Medical Center, Honolulu, HI
Background:
Frontonasoethmoidal encephalomenigoceles, rarely seen in the Western
Hemisphere, remains a challenging clinical entity. This midline facial
deformity involves a central herniation of a glial mass which ‘pushes outward'
and deforms the medial orbit, medial canthus, nasomaxillary process and nasal
structures without resulting in hypertelorbitism. The ‘Chula' repair, named
after King Chulalongkorn of Thailand, and other techniques focus on
extracranial resection and nasal dorsal reconstruction. In the HULA repair we
describe resection of the deforming mass, repair of the cranial base defect and
complete reconstruction of the midline hard and soft tissue structures.
Methods:
Filipino patients diagnosed with frontonasoethmoidal encephalomenigoceles were
treated by a multidisciplinary team during joint civilian/military humanitarian
missions at Tripler Army Hospital (n=12). Demographic, medical history and CT
scan information was recorded. Operative technique evolved and varied slightly
depending on the deformity but followed tenets of the HULA Frontoethmoidal
Encephalocele Correction (Figure 1): H = Hard split cranial bone, pericranial
flap, Fibrin Glue sealant after ligation of cyst stalk and dura repair; U =
Unification of supraorbital bar after midline resection and inward rotation; L
= Low nasal radix position for full thickness cantilever bone graft; A =
Adjustment of medial canthal position and nasal maxillary process after
resection of midline accessory nasal bone. Postoperative and follow-up
assessment was based on examination, photographic images, CT scans, parental
surveys, the Whitaker reconstructive score and developmental testing.
Results:
Patients ranged in age from 5 to 12 years; there were 67% females and 33%
males. All cases involved frontoethmoidal or nasoethmoidal defects. Sixty-six
percent of patients underwent central nasal skin excisions of ‘damaged,' or
poor quality, hyperpigmented skin. Patients with undamaged nasal skin did not
require an external skin incision but instead had bilateral maxillary
gingivobuccal sulcus incision for removal of the central mass. In these patients
an intercartilagenous nasal incision was used to place the cantelever bone
graft. After the HULA procedures no patients manifested cerebrospinal fluid
leaks, infection, or elevated intracranial pressures. Follow up at 6 months-4
years revealed satisfactory correction of the deformities (mean Whitaker score
of 1.3=no or minor soft tissue revision only necessary) (Figure 2). Parental
survey showed very good to excellent aesthetic outcome with a high degree of
satisfaction. Follow-up developmental tests showed normal scores in preschool
tests (mean score=102) and global evaluations with normal memory and attention
skills.
Conclusion:
Our outcomes demonstrated that the HULA technique was a safe and effective
approach to correct the complex craniofacial anomaly of frontoethmoidal
encephalomenigoceles.
Paper: Ten-Year Review of a Combined Open Cleft Rhinoplasty Incision Utilizing the Dibbell and Tajima Techniques
Roberto L. Flores, MD, Plastic Surgery, New York University Medical Center, New York, NY
Alexander M. Sailon, BA, Plastic Surgery, New York University Medical Center, New York, NY; Court B. Cutting, MD, Plastic Surgery, New York University Medical Center, New York, NY
Background: This study assesses the safety and efficacy of a novel cleft rhinoplasty incision that combines the Dibbell, Tajima and open rhinoplasty incision sets. The Dibbell technique simultaneously corrects the lateralized alar base and depressed lower lateral cartilage on the affected side. The Tajima technique corrects nostril apex overhang and creates a soft triangle. These incisions, however, provide limited access to the nasal tip, making refined adjustments and grafting in this area difficult. By combining the Dibbell, Tajima and an open-rhinoplasty incisions, the dome cartilages can be directly visualized, facilitating cartilage repositioning/grafting and tip refinement while correcting the deformities of alar base, nostril dimension and nostril apex height.Methods: A single-surgeon, 10-year, retrospective review of 157 consecutive unilateral cleft lip rhinoplasties was done. Non-syndromic patients who underwent a combined open incision/Dibbell/Tajima approach and who had a follow-up of greater than 8 months were included. Indications for the combined approach were lateralization of the alar base associated with a depressed dome and nostril apex overhang on the affected side. A total of 35 patients were identified. Standardized patient photographs were examined in frontal and worm’s-eye view in a subset of 17 patients who had both preoperative and postoperative photographs. Farkas normal values were applied to the medial canthal distance and from this value metric measurements of changes in alar base width, nostril dimension and nostril apex height were derived.
Results: Of the 35 study patients, none experienced complications due to skin envelope ischemia or cartilage graft infection. The revision rate of alar base position was 11% (4 of 35), depressed lower lateral cartilage 3.9% (1 of 35) and nostril apex overhang 3.9% (1 of 35). Cartilage grafting was performed in 54% (19 of 35) mostly in the form of a columellar strut (n=16) with or without additional tip grafting. There was a statistically significant decrease in alar base width (19.8mm vs. 18.3mm, p<0.01) and nostril width (9.9mm vs. 7.9mm, p<0.01) after the procedure. The difference in nostril height between the affected and non-affected side decreased (1.8mm vs. 0.9mm, p<0.05) suggesting that improved nostril height symmetry is achieved. On frontal view, the difference in nostril apex height between the affected and non-affected side was decreased when related to the inferior border of the nasal tip (1.8mm vs. 1.1mm, p<0.05).
Conclusion: An open rhinoplasty incision that combines the Dibbell and Tajima techniques is safe and associated with a low revision rate. The incision provides wide exposure to the nasal tip, facilitating cartilage grafting and tip refinement in the dome area, common procedures in our series. This technique results in a statistically significant decrease in alar base and nostril width, and a greater symmetry of nostril height and nostril apex height between the affected and non-affected sides.
Paper: Novel Utilization of The Buccal Fat Pad Flap for Congenital Cleft Palate Repair
Benjamin Levi, MD, University of Michigan, Ann Arbor, MI
Steven J. Kasten, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI; Steven R. Buchman, MD, Plastic Surgery, F7859 Mott Children's Hospital, Ann Arbor, MI
Abstract: Novel Utilization of The Buccal Fat Pad Flap
for Congenital Cleft Palate Repair.
Background: The buccal fat pad (BFP) has been described in
reconstructive surgery for over 30 years for intraoral reconstruction after
tumoral excision. We describe a new use
of the BFP: Furlow repair coupled with pedicled BFP flaps to cover the exposed
bone of the hard palate and midline areas of high tension in primary cleft
palate repair. We believe our technique
has several beneficial attributes: it can be used to cover denuded palatal
bone, potentially decreasing scar contraction induced by the lateral tissue
defect and thereby deterring subsequent restriction of transverse maxillary
growth. Using this technique can also
buttress the soft tissue repair at the junction of the hard and soft palate
where fistula formation is most common.
Methods:
Double reversing Z-plasties for a Furlow palatoplasty and the buccal fat pad
flap harvest site are marked out (Figure 1).
The double reversing z-plasties are completed and then the midline, two myomucosal flaps of the hard
palate are closed often leaving a wide gap of bone all the way around the
patient's hard palate (Figure 2). A curved
iris scissors is placed in the superior buccal sulcus just lateral to the
maxillary tuberosity (Figure 1) and inserted directly through the mucosa and
spread resulting in BFP extrusion. The
BFP flap is then teased out slowly making sure not to avulse it from its blood
supply (Figure 3A and 3B). Once an
adequate amount of tissue is harvested, it is advanced into the lateral tissue
defect and secured over the underlying exposed bone and midline areas of high
tension (Figure 4).
Results: Between
April 2007 and December 2007 seven patients underwent primary cleft palate
repair using the newly described technique.
No patients had complications caused by the BFP at the time of
surgery. For all patients, the recipient
areas fully epithelialized within 4 weeks of the surgery and appeared to have
robust palatal mucosa (Figure 5). No
patients developed fistulas in their first month of follow up. One patient had postoperative thrush which
resolved with treatment.
Conclusions: This
procedure offers a simple and safe way to improve our current method of repair
for primary cleft palates. Technically, there is minimal dissection involved in
developing the BFP flap and it offers a significant amount of tissue. Recent uses of acellular dermal matrices show decreased fistula rate which is
attributed to the increased tissue layer.
We prefer our method to uses of allografts in palatal repair because it
offers a significant amount of vascularized tissue and avoids the risks of
using non-autologous materials.
Furthermore, we contend that the BFP flap brings vascularized tissue
onto the lateral exposed bone caused by medial transposition of the hard
palatal myomucosal flaps, potentially restoring blood supply and assuaging any
potential for growth restriction.
Finally, we feel that the BFP flap may prove to be a useful tool in the
armamentarium of the cleft surgeon to prevent fistula at the hard and soft
palatal junction and a better alternative than the use of an acellular dermal
matrix (Alloderm). Transverse growth
discrepancy and palatal fistulas are huge dilemmas that face plastic surgeons
as well as orthodontists, dentists and oral surgeons. We believe that this exciting new technique
may help decrease the biomedical burden of the consequences and complications
of cleft palate repair.
Table 1: Summary of Cases and follow up Data.
Patient #
|
Patient age at time of surgery
|
Cleft (unilateral or bilateral)
|
Fistula?
(Y or N)
|
Mucosalized by day 28? (Y or N)
|
Infection? (Y or N)
|
1
|
11months
|
Bilateral
|
N
|
Y
|
N
|
2
|
14months
|
Bilateral
|
N
|
Y
|
Y (thrush)
|
3
|
15months
|
Unilateral
|
N
|
Y
|
N
|
4
|
12months
|
Unilateral
|
N
|
Y
|
N
|
5
|
17months
|
Unilateral
|
N
|
Y
|
N
|
6
|
21months
|
Bilateral
|
N
|
Y
|
N
|
7
|
15months
|
Bilateral
|
N
|
Y
|
N
|
Paper: Supraclavicular Artery Flap for Head and Neck Oncologic Reconstruction: Indications and Outcomes
Perry H. Liu, MD, Plastic Surgery, Tulane University, New Orleans, LA
Mark Lee, MD, Tulane Univ. School of Medicine, New Orleans, LA; Paul L. Friedlander, MD, Otolaryngology, Tulane University, New Orleans, LA; Ernest S. Chiu, MD, Tulane Health Science Center, New Orleans, LA
Objective
Head and neck soft tissue oncologic resections often result in complex reconstructive problems that require a dependable and vascular local, regional, or free flap to restore both form and function. With recent advances in microsurgical free-tissue transfers, the reconstructive bar has been raised. Significant donor site morbidity is neither acceptable nor necessary. Local flaps are often of inadequate size while regional muscle flaps (pectoralis major, deltopectoral, trapezius) are not only bulky, but are often associated with significant donor site morbidity. Microsurgical free flaps (forearm, anterolateral thigh, parascapular, abdominal) are ideal but require technical expertise and increased operative time. For patients who are poor free flap candidates, the pedicled supraclavicular artery flap offers a local-regional flap alternative with comparable functional reconstructive results and minimal donor site morbidity. Initially described for skin resurfacing after burn/trauma scar contracture release, this flap is a versatile, thin, fasciocutaneous flap that can be harvested easily and quickly. We demonstrate its utility and durability in a variety of neck and lower face reconstructive problems.
Methods
Over a six month period, tumor ablation defects of the neck and lower face were reconstructed using a pedicled supraclavicular artery rotation flap. All pedicle vessels were pre-operatively mapped using a handheld Doppler probe. Flap design was based upon the dopplered vascular anatomy and harvested on the non-radiated side when possible. The traditional distal to proximal as well as an alternate anterior to posterior subfascial flap harvest techniques were utilized. Complications and functional outcomes were assessed.
Results
A pedicled supraclavicular artery flap was used to reconstruct partial and circumferential pharyngeal, tracheal-stomal, mandible, oral cavity, and neck contour defects. All flaps (n=10) were harvested in under one hour. All patients had uneventful postoperative recoveries. All ablative wounds and donor sites were closed primarily and did not require additional surgery. One patient, after undergoing a hemi-circumferential pharyngeal reconstruction with a normal swallowing study 1 week postoperatively, developed a small controlled leak that subsequently resolved. This patient had received preoperative radiation and likely disrupted the suture line repair with overly eager oral intake following the swallowing study. Another radiated patient, after undergoing mandibular fibular free flap and soft tissue reconstruction, developed distal supraclavicular flap necrosis secondary to tight skin closure over the flap. None of the patients reported any functional donor site morbidity. One patient noted referred sensation to the shoulder in the immediate postoperative period.
Conclusions
This is the first reported series describing the use of a pedicled supraclavicular artery flap for reconstructing a variety of head and neck oncologic defects that would otherwise have required a regional muscle flap or free tissue transfer. We demonstrate its utility in a variety of head and neck reconstructions beyond skin resurfacing, potentially making free forearm and anterolateral thigh flaps a secondary reconstructive option. The supraclavicular artery flap is an excellent flap option for poor microvascular surgical candidates as well as individuals with either high recurrence risk or advanced disease. This thin flap is easy and quick to harvest, has a reliable pedicle, and has minimal donor site morbidity. It is a versatile under-utilized flap that should be in every head and neck reconstructive surgeon’s armamentarium.
Paper: Mercedes Benz Pattern Complex Craniosynostosis
Jennifer L. Rhodes, MD, The Craniofacial Center, Medical City Dallas Hospital, Dallas, TX
Jeffrey A. Fearon, MD, FACS, FAAP, Dallas, TX
PURPOSE:
The “complex craniosynostoses,” which include all non-syndromic multiple
sutural fusions, represent a small fraction of patients presenting with
craniosynostosis. Among the complex synostoses is the Mercedes Benz pattern,
identified in a focused report of 3 children with sagittal and bilateral
lambdoid synostosis. The purpose of
this report was to retrospectively review our series of the Mercedes Benz
pattern craniosynostosis in order to identify associated anomalies and to
assess outcomes, in hopes of improving treatment strategies.
METHODS: A retrospective clinical review was
performed of all patients with craniosynostosis presenting to our craniofacial
center using a prospectively maintained computer database. Records of all
patients presenting with the Mercedes Benz pattern were reviewed. Growth was assessed by direct anthropologic
measurements that were converted to standard Z-scores for comparative purposes
and significance was assessed by the Student's test.
RESULTS: Over a 17-year period, of 802 patients
presenting with craniosynostosis, 11 patients with the Mercedes Benz pattern
synostosis were identified (1.4%). 3/11 patients had additional sutural
involvement (2 unicoronal, 1 metopic), and 2/11 had identifiable genetic
syndromes. Those patients with an isolated Mercedes Benz pattern of
craniosynostosis underwent a single posterior cranial vault remodeling
procedure, at an average age of 7-months.
Patients with additional sutural involvement (n=3) required subsequent
remodeling procedures. Almost two
thirds of all patients (7/11) had cerebellar tonsillar herniation on initial
pre-operative imaging, and 4 symptomatic patients (36%) have required surgical
intervention. Symptomatic Chiari
malformations did not present until after two years of age. Serial pre- and postoperative anthropologic
measurements show that with growth the skull shape becomes slightly more
brachycephalic, with overall growth in head circumference and skull length less
than predicted. At a mean follow up of
over 4 years, (range: 8 months – 6.5 years), overall cognitive function appears
grossly normal in all but one patient (diagnosed concurrently with Opitz BBB).
CONCLUSION: Children affected with the
Mercedes Benz pattern of craniosynostosis do not have normal growth
postoperatively. Diminished growth is
seen in overall head circumference and skull length (resulting in progressive
brachycephaly). Based on these
findings, in spite of the involvement of the sagittal suture, the goals for
surgical correction should include posterior lengthening. We also identified a significant association
with progressive symptomatic cerebellar tonsillar herniation and, therefore,
recommend routine screening postoperatively with magnetic resonance imaging.
Panel: Treating Devastating Maxillofacial Trauma - Lessons Learned from the War Abroad and the War in the Inner-City
Moderator: Thomas G. Crabtree, MD
Raymond Harshbarger, MD
Eduardo Rodriguez, MD
Objective(s):Develop a deeper understanding of the novel challenges in maxillofacial reconstruction created by today's high powered weaponry. Following a brief historical perspective on the advances in civilian and military maxillo-facial repair accelerated by wartime, a selection of practicing civilian and military panelists will highlight new challenges, established treatment successes and vexing problems in need of a solution. Specific case discussion and treatment algorithms will conclude the panel and audience members will have ample time to question the panelists.
Lecture: 2008 ASMS Converse Lecture: Innovative Evolutions in Surgery of the Cranio-Maxillofacial Skeleton - A Historical Perspective
Hugo L. Obwegeser, MD
Objective(s):The American Society of Maxillofacial Surgeons is proud to present Hugo L. Obwegeser, MD, DMD as the 2008 Converse Lecturer. An innovator and pioneer in the development of craniomaxillofacial surgery, Dr. Obwegeser will chronicle the evolution in surgery of the craniomaxillofacial skeleton, highlighting surgical advances, but also the diagnosis and planning for the correction of congenital, developmental and acquired abnormalities of the craniomaxillofacial complex.
During his productive career, Dr. Obwegeser has held multiple academic positions, eventually serving as Director of the Clinic for Maxillofacial Surgery at the University Hospital in Zurich, Switzerland from 1974 until 1987. In 2000, he published the seminal textbook, Mandibular Growth Anomalies: Terminology, Aetiology, Diagnosis, Treatment. Dr. Obwegeser has received numerous honors and awards for his work and service in the field and has lectured extensively both nationally and internationally.
Panel: Local Flaps in Head and Neck Reconstruction
Moderator: Scott Paul Bartlett, MD
Gary C. Burget, MD
Frederick J. Menick, MD
Barry M. Zide, MD, DMD
Julian J. Pribaz, MD
Objective(s): Participate in a comprehensive review of the assessment and management of facial wounds following trauma and skin cancer removal.
Panel: Facilitating Innovation: PSEF Research Forum and Awards
Moderator: Charles E. Butler, MD
Linda G. Phillips, MD
Peter C. Neligan, MB
William M. Kuzon, Jr, MD, PhD
Richard A. D'Amico, MD
Objective(s):1. Current and New Leadership will provide an overview of the current environment and PSEF’s role and focus in growing the research and innovation engine
2. Demonstrate how clinically relevant and translational projects will benefit the practice of plastic surgery and patient outcomes
3. Highlight PSEF supported research and showcase the potential that these projects have to change clinical practice
4. Announce recipients of the National Endowment and Scientific Essay Contest
5. Conduct an interactive audience discussion to explore emerging areas where further research and scientific evidence is needed
Panel: Creating the Beautiful Smile - Perioral Rejuvenation
Moderator: Seth R. Thaller, MD
Andrew M. Wexler, MD
George W. Weston, MD
Michael A. C. Kane, MD
Jeffrey M. Kenkel, MD
Objective(s):Evaluate various available management options for safely providing patients with rejuvenation of the often overlooked peri-oral region. Analyze the normal and abnormal anatomy of the peri-oral region, recognize the stigmata of peri-oral aging and identify how to avoid untoward sequelae from treatment of peri-oral rejuvenation procedures.
Panel: Management of Residual Nasal Fracture Deformities
Moderator: Samuel Stal, MD
Joseph S. Gruss, MD
Larry H. Hollier, Jr, MD
Objective(s):Patients who desire a rhinoplasty frequently have a significant history of nasal injury with major functional and anatomic deformities. Discuss diagnosing and defining the deformity, developing an individualized plan for improving the airway and appearance, sequencing and surgical do's and don'ts, long term results, and common problems and what they would do differently now.
Panel: Essential Steps to Successful Primary Rhinoplasty
Moderator: Jack P. Gunter, MD
Bahman Guyuron, MD
Joseph M. Gryskiewicz, MD
Rod J. Rohrich, MD
Dean Toriumi, MD
Objective(s): Each panelist will present what they feel are the most important factors in achieving a successful primary rhinoplasty. Examine and contrast expert opinions and interact with panelist members to rank and prioritize the factors in achieving a successful outcome.
Panel: My Reconstructive Breast Practice - What I No Longer Do
Moderator: Scott Spear, MD
Dennis C. Hammond, MD
Joseph J. Disa, MD
Albert Losken, MD
Maurice Nahabedian, MD
Objective(s): Learn updates for performing reconstructive breast surgery and innovations and improvements in the field.
Lecture: PSEF Maliniac Lecture: From Zero to Abundance - A Model of An International Teaching and Training Craniofacial Center
Yu-Ray Chen, MD
Dr. Yu-Ray Chen of Taiwan will present a model of international plastic surgery training and the value of a center of excellence as he presents the 2008 PSEF Maliniac Lecture.
Dr. Chen began his medical training at the National Taiwan University Medical School in 1972 and continued on to his general surgery residency at the National Taiwan University Hospital and plastic surgery residency training at the Chang Gung Memorial Hospital. After completing clinical and research fellowships at both the University of Texas Southwestern Medical School in Dallas and at the Hospital for Sick Children at Toronto University between 1979 and 1980, Dr. Chen returned to his home in Taiwan and began his practice at the Chang Gung Memorial Hospital. There he served as Chairman of the Department of Plastic Surgery, Chief of the Department of Surgery, as well as the Director of the Craniofacial Center, a position he held until 1997. Dr. Chen assumed the office of Superintendent of Chang Gung Memorial Hospital from 1997-2003 before becoming Chairman of the Chang Gung Steering Committee, charged with the management of six teaching hospitals and institutes with over 1,600 attending physicians.
Objectives: Dr. Yu-Ray Chen of Taiwan will present a model of international plastic surgery training and the value of a center of excellence as he presents the 2008 PSEF Maliniac Lecture.
Dr. Chen began his medical training at the National Taiwan University Medical School in 1972 and continued on to his general surgery residency at the National Taiwan University Hospital and plastic surgery residency training at the Chang Gung Memorial Hospital. After completing clinical and research fellowships at both the University of Texas Southwestern Medical School in Dallas and at the Hospital for Sick Children at Toronto University between 1979 and 1980, Dr. Chen returned to his home in Taiwan and began his practice at the Chang Gung Memorial Hospital. There he served as Chairman of the Department of Plastic Surgery, Chief of the Department of Surgery, as well as the Director of the Craniofacial Center, a position he held until 1997. Dr. Chen assumed the office of Superintendent of Chang Gung Memorial Hospital from 1997-2003 before becoming Chairman of the Chang Gung Steering Committee, charged with the management of six teaching hospitals and institutes with over 1,600 attending physicians.
Since 1980, Dr. Chen has performed over two thousand mid-facial and mandibular osteotomies and numerous cleft and intracranial reconstructions. He is widely published in one of his personal areas of interest: craniofacial fibrous dysplasia. He has also developed several modifications of osteotomies in the maxillofacial region. A staunch advocate of education and research, Dr. Chen has been involved in the training of more than 250 plastic and craniofacial fellows from 35 countries, authoring more than 150 publications during his career.
Dr. Chen also has a distinguished service career. In his homeland of Taiwan, he has been elected President of the Cleft Palate and Craniofacial Association, the Plastic and Reconstructive Surgical Association, and the Society of Aesthetic Plastic Surgery. Internationally, he has also been elected to serve as the Secretary of the Asian-Pacific Craniofacial Association (1993-1997), the President of the International Society of Craniofacial Surgery (1997-1999), and the General Secretary of the Asian Pacific Section of IPRAS (2001-2005).
Dr. Chen will present the Maliniac Lecture entitled “From Zero to Abundance: A Model of an International Teaching and Training Craniofacial Center” on Tuesday, November 4 at 9:45am in Session A of the Chicago McCormick Center. This year marks the 31st anniversary of the Maliniac Lecture, presented each year in honor of Jacques Maliniac, MD, founding member of the Plastic Surgery Educational Foundation.
Panel: The Science of Fat Transfer - The Skinny on Fat
Moderator: J. Peter Rubin, MD
Gino Rigotti, MD
Adam J. Katz, MD
Stephen B. Baker, MD, DDS
Karol A. Gutowski, MD
Objective(s): Assess evidence based factors that impact fat graft survival, including the impact of harvest technique, fat processing, and injection technique. Discuss Adipose Stem Cells and their potential role in graft survival in conjunction with a review of scientific data addressing the addition of exogenous compounds to improve graft survival. Expand knowledge of fat grafting as a therapy for radiation injury.
Paper: Safety and Efficacy of the On-Q Pain Relief Pump in Pediatric Plastic Surgery
Patrick Cole, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Yoav Kaufman, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Larry Hollier, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Samuel Stal, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Background: Optimal post-operative pain relief is critical in pediatric surgery; however, systemic pain medications are associated with a host of unwanted side effects. The use of continuous local analgesic infusion pumps provides adequate pain relief while avoiding serious complications of more systemic treatment. While many reports document the effectiveness of these techniques in the adult population, no prospective studies demonstrate the safety and efficacy of these devices in pediatric surgery. Methods: The present study is a prospective, randomized, double-blind study employing the On-Q pain pump in 24 patients (mean age: 12 years). All patients underwent alveolar bone grafting for cleft repair following iliac crest bone harvest. The On-Q pain pump catheter was placed in the subfascial plane of the iliac crest harvest site. While 12 patients received 0.2% bupivicaine solution, 12 patients received 0.9% normal saline placebo via the pain pump system. Over the immediate 24-hour post-operative period, oral and intravenous pain medication was measured, as were required levels of antiemetic (Zofran). Results: Within the first 12 post-operative hours, patients receiving bupivacaine infusion via the On-Q pain pump required significantly less (p=0.02) pain medication compared to the placebo group. Between 12 and 24 hours post-procedure, an even more statistically significant decrease in analgesic requirement was noted (p=0.004). Finally, patients in the control group were 9 times more likely to require antiemetic medication (p=0.026). No postoperative morbidity was noted in any member of either study group.Conclusion: Following iliac crest bone harvest for alveolar cleft repair, continuous infusion of 0.2% bupivacaine via the On-Q pain pump greatly diminishes narcotic requirement for adequate pain control. Use of the On-Q pain pump system to provide post-operative local analgesia is safe and reliable.
Paper: Supportive Therapy with Donor Bone Marrow Cells and Presence of Regulatory CD4+/CD25+ T-Cell Promotes Face Transplant Survival
Aleksandra Klimczak, PhD, Plastic Surgery, Cleveland Clinic, Cleveland, OH
Mehmet Unal, MD, Plastic Surgery, Cleveland Clinic, Cleveland, OH; Yavuz Demir, MD, Plastic Surgery, Cleveland Clinic, Cleveland, OH; Maria Siemionow, MD, PhD, Plastic Surgery, Cleveland Clinic, Cleveland, OH
Purpose: We have formerly achieved functional tolerance in fully MHC miamatched rat facial allotransplantation model under cyclosporine-A (CsA) monotherapy. In this study we tested the effect of donor bone marrow transplantation (DBMT) under short-term alpha-betaTCRmAb and CsA 7-day protocol on development of chimerism, allograft survival, and presence of regulatory T-cells in face allograft model across MHC barrier.
Methods: Thirty six hemiface allotransplantation were performed between LBN(RT1l+n) donors and LEW(RT1l) recipients in 6 groups (6 rats each). Controls: Group 1 isograft and Group 2 allograft without treatment, Group 3 received intraosseous DBMT only. Groups 4, 5 and 6 received alpha-betaTCR/CsA 7-day therapy. Additionally Groups 5 and 6 were augmented with intraosseous DBMT of 35x106, and 100x106 of bone marrow cells (BMC) respectively. Before transplantation BMC were stained with PKH dye to evaluate engraftment and migratory process of donor BMC.
Flow cytometry assessed immunodepletion of T–lymphocytes, donor-specific chimerism for MHC class I (RT1n) antigens and presence of regulatory T-cells CD4+/CD25+. Grading of graft rejection was assessed by H+E staining.
Results: Isograft controls survived indefinitely, whereas controls without immunosuppression rejected transplanted allograft within 5 to 8 days. Group 3 treated with only DBMT accepted transplant up to 13 days. Median survival time (MST) of facial allograft (Group 4) under alpha-betaTCR/CsA therapy was 35 days. In both Groups 5 and 6 augmented with donor BMC MST was 48 days. However, the longest survival time in Groups receiving 35x106 or 100x106 BMC was 465 and 498 days respectively. In long-term survaivals split tolerance was found as presented by acceptance of skin and rejection of hair components.
PKH-positive cells of donor origin were present within lymphoid organs and skin of recipients. In rejected allografts T-cell chimerism declined <1%, and B-cell chimerism was at 4.5% of CD45RA/RT1n. In contrast, in long-term survival animals T-cell chimerism was 2%-4% (RT1n) during follow-up period and B-cell chimerism reached 12.4% CD45RA/RT1n at day 465 post-transplant. At day 7 post-transplant, regulatory CD4+/CD25+ T-cells initially were detected at 1.8%, however in long-term survivals reached 4.0%, whereas rejected allografts reveled 2.2% of CD4+/CD25+ T-cells at the time of euthanasia.
Conclusion: Long-term face allograft survival was achieved under 7-day alpha/beta-TCRmAb/CsA protocol augmented with DBMT without chronic immunosuppression. Long-term allograft acceptance was supported by development of regulatory T-cells and maintenance of donor T-cell and B-cell chimerism.
Paper: A Novel Technique for Sutureless Microvascular Anastomosis Using Thermoreversible Poloxamers
Edward I. Chang, MD, Surgery, Division of Plastic Reconstructive Surgery, Stanford University, Stanford, CA
Michael G. Galvez, BA, Surgery, Division of Plastic Reconstructive Surgery, Stanford University, Stanford, CA; Michael T. Longaker, MD, MBA, Stanford University, Children's Surgical Research, Stanford, CA; Geoffrey C. Gurtner, MD, Stanford University, Stanford, CA; Cynthia Hamou, MD, Surgery, Division of Plastic Reconstructive Surgery, Stanford University, Stanford, CA
Introduction: The ability to perform microvascular anastomosis for free tissue transfers and digital replants is tedious, time consuming, and requires a skilled microsurgeon. While a myriad of devices have simplified these challenging operations, all the current devices introduce foreign materials which stimulate a foreign body reaction predisposing such anastomoses to stenosis or thrombosis. We have developed a novel sutureless technique for performing these complex procedures using thermoreversible poloxamers.
Materials and Methods: Rheological studies were used to engineer a formulation of P407/P188 to obtain a phase transition temperature at 40°C. Poloxamer formulations were tested on HUVECs in vitro to assess for toxicity and effects on proliferation. Anastomoses were performed on Fisher rat aortas (avg. diameter 1.18±0.02mm) using our sutureless technique (n=30) and with conventional 10-0 nylon sutures (n=30). CT angiograms, ultrasound Doppler, burst strength assays, and histology were performed at designated timepoints. Poloxamer mediated heparin delivery was assessed in vitro using HUVECs and tissue factor pathway inhibitor (TFPI) ELISA.
Results: A formulation of 17% P407 and 6% P188 achieved a phase transition temperature of 40°C and was used for all subsequent experiments. Sutureless anastomoses were completed more efficiently than the hand sewn technique (8.1 ± 2.4 min vs. 47.3 ± 5.0 min, p<0.05) with equivalent burst strengths (>1200mm Hg, p>0.05). CT angiograms demonstrated equivalent patency in end-to-end anastomoses; however, end-to-side anastomoses could not be performed using traditional techniques (p<0.001). Doppler analysis demonstrated equivalent patency, vessel diameter, and volumetric flow (116.1mL/sec vs. 107.2 mL/sec, p>0.05) between sutureless and hand-sewn anastomoses. Histology demonstrated dramatically decreased inflammation and fibrosis in the sutureless group compared with the traditional technique. Application of poloxamer did not demonstrate any evidence of toxicity in vitro or in vivo. Heparinized poloxamer-induced a significant percentage increase in secretion of TFPI compared with heparin administered directly to HUVECs (231.8%, p<0.05) with effects lasting up to 24 hours (125.4%, p<0.05).
Conclusions: Sutureless anastomosis can be performed reliably, more efficiently, and with less intimal damage than hand-sewn anastmosis. In addition, poloxamers can also be employed as a delivery agent for anti-thrombotics simultaneously to further preserve graft patency. This technology offers a promising alternative to sutured anastomosis and may have a profound impact on the field of reconstructive microsurgery.
Paper: Repair of Radiation Damage in a Novel Skin Injury Model with Microstructural Fat Grafting
Christopher C. Chang, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY
Vishal D. Thanik, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY; Robert J. Allen, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY; Jamie P. Levine, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Pierre B. Saadeh, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Stephen M. Warren, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Sydney R. Coleman, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Alexes Hazen, MD, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, NY
IntroductionAnecdotal clinical reports suggest that subcutaneous fat grafting can ameliorate radiation skin damage. Adipose derived progenitor cells may play a role in this process. In order to study this phenomenon, we have developed a novel mouse model of radiation-induced skin injury and used low-pressure, high-pass fat transfer (Coleman method) to deliver lipoaspirate beneath the irradiated skin.MethodsThe dorsal skin of adult wild-type FVB mice was isolated with a low-pressure, non-ischemic clamp and exposed to a single dose of 45Gy XRT (dose determined through preliminary experiments). Skin changes were assessed by insonation, gross, H&E, and immunohistologic (COX-IV stains) evaluation every other week up to 6 weeks after irradiation. Human lipoaspirate was harvested from healthy female donors and processed (Coleman method). Refined fat was transferred (1cc syringes) for immediate transplantation. Six weeks after XRT, mice with visible partial thickness radiation ulcers were infiltrated subdermally with 1.5mL of human fat using an 18-gauge Coleman cannula (fan-like pattern over mouse dorsum, 0.033mL fat injected/ pass). Controls were not irradiated.ResultsAll mice tolerated irradiation. Visible erythema, dermal thickening and skin changes were observed at each post-irradiation time point. Sirius red staining of skin biopsies demonstrated increased collagen and fibrosis of the dermal layer. This correlated with doppler analysis, which showed decreased dorsal skin perfusion. Interestingly, human fat xenograft administration yielded minimal inflammation in control and treatment groups. Whole mount analysis showed vascular infiltration of the grafted fat. COX-IV staining demonstrated incorporation of human tissue elements, indicating vascularity was human-derived. Histological analysis demonstrated vascularized viable human adipose tissue with nominal peripheral fat necrosis and fibroblastic infiltration. Fat grafting resulted in rapid improvement in XRT skin changes compared to controls.DiscussionThis novel murine model of radiation injury is the first to limit injury to the skin and reveals consistent, nonlethal dermal changes similar to human injury. Interestingly, xenogeneic fat transfer incorporated into the host animal and was not acutely rejected. Furthermore, subdermal fat grafting improved overlying irradiated skin quality and aided in ulcer repair.
Paper: Application of Poly-Dihydroacetate Bioadhesive Signficantly Reduces Post-Operative Seroma Formation in a Rat Mastectomy Model
Sunil P. Singh, BA, School of Medicine, New York University, New York, NY
David Putnam, PhD, Biomedical Engineering, Cornell University, Ithaca, NY; Peter Zawaneh, BS, Biomedical Engineering, Cornell University, Ithaca, NY; Jason A. Spector, MD, Division of Plastic Surgery, Weill Cornell Medical College, New York, NY
Application
of Poly-Dihydroacetate Bioadhesive Signficantly Reduces
Post-Operative Seroma Formation in a Rat Mastectomy Model
Sunil P. Singh, BA, Peter Zawaneh, BS, David Putnam, Ph.D., Jason
A. Spector, MD
Background: Seromas are
common post-operative complications in both cosmetic and reconstructive surgery
that, without timely intervention, may result in significant morbidity
including disfigurement, pain, infection (which can be especially problematic
when implants or other foreign materials have been placed) or even formation of
permanent cystic cavities. They are especially common in ablative procedure,
such as mastectomies, that require extensive dissection and create large surgical
voids. Once present, seromas
may persist despite repeated aspiration, resulting in distress for both patient
and surgeon alike. Measures to prevent the formation of seromas,
such as “quilting” sutures and use of fibrin or other biologic sealants, have
been disappointing at decreasing the incidence of post-operative seroma
formation.
We have developed a novel biocompatible and biodegradable injectable hydrogel based on polyethylene glycol and a
polycarbonate of dihydroxyacetone (PEG-pDHA). This polymer has significant bioadhesive
properties; it is fabricated from compounds naturally derived from the human
body (DHA) and is broken down to natural body byproducts including carbon
dioxide and water. Unlike current tissue sealants, which bind to tissue with a
low binding constant, our polymer reacts covalently through the formation of a
Schiff-base, resulting in a binding constant of 1015 M-1.
This study set out to determine the in
vivo efficacy of our novel compound in preventing the formation of seroma
in a rat mastectomy model.
Methods: This study used a previously described rat
mastectomy model to induce seroma formation.
Fifteen male Sprague-Dawley rats (9
experimental, 6 controls) underwent the procedure. Starting with a midline incision, a skin flap
was raised over the right chest, the right pectoralis
major muscle was excised and a right axillary lymphadenctomy performed under an operating microscope. Experimental rats received 0.5cc of polyDHA into the wound bed before closure while controls received
0.5cc of saline into the wound bed before closure. Animals were sacrificed on
post operative day #7 by carbon dioxide asphyxiation followed by cervical
dislocation. Seroma fluid was aspirated percutaneously via 18 gauge needle and measured. The incision site was then opened and
inspected for adhesions and any additional fluid remaining was removed by
needle aspiration. Biopsies of the skin flap and underlying wound bed were sent
for histologic analysis based on. In order to
determine in vivo biocompatibility of
the polymer, sections were analyzed for evidence of inflammation in the area of
application. Seroma accumulation (total volume) was analyzed using the unpaired
student's t test.
Results: Poly-DHA treatment resulted in a 98%
decrease in seroma accumulation (mean volume=0.04cc) versus controls (mean
volume=2.28cc) (p<0.001; Fig 1). Gross adhesions were seen between the skin
flap and chest wall in the poly-DHA group while none were seen in the control
group. Histologic examination demonstrated no
evidence of increased inflammation reaction in poly-DHA treated animals versus
controls. There were no differences in fibroplasia, inflammatory cell infiltration or neovascularization, all of which are consistent with normal
changes in early stages of wound healing.
Conclusion: Our in
vivo data demonstrates that our novel polymer, poly-DHA, has considerable bioadhesive properties, resulting in a significant
reduction in seroma formation after mastectomy. Because our polymer is
extremely efficacious, inexpensive and free of infection risk, we anticipate
tremendous translational application of our novel compound in the realm of
plastic and reconstructive surgery.
Figure 1:
Paper: Scar-improving efficacy and safety of intradermal avotermin, a new class of regenerative medicine (pre-clinical and clinical studies)
James Bush, MBChB, Clinical Trials Unit, Renovo, Manchester, UK, United Kingdom
Piyush Durani, MBBChir, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Karen So, MBBS, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Lisa Taylor, MBBCh, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Gaynor James, BSc, MSc, Biometrics Department, Renovo, Manchester, United Kingdom; Sharon O'Kane, BSc, (Hons), PhD, Executive Director, Research and Development, Renovo, Manchester, United Kingdom; Mark W.J. Ferguson, BDS, PhD, DMSci, Executive Director, Renovo, Manchester, UK, United Kingdom; Nick Occleston, PhD, Vice President of Discovery, Renovo, Manchester, United Kingdom; Hugh Laverty, PhD, Discovery, Renovo, Manchester, United Kingdom
Background: There is a significant, unmet medical need for effective treatments that reduce scarring, with patients indicating that they value any improvement in scarring. Transforming growth factor beta 1 (TGFb1) has been shown in numerous studies to play a key role in promoting scarring and fibrosis, and we have previously reported that TGFb3 demonstrates an isoform specific difference from TGFb1 and reduces scarring in pre-clinical models. We present here the translation of these pre-clinical data to the clinic with the results of a phase II randomized, placebo-controlled human clinical trial investigating the optimal concentration of a single intradermal application of avotermin (TGFb3) for the improvement of scarring, when administered to incisional wounds with approximated margins. We also report data from preclinical studies which elucidate the molecular, cellular and tissue mechanisms of action of avotermin that underlie its effects.Methods: In the clinical study (RN1001-0050), healthy volunteers received a total of eight standardized, 1cm, full-thickness incisions, four on the inner aspect of each arm. After wound closure, both margins of each site received an intradermal injection of study treatment, with sites randomized to one of four doses of avotermin (5, 50, 200 or 500ng/100µL/linear cm wound margin) or placebo. The study was powered to show treatment differences (avotermin vs placebo) in the total scar score (ToScar), a summary measure of how closely scars resemble normal skin over time. ToScar was calculated by summing scores assigned to standardized photographs of scars at Week 6 and Months 3, 4, 5, 6 and 7 post-surgery by an Independent External Scar Assessment Panel (IESAP, Lay Panel) using a 100mm visual analogue scale (VAS). Assessments were also conducted by investigators and an IESAP (Clinical Panel; a facial plastic surgeon, five aesthetic dermatologists). All assessors were blinded to treatment. In pre-clinical studies a range of relevant in vitro and in vivo models were utilized to evaluate the isoform specific effects and mechanism of action of avotermin at the intracellular signalling, gene expression, cellular function and tissue level, including in vivo temporal and spatial analysis of key molecular and cellular processes in a rat full thickness cutaneous incisional wound model following avotermin treatment. Results: The clinical trial included 39 subjects (97% Caucasians, 64% males, median age 34 years), who received 312 incisions overall. The primary objective was met with avotermin achieving statistically significant improvements in ToScar versus placebo, with the 200ng/100µL/linear cm dose achieving the greatest magnitude of scar improvement (p<0.0001). VAS scores from the IESAP (Lay Panel) and IESAP (Clinical Panel) also showed that avotermin achieved statistically significant improvements in scars at Month 7 (p<0.02 versus placebo). All avotermin doses showed a favorable safety profile and there was no evidence of systemic absorption. Mechanism of action studies demonstrated that avotermin (TGFb3) elicits isoform specific effects on: signal transduction; regulation of extracellular matrix/remodelling genes; attenuated inflammation; increased cell migration and an earlier resolution of wound myofibroblasts resulting in the regeneration of a collagen architecture within the scar that is more similar to normal surrounding skin.Conclusions: In this phase II clinical trial intradermal administration of avotermin at the time of surgery resulted in statistically significant improvements in scar appearance compared with placebo, with the data demonstrating that the optimal dose of avotermin was 200ng/100µL/linear cm of wound margin. The molecular and cellular mechanism of action of avotermin identified to date provides a clear scientific rationale to underpin its scar reduction effect. These clinical data demonstrate avotermin, a new class of prophylactic medicine, improved scar appearance and indicates the potential of avotermin to add to good surgical technique for the improvement of scar appearance.
Panel: Breast Outcomes - From Research to Practice
Moderator: Carolyn L. Kerrigan, MD
Amy Alderman, MD, MPH
Edwin G. Wilkins, MD, MS
Andrea L. Pusic, MD, MHS
E. Dale Collins, MD
Objective(s): Identify methods to integrate outcome measurement into a breast surgery practice to facilitate quality improvement efforts and ultimately improve patients’ satisfaction with breast surgery outcomes.
Paper: Patient Satisfaction in DIEP Flap Breast Reconstruction: A Comparative Evaluation with TRAM Flap, Latissimus Flap, and Implant Techniques
Janet H. Yueh, BA, Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
Eran D. Bar-Meir, MD, Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Adam M. Tobias, MD, Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Theodore T. Nyame, BA, Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Bernard T. Lee, MD, Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA; Donald J. Morris, MD, Longwood Plastic Surgery, P.C., Brookline, MA; Sumner A. Slavin, MD, Brookline, MA
Introduction: Breast reconstruction is an essential component of
the overall treatment plan for patients considering mastectomy. As perforator
flap techniques, such as the deep inferior epigastric perforator (DIEP) flap,
continue to gain in popularity there is still no consensus on the optimal
method of reconstruction. Over the past decade, patient satisfaction has gained
widespread recognition as an important outcome measure for quality of care.
The purpose of this study is to compare patient satisfaction with the DIEP flap
to the more commonly practiced techniques in breast reconstruction and identify
factors influencing satisfaction.
Methods: A
retrospective chart review was performed on all women who had undergone post
mastectomy breast reconstruction at an academic teaching hospital. A total of
604 patients who had a primary reconstruction with a tissue expander/implant,
latissimus dorsi flap, pedicled or free transverse rectus abdominis
myocutaneous (TRAM) flap, and deep inferior epigastric artery perforator (DIEP)
flap were identified between the years of 1999 and 2006. Both unilateral and
bilateral procedures were included as well as immediate and delayed
reconstructions. A questionnaire was designed to collect the following
information from patients after reconstruction: (1) demographic information,
(2) types of breast reconstruction options presented, (3) assessment of patient
satisfaction with their procedure consisting of the seven general and aesthetic
questions developed by the Michigan Breast Reconstruction Outcome Study, and
(4) health related quality of life questions provided by the SF-12 Health
Survey Questionnaire. Comparison of dichotomous variables across
reconstructive groups was performed using a Fisher's exact test or Chi squared
test. Quality of life rating scales were compared across reconstructive groups
using one-way analysis of variance. Statistical significance was indicated for
values of p < 0.05.
Results: Patient
response to the questionnaire was 64.2 percent, with 388 completed
questionnaires returned. This group included 72 tissue expander/implant
patients, 94 latissimus dorsi flap patients, 122 TRAM flap patients, and 100
DIEP flap patients. There were no significant differences in the SF-12 quality
of life scores among the four groups. In comparison to all the other
reconstructive procedures, the DIEP flap patients had the highest levels of
general and aesthetic satisfaction (p = 0.007 and p = 0.021).
Reconstruction using an abdominal donor site (DIEP, TRAM) had a significantly
higher general and aesthetic satisfaction rate than non-abdominal
reconstructions (p = 0.009 and p = 0.004, respectively). When
compared directly with the TRAM flap group, the DIEP flap group had a higher
general satisfaction rate, however, the aesthetic satisfaction rate was
similar. The timing of breast reconstruction after mastectomy showed a trend
towards higher satisfaction rates in immediate over delayed reconstruction.
Patients who underwent unilateral and bilateral breast reconstructions had
similar overall satisfaction scores; however, subgroup analysis indicated that
the bilateral TRAM cohort had a lower general satisfaction rating (p =
0.041). Whether patients had mastectomy for treatment of breast cancer or
prophylaxis, satisfaction rates were similar. Finally, as the age of the
patient increased at the time of reconstruction, there was a trend towards
lower general satisfaction levels (p = 0.086); however aesthetic
satisfaction remained relatively constant over different age groups.
Conclusions: Breast
reconstruction with the DIEP flap has the highest patient satisfaction rates
among the four types of reconstruction evaluated. Although reconstruction
based on an abdominal donor site revealed higher overall levels of satisfaction,
the DIEP flap patients had a higher general satisfaction level when compared to
a traditional TRAM flap. Patient reported aesthetic satisfaction rates were
similar among the various autologous techniques and higher than implant-based
reconstruction. Discussing satisfaction outcomes with patients will help in
making educated decisions about breast reconstruction.
Table: Patient satisfaction among the
four reconstruction options.
| Tissue expander / Implant | Latissimus dorsi +/- Implant | Pedicled & free TRAM | DIEP | Cumulative |
General Satisfaction | 60.9% | 57.8% | 65.5% | 79.8% | 66.6% |
Aesthetic Satisfaction | 52.2% | 60.0% | 69.7% | 72.7% | 65.0% |
Paper: A Review of 123 Consecutive Breast Reconstructions with the Muscle-Sparing (MS-2) Free TRAM flap. Is There Any Place for the DIEP Flap?
Jose R. Castello, MD, PhD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Lawrence Garro, MD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Introduction: The deep inferior epigastric perforator (DIEP) flap was
developed in an attempt to decrease abdominal morbidity after breast
reconstruction when compared with the conventional free transverse rectus
abdominis musculocutaneous (TRAM) flap. However, the advantages of using the
DIEP flap over the muscle-sparing free TRAM flap (MS-2) are not well established.
Both techniques optimize abdominal function by maintaining the vascularity,
innervation, and continuity of the rectus abdominis muscle. Ultrasonographic
studies demonstrate a significant degree of muscular atrophy after a DIEP flap
dissection, and recent works have showed similar donor-site morbidity and
functional outcomes, while the DIEP flap is more prone to venous congestion and
flap-related complications and may require longer operative times, especially
when anatomy is unfavorable.
Methods: The aim of this study was to compare donor-site morbidity and
flap-related complications after unilateral breast reconstruction with the MS-2
flap and published data of women reconstructed with unilateral DIEP flaps. The
study included 123 women who have had breast reconstruction using the MS-2 flap
over a 4-year period. Fifty-seven percent were performed immediately and 43
percent were delayed.
Results: Mean follow-up was 22 months. Outcome included fat necrosis in
18 patients (14.6%), venous congestion in 1 (0.8%), partial necrosis of the flap
in 1 (0.8%), and total necrosis in 3 (2.4%). An abdominal bulge occurred in 5
women (4%). Mean operative time was 6.5 hours for immediate reconstruction and
5.8 hours for delayed reconstruction. Comparative results are shown in Table 1.
Conclusion: Our results are similar to those published by other authors
using the MS-2 and DIEP flaps. There is no difference in flap-related
complications and donor-site morbidity between using the MS-2 flap and the free
DIEP flap. However, comparison between data in different series must be
interpreted cautiously. Some authors only report complications requiring
surgical revision while others not. Fat necrosis is difficult to measure,
especially after skin- sparing mastectomy, and some abdominal bulges may be
minor and not require reparation. Total necrosis may be attributed to technical
problems during vascular anastomosis and not be related to flap dissection.
Operative time is not reported in most of the series and may not be compared;
however, in our practice dissection of an MS-2 flap takes less time than a DIEP
flap.
Most of the authors recommend using the most expeditious and reliable flap based
on the vascular anatomy. Thus, on patients whose anatomy reveals perforators of
adequate size, the DIEP flap is selected. However, we prefer to perform MS-2
flaps in all the patients, even if their anatomy is favorable for a DIEP flap,
obtaining predictable results in less operative time.
Table 1. Comparative results between published data and this study (% of
patients with a given complication).
| DIEP (literature data) | MS-2 (literature data) | MS-2 (this study) |
Fat necrosis | 6-17 | 5.8-14 | 14.6 |
Venous congestion | 2-15 | 3 | 0.8 |
Abdominal bulge | 1-10.4 | 2-6.5 | 4 |
Partial necrosis | 1-7 | 0.1-1 | 0.8 |
Total necrosis | 0.5-4.5 | 0-3 | 2.4 |
Operative time (hours) | 4.5-7.5 | - | 5.8-6.5 |
Paper: Do Pre-existing Abdominal Scars Threaten Wound Healing in Abdominoplasty?
Michele A. Shermak, MD, FACS, JHBMC Division of Plastic Surgery, Baltimore, MD
Jessie E. Mallalieu, MS, PA-C, Plastic Surgery, Johns Hopkins Medical Institutions, Baltimore, MD; David Chang, PhD, MPH, MBA, Surgery, Johns Hopkins Medical Institutions, Baltimore, MD
Purpose: Abdominoplasty is the third most popular surgical procedure performed in plastic surgery, and one of the fastest rising in prevalence, partly due to the growing number of massive weight loss patients. Pre-existing abdominal scars, particularly the right subcostal (Kocher) scar used for open gallbladder removal, may threaten healing after abdominoplasty due to decreased blood supply. We aimed to determine if patients with pre-existing Kocher scars or upper midline scars from open gastric bypass surgery (gbs) had actually experienced increased risk of complications, and specifically, wound healing problems.
Methods and Materials: Review of operative and clinic notes of all patients who had abdominoplasty from March 1998 to February 2008 was performed. Variables studied included age, gender, BMI, medical and surgical history, and postoperative complications. The most frequent complications were wound healing problems and seromas, but other complications included postoperative bleeding and venous thromboembolism, for example. Statistical analysis to assess outcomes was performed in Stata SE, version 9.
Results: 420 abdominoplasty procedures took place. The patient population was comprised of 88.6% women, and shared an average age of 42 years. Within the overall group, 62.2% had open gbs and 19% had laparascopic gbs. Seven percent (n=29) of the patients had a Kocher scar. Mean BMI at the time of abdominoplasty was 33 (range: 19.5 to 88). Overall risk of any complication was 32.9%, with risk of wound healing problem, 18.3% and seroma, 14.9%. Chi square analysis revealed significance in the relationships between any abdominal scar and any complication (p=0.001) and wound healing problem as a specific complication (p=0.009). The Kocher scar was significantly associated with wound healing problems (=0.003), but not seromas. The upper midline incision also had a higher association with any complication, but not with wound healing or seroma complication. Multivariate analysis, controlling for age, gender, medical comorbidities, smoking history and BMI, indicated no significant relationship existed between abdominal scars and postoperative complications. While this relationship dropped out in the adjusted analysis, BMI revealed itself to be the variable providing the greatest detriment to successful wound healing. With every unit increase in BMI, a 5% increase in risk of any complication and a 6% increased risk in wound healing was calculated (p=0.001). There was no difference in complications between the open and laparascopic gbs groups, indicating the upper midline incision did not pose a threat to wound healing, whereas BMI did.
Conclusions: While the Kocher scar seems to pose a threat to wound healing in abdominoplasty, this analysis reveals that it is BMI, not the Kocher scar, that poses the greater threat. Upper midline incisions also do not present a risk to wound healing in abdominoplasty. While caution is recommended in undermining toward the right upper quadrant when a Kocher scar exists, we find that including BMI in the analysis disabled the risk of Kocher scar in causing wound healing problems.
Lecture: Novel Concepts in Contouring the Nasal Tip
Dean Toriumi, MD
Objective(s): Discuss new concepts in nasal tip contouring that focus on favorable and unfavorable shadowing of the nasal tip. Less emphasis will be placed on narrowing the nasal tip and more emphasis will be placed on reorienting existing nasal tip structures and placement of cartilage grafts to create a favorable tip contour. Techniques such as dome sutures, tip grafts and alar rim grafts will be discussed and demonstrated using video and illustrative patient cases. Repositioning the cephalically oriented lateral crura with lateral crural strut grafts will be discussed as well. The objective of this presentation is to convey the importance of creating a normal yet aesthetically pleasing nasal tip that is not overly narrowed or pinched.
Paper: Autogenous Schwann Cells in Nerve Allografts Indicate that Anti-CD40 Ligand Costimulatory Blockade Induces a Permissive State
Alison M. Tisack, BS, Plastic Surgery, University of Michigan, Ann Arbor, MI
Paul S. Cederna, MD, Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI; Melanie G. Urbanchek, PhD, Plastic Surgery, University of Michigan, Ann Arbor, MI; Daemeon Nicolaou, BS, Medical School, Univeristy of Michigan, Ann Arbor, MI; Deborah Yu, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Introduction:
Schwann cells (SC) are the most antigenic component of peripheral nerve
allografts. As such, defining the fate of SC after allotransplantation will define
the duration of antigenic stimulation. Experimentally blocking the binding of
CD40 to its ligand, CD40L, extends tolerance to nerve allografts. MR1 is an
antibody which binds with CD40L thus blocking the CD40-CD40L costimulation
pathway. We hypothesize that following nerve allografting, SC are tolerated while
being replaced with autogenous SC from the proximal and distal nerve ends if MR1
is administered at the time of grafting. As a functional test of our grafts, we
measure differences in muscle contractile maximal forces for the reinnervated
extensor digitorum longus (EDL) muscles.
Methods:
Rosa26Bl/6 mice are a C57Bl/6 mutant strain containing the beta-galactosidase
gene that stains SC an insoluble blue. We studied four groups of Rosa26Bl/6
mice (n= 6); three groups received an 8 mm sciatic nerve graft while the Sham
group had no graft. The Allograft with saline and the Allograft with CD40/CD40L
mAb (MR1) groups each received BALB/c nerve grafts while the Isograft group
received C57BL/6 grafts. MR1 was administered IP on day 0 to the allograft
with MR1 group while all other groups received saline. On POD 21, extensor
digitorum longus (EDL) muscles were harvested and maximal isometric force was
measured in vitro. The sciatic nerves were harvested and stained by X-gal
assay for beta-galactosidase. Histomorphometric analysis of SC was then
performed for each nerve graft.
Results: Sham Rosa26Bl/6 nerves contained 1105.2 β-Gal+
SC per 106 µm2 nerve CSA while all other groups showed
lower counts of β-Gal+ SC (Table). Isogeneic C57Bl/6 nerve
grafts contained 23.5% of the β-Gal+ SC count when normalized
to sham group density. Nerve allotransplantation with MR1 averaged β-Gal+
SC counts comparable to that of the isograft group
with 181.4% the number of autogenous SC. Nerve allotransplantation
without MR1 averaged fewer β-Gal+ SC with only 16.3% that of
the isograft group. Boxplot 1 demonstrates the
recovery of EDL muscle force for all experimental groups with Sham force >
Allograft with MR1 force > Allograft with saline force > Isograft with
saline force.
Conclusions: Allografts treated with MR1 have 1113% more
autogenous SC per 106 µm2
nerve CSA than do allografts treated with saline. SC
migration into the nerve graft of allografts treated with MR1 is comparable to
that of isografts treated with saline. Recovery of muscle force production
following nerve allotrasplantation was improved with MR1 treatment when compared with saline controls. These data are
indicative of a permissive state which allows migration of autogenous SC into
the nerve graft.
Table. β-Gal+
Schwann cells counted in Rosa26Bl/6 mouse nerve
grafts 21 days post operative.
| Group |
Sham + Saline | Isograft + Saline | Allograft + Saline | Allograft + MR1 |
n | 3 | 3 | 2 | 3 |
SC/ 106 µm2 nerve CSA* | 1105.2 ± 614 | 260.1 ± 233 | 42.4 ± 21.5 | 471.8 ± 347 |
% SC migration compared to Isograft + Saline Group | --- | 100 | 16.3 | 181.4 |
*Values shown as mean ± SD. The nerves were cut mid-graft and quantification of SC was done by counting blue (autogenous) cells per 106 µm2 nerve cross sectional area (CSA). SC= Schwann cell |
Paper: Paraspinous Muscle Flap Reconstruction of Complex Midline Back Wounds: Risk Factors and Incidence of Post-flap Complications at a Busy Regional Spine Center
Alexander F. Mericli, BS, Plastic Surgery, Jefferson Medical College, Philadelphia, PA
Nicholas Tarola, MD, Plastic Surgery, Jefferson Medical College, Philadelphia, PA; John H. Moore, MD, Plastic Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA; Steven E. Copit, MD, Plastic Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA; James W. Fox, MD, Plastic Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA; Gary A. Tuma, MD, Philadelphia, PA
PURPOSE: The purpose of this study is to examine the effect of various preoperative risk factors on postoperative complications after paraspinous muscle flap reconstruction of non-healing back wounds. As one of thirteen spinal cord injury centers in the United States, exposure to complicated spinal problems is common. With increasingly complex spine surgeries now performed on a more comorbid patient population, the reconstruction of midline back wounds from these procedures is becoming a frequent dilemma encountered by plastic surgery.METHODS: An 11-year retrospective office and hospital chart review was conducted between July 1996 and August 2007. All patients who underwent reconstruction using paraspinous muscle flaps during this time period were included. There were 92 patients in the study, representing the largest reported series to-date for this procedure.RESULTS: Over an 11-year period, 92 patients underwent spinal wound reconstruction using the paraspinous muscle flap technique. Mean length of follow up was 120 days. Wound complications necessitating reconstruction included infection (75/92; 82%), dehiscence (16/92; 17%), seroma (10/92; 11%), and hematoma (6/92; 7%). 23 patients (25%) developed a post-flap wound complication and 15 patients (16%) developed a post-flap wound complication requiring hospital admission. Post-flap complications included infection (12/92; 13%), seroma (11/92; 12%), hematoma (1/92; 1%), and dehiscence (1/92; 1%). Preoperative risk factors and their associated complication rate are described in Table 1. Risk factors associated with a statistically significant (p<.05) increased rate of post-flap wound complication included emergent initial spine surgery, a history of more than two spine surgeries, hypertension, radiation to the wound area, smoking, a history of quadriplegia, and lumbosacral wound location. Malnutrition (albumin<3.5), obesity, chronic steroid use, anemia, and diabetes were not associated with a significantly increased rate of post-flap wound complications. 86/92 (93%) patients undergoing wound reconstruction had initial spine surgery requiring hardware. Patients who retained their hardware (50/86) had significantly fewer post-flap complications compared to patients who had their hardware removed pre-flap (26/86) (14% vs. 31%; p<.001). Patients with retained hardware had a shorter length of stay compared to patients whose hardware was removed (19 vs. 23 days).CONCLUSION: This patient population possesses multiple comorbidities making complex wound healing difficult. Several specific risk factors are associated with an increased rate of post-reconstruction wound complication. From a plastic surgery perspective, an attempt should be made to salvage hardware with the use of paraspinous muscle flaps, as salvage is associated with fewer post-flap wound complications and a shorter length of stay.
> >Table 1: Odds Ratio and Rate of Complication associated with various preoperative wound healing risk factors | Complication Rate (%) | % Pt in Group with Complications | Odds Ratio | Confidence Interval | P |
Hx. Of > 2 spine surgeries | 78.6 | 57.1 | 3.23 | 1.17-8.9 | 0.0007 |
Hypertension | 43 | 27 | 1.22 | 0.98-1.52 | 0.02 |
Chronic Steroids | 40 | 26.7 | 1.04 | 0.66-1.63 | 0.4 |
Diabetes | 31 | 17.2 | 0.85 | 0.61-1.17 | 0.34 |
Radiation History | 62.5 | 37.5 | 3 | 0.66-5.34 | 0.04 |
Collagen-Vascular Disease | 50 | 40 | 1.53 | 0.53-2.74 | 0.31 |
Current or Former Smoker | 43 | 30 | 1.2 | 0.49-2.84 | 0.35 |
Current Smoker | 50 | 33.3 | 1.76 | 0.71-2.29 | 0.04 |
Former Smoker | 36.8 | 26.3 | 0.93 | 0.33-2.6 | 0.45 |
Anemic (Hb<10) | 29.5 | 22.7 | 0.49 | 0.21-1.20 | 0.11 |
Malnutrition (alb<3.5) | 38 | 25.8 | 0.8 | 0.52-1.23 | 0.13 |
Obese | 40.6 | 28.1 | 1.1 | 0.75-1.5 | 0.35 |
Quadriplegia | 100 | 50 | 4.06 | 2.3-5.82 | 0.01 |
Emergent Spinal Surgery | 56.2 | 43.8 | 2.19 | 1.62-4.12 | 0.04 |
Lumbar Wound Location | 48.1 | 37.0 | 2.99 | 1.19-7.49 | 0.01 |
Thoracic Wound Location | 43.3 | 26.7 | 1.39 | 0.57-3.38 | 0.49 |
Cervical Wound Location | 29.6 | 18.5 | 0.59 | 0.23-1.55 | 0.35 |
Paper: An Anatomical Study of the Superficial Peroneal Nerve Accessory Artery and Its Perforators, and Clinical Application of Superficial Peroneal Nerve Accessory Artery Perforator Flaps
Tae Hyun Choi, MD, PhD, Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Medical Center, Daegu, South Korea
Jun Hyung Kim, MD, PhD, Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Medical Center, Daegu, South Korea; Kihwan Han, MD, PhD, Department of Plastic and Reconstructive Surgery, Dongsan Medical Center, Keimyung University, Daegu, South Korea; Daegu Son, MD, PhD, Department of Plastic and Reconstructive Surgery, Keimyung University Dongsan Med. Cntr, Daegu, South Korea
An Anatomical
Study of the Superficial Peroneal Nerve Accessory Artery and Its Perforators,
and Clinical Application of Superficial Peroneal Nerve Accessory Artery
Perforator Flaps
Background: In the 1990s, skin island flaps supplied by the vascular axis of
sensitive superficial nerves, like the sural and saphenous nerves, were
introduced. Flaps supplied by the superficial peroneal nerve accessory artery
(SPNAA), however, are still not commonly used. The
aim of this study is to understand the anatomical structure of the SPNAA and
its perforators, and to utilize SPNAA
perforator flaps in the clinic.
Methods: We dissected sixteen cadavers and assessed the location and number of the SPNAA, its perforators, and the septocutaneous
perforators originating from the anterior tibial artery. The largest diameter
of the SPNAA was also measured.
A SPNAA
perforator flap was applied to thirteen patients, the
free flap was applied to twelve patients, and the pedicled flap was applied to
one patient.
Results: The origin of the SPNAA was 4 to 8 cm (average 5.5 cm) away from the
fibular head. The SPNAA was 7 to 16 cm in length (average 12.33 cm),
originating from the superior lateral peroneal artery and gradually
disappearing between 15 and 22 cm (average 17.06 cm) from the fibular head. The
largest diameter of the SPNAA was between 0.6 and 1.2 mm (average 0.85 mm). The
number of perforators in SPNAA examined ranged from zero to eight (average 4.5).
Of these, the number of septocutaneous perforators ranged from zero to six (average
3.19), and the number of musculocutaneous perforators ranged from zero to three
(average 1.31).
The size of the flap ranged
from 3.5 x 6 cm to 9 x 12 cm (mean 65.5 cm2). The complete follow-up
period ranged from 6 to 24 months (mean 9 months). Although
one flap was lost due to arterial thrombosis, the procedure was successful in
the remaining twelve patients. The flap was very
thin, comparable in thickness to the recipient site (i.e. foot, ankle,
pretibia, knee or hand), and thus, aesthetically appealing.
Conclusion: SPNAA perforator flaps could be an
excellent alternative to perforator flaps that use the lower leg as a donor
site.
Legends
Fig. 1. (Above,
left) Preoperative view. (Above, right) Preoperative design of the SPNAA
perforator flap. (Below, left) The septocutaneous perforator of the SPNAA
(yellow arrow) is the pedicle of this flap. Black arrow indicates the SPN. EDL:
extensor digitorum longus. PL: Peroneus longus. (Below, right) Post-operative
observation six months after surgery.
Panel: In the News: Reconstructive Innovations
Moderator: Keith E. Brandt, MD
Objective(s):Watch and learn from member submitted videos highlighting techniques and innovations that will enable to you to perform reconstructive procedures faster and more safely while obtaining better results. This Reconstructive News Broadcast will feature adjunctive components to recognized procedures and demonstrations of how to easily perform difficult procedures.
Paper: Occupational Injuries in Plastic Surgeons
Pranay M. Parikh, MD, Plastic Surgery, Georgetown University, Washington, DC
Steven P. Davison, MD, DDS, Plastic Surgery, Georgetown University Hospital, Washington, DC; Avery C. Capone, BSc, Georgetown University Hospital, Washington, DC; Mark Clemens, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC; Ken Means, MD, Curtis National Hand Center, Union Memorial Hospital, Baltimore, MD
Purpose: To date, information on occupational injuries associated with the work of surgery has been limited. The purpose of this study is to assess the potential occupational hazards faced by surgeons while operating, to identify the most common disorders experienced by surgeons and estimate their prevalence, and to identify potential risk factors associated with injuries in surgeons.
Methods: All practicing plastic surgeons were eligible for inclusion in the study. Participating surgeons completed a standardized survey instrument assessing demographic information (age, gender, years operating, specialty, loupe use, and microscope use), the incidence, frequency, severity, and etiology of injuries of the head, neck, back, and upper extremity, as well as the validated QuickDASH instrument to assess the degree of disability resulting from surgeons’ injuries. Multivariate regression analysis of the data was performed to identify associations between injuries and risk factors.
Results: 210/292 surgeons contacted completed surveys, yielding a response rate of 72%. In the head, neck, and back, the most commonly reported injuries were muscle strains (66%), vision changes (38%) and cervical disc degeneration (33%). In the upper extremity, the most commonly reported injuries were carpal tunnel syndrome (19%), shoulder arthritis (18%), and medial/lateral epicondylitis (16%). 75% of participants reported at least 1 percutaneous exposure within the 12 months of survey participation, while 52% experienced splash exposures. 55% of participants were being treated for health conditions related to operating, with medication, physical therapy, or surgery. 62% of participants who reported an injury perceived their injuries to be related to the work of operating. The average QuickDASH: score of those surveyed was 4.80, with mean work module scores and mean ports/performing arts module scores of 3.83 and 6.39 respectively. Age, number of years in practice, and loupe use were significantly associated with reported injuries.
Conclusion: Injuries of the neck, back, and upper extremity were prevalent in our sample of surgeons. Although the majority of participants perceived these injuries to be related to the work of operating, the vast majority did not feel that their injuries resulted in occupational or personal disability. Although no causal relationships can be determined from this survey, efforts to better understand the incidence of these injuries may provide valuable information to improve operating room ergonomics and workplace safety for surgeons.
Paper: Flexor Tendon Tissue Engineering: the Biomechanical analysis of explanted Acellularized Tendon Constructs
Andrew Zhang, MD, Plastic Surgery, Stanford University, Stanford, CA
Sae Ki, MD, Stanford University, Stanford, CA; Sepideh Saber, BS, Stanford, Stanford, CA; Hung Pham, BS, Plastic Surgery, VA Palo Alto Health Care, Palo Alto, CA; Derek Lindsey, BS, Bone and Joint Center, VA Palo Alto Health Care, Palo Alto, CA; James Chang, MD, Div of Plastic Surgery Stanford Univ., Palo Alto, CA
Purpose:The demand for tendon grafts frequently exceeds supply in mutilating hand injuries. Our tissue engineering model uses the acellularized rabbit forepaw zone II flexor tendon as the scaffold. Cultured tenocytes and adipoderived stem cells (ASCs) are seeded onto acellularized tendon to create novel tendon constructs. Previous studies have established that these constructs are viable in vitro, and that the constructs along with acellularized scaffold maintain comparable tensile strength to fresh tendons in vitro. The purpose of this study is to investigate the in vivo integrity of our scaffold and tendon constructs.
Methods:The experimental cohort contains three groups including 1) acellularized tendon scaffolds, 2) constructs seeded with cultured tenocytes, 3) constructs seeded with ASCs. These constructs were grafted to span a 2 cm gap in rabbit zone II 3rd digit FDP tendons. Our controls included autologus tendon graft over the same area in the adjacent 4th digit and intact fresh tendon in the 2nd digit. All tendons subject to grafting, autologus or tendon engineered constructs, were detached from proximal muscle to prevent post-op rupture. Macroscopic and histological appearance along with mechanical testing for ultimate tensile stress were determined at 2 and 4 weeks time points. Statistical analysis was performed using the paired two-tailed student t test.
Results & Conclusions:Acellularized scaffold and seeded tendon constructs, tenocytes or ASCs have macroscopic appearances indistinguishable from autologus graft and fresh tendon at all time points. There did not appear to be significant adhesion formation between the grafts and the tendon sheath. Histologically, collagen architecture was preserved in all experiments groups. Fibroblast-like cells were irregularly distributed over the surface of the grafts. Minimal cell penetration into the collagen architecture was noted, however it appears that there was more cell penetration as time elapsed. The ultimate tensile stress was not statistically different between our three experimental cohorts and autologus graft and fresh tendon controls. At 2 weeks time point, the average ultimate tensile stress for intact tendon was 60 (N/mm2) compare to 52 (N/mm2) for autologus graft (n=12; P=0.2), 61.2 (N/mm2) for acellularized tendon (n=3, P=0.46), 46 (N/mm2) for Tenocyte seeded constructs (n=4, P=0.55), and 67 (N/mm2) for ASC seeded constructs (n=7; P=0.12). At 4 weeks, the average ultimate tensile stress for intact tendon was 53 (N/mm2) compare to 42 (N/mm2) for autologus graft (n=7; P=0.13), 46 (N/mm2) for acellularized tendon (n=3; P=0.5), 41 (N/mm2) for Tenocyte seeded constructs (n=3; P=0.29), and 42 (N/mm2) for ASC seeded constructs (n=3; P=0.3).
Relevance: Our study suggests that tissue engineered grafts remain viable in the short-term in vivo. Surprisingly, acellularized tendon alone retained strength and may be a suitable substitute for autologus grafting in the short term. Further work will include longer follow up and analysis of repair strength and construct gliding characteristic.
Paper: The First 1400 Consecutive Cases of Wide Awake Hand Surgery in a Single Surgeon's Practice: Lessons Learned
Donald H. Lalonde, MD, Dalhousie Universily, Saint John, NB, Canada
Janice F. Lalonde, RN, Saint John, NB, Canada
Hypothesis: What were the most important lessons learned in the first 1400 consecutive cases of wide awake hand surgery in a single surgeon’s practice?
Methods: Wide awake hand surgery is performed with no sedation, no general anesthesia, and no tourniquet. Only lidocaine with epinephrine is injected directly into the affected parts of the hand and fingers for anesthesia and hemostasis. The author has kept careful records of all of the patients in his hand surgery practice in which 95% of surgery is now performed with the wide awake approach.
Results: The first 1400 consecutive wide awake cases included 628 carpal tunnels, 167 trigger fingers, 129 operative reduction of hand fractures, 51 Dupuytren’s, 34 extensor tendon repairs, 22 flexor tendon repairs, 11 trapeziectomies for basal joint arthritis, 6 tendon transfers and 2 tendon grafts.
Summary: The wide awake approach has its greatest advantages in flexor and extensor tendon surgery (repairs, transfers, and grafting), in finger fracture surgery, and in complex secondary procedures because the surgeon can watch cooperative comfortable patients actively move reconstructed tendons and bones during the surgery and he can make adjustments to the repair before closing the skin. Carpal tunnels and trigger fingers can be performed with great convenience and efficiency for both the patient and the surgeon. Elderly patients or those on multiple medications avoid the risks and inconveniences of general anesthesia and hospital admission. However, repeat surgery for Dupuytren’s contracture remains a challenge because of persisting bleeding in spite of epinephrine injection.
Panel: ASPS/ASRM Panel: Reconstructing the Future
Moderator: Lawrence B. Colen, MD
Peirong Yu, MD, MS
Susan E. Mackinnon, MD
Darrell Brooks, MD
Objective(s):Reconstructive surgery is constantly evolving. “New” solutions for “old” problems are the hallmarks of our specialty. Learn “techniques in evolution;” procedures that may well become the “gold standard” in the future.
Paper: In Vivo Electrophysiologic Properties of Poly 3,4-ethylenedioxythiophene (PEDOT) in a Biosynthetic Nerve Interface
Brent Egeland, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
William M. Kuzon, Jr, MD, PhD, University of Michigan, Ann Arbor, MI; Paul S. Cederna, MD, Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI; Melanie Urbanchek, PhD, Plastic Surgery, University of Michigan, Ann Arbor, MI; David Martin, PhD, Materials Science & Engineering, University of Michigan, Ann Arbor, MI; Richardson-Burns Sarah, PhD, Materials Science and Engineering, University of Michigan, Ann Arbor, MI
Introduction:
Extremity amputation causes substantial functional deficits and reductions in tactile interactions with the environment while performing activities of daily living. Restoring mechanical and sensory function following amputation is critically important. Robotic prosthetics can restore many of the necessary functions, yet a high fidelity interface with cortical or peripheral signals remains elusive. Existing capacitive and myoelectrical peripheral interface devices have poor durability and fidelity for detecting small specialized physiologic currents. Biointegrated neural prosthetic interfaces must address the conversion of physiologic, ion current derived action potentials (<1mA) to electron mass-transport currents for device and electronics circuitry. One of our aims is developing a durable, high-fidelity, biologically integrated neural prosthetic interface that will detect peripheral nervous system (PNS) motor signals allowing robotic prosthetics control. In this study, we evaluate in vivo conductive properties of a bioartifical PNS interface utilizing poly 3,4-ethylenedioxythiophene (PEDOT), a novel, highly electroconductive, biocompatible compound polymerized on a chemically acellularized muscle scaffold.
Methods: A rat (Fischer Scientficic F344) hindlimb peroneal nerve model was used for all experiments. We tested several biomaterials ability to detect and propagate an efferent action potential across a nerve gap, and stimulate a corresponding action potential in the distal peroneal nerve in the acute setting. The purpose of these experiments was specifically determine if the electroconductive polymer, PEDOT, could detect and stimulate physiologic action potentials for use as a PNS interface, not to design a biomaterial to be used as a nerve graft clinically. Three artificial, biologic, and bioartificial constructs were evaluated in a peroneal nerve gap model: 1) Chemically acellularized rat muscle (ACM), 2) Acellular muscle treated with Iron (III) Chloride, a PEDOT polymerization reagent (ACM-Fe), and 3) Acellular muscle treated with a PEDOT chemical polymerization process (ACM-PEDOT). These materials do not possess cellular machinery necessary for action potential propagation and presumably conduct via electron mass transport. Control groups for these experiments included: 1) Intact peroneal nerve (Intact) (N=70), 2) Intact nerve in presence of lidocaine (to confirm stimulator derived action potential versus electron current) (Intact-Lido), 3) a single coaptaion epineural repair (Epineural) 4) Nerve gaps with no graft for reconstruction (Nerve Gap), and 4) Autogenous nerve (Nerve Graft). N=5 for each experimental group. Peroneal nerve gap lengths were 0,5,10,15 and 20mm. All nerve and material coaptations were performed with 10-0 nylon suture using a standard epineural suture technique. We evaluated the electrophysiologic properties in each experimental group by exogenously stimulating the peroneal nerve proximal to the coaptation site in vivo and measuring distal to the distal coaptation site using standard NCV/EMG techniques. Stimulation amperage (mA) was varied to obtain maximal EMG response (mV) in the extensor digitorum longus (EDL) muscle, with measurement of the associated nerve conduction latency (ms) and velocity (m/s).
Results:
Exogenous nerve stimulation proximally in the intact peroneal nerve gerenerated typical action potentials distally; this response was eliminated when voltage gated sodium channels were blocked by lidocaine. NCV/EMG results (Table 1) demonstrate ACM-PEDOT constructs conduct physiologic currents (0.53 ± 0.19 mA) up to 20mm with maximal amplitude of 16.60 ± 5.29 mV, and latency of 1.09 ± 0.15 ms. These ACM-PEDOT data are consistent with NCV/EMG values for intact nerve or from similar length nerve autografts. ACM-PEDOT constructs showed a statistical increase in conductive velocity (40.22 ± 8.71 m/s) compared with intact nerve (22.15 ± 3.68 m/s). 10mm ACM and ACM-Fe constructs were non-conductive and thus, longer lengths were not tested.
Conclusions:
PEDOT coated acellular muscle constructs can transmit the small currents (<1 mA) associated with physiologic action potentials in vivo. This indicates that the proximal nerve action potential can be electrically "sensed" via a PEDOT construct. Given the physiologically compatible conductive properties of this novel biomaterial, we have initiated development of implantable, long term, integrated bioelectrical coupler between the proximal nerve segment and the PEDOT construct, and between the PEDOT construct and electronics, with the ultimate goal of providing appropriate afferent control to a prosthetic limb.
Paper: Peripheral Nerve Tumors: Reconstructive Options and Treatment Algorithm
Ali Al-Attar, MD, PhD, Department of Plastic Surgery, Georgetown University Hospital, Washington, DC
Ivica Ducic, MD, PhD, Plastic Surgery, Georgetown Uiversity Hospital, Washington, DC; Daniel M. Barrett, MS, Virginia Commonwealth University, Richmond, VA
Background: Peripheral nerve tumors are mostly benign tumors, however their excision can lead to profound functional deficit. While physical examination, imaging, and electrodiagnostic studies can strongly suggest the diagnosis of a peripheral nerve tumor, surgical management is not as straightforward. This prospective study evaluates a treatment strategy that is reliable, safe, and offers maximal functional recovery.
Methods: Twenty patients with peripheral nerve tumors were treated using a uniform surgical paradigm between 2003 and 2007. Surgical tumor excision and reconstruction was performed in a single stage. No biopsies were performed. Nerve fascicles were dissected off of the tumor under magnification, and sacrificed nerve fascicles were reconstructed using nerve conduits. Patients were followed clinically from six to twenty-four months, and neuropathic pain and functional outcome were assessed.
Results: All twenty consecutive patients had neuropathic pain in the distribution of the affected nerve before tumor excision; only one patient had pain that persisted postoperatively. Seventeen of the twenty patients had complete functional recovery following nerve reconstruction. No perioperative complications occurred.
Conclusions: Peripheral nerve tumors require highly-specialized surgical care to ensure optimal functional results. Single-stage tumor excision under magnification, with immediate reconstruction, permits functional recovery and minimizes scarring. Biopsy is indicated only if quick tumor growth is observed, or if imaging suggests malignancy. Functional recovery and complete pain relief should be expected in the majority of cases, with minimal morbidity.
Paper: Augmentation of the Regeneration of Peripheral Nerve Defects with the Transplantation of Donor Derived Bone Marrow Stromal Cells
William Duggan, MD, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
Christopher Grykien, N/A, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH; Aleksandra Klimczak, PhD, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH; Dileep Nair, MD, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH; James Gatherwright, N/A, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH; Siemionow Maria, MD, PhD, MSc, Department of Plastic Surgery, Cleveland Clinic, Cleveland, OH
Purpose: Nerve grafting has been the most widely accepted surgical intervention for the repair of peripheral nerve defects. Traditionally however, such interventions have been associated with varying degrees of donor site morbidity. In the search for alternative methods of peripheral nerve repair we have experimented with the use of biological and artificial materials for the creation of nerve conduits. This study was performed to assess the effects of bone marrow stromal cells (BMSC) in nerve gaps repaired with isogenic epineural tubes filled with isogenic and allogenic BMSCs.
Methods: A total of 54 epineural tubes were transplanted in 3 experimental groups (18 animals in each group). Group 1 was control saline, Group 2 isogenic BMSCs and Group 3 allogenic BMSCs. In Groups 2 and 3, BMSCs were stained with PKH-dye before transplantation, to assess nerve engraftment and migration. After staining 2.5-3.0 x 106 cells were delivered directly into the transplanted epineural tube. Evaluations were performed at 6, 12 and 18 weeks post-transplant. Sensory and motor recoveries were evaluated by Gastrocnemius Muscle Index (GMI) ,pinprick, toe-spread and Somato-Sensory Evoked Potentials (SSEP). Axonal countings were performed in addition to immunostaining with nerve growth factors: NGF, Laminin B2, GFAP, VEGF and Von Willebrand Factor for the assessment of the expression of neurotrophic factors and regenerative potential of transplanted BMSCs.
Results: 6 weeks post transplantation all groups scored 3 on the pin-prick test. Toe spread for groups 1,2 and 3 were respectively 1.7; 2; 1. SSEPs in groups 1, 2 and 3 (P1, N2-latencies; P1, N2 % of normal values) were respectively (20.2; 23.6; 113; 95), (17.5; 18.1; 98; 73) and (15.7; 21.65; 88; 87). GMIs in groups 1,2 and 3 were respectively (0.45; 0.48; 0.47). Group 2 showed a higher number of regenerated axons (90.6 ± 26.9) compared to Group 1 (71.4 ± 3.0) and 3 (76.4 ± 5.4). In groups 2 and 3 (with BMSCs) PKH positive cells in addition to NGF, Laminin B2, GFAP, VEGF and Von Willebrand Factor were found in the transplanted tubes. 18 weeks post transplant isogenic stromal cells (Group 2) expressed neurotrophic factors in the distal portion of the transplanted nerve in contrast to the allogenic group (Group 3) in which neurotrophic factors were expressed in the middle portion of the transplanted nerve. NGF-staining in combination with PKH-staining confirmed that BMSCs differentiated into neural tissues. Upregulation of Laminin-B2 in both groups indicated active nerve regeneration.
Conclusion: Co-transplantation of BMSCs within epineural tubes enhanced nerve regeneration of peripheral nerve defects and confirmed the regenerative potential of BMSCs through their differentiation into neural tissue. Isogenic BMSCs showed a greater regeneration potential than allogenic BMSCs. These findings correlated with functional recovery of the nerves as measured by SSEP and axonal regeneration utilizing electron microscopy.
Lecture: MRSA - A Note of Caution for Plastic Surgeons
Denise Murphy, RN, MPH, CIC
Objective(s): Discuss the epidemiology of MRSA and risk factors for community and hospital-acquired strains, identify specific evidence-based, as well as controversial, actions to prevent the spread of MRSA in the hospital and community, and understand the unique risk factors and infection prevention needs of patients undergoing clean surgical procedures.
Paper: Soft Polypropylene Mesh, But Not Cadaveric Dermis, Significantly Improves Outcomes in Massive Midline Hernia Repairs Using the Components Separation Technique
Jason H. Ko, MD, Plastic and Reconstructive Surgery, Northwestern University, Chicago, IL
Benjamin C. Paul, BA, Northwestern University, Chicago, IL; David M. Salvay, BS, MS, Chemical and Biological Engineering, Northwestern University, Evanston, IL; Gregory A. Dumanian, MD, Northwestern Memorial Hospital, Chicago, IL; Edward Wang, PhD, Surgery, Northwestern University, Chicago, IL
Purpose
The use of acellular cadaveric dermis for reconstruction of
abdominal wall defects has gained popularity over the past several years,
especially for procedures in a contaminated field. Though cadaveric dermis promotes tissue ingrowth and neovascularization, recent literature, in
conjunction with our experience, has led us to question the long-term tensile
strength and durability of cadaveric dermis in abdominal reconstruction. We limited our internal database review to
all consecutive patients who underwent a modified components
separation procedure by a single surgeon using either an acellular cadaveric
dermis or soft polypropylene mesh underlay for closure of a midline ventral
hernia defect. Our goal is to determine the
overall procedure success and complication rates of cadaveric dermis versus
soft polypropylene mesh underlay in abdominal wall reconstruction.
Methods
Between September 2004 and September 2007, 47 patients had a components
separation technique where either acellular cadaveric dermis (n=19) or soft
polypropylene mesh (n=21) was used as an underlay for fascial reinforcement but
never as a “bridging material” at the time of primary or subsequent repairs
(Figure 1). Additional patients (n=7) had
cadaveric dermis placed during one procedure, followed by soft polypropylene in
a subsequent surgery for the treatment of recurrence. In order to preserve periumbilical
perforators and skin blood flow, the external oblique releases were performed
through bilateral 6-cm transverse incisions that were made just inferior to the
lowest aspect of the rib cage (Figure 2).
Results
The cadaveric dermis
and soft polypropylene groups were similar in terms of patient demographics
(Table 1), the main difference being the presence of contamination at the time
of surgery—31% for the cadaveric dermis group compared to only 7% for soft
polypropylene (p=0.0366). The use of acellular
cadaveric dermis was associated with a 42% “true” recurrence rate that required
re-operation, whereas soft polypropylene mesh had a significantly lower
recurrence rate of 11% (p=0.0124). In
patients where cadaveric dermis was used, the major complication rate was 15% with
a minor complication rate of 12%, while soft polypropylene mesh was associated
with a slightly lower rate of 11% for both major and minor complications. In terms of minor complications seen in both
groups, cadaveric dermis demonstrated an increased incidence of post-operative cellulitis (11.1% compared to 3.3%). Two patients in the cadaveric dermis group
required operative re-exploration for bowel obstructions, one of which was
secondary to an incarcerated recurrent hernia.
No patients in the soft polypropylene group have developed a bowel
obstruction due to adhesive disease; however, one patient in the soft
polypropylene group underwent a surgical revision at an outside hospital for
undetermined reasons.
Conclusion
Our study demonstrates that soft polypropylene mesh exhibits
markedly improved recurrence rates compared to acellular cadaveric dermis when
used as a fascial underlay during components separation for abdominal wall
reconstruction. Although the difference
in recurrence rates may be partly due to the increased presence of
contamination at the time of cadaveric dermis implantation, the long-term
strength of the midline hernia repair, regardless of contamination, was not
augmented by cadaveric dermis. The long-term
strength and durability of intraabdominal soft polypropylene mesh are superior
to those seen with acellular cadaveric dermis, and to this point, late mesh infections,
fistulas, and bowel adhesions have not been observed in the soft polypropylene
group.
Paper: Component Separation Technique with Underlay Acellular Dermal Allograft (AlloDerm) for the Reconstruction of Complex Abdominal Wall Defects
Mazen S. Harake, MS, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Amy Shanks, MS, Anesthesiology, University of Michigan, Ann Arbor, MI; Melanie G. Urbanchek, PhD, Plastic Surgery, University of Michigan; Daniel J. Krochmal, MD, General Surgery, Mayo Clinic - Scotsdale; Laura Pressley, BA, Anesthesia, University of Michigan, Ann Arbor, MI; William M. Kuzon, Jr, MD, PhD, University of Michigan, Ann Arbor, MI; Michael Franz, MD, General Surgery, University of Michigan
Background: In patients with ventral hernias, primary fascial approximation results in a 40-50% risk of recurrence. The use of synthetic mesh has decreased recurrence rates to 20-25%, but carries its own subset of risks including infections, fistulas, and other complications often mandating implant removal. The component separation technique (CST) provides a medial mobilization of bilateral musculocutaneous units for closure without prosthetic material and may lower hernia recurrence rates. Purpose: In this retrospective study, we reviewed our series of patients at the University of Michigan, comparing complex incisional hernias repaired using the CST without a prosthesis or CST with the addition of an underlay acellular dermal allograft (AlloDermTM; LifeCell Corporation, Branchburg, NJ).Methods: After receiving Institutional Review Board approval, one hundred and fourteen patients were identified that were treated between March 2002 and November 2007. In all patients, the surgical technique involved musculofascial release of the external oblique muscle lateral to the linea semilunaris line. In 36 of 114 patients, a single-layer of AlloDermTM was implanted beneath the fascial edges of defect as an “underlay” interposition under moderate tension. After bilateral midline advancement of musculofascial units, a tension-free midline closure was performed. Patient demographics, preoperative risk factors, surgical indications, operative technique and details, and postoperative complications including recurrence rates were extracted from the clinical record. Pearson Chi-Square, Fisher’s Exact Test, and Mann Whitney U Test were used for analysis using SPSS v. 15 as appropriate.Results: Component separation technique (CST) was performed in seventy-eight patients without a prosthesis and in thirty-six patients using reinforcement of an underlay AlloDermTM. There were no statistical differences between the groups in terms of average age (52 versus 54 years), Body Mass Index (33 versus 35 kg/m2), male ratio (51% versus 44%), or history of previous surgeries (70% versus 78%). The average size of hernia defect in each group was statistically different 322 cm2 in the patients receiving CST alone versus 453 cm2 in the patients receiving CST and an underlay (p = 0.02). Postoperative complications including infection, seroma, and skin dehiscence were increased in patients repaired using CST without prosthesis compared with CST and AlloDermTM (p £ 0.05). In the CST without prosthesis group compared to the CST with AlloDermTM group, the recurrence rate was 24% (n=19) versus 14% (n=5), but this difference did not achieve statistical significance.Conclusions: This study demonstrates that component separation technique with the addition of a single-layer of underlay AlloDermTM implant in abdominal wall reconstruction and incisional hernia repair decreases postoperative complications and suggests that the recurrence rate may be lower with an AlloDermTM underlay. By optimizing tension, reinforcing and providing an adequate biocompatible prosthetic support, CST with a single-layer of underlay AlloDermTM should be considered for complex and recurrent hernia repair.
Paper: A Systematic Review of Outcomes and Complications of Reconstruction and Amputation of Type IIIB and IIIC Open Fractures of the Tibia
Daniel Saddawi-Konefka, BS, Plastic Surgery, University of Michigan, Ann Arbor, MI
H. Myra Kim, ScD, Center for Statistical Consultation and Research, University of Michigan; Kevin C. Chung, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Purpose: Open fractures of the tibia are common after high energy trauma. The question of whether to recommend amputation or limb salvage remains unanswered. Despite the abundance of literature on this topic, no formal systematic review comparing the two treatment options for open type IIIB and IIIC tibial fractures has been performed to critically compare outcomes. The purpose of this study is to conduct a systematic review to derive evidence-based recommendation concerning primary amputation versus limb salvage for IIIB and IIIC open fractures of the tibia.Methods: We performed a formal systematic review of observational studies comparing outcomes of primary amputation and limb salvage in type IIIB and IIIC open tibial fractures. We searched MEDLINE, CINAHL and EMBASE, for articles that met our pre-determined inclusion and exclusion criteria. The outcomes of interest included: duration of hospital stay, clinical complications, total rehabilitation time, quality of life, limb function, pain, and time until return to work. Pooling of statistical data was performed when possible.Results: We reviewed 1,947 articles, and twenty-six observational studies were included in our analysis. Length of hospital stay was similar for patients who underwent salvage (52 days: range 25-129) and those who underwent amputations (63 days: range 28-101). The most common complications after salvage attempts were nonunion (18%), osteomyelitis (16%), secondary amputation (9%) and flap failure (6%) based on our pooled analysis. These rates were regressed over year of publication to evaluate historical trends. The rate of secondary amputation decreased significantly over time (p=0.02). The rates of nonunion, osteomyelitis and flap failure all trended down over time but were not significant (p=0.09, p=0.21, p=0.87, respectively). Patients who underwent salvage took an average of 7.7 months to full-weight bearing (range 3.6-8.4 months) and an average of 11.0 months to union (range 7.9-12.3 months). Pain, quality of life and limb function outcomes differed between studies. Methods of assessment were varied across studies so outcomes could not be combined. Percent of patients who were able to return to work for patients who underwent salvage was 58% (range 19-100%) and for patients who underwent amputation was 73% (range 50-100%).Conclusions: The current literature offers no evidence to support uniformly superior outcomes of either primary amputation or limb salvage for IIIB and IIIC tibial fractures. Given the current abundance of literature, it is unlikely that additional outcomes trials will support either of these two management options. The next phase of research should be an economic analysis that incorporates preference (utility) and cost in the analyses to determine the most optimal strategy based on these two factors.
Panel: Coverage of the Lower Third of the Tibia
Moderator: Dennis P. Orgill, MD, PhD
Jeffrey E. Janis, MD
Raj Sood, MD
Geoffrey C. Gurtner, MD
Seng-Feng Jeng, MD
Objective(s): Discuss lower third reconstruction using local flaps, skin grafts, and free flaps. Analyze other alternatives including amputation and other medical devices such as Vacuum Assisted Closure and Skin Substitutes. Examine the future including stem cells, tissue engineering and advanced prostheses. Patient safety will be emphasized, including a discussion on appropriate patient selection and evidence based care.
Paper: Efficacy of Intralesional Fluorouracil Treatment for Problematic Scars
Aamir Siddiqui, MD, Division of Plastic Surgery , K-16, Hnery Ford Hospital, Detroit, MI
Mounir Haurani, MD, Department of Surgery, Henry Ford Hospital, Detroit, MI; Peter Hammal, BS, Wayne State University, School of Medicine, Detroit, MI
Introduction: Keloids scars can be uncomfortable, disfiguring and aesthetically undesirable. Our initial work with low dose intralesional fluorouracil (5-FU) showed it to be useful for controlling the growth of keloids and hypertrophic scars. Our hypothesis for this project was that intralesional 5-FU is more effective at controlling keloid scar growth and symptoms related to recurrant keloid scars than corticosteroids. Our outcome measures were scar volume and symptoms inventory.
Method: An institutionally approved prospective randomized study was designed. All patients had failed previous steroid therapy and/or excision. All patient agreed to possible off-label use of 5-FU. All patients underwent excision of the scar followed by regular injections of either 60 mg of Kenalog 40 (Triamcinolone) or 50 mg fluorouracil. No patient received more than 10 injections within the 12 months treatment window. Patients were then followed for an additional one year off therapy. Patient questionnaires were completed at specific intervals. Molds were made of the scars at four timepoints; pre-excision, post-excision, after completion of the 12 month treatment protocol and one year post-treatment (off therapy). Molds were made using Thixotrophic Vinyl Polysiloxane an isothermic dental mold material. Volume displacement was employed to determine volume of each scar.
Results: 38 patients completed the treatment protocol as well as the one year monitoring off treatment. Scar volumes this timepoint (post treatment) were 0.60 ± 0.40 cm3 for the steroid group and 0.44 ± 0.01 cm3 for the 5-FU group. There was no statistically significant difference between the groups at this timepoint. Reported symptom improvement was 72% for the steroid group and 75% for the fluorouracil group. . Recurrence was defined as ≥ 50% increase in measured scar volume relative to the original scar volume. Post treatment only the steroid-treatment group had a single recurrence. There were no recurrences in the fluorouracil group at that timepoint. At the one year follow-up (off treatment) mean scar volume was 0.97 ± 0.57 cm3 for the steroid group and 0.47 ± 0.39 cm3 for the fluorouracil group. The steroid-treated scars were statistically significantly larger than the fluorouracil-treated scars at one year follow up (p < 0.01). Additionally, the steroid group had three recurrences and the fluorouracil group had one at one-year follow-up. With regards to subjective symptom relief at one year, it decreased by two patients in the steroid group (61% of patients stated improvement) and one patient in the fluorouracil group (70%). The steroid group had no complications. The fluorouracil group had two patients with skin breakdown at the injection site during a single treatment. Both of these patients healed and went on to complete the treatment protocol without further difficulty. Conclusion: We used a prospective randomized study model to evaluate the role of two different medications in the management of recalcitrant keloids. No statistical difference was noted at the completion of the 12 months of treatment between the medications. At one year post treatment, the steroid treatment group not only had more cases of recurrence but also a statistically significant overall volume growth of the scars compared to the fluorouracil treatment group. Fluorouracil maintained the scar volume one year post-treatment. Our method of tracking the scars included both subjective symptoms and volume analysis. Symptom improvement was similar between the two groups and did not change much after a year off therapy. Our results show that post excision scar volume is better maintained long-term with fluorouracil compared to triamcinolone. Minimal morbidity was noted in the fluorouracil group. In our hands, volumetric analysis in conjunction with patient symptoms rating is a straightforward method for evaluating scar treatment protocols. Volumetric tracking of scars is a safe, reliable and reproducible technique for evaluating and comparing scar therapies. It allows for objective comparison of lesions regardless of location, orientation or shape. Intralesional fluorouracil is a safe and effective means of controlling problem scars both is terms of scar size and symptom control. It should be considered as another option for patients suffering from problematic scars.
Paper: The Vascular Supply of Muscles of the Body
Khalid Almutairi, MD, Plastic Surgery, Dalhousie University, Halifax, NS, Canada
Maolin Tang, MD, Department of Anatomy, Wenzhou Medical College, Wenzhou, China; Steven F. Morris, MD, MSc, Plastic Surgery, QEII Hlth Sci Ctr NHI Site Plas Surg, Halifax, NS, Canada
Introduction:
Knowledge of the vascular anatomy of skeletal muscles is of great importance to the reconstructive surgeon. Mathes and Nahai originally presented their classification in 1981 based on the pattern of vascular supply to individual muscles, and today this classification is very popular.
The objective of this study was to review the pattern of vascular supply to of skeletal muscles of the human body in a series of 40 cadavers.
Methods:
The lead oxide, gelatin and water arterial injection technique was utilized in a series of 40 cadavers. A total of 2339 muscles were individually dissected, and two dimensional angiograms were obtained. The angiograms were scanned, and the vascular supply to each muscle was classified according to the five groups described by Mathes and Nahai. The variability of muscle vascular supply was assessed.
Results:
A total of 72% of all muscles studies could be classified according to the Mathes and Nahai classification. We found that many muscles had variable patterns of vascular supply (28%), and a significant number of muscles exhibited a pattern of vascular supply which did not fit the Mathes and Nahai’s classification.
Conclusion:
This study demonstrates the excellent quality of angiograms produced by the lead oxide injection technique. As well, we observed significant vascular variability in skeletal muscle which can produce variable clinical results.
Paper: Advancement Of Muller's Muscle-Levator Aponeurosis Composite Flap For Correction Of Blepharoptosis
Dae-hwan Park, MD, PhD, Plastic and Reconstructive Surgery, Catholic University of Daegu, Daegu, South Korea
Background: Muller's muscle plays an important role in maintaining the position of the upper eyelid. The muscle itself has power to elevate the upper eyelid about 2 mm as showing 2 mm drooping of the upper eyelid in Horner's syndrome and the muscle is the important transmitter of the levator muscle action to the tarsal plate, so it should be preserved as much as possible in the operative procedure for blepharoptosis.
Methods: A total of 182 cases (240 eyelids) underwent advancement of the Muller's muscle-levator aponeurosis composite flap from September 1988 to December 2005 to correct mild to moderate congenital blepharoptosis with fair to good levator function and to correct mild to severe acquired blepharoptosis. Seventy-four percent (135 cases) was congenital blepharoptosis and sixty four percent (116 cases) was unilateral blepharoptosis. Follow up period was from 6 months to 18 years (average follow-up of 20 months).
Results: In operative results, 164 of 182 cases (90.1%) was restored to excellent range of the desired eyelid height in primary gaze after first operation but remaining 18 cases had minor revisions to make symmetrical and desired eyelid height. Most common complication was undercorrection of the ptosis. Conclusion: This procedure is simple and physiological procedure with no or minimal sacrifice of the Muller's muscle, yielding predictable and satisfactory results.
Panel: The South American and European Perspective - Refinements in Body Contouring
Moderator: Jeffrey M. Kenkel, MD
Dirk Richter, MD
Claude LeLouarn, MD
Ricardo C. Ribeiro, MD
Objective(s): Examine current status of lipoabdominoplasty and learn about new techniques in body contouring.
Paper: A Retrospective Study of Thigh Reductions by Medial Vertical Thigh Excision
Al Aly, MD, Iowa City Plastic Surgery, Coralville, IA
Amitabh Singh, MS, DNB, MCh, Iowa City Plastic Surgery, Coralville, IA; Albert E. Cram, MD, Iowa City Plastic Surgery, Coralville, IA
INTRODUCTION Thigh reduction after massive weight loss is a difficult operation potentially fraught with complications. We present a medial vertical thigh reduction technique that is designed specifically to treat large massive weight loss thigh deformities and avoid the risk of the two most dangerous complications; labial spreading and permanent lymphedema.
MATERIALS & METHODS
Surgical technique: A vertical ellipse is marked on the medial aspect of the thigh making sure that the top of the ellipse is posterior enough so that if a horizontal component is required to work out a “dog ear” superiorly, it will not pull on the labia and the femoral triangle region is avoided. The amount of horizontal excess to be resected at any point along the entire ellipse is based on trying to attain a “cone” shaped thigh with the widest aspect about 2 inches below the perineal crease and the narrowest aspect just above the knee prominence. At surgery the proposed ellipse of excision is liposuctioned aggressively to deflate the area but leave the underlying lymphatics as intact as possible. Prior to resecting, the edges of the proposed excision are “tailor-tacked” with staples along the entire ellipse, which will simulate the result of surgery before making any cuts. Adjustments are made accordingly and the ellipse is then resected and the wound is closed.
A retrospective analysis of patients who underwent thigh reduction in our practice from 2005 to 2007 was performed. Patients were included if they had undergone a prior belt lipectomy procedure and were excluded if they underwent other methods of thigh reduction. Patient charts and photographs were reviewed and the variables mentioned in the Result section were recorded.
RESULTS 12 patients fit the criteria mentioned above. Their average highest BMI was 56.22 and the average BMI at thigh reduction was 29.26. Average follow-up interval was 7 months (213.8days) with a range of 11 days to 2 1/2 yrs. Liposuction of the thighs was done along with belt lipectomy in 83%, prior to thigh reduction (interim liposuction) in 33%, and concomitant liposuction of other areas of the thigh during the reduction in 33 %. 33% had a small horizontal component added to the vertical excision to treat a small superior dog ear. 42% had minor wound dehiscence treated by conservative wound management, 17% had a seroma and one patient, 8.3%, had minimal scar hypertrophy. 75 % of the patients who underwent an interim liposuction procedure had some complication and the same was true of those who had a horizontal component added to the vertical excision. No incidence of hematoma, infection, skin necrosis, DVT, permanent lymphedema or labial spreading was noted. See figure 1 for a representative case.
Figure 1. This photograph shows one of the patients included in the study; prior to, above, and after, below, medial vertical thigh reduction. The patient underwent a belt lipectomy prior to the thigh reduction.
CONCLUSION The vertical thigh reduction technique presented here is based on the fact that most of the excess created by massive weight loss is horizontal in nature requiring a vertical excision. This places all the tension of closure in a horizontal direction thus avoiding potentially disastrous labial spreading. Avoidance of the femoral triangle, which contains the most important lymphatic station of the lower extremity, along with leaving behind as many lymphatic channels intact in the area of resection as possible also reduces the risk of permanent lymphedema. It is our conclusion therefore that the vertical thigh reduction technique presented here avoids labial spreading and permanent lymphedema.
Keywords: Body contouring, Thigh lift, Thigh reduction, lymphedema, labial spreading
Paper: A Retrospective Analysis of Elective Labia Minora Reduction with Regard to Operative Technique, Outcomes and Patient Demographics
Daniel A. Medalie, MD, Metrohealth Medical Center, Cleveland, OH
Purpose: This retrospective
study was designed to evaluate the author's experience performing labia minora
reduction over the last five years.
Methods: The operations were evaluated by chart review, and the results were
evaluated by before and after photo review paired with patient response to a
questionnaire. Factors assessed included patients' reasons for the surgery,
patient satisfaction with the procedure, operation duration and location,
operative technique and outcomes. The study was also designed to evaluate
typical patterns of labial hypertrophy and outcome based on starting
classification.
Results: Over the last five years the author has performed 118 labia minora
reductions. The majority of these operations were performed in the last
three years as the procedure has grown in popularity. The author currently
performs 4-6 procedures per month. 13% were performed in combination with
vaginoplasty to tighten the vaginal introitus. 24% were performed in
combination with other surgeries such as bladder suspension (dual surgery with
a urogynecologist), abdominoplasty and breast augmentation. Patient ages ranged
from 16 to 57. Reasons given for undergoing the surgery included irritation or
discomfort with activity or intercourse and embarrassment at the appearance of
the labia. 100% of patients who responded to the questionnaire stated that they
were happy that they had undergone surgery.
Initially the surgeries were uniformly performed in
surgery centers with either general anesthesia or deep sedation. In the last
two years, more than half of isolated labiaplasties have been performed in a
well-equipped clinic procedure room with local anesthetic and mild or no oral
sedation. Operative time is routinely under 1 hour. Post-op care includes 5
days of antibiotics and two weeks of topical Bacitracin ointment as well as
sitz baths. Vaseline to the operative site is then recommended for an
additional two weeks. The patients are told to refrain from intercourse for 1
month post-op.
Labia Minora hypertrophy can be classified into three
main sub-types: central (fig A, B),
diffuse (fig C,D), and anterior (fig E, F). The majority of observed
hypertrophy follows a central pattern with the excess tissue located equidistant
from the anterior and posterior extent of the labia. All sub-types were treated
with a similar "V" wedge central excision with occasional anterior
perpendicular extensions to eliminate multiple folds in the tissue. No clitoral
unhooding procedures were performed. Results were most favorable with the
central hypertrophy pattern (Fig. A, B), but all patterns responded fairly well
to the basic operation (see figs A-F).
Complications were classified as minor (no intervention
necessary), medium (minor intervention required or prolonged recovery) and
major (serious medical intervention required or chronic patient complaints).
There were no major complications. Minor complications included local
irritation lasting longer than 1 month and suture breakage that was allowed to
heal secondarily. Medium complications included infection requiring
antibiotics, prolonged irritation (up to three months) or poor scar or
asymmetry requiring minor surgical correction.
Infections were rare and limited to yeast
infections from peri-operative antibiotics and occasional stitch abscesses from
deep vicryl sutures. 7 revisions were performed to correct asymmetry,
persistent hypertrophy or uneven scars, 5 of which were performed in the
clinic. The longest reported chronic irritation and pain with intercourse was 4
months in 1 patient and three months in 4 patients. This seemed to correspond
with the duration of the deep vicryl sutures.
Conclusions: Surgical reduction of the labia minora is a quick and well
tolerated procedure that can frequently be performed in a well equipped clinic
or office procedure room. Complications are rare and correctible. Even patients
with complications express satisfaction with the procedure
Paper: Gender Dependent Outcomes in Body Contouring Surgery
Tae Chong, MD, Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
Jeffrey Gusenoff, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA; Ian Valerio, MD, MS, MBA, Plastic and Reconstructive Surgery, Magee Womens' Hospital, The University of Pittsburgh Medical Center, Pittsburgh, PA; Angela Y. Song, MD, plastic and Reconstructive Surgery, University of Pittsburgh Med Ctr, Pittsburgh, PA; Devin Coon, MS, Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA; J. Peter Rubin, MD, Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
Background: Gender dependent outcomes in the surgical patient have been documented in the bariatric, trauma, and critical care/infectious disease literature. Body contouring surgery is technically demanding and a significant physiologic stress on the massive weight loss patient. Little is known about the effects of gender in this population
Method: Data was collected prospectively on all body contouring patients and their operations by a single surgeon (JPR) over a 4 year time period. Patient variables that were collected included: comorbid conditions, preoperative BMI, maximal BMI, age, and gender. Outcomes assessed included: operative time, deep venous thrombosis, pulmonary embolism, seroma, hematoma, surgical site infection, dehiscence, transfusion, and reoperation. Chi square analysis was utilized for dichotomous variables and Student's t-test for continous data. Significant factors were then evaluated using a binary logistic regression. Statistical significance was assigned if p values <0.05. SPSS statistical software was utilized for data anlaysis.
Results: Over the 4 year time period, 435 women and 48 men (8.9%) underwent body contouring surgery. The overall incidence of hematoma and seroma formation was 4.1% and 14.3%, respectively. Male gender was associated with an increased risk of hematoma (6/48, OR 4.22, p<0.05) and seroma formation (12/48, OR 2.15, p<0.05). However, male gender was not an independent predictor of wound dehiscence, flap loss, transfusion, or surgical site infection. Furthermore, while men were more likely to develop hematoma and seroma, this was not associated with an increased incidence of reoperation.
Conclusion: There are differences in surgical outcomes based on gender in the body contouring population. Males are at an increased risk of hematoma and seroma formation. These differences require further study.
Paper: Recommendations for Patient Safety in Body Contouring Surgery After a Review of 4,000 Consecutive Cases
Christopher K. Patronella, MD, FACS, The Aesthetic Center for Plastic Surgery (ACPS), Houston, TX
Amado Ruiz-Razura, MD, FACS, The Aesthetic Center for Plastic Surgery (ACPS), Houston, TX; German Newall, MD, FACS, The Aesthetic Center for Plastic Surgery, Houston, TX; Henry A. Mentz, MD, FACS, The Aesthetic Center for Plastic Surgery, Houston, TX
In recent years, there has been an increasing demand among plastic surgeons for patient safety that specifically addresses the complications suffered by certain patients regarding deep venous thrombosis (DVT) and pulmonary embolism (PE). In a survey conducted by Broughton et al. [4], he reveals that less than 50% of plastic surgeons use thromboprophylaxis as part of their standard protocol when performing aesthetic surgery. Pulmonary embolism represents the third highest cause of postoperative death in the US. Unfortunately, current data regarding this problem connected to aesthetic surgery is very limited. For this reason, it is our mission to share with fellow plastic surgeons our experiences taken from 17 patients, who have suffered from DVT/PE complications, in a review of 3,871 consecutive procedures performed over the last seven years in our center.
We conducted a retrospective chart review to identity the common factors responsible for causing DVT/PE among those high-risk patients who undergo aesthetic surgery. Of these cases, we have calculated the following incidence rates: 0.46% for DVT, and 0.08% for PE. We discovered that a culmination of factors working in a synergistic way plays a significant role in the development of DVT/PE. We conclude that a carefully planned out, comprehensive, appropriately enforced protocol is necessary to reduce the rate of thromboembolic events. Practical safety measures and technical recommendations are presented that strongly encourages the use of thromboprophylaxis during the preoperative, intraoperative and postoperative phases of aesthetic surgical procedures. Feel that DVT and PE should be an equal partnership between patient and surgeon.
Paper: Simultaneous Breast and Abdominal Aesthetic Procedures Performed Under Sedation
Joshua D. Zuckerman, MD, Plastic Surgery, Brown University/Rhode Island Hospital, Providence, RI
Vineet Mehan, MD, Plastic Surgery, Brown University/Rhode Island Hospital, Providence, RI; Rahim Nazerali, MPH, Plastic Surgery, Brown University/Rhode Island Hospital, Providence, RI; Erik A. Hoy, MD, Plastic Surgery, Brown University/Rhode Island Hospital, Providence, RI; Douglas Blake, MD, Providence Anesthesiologists, Providence, RI; Richard J. Zienowicz, MD, Plastic Surgery, Brown University, Providence, RI
.
Background: Intravenous sedation, supplemented by local and regional anesthesia, is becoming increasingly established as the anesthetic method of choice for a wide variety of aesthetic surgical procedures. It offers such advantages over general anesthesia as obviation of risk associated with intubation, reduction of post-operative nausea and vomiting (PONV), and containment of cost. Additionally, it allows a multitude of procedures to be performed in the office or outpatient setting, granting greater convenience and flexibility to both patient and surgeon. While several prior reports exist regarding either abdominoplasty or breast procedures performed under sedation, it had previously not been considered feasible to undertake simultaneous major aesthetic operations of both abdomen and breast without the employment of general anesthesia. We demonstrate a technique employing intercostal blocks and regional anesthetic, supplemented by propofol/ketamine for intravenous sedation. Objective: To demonstrate the safety and effectiveness of intravenous sedation, with local and regional anesthetic blockade, for concurrently-performed major breast and abdominal aesthetic procedures, through a review of experience at the authors' institution.
Patients and Methods: Over a five-year period from 2002-2007, 66 patients were operated on by a single surgeon/anesthesiologist team in one hospital-based ambulatory surgery center. All were ASA class I or II. All patients underwent abdominoplasty, concurrently performed with breast augmentation and/or mastopexy, under intravenous sedation with propofol infusion, ketamine, midazolam, fentanyl, and meperidine. Of these, 32 patients (48%) underwent additional procedures, including suction-assisted lipectomy (SAL), brachioplasty, and hernia repair. In all cases, supplemental local anesthesia was given in the form of lidocaine and bupivacaine instilled along incision lines, as well as field blocks for breast procedures. All patients underwent bilateral anterior intercostal blocks with bupivacaine and epinephrine, along the mid-axillary line. Additionally, 56 patients (85%) received bilateral posterior intercostal blocks with bupivacaine and epinephrine. SAL, where performed, was done so with tumescent lidocaine and epinephrine. PONV prophylaxis was given in the form of dexamethasone, in addition to ondansetron, metoclopromide, and/or dolasetron. A retrospective chart review was performed, evaluating operative and recovery room time, maximum O2 requirement in the post-anesthesia care unit (PACU), maximum PACU analog pain scale (0-10), operative complications, and need for hospital admission.
Results: Mean operative time was 224 min. (SD 111 min.). Mean time from end of surgery to transfer to PACU, representing emergence from anesthesia, was 7 min. (SD 5 min.). Mean time spent in the PACU prior to discharge was 111 min. (SD 53 min.). Mean PACU pain scale was 2.1 (SD 3.0). Maximum O2 requirement in the PACU averaged 2.3 L/min (SD 1.6 L/min). 4 patients (6%) required subsequent overnight admission to the hospital, for post-operative pain control. All the rest were weaned off O2 and discharged home on oral narcotic medications. There were no intraoperative complications, and no patients required conversion to general anesthesia. None of the discharged patients required readmission for pain control or nausea. Conclusions: These results demonstrate that simultaneous major abdominal and breast aesthetic procedures can both safely and effectively be performed under intravenous sedation. The technique requires the patient to begin in the prone position for posterior intercostal blocks (if needed) and additional anterior intercostal blocks and infiltration of local anesthetic. Intravenous sedation is administered utilizing a propofol and ketamine infusion. We show that these patients tolerated the procedures with a high level of patient comfort, and exhibit a low incidence of complication.
Panel: Special Closing Session: Inspiring Innovation - Transcending and Amplifying Development Through Technology and Research
Moderator: Andrew Lee, MD
William M. Kuzon, Jr, MD, PhD
J. Peter Rubin, MD
Susan E. Mackinnon, MD
Wayne Morrison
Objective(s): Historically, plastic surgeons have been on the leading edge of medical innovations, and recent advances in techniques and technologies have only scratched the surface of what promises to be a new era in patient care. Innovation is a key component to advancing clinical practice, maintaining quality outcomes, and enhancing patient quality of life; one that crosses all specialties and geographic boundaries. We are looking at a future that holds enormous opportunities for innovation - from new diagnostics to new devices. Plastic surgeons are involved in the development of current and emerging technologies and innovations poised to transform the clinical practice of plastic surgery and the entire medical landscape. What are these innovations and what impact will they really have on how we practice medicine? What opportunities lie ahead? Innovation is the future - how do we ensure we continue to fuel the innovation engine that will power what is on the next horizon?
Panel: Radiation and the Breast - Long-Term Issues in Breast Reconstruction
Moderator: Neil A. Fine, MD
E. Dale Collins, MD
Andrea L. Pusic, MD, MHS
Elisabeth K. Beahm, MD
Scott L. Spear, MD
Objective(s): Discuss types of radiation, effects of radiation and how this information can be used to make informed decisions on how to treat women who will undergo or have undergone radiation therapy for breast cancer.
Paper: Single-Stage Immediate Breast Reconstruction Using Silicone Implants: An Outcomes Analysis of 73 Consecutive Procedures
Lisa M. Hunsicker, MD, Revalla Plastic Surgery, Littleton, CO
Abstract
Single-Stage Immediate Breast
Reconstruction Using Silicone Implants: An Outcomes Analysis of 73 Consecutive
Procedures
Background: Primary breast reconstruction usually consists
of single-stage flap or two-stage tissue expander/implant reconstruction
techniques. The purpose of this study was to analyze a single surgeon's
consecutive series of single-stage reconstruction, without use of tissue
expanders, proceeding immediately with placement of silicone implants.
Methods: Between June 2003 and December 2007, 73
immediate breast reconstructions with silicone implants were performed in 40
patients, mean age of 49 years old (range 26-68 years old), who underwent
mastectomies. The surgical technique
utilized acellular dermal matrix as a pectoralis major muscle extension after
release of the pectoral inframedial fibers to allow higher volume silicone implants
to be used and provide adequate implant coverage. Average silicone implant size was 500cc
(range 275cc-700cc). Skin sparing
mastectomies provided enough viable skin to easily allow primary closure of the
skin for a single stage reconstruction. All
reconstructions were performed by a single surgeon in a private hospital
setting. The charts were reviewed
retrospectively for morbidity and outcomes.
Results: The mean follow-up time was 20.7 months, (range
2-56 months). There were 71 successful
breast reconstructions (97.3%) that provided single stage restoration of the
breast mound. In the 40 patients, there
was one DVT (2.5%) and one post-operative altitude-related hypoxic episode
(2.5%). In the 73 reconstructions, there
were zero hematomas, three sterile seromas (7.5%), one infected seroma (2.5%) requiring open
capsulectomy six months post-operatively, seven surgical site infections (9.6%),
three non-surgical site infections (7.5%), 10 mastectomy skin debridements (13.7%), 10 capsular contractures (13.7%)-four
due to radiation therapy, one due to infected seroma, and five idiopathic. Two
breast reconstructions (2.7%), in one patient, were unsuccessful due to beta-hemolytic
streptococcal sepsis five weeks post-operatively due to severe streptococcal
pharyngitis. Both implants were explanted, however, intra-operative cultures were negative
for any infection. Of the 71 successful
breast reconstructions, one had prior lumpectomy with radiation therapy five years
prior to mastectomy, one had radiation therapy 21 years prior to mastectomy for
treatment of Hodgkin's Lymphoma, and eight had unexpected post-operative
radiation therapy. There was no loss of
reconstructions in the radiated breasts (13.7% of total reconstructions).
Conclusion: Immediate reconstruction with silicone
implants utilizing acellular dermal matrix and skin sparing mastectomy is a
safe and efficacious single stage breast mound reconstruction technique.
Lisa M. Hunsicker, MD
FACS
Photos
Single-Stage Immediate Breast
Reconstruction Using Silicone Implants: An Outcomes Analysis of 73 Consecutive
Procedures
26 yo female, before and 6 months
after surgery with Mentor 600cc smooth, round, moderate profile silicone gel
implants bilaterally.
35 yo female, before and 18 months
after surgery with Mentor 500cc smooth, round, high profile silicone gel
implants bilaterally.
52 yo female, before and 6 months
after surgery with Mentor 600cc smooth, round, moderate
profile silicone gel implants bilaterally.
69 yo female, before and 36 months
after surgery with Mentor 600cc smooth, round, moderate profile silicone gel
implants bilaterally (and 30 months after surgery from open capsulectomy due to
infected seroma).
Lisa M. Hunsicker, MD
FACS
Paper: Immediate Breast Reconstruction After Skin-Sparing Mastectomy with the Latissimus Dorsi Flap and Low Profile Round Breast Implants. Evaluation of Results in 164 Consecutive Cases
Lawrence Garro, MD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Jose R. Castello, MD, PhD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain; Concepcion Minguez, MD, Plastic Surgery, Hospital Universitario Puerta de Hierro, Madrid, Spain
Introduction: Skin-sparing mastectomy (SSM) has become an established
procedure in breast surgery with similar oncological outcome and higher
aesthetic results when compared with conventional mastectomies, especially when
combined with immediate autologous reconstruction. The latissimus dorsi
myocutaneous flap in combination with prosthesis is a well-established procedure,
mainly indicated in patients in whom the use of abdominal flaps is precluded.
However, a variety of techniques has been proposed regarding latissimus dorsi
management (fixation of muscle, denervation, transection of humeral insertion),
implant positioning (subpectotal or not), and type of implant (anatomical or
round, expander or final implant).
Methods: We performed a retrospective review on 164 consecutive immediate
breast reconstructions after SSM with a latissimus dorsi flap combined with a
low profile round silicone gel breast implant. In all cases, the muscle was
transected from its humeral insertion and was not denervated or fixed in any
form to the chest wall. The pectoral muscle was left untouched. This technique
was indicated only in patients in whom the use of abdominal flaps was
contraindicated. Flap and donor-site complications and oncologic status were
evaluated. Information on aesthetic results and patient satisfaction was
collected.
Results: Mean follow-up was 39 months. No local recurrences were observed.
The cosmetic result was considered good or very good in 91 percent, and the
majority of patients were either very satisfied or satisfied. Complications
occurred in 25 patients, consisting of dorsal seroma (4.2% patients), post-operative
hematoma (1.2% patients), skin necrosis of the SSM (3.6% patients), capsular
contracture of the implant (6% patients), and dorsal pain (1.8% patients). All
complications except 4 were treated by conservative means. There were no flap
related complications. One-third of the patients referred tenderness at the
axilla and involuntary movements of the transferred muscle, but none requested
surgical revision. There were no complaints regarding loss of shoulder force and
function.
Conclusions: The latissimus dorsi myocutaneous flap combined with a low
profile implant is a consistent technique for breast reconstruction following
SSM. On the basis of our observations, pectoralis muscle does not need to be
elevated to obtain a complete muscular coverage of the implant, thus reducing
operative time and morbidity. We recommend keeping the latissimus dorsi muscle
innervated to maintain trophicity and prevent volume reduction and contraction
of the flap. Transection of the humeral insertion avoids bulging in the axilla.
Fixation of the muscle to the chest wall is not needed and may produce
deformities if incorrectly placed.
Breast implants in this type of reconstruction must be capable of completely
filling the wide base of the mastectomy, while projection is achieved with the
autologous component of the reconstruction. Breast shape is restored with the
skin paddle of the flap after SSM. Thus, low profile round implants are
preferred (Fig. 1).
Fig. 1. Immediate breast reconstruction after skin-sparing mastectomy with
the latissimus dorsi flap and low profile round breast implants.
Paper: Vertical Reduction Mammaplasty: Quantification of the Learning Curve in One Hundred Consecutive Cases by a Single Surgeon
Clark Friedrich Schierle, MD, PhD, Division of Plastic Surgery, Northwestern University, Chicago, IL
Jonathan Tresley, BA; Laurie A. Casas, MD, Glenview, IL
Background: Reduction mammaplasty utilizing a vertical scar
and a superior or medial dermoglandular pedicle provides several widely
accepted advantages over alternative techniques. Authors have often cited the
"intuitive" nature and difficult learning curve of the technique as impediments
to its widespread use. Here we seek to quantify the learning curve of this
operation in an effort to determine the critical factors for mastering this
powerful technique and minimizing complications. Methods: One hundred consecutive
vertical incision breast reductions performed by a single surgeon were reviewed
in an attempt to quantify the rate of improvement in several key objective and
subjective outcome measures over time. Variables analyzed included patient
demographic information, BMI, predicted and actual weight of resection, IMF
repositioning, pre- and post-operative symmetry as measured both subjectively
and objectively, pedicle choice, and rates of minor and major complications.
The one hundred cases were divided into temporal quartiles for analysis of
various performance measures as the senior surgeon gained comfort and
familiarity with the technique. Data from the four quartiles were compared
using the ANOVA and Mann-Whitney U tests for normally distributed non-parametric
variables, respectively. Results: The mean pt age was 31 (range: 17-62) with a
BMI of 24.8 (range 17.8-33.8). These parameters did not fluctuate significantly
between quartiles. Postoperative improvement in breast symmetry (measured by
both a subjective grading system and sternal notch to nipple-areola complex
distance) and rates of major complications decreased in a statistically
significant fashion from the first 25 cases to the last 25. There was no
statistically significant change in minor complications (spit stitches, wound
erythema, etcÉ) suggesting that these represent risks inherent to surgery.
There was a marked improvement approaching statistical significance in the
concordance between predicted and actual weight resected from the first quartile
to the last. The senior author's refinements to this technique resulting in
improved outcomes are presented including the necessity of preoperative skin/
glandular quality assessment, an algorithm for determining choice of pedicle,
and adequate fixation of both gland and skin to control breast shape and
position Conclusions: Quantitative learning curve analysis is becoming
widespread in other surgical fields, as the pay-for-performance paradigm has
taken hold. This study represents the first report of quantitative
"single-surgeon" learning curve analysis in the plastic surgical literature.
Our data clearly demonstrate that the "learning curve" of the v ertical scar
technique can be quantified in terms of subjective and objective criteria.
Continued analysis of outcomes is critical for identifying areas for constant
refinement of technique, however detailed quantitative statistical analysis
such as presented here can aid in determining an average number of cases
necessary to attain safety and proficiency.
Paper: Breastfeeding after Augmentation Mammaplasty
Norma I. Cruz, MD, University of Puerto Rico, Med. School, San Juan, PR
Leo Korchin, DDS, MS, Plastic Surgery, University of Puerto Rico, San Juan, PR
Introduction: Breastfeeding problems after augmentation mammaplasty, such as insufficient lactation, have been reported.
Method: The breastfeeding success of women who had augmentation with saline implants and had a live birth subsequent to their surgery (n=107) was compared to that of women of similar age who had hypoplastic breasts and had children before their consultation (n=105). A trained female interviewer used a standardized questionnaire to collect data on demographics and breastfeeding success. Patient information requested included age, location of breast incision, presence of normal nipple sensation (as judged by patient), whether breastfeeding was attempted, if it was successful, and the need to supplement with formula. For our study a period of two weeks or more was chosen as the defining duration of a successful breastfeeding attempt. Those individuals judged to be able to breastfeed were further classified on the basis of having breastfed exclusively or with supplementation.
Results: The groups were not significantly different in age (22±7 vs. 23±5). There was, however, a significant difference (p<0.05) between the control and study group in the breastfeeding success and need to supplement feedings. Successful breastfeeding occurred in 88% of the control and 63% of the study group. A need to supplement breast feeding occurred in 27% of the control group, but increased to 46% in the study group. No significant difference (p>0.05) was found in the breastfeeding experience between periareolar and inframammary approaches. Loss of nipple sensation after augmentation mammaplasty was reported by 2% of both the periareolar and inframammary subgroups.
Conclusion: The success rate of breastfeeding decreases about 25% and the need to supplement breastfeeding increases 19% in young women with hypoplastic breasts following augmentation mammaplasty.
Paper: Free Flap Breast Reconstruction in Advanced Age: Is it Safe?
Jesse Selber, MD, MPH, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
Meredith Bergey, MPH, MSc, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Seema Sonnad, PhD, Department of Surgery, University of Pennsylvania, Philadelphia, PA; Joseph M. Serletti, MD, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA
Background: Free flap breast reconstruction has become the method of choice for multiple centers performing autogenous reconstruction. Patients of advanced age may not be offered this most satisfactory method of reconstruction because of their increased prevalence of medical co morbidities and surgical risks. The purpose of this study is to determine if the rate of medical and surgical complications following free flap breast reconstruction in patients of advanced age is higher than those in the general population.
Materials and Methods: A retrospective review of 970 free, muscle sparing TRAMs, DIEPs and SIEAs by a single surgeon over a 15 year period was performed. The study population was subdivided into 920 patients under 65 years of age and 50 patients 65 years of age or older. Population variables included length of follow up, BMI, past medical history including hypertension, diabetes, peripheral vascular disease, heart disease, chronic obstructive pulmonary disease, preoperative and post-operative chemotherapy and radiation therapy, and history of smoking. Operative variables included timing of reconstruction, recipient artery and vein, anastamotic technique, intraoperative blood transfusion, and intra-operative use of heparin. Outcome variables included medical complications, length of stay, and surgical complications including abdominal hernia, fat necrosis, partial and total flap loss, vessel thrombosis, hematoma and seroma, mastectomy flap loss and wound infection. All analyses were also performed by procedure to see if there were differences by age for free TRAMs, DIEPs and SIEAs. Statistical Analysis included Chi-Squared Analysis and Fisher’s Exact test for all non-parametric outcome variables.
Results: The mean age of the population was 47, range 24-79 years old. For population variables, there was no difference in length of follow up, history of smoking, diabetes, peripheral vascular disease, heart disease or COPD between the <65 and 65 and over groups. The older group did have a higher prevalence of hypertension (40% v 19%, p < 0.001), a higher average BMI (31 v 28, p = 0.046), as well as lower rates of pre-operative (26% v. 4%, p = 0.001) and post-operative (16% v 2%) chemotherapy. In terms of operative variables, the older group received more intra-operative blood transfusions (8% v 2%, p = 0.023) and the coupler was used less often (10% v 29%, p = 0.023). For outcome variables, there was no difference in length of stay (3.5 days), medical complications (4%), or surgical complications (32%), including both donor site morbidity and flap complications. There was no difference in return to the OR, or operative revision rate. When these variables were further analyzed among the operative sub-groups, fTRAM, DIEP and SIEA, there were no additional significant findings.
Conclusions: In spite of higher rates of hypertension, a higher average BMI, and a higher rate of intra-operative blood transfusions, the 65 and over group had an equivalent rate of medical and surgical complications, equivalent revision and take-back rates, and similar lengths of stay. Conventional wisdom suggesting that free flap breast reconstruction should be restricted to a younger, and thus hardier patient population, is not supported by this study.
Poster: A Comparative, Long Term Assessment of Soft Tissue Substitutes: AlloDerm, Enduragen, and Dermamatrix
Kyle Gordley, MD, Plastic Surgery, Baylor College of Medicine, Pearland, TX
Patrick Cole, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Yoav Kaufman, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Larry H. Hollier, Jr, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Despite the recent introduction of several collagen based soft tissue substitutes, a lack of comparative clinical and histological analysis has complicated long term characterization. Ideally, such material would be durable, nonimmunogenic, virtually noninfectious, and would maintain consistency for an extended time period. Although AlloDerm (cadaveric dermal matrix), Enduragen (porcine dermal matrix), and Dermamatrix (cadaveric dermal matrix) reportedly offer these characteristics, comparative analyses of these materials over an extended time period is presently nonexistent. In the present study, the long-term clinical and histologic response of these three popular collagen-based materials in the in vivo murine model. Methods: Adult mice (n=8) received standardized 3mmX1cmX1cm AlloDerm, Enduragen, and Dermamatrix implants in individual dorsal subcutaneous pockets at Day=1. At time periods 3,6,9, and 12 months, n=2 mice were harvested for examination of all implant materials. Composites of skin, subcutaneous tissue, implant, and underlying muscle were harvested for qualitative study. Upon clinical analysis, graft materials were evaluated for migration, firmness, and mass maintenance. Histologically, specimens were analyzed for inflammatory response, encapsulation, and degree of tissue incorporation. Results: Although histological assessment of all three samples demonstrated similar encapsulation, peripheral infiltration, and surrounding inflammation, substantial variation was apparent on macroscopic evaluation. Enduragen maintained its original shape, and developed a cartilaginous firmness. Alloderm samples developed a loose, folded spherical shape, and were palpably firm. Dermamatrix, the second cadaveric dermal implant, both maintained its original shape and consistency. Despite these deviations in form, the volume and mass of all implants remained unchanged throughout the study period. Additionally, implant migration or extrusion was not observed. Conclusions: Histologically, all implant materials evaluated in the present study promoted neovascularization, incorporation, volume maintenance, and a high degree of host tolerance. However, subtle differences in microscopic behavior likely explain significant, long term variations in graft consistency and structure.
Poster: Asymmetric Crying Facies: A Possible Marker for Congenital Malformations
Osman Akdag, MD, Plastic Surgery, Selcuk University, Meram Konya, Turkey
Mustafa Sutcu, MD, Plastic Surgery, Selcuk University, Meram Konya, Turkey; Mustafa Keskin, MD, Selcuk University, Meram Konya, Turkey; Zekeriya Tosun, MD, Plastic Surgery, Selcuk University, Meram Konya, Turkey; Nedim Savaci, MD, Plastic Surgery, Selcuk University, Konya, Turkey
IntroductionAsymmetric crying face (ACF) is a minor anomaly where in one side of the mouth does not descend during crying. A congenital asymmetric crying face is caused by congenital hypoplasia or agenesis of the depressor anguli oris muscle on one side of the mouth. Asymmetric crying face (ACF) is a minor anomaly found in 3–8 per 1,000 births, which may be associated with other anomalies. This association has been reported in 20–70% of cases, most commonly in the cardiovascular system (44%) and less frequently involving the genitourinary, musculoskeletal, cervicofacial, respiratory, and, rarely, the endocrine system.
Case I A 12 month-old female child presented with cyanosis and recurrent respiratory tract infections. Asymmetric facies on crying had been noticed since birth. Examination and echo findings revealed tetralogy of fallot. There was a depression of the lefy angle of the mounth.
Case II A 10 month-old female child presented with cleft palate. During a routine physical examination, asymmetric crying face was noticed; the left corner of the mouth drew right and downward, while the left corner did not move when the baby cried. Forehead wrinkling, eye closure, and nasolabial fold depth remain intact and equal on both sides. These findings differentiate this disorder from a facial nerve palsy. Veau Wardill Kilner palatoplasty was performed. There were no intraoperative or postoperative complications and no relapse was observed in 16 months of follow up.Discussion Asymmetric crying facies (ACF) is a minor congenital anomaly seen in newborns. It is caused by either agenesis or hypoplasia of the depressor anguli oris muscle. This unilateral facial weakness is first noticed when the infant cries or smiles, affecting only one corner of the mouth, i.e., lower lip, and occurs on the left side in nearly 80% of cases. The face appears symmetric at rest, but the mouth is pulled downward to one side when crying. Asymmetric crying facies is a minor isolated finding in most cases; however the interesting aspect of this abnormality is the association with other major congenital anomalies. Hence all newborns should be carefully examined for this subtle facial sign and if found, a search for other anomalies should be performed. In addition, a multidisciplinary team should follow these patients, with screening for complications and appropriate management.
Poster: Refinements in Abdominoplasty: A 20-year single surgeon review
Andrew P. Trussler, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX
Dan Hatef, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Jon Kurkjian, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Rod J. Rohrich, MD, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
Purpose:The use of liposuction combined with abdominoplasty has been a controversial technique. Liposuction can dramatically improve the aesthetic result of an abdominoplasty, though the combination of techniques has been associated with an increased rate of venous thromboembolism (VTE) and wound healing complications. Through improvements in VTE prophylaxis, refinements in liposuction techniques, and an understanding of anatomy, this cumulative risk has decreased, though the negative stigmata persist. The purpose of this study is to describe the evolution of abdominal body contouring through the review of a single surgeon’s 20 year experience with abdominoplasty. Evaluation of this experience will highlight the significant contributions which have led to the improvement in the safety and efficacy of this technique.
Method:A retrospective review of patients undergoing abdominoplasty procedures was performed. Patient demographic information and procedural information including post-operative course and complications were recorded. Pre-operative and post-operative photographs were scored by blinded evaluators for aesthetic result and scar quality.
Results:Three hundred patients (N=300) undergoing abdominoplasty from 1987 to 2007 were included in the study. The use of a “superwet” liposuction technique in combination with abdominoplasty significantly decreased intra-operative blood loss (p<0.04), length of hospital stay (p<0.05), and blood transfusion requirement (p<0.01). Liposuction volume and region had no significant effect on abdominoplasty outcome, though refinements in operative technique, including abdominal and flank ultrasonic-assisted liposuction, high superior tension, and limited abdominal undermining did improve the post-operative aesthetic score. Venous thromboembolic (VTE) events significantly decreased with aggressive VTE prophylaxis (P<0.01).
Conclusion:The technical evolution of a single surgeon’s 20 year experience demonstrates liposuction can be safely and effectively combined with abdominoplasty. Pre-operative trunk analysis, intra-operative surgical refinements including super wet liposuction technique and peri-operative VTE prophylaxis significantly improve the outcome of abdominoplasty.
Poster: The Management of Hypertension in the Facelift Patient: Results of a National Survey
Andrew P. Trussler, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX
Dan Hatef, MD, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Spencer Brown, phd, Plastic Surgery, University of Texas Southwestern, Dallas, TX; Rod J. Rohrich, MD, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
Purpose
Hypertension is a common chronic medical condition. In the facelift patient, uncontrolled hypertension is a difficult acute condition, which can lead to significant complications in the perioperative period. The treatment of hypertension in the ambulatory medical setting has been standardized, though its treatment in the cosmetic surgery setting has been relatively ambiguous. The purpose of this study was to evaluate the current national trends in face lift practice and perioperative hypertension management.
Methods
Members of the American Society of Aesthetic Plastic Surgery (ASAPS) were surveyed regarding the management of hypertension in the perioperative period. Geographic location, surgeon volume, facelift method, and hematoma rate were evaluated.
Results
A response rate of 35.4 % (CI 95%) was attained with a total of 1776 surveys mailed and 629 surveys completed. Respondents were evenly distributed across the southern United States and, east and west coasts. West coast respondents reported a significantly higher annual number of face lifts as compared to the rest of the country. SMAS plication under general anesthesia performed as an outpatient procedure was the most common practice nationally for facelifts. The perioperative management of blood pressure was consistent with all respondents. Beta-blockers were commonly utilized throughout the perioperative course, though alpha agonists were reported more frequently by higher volume and more senior plastic surgeons (p<0.0001). Hematoma rate did not vary with medication type. Medical treatment at an intra-operative systolic blood pressure (SBP) threshold below 100 (p<0.04) and a post-operative SBP threshold above 140 (p<0.05) did significantly affect surgeon reported hematoma rate.
Conclusion
The most common practice trend currently in the United States for facelift surgery is SMAS plication under physician administered general anesthesia in an outpatient setting. Alpha agonists are more commonly utilized by experienced plastic surgeons in face lift surgery; however treatment threshold for systolic blood pressure significantly affects hematoma rate, not medication type.
Poster: Use of Preputial Flap for Scrotal Reconstruction after Fournier's Gangrene
Aisha White, MD, Plastic Surgery, University of Illinois at Chicago, Chicago, IL
Ramasamy Kalimuthu, MD, FACS, Plastic Surgery, Advocate Christ Hospital, Oak Lawn, IL
Debridement of Fournier's gangrene frequently results in scrotal skin defects with exposed testes. Scrotal reconstruction is important for functional, cosmetic, and psychological reasons. Many methods of scrotal reconstruction have been described, including skin grafting, a variety of local and regional flaps, and tissue expansion. Preputial flaps are discussed in the literature most commonly for scrotal reconstruction in cases of congenital scrotal agenesis and for correction of buried penis. We describe a one-stage technique for scrotal reconstruction using a preputial skin flap in a patient with a large scrotal skin defect with an exposed testis following debridement for Fournier's gangrene. This is a simple technique that can be used alone or in combination with other local flaps to provide stable testicular coverage with good cosmesis.
Poster: A NEW Treatment APPROACH for Sagittal Synostosis Surgery and Its Preliminary Results
M.Onur Cukurluoglu, MD, Plastic Surgery, Gazi University, Ankara, Turkey
Gokhan Kurt, MD, Neurosurgery, Gazi University, Ankara, Turkey; Fikret Dogulu, MD, Neurosurgery, Gazi University, Ankara, Turkey; Selahattin Ozmen, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Zerrin Ozkose, MD, Anaeshtiology, Gazi University, Ankara, Turkey; C. Reha Yavuzer, MD, Plastic surgery, Gazi University, Gazi Hospital, Ankara, Turkey; Kemali Baykaner, MD, Neurosurgery, Gazi University, Ankara, Turkey
Purpose: Various techniques have been performed for the correction of
sagittal synostosis. The goal of modern
craniofacial surgery is to achieve calvarial remodeling with minimally invasive surgical interventions.
The aim of this study is to describe a
new surgical technique for the treatment of sagittal synostosis and evaluate its
results by assessing cranial morphologic changes over time.
Material and Methods: From years 2003 to 2006,
18 patients with nonsyndromic single suture sagittal
synostosis have been operated with this new surgical technique. This technique
is a simple cranioplasty which includes two thin bone strips craniectomy nearby the sagittal sinus and long parietal barrel-stave
osteotomies. Anterior border of these strips is coronal suture, posterior
border is lamdoid suture. Strips are located in 2 cm distance to sagittal suture and the width of
these strips are 2 cm. Strips are fixed
using resorbable systems and placed to a more lateral position than their
original position (Fig. 1). Cranial lateral expansion is achieved due to
pressure of the skin flap and elasticity of resorbable fixation system.
|
| |
Figure 1: The schematic presentation of the
operational sequence.
3D Computed tomography, the cephalic index and
the axial width ratio measures are obtained preoperatively and postoperatively
at 6 and 12 months.
Results: The patient population consisted of
15 boys and 3 girls. The surgical age
changed from 5 to 14 months
(mean, 7.5 months), mean
operation time was 120 minutes, ICU stay was 24 hours, hospital stay was 5 days
and mean follow-up was 22 months (6-48). There were no major complications, BOS
leakage, infections, mortality or the need for repeated remodeling procedure. The Cephalic Index changed from a mean
preoperative value of 63.44% to
a postoperative mean value of 71.77% (P = 0.008). The mean
Axial Width Ratio changed from a preoperative 78.55% to 73.8% (P = 0.007). (Fig.<2)
\s
Fig 2: Pre and postoperative cranial
measurements.
Conclusions: This new technique can be used to
allow for immediate lateral expansion. Improvement of cranial shape was obtained in early
postoperative period for this lateral expansion. Although a few cranial indices have been found to be out of normal range,
the difference between preoperative and postoperative cranial measures is
statistically significant. This new procedure can be considered as an effective
and safe surgical approach for sagittal synostosis treatment, evidenced by minimal morbidity,
favorable cranial morphological changes and absence of mortality.
Poster: Comparison of Chimerism Induction after Donor Bone Marrow Transplantation Into Different Recipient Compartments
Erhan Sonmez, MD, Plastic Surgery, The Cleveland Clinic, Cleveland, OH
Aleksandra Klimczak, PhD, Plastic Surgery, The Cleveland Clinic, Cleveland, OH; Maria Siemionow, MD, PhD, Plastic Surgery, The Cleveland Clinic, Cleveland, OH
Purpose:
This
study was designed to evaluate the efficacy of different routes of BMC transplantation
on development of donor specific chimerism across major histocompatibility
complex barrier under 7-day alpha-beta-TCR/CsA treatment protocol.
Methods:
Thirty
two BMC transplantations were performed between ACI (RT1a) donors
and Lewis (RT11) recipients. In 8 groups (n=4 of each group) each
receiving 100x10 6 BMC, following BMC delivery routes included: intravenous
(Groups 1 and 2), intraosseus (Groups 3 and 4), renal intra-capsular (Groups 5
and 6) and intra-testicular (Groups 7 and 8). Groups 1,3,5,7 (controls)
received BMC transplantation without immunosuppression, whereas groups 2,4,6,8
received BMC transplantation under 7 day alpha-beta-TCR/CsA protocol. Flow
cytometry monitored immunodepletion and donor specific chimerism for MHC class I
for T-cells, B-cells and monocyte/granulocyte antigens.
Results:
All
animals survived without development of graft-versus-host disease up to 35 days.
In summary: As early as 7 day post-transplant in intra-testicular and renal
intra-capsular transplanted groups under alpha-beta-TCR/CsA therapy, chimerism
was supported predominantly by T-cells, and monocyte/granulocyte populations.
During follow-up period at day 35 post-transplant, chimerism declined in all
transplanted groups. In treatment groups chimerism decreased by 49% after
intravenous, 22% after intraosseus, 78% after intracapsular, and 85% after
intra-testicular BMC delivery.
Despite
the fact that the highest level of chimerism decline was found after
intra-testicular and intra-capsular BMC transplantation, total level of
chimerism was still superior compared to intraosseus and intravenous BMC
transplantation, and was assessed as follows: 13.27% (intra-testicular), 22.71%
(intra-capsular), 11.46% (intraosseus), 7.49% (intravenous) respectively.
All
animals are still under observation in good condition and long-term results
also will be presented.
Conclusion:
Our
observations indicate that chimerism induction and maintenance is superior when
BMC is delivered into privileged environment (intraosseus) or to barrier
carrying organ such as renal intra-capsular and intra-testicular BMC delivery
compared to standard intravenous injection. This study has proven that BMC
transplantation into immuno-privileged compartment may be a preferred method of
transplantation and currently studies are carried out testing its efficacy in
composite tissue transplantation models.
Poster: Resident's Views of Plastic Surgery in the Geriatric Population: An Objective Learning Needs Assessment
Benjamin Levi, MD, University of Michigan, Ann Arbor, MI
Steven J. Kasten, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI; Brent C. Williams, MD, Internal Medicine, University of Michigan, Ann Arbor, MI; Lauren Clevenger, BS, Plastic Surgery, University of Michigan, Ann Arbor, MI
Purpose: Increasing life expectancy of Americans,
coupled with the general increase in population, suggest that we will have an
expanding population of elderly patients for whom to provide health care. This
study was undertaken specifically to identify educational needs for plastic
surgery residents at our institution regarding the care of elderly patients.
Methods: A focus group on learning needs in caring for
older adults was conducted and transcribed with a volunteer, representative
sample of University of Michigan Plastic Surgery residents. Three
investigators independently reviewed the transcript, using a “concept
identification” technique to form distinct “codes.” Codes consisted of
brief phrases that characterized the content of resident statements. Each
investigator independently organized the codes within the context of the six
general competencies of the Accreditation Council for Graduate Medical Education
(ACGME), using a best-fit method. Inter-rater agreement was assessed by
raw agreement, kappa and interclass correlation. The codes were next
analyzed to determine whether they reflected an area of educational need,
demonstrated residents felt they already had adequate understanding in this
area, or it was not explicit.
Results: Eight plastic surgery residents participated
in the focus group. Each investigator independently coded between 115 and
120 concepts. After discussion, the investigators agreed on one set of
118 codes, categorized by ACGME competency. Raw agreement (82-90%) and
kappa (0.846 and 0.878) were excellent. Agreement between all three
judges using interclass correlation was also excellent (0.855). Educational
need was explicit in 89 (75%) of the concepts coded and implied in another 13
(86% total). The highest number of codes were noted in the areas of
medical knowledge, and interpersonal and communication skills and the lowest
number in professionalism.
Conclusion: The perceptions of our residents are
consistent with the views of the American Geriatrics Society that a more formal
education is necessary in graduate surgical education to adequately prepare for
the challenges of plastic surgery in the future. The realm of medical
knowledge related to safe and effective perioperative care and patient
selection was identified as the area of greatest need. The concept coding
technique is a useful tool for qualitative and quantitative analysis of focus
group results, and facilitates segregation of the identified concepts within
the context of the ACGME competencies.
Poster: The Reconstruction Of Full-thickness Chest Wall Defects Using Free Thigh Flaps
Masaki Takeuchi, MD, Plastic and Reconstructive Surgery, Nihon University School of Medicine, Tokyo, Japan
Kenji Sasaki, MD, Plastic and Reconstructive Surgery, Nihon University Schhol of Medicine, Tokyo, Japan; Motohiro Nozaki, MD, Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
[Purpose] Although there are reports of many methods of full-thickness chest wall reconstruction, it remains still challenging. For full-thickness chest wall reconstruction, not only soft tissue coverage but also skeletal support must be considered. As material for skeletal support of the chest wall, various materials can be selected. In specific situation, fascia lata provides rigid support. This study reviews reconstructions using free thigh flaps with rigid vascularaized fascia lata to cover full-thickness defects of the chest wall caused by oncological resections.[Materials and Methods] 35 patients underwent reconstructions of the full-thickness chest wall defects last 10 years using pedicled and free flaps. In 9 of these patients, pedicled myocutaneous flaps can not be available or inappropriate for reconstruction in the case of the entire upper chest wall defect or extensive lateral chest to back defect including latissimus dorsi muscle area; the free thigh flaps with rigid vascularaized fascia lata were selected. All 9 cases had malignant invasive or primary chest wall tumors and underwent wide full-thickness chest wall resections. The flaps which were used for reconstruction, were 7 free anterolateral thigh flaps and 2 free combined tensor fasciae latea flap and free anterolateral thigh flaps.[Results] No flaps were lost. No respiratory complication occurred. Sufficient chest wall stability was obtained. Donor site morbidity was less even when the skin grafting was needed.
[Conclusion] Free thigh flap (anterolateral thigh flap and/or tensor fasciae latae myocutaneous flap) with rigid vascularized fascia successfully can be used in reconstruction for large full-thickness chest wall defects.
Poster: Use of Validated Learning and Teaching Assessment Tools to Improve Resident Education
Megan C. Jack, MD, Plastic Surgery, University of North Carolina, Chapel Hill, NC
Sonya B. Kenkare, BS, Plastic Surgery, University of North Carolina, Chapel Hill, NC; Benjamin R. Saville, BS; Stephanie K. Beidler, MD, Plastic Surgery, University of North Carolina, Chapel Hill, NC; Alisha N. West, MD, Otolaryngology, University of North Carolina, Chapel Hill, NC; John A. Van Aalst, MD, Plastic Surgery, University of North Carolina, Chapel Hill, NC
PURPOSE: Academic medical institutions are increasingly under the burden of training the next generation of surgeons in a more time-constrained environment. Work-hour restrictions have potentially decreased the time during which a resident may experientially learn through patient and faculty interaction. Time constraints combined with rapidly advancing technology complicate surgical education, mandating improved efficiency in teaching. Education within the medical community is unique in that many clinical surgeons do not have formal training in teaching methods, thereby forcing them to learn to teach by experimenting. This suggests clinical faculty may lack awareness of the different teaching methods available. Few studies have previously assessed surgical learning styles; fewer studies have focused on surgical sub-specialties, such as Plastic Surgery. No studies have evaluated surgical teaching styles. This study aims to determine differences in preferred learning and teaching styles among surgical faculty and residents at an academic medical institution in order to improve resident education and faculty teaching.
METHODS and MATERIALS: The Kolb Learning Style Inventory (HayGroup; Boston, MA) determines an individual’s predominant learning style based on Experiential Learning theory. The experiential “cycle of learning” includes concrete experience (experiencing), reflective observation (reflecting), abstract conceptualization (thinking), and active experimentation (doing). Combinations of these learning cycle components form four Learning Styles: Diverging (experiencing/reflecting), Assimilating (reflecting/thinking), Converging (thinking/doing), Accommodating (doing/experiencing). The Grasha-Riechmann Teaching Style Survey determines an individual’s preferred teaching style. Grasha describes five Teaching Styles: Expert (transmits information), Formal Authority (structured instruction), Personal Model (teach by example), Facilitator (consultant, guides students), and Delegator (assigns task, teacher as a resource). Based on the preferred teaching methods employed by each group, combinations of the five styles create four Teaching “Clusters:” 1 (teacher-centered, knowledge acquisition), 2 (teacher-centered, role modeling), 3 (student-centered, problem-solving), and 4 (student-centered, facilitative). For both learning and teaching, an individual ideally incorporates all methods; however, people have stronger preferences for certain methods. Although there is no single best style, a person can improve his/her learning and teaching by incorporating methods used in the styles they use less preferentially.
The Kolb Learning Style Inventory and Grasha-Riechmann Teaching Style Survey were administered to participants (n=157) including surgical faculty (n=61) and residents (n=96) after informed consent (IRB # 06-0612). A specific subset of participants included all Plastic Surgery faculty (n=7) and residents (n=5) for pilot sub-specialty analysis. Responses were tabulated by protocols established by the creators of the validated tools. Statistical evaluation was performed using Fisher exact test.
RESULTS: Faculty and residents most commonly preferred the Converging Learning Style (34% and 48%; Table 1); comparisons of this preference approached statistical significance (p=0.054); stronger preference differences were noted in the Assimilating Learning Style (p< .01). Both faculty and residents preferred Teaching Cluster 4 (student-centered, facilitative); however, there was a statistically significant difference in preference for Cluster 2 (faculty, 28% and residents, 16%; p=0.05). Subset analysis of Plastic Surgery faculty and residents showed no statistically significant differences in learning or teaching styles. The Converging Learning Style and Cluster 4 Teaching were most commonly preferred in Plastic Surgery.
CONCLUSIONS: Compared to surgeons overall, these findings suggest Plastic Surgery residents utilize learning and teaching methods that more closely align with those of their faculty. Larger-scale, multi-center studies using these tools are necessary to accurately determine whether statistical differences exist between Plastic Surgery faculty and resident preferences. Recognition of surgical faculty and resident learning and teaching style differences provides an informed basis for improvement in resident education and faculty teaching. Adapting teaching methods to address specific learning styles increases teaching efficiency, thereby improving medical education under work-hour restrictions. Table 1. Comparison of faculty and resident preferred Teaching and Learning Styles LearningStyle | % Faculty Overall | % Resident Overall | p-value | % Faculty Plastic Surgery | % Resident Plastic Surgery | p-value |
Diverging | 22% | 19% | 0.39 | 14% | 20% | 0.85 |
Assimilating | 29% | 8% | <0.01 | 29% | 0% | 0.32 |
Accommodating | 15% | 24% | 0.13 | 0% | 20% | 0.42 |
Converging | 34% | 48% | 0.054 | 57% | 60% | 0.69 |
Teaching Cluster | % Faculty Overall | % Resident Overall | p-value | % Faculty Plastic Surgery | % Resident Plastic Surgery | p-value |
1 | 6% | 7% | 0.56 | 0% | 20% | 0.42 |
2 | 28% | 16% | 0.05 | 0% | 20% | 0.42 |
3 | 15% | 13% | 0.43 | 14% | 20% | 0.84 |
4 | 33% | 36% | 0.38 | 57% | 40% | 0.50 |
5* | 18% | 28% | 0.11 | 29% | 0% | 0.32 |
*Cluster 5 is designated for subjects who did not fall into Clusters 1-4 according to the Grasha-Riechmann Teaching Style scoring protocol.
Poster: A New Diagnostic Algorithm for Early Prediction of Vascular Compromise in 208 Microsurgical Flaps Using Tissue Oxygen Saturation Measurements
Alex J. Keller, MD, North Shore Long Island Jewish Health System, Great Neck, NY
Purpose: The
purpose of the study was to evaluate the detection of vascular complications
earlier than clinical evidence using a noninvasive near-infrared tissue oximeter
monitor.
Clinical signs of vascular obstruction in
microsurgical free tissue transfer are often recognized late. Early detection of
circulatory compromise allows for earlier re-exploration and better outcomes.
208 flaps in 145 patients undergoing autologous
tissue perforator free flap breast reconstruction were enrolled in a flap
monitoring study from January 2005 to January 2008. The monitoring study was in
addition to the clinical monitoring protocol already in place.
Methods & Materials: The
monitoring method studied was the ViOptix ODISsey™ Tissue Oximeter. The device
uses an optical tissue characterization based on measuring scattering and
absorption of near infrared light which is related to the oxygen content of the
hemoglobin in that particular tissue. The tissue oximeter documents changing
flap physiology in real time, captures and displays the data graphically.
Tissue oxygen saturation and its derivates were
evaluated as candidates for a more sensitive algorithm to predict vascular flap
complications. Criteria studied in various combinations were the
absolute value of tissue oxygen saturation (StO2), the amount of its change (DStO2)
and the rate of its change (ΔStO2/Δt).
Experience:
208 monitored breast flaps
[197 DIEP, 10 s-GAP, 1 SIEA] in 145
patients (62 bilateral and 84 unilateral). Patients were monitored
intra-operatively and post-operatively for 36 hours
Results: No
flap being monitored was lost. Among the 208 flaps monitored, five patients
exhibited complications that were predicted by the tissue oximeter before
clinical signs were evident.
If blood flow was completely occluded by
either venous or arterial thrombosis, the tissue oximeter provided information
that enabled diagnosis to be made in less than one hour.
Eight additional surgeries were performed for
vascular problems: 2 Hematoma: 1 without compromise, 1 with compromise; 4
Venous: 1 intraop, 1 extra superficial vein thrombosis, 2 deep vein thromboses;
2 Arterial.
StO2 and its drop rate are two hypoxia
indicators used simultaneously in flap monitoring. The drop rate indicator
DStO2/Dt,
when it is equal to or greater than 20% per hour sustained more than 30 minutes predicted vascular
complications.
|
StO2 and its drop rate can be combined to indicate possible hypoxia in a flap. All flaps with StO2 ≤30% and ΔStO2/Δt ≥ 20% per hour were flaps with complications |
Diagnostic Accuracy |
Criterion | StO2£30% & ΔStO2/Δt ³20%/h |
True positive (a) | 4+3* |
False positive (b) | 0 |
False negative (c) | 0 |
True negative (d) | 201 |
Sensitivity (a/(a+c)) | 100% |
Specificity (d/(b+d)) | 100% |
PPV** (a/(a+b)) | 100% |
NPV*** (d/(c+d)) | 100% |
|
*
These 3 cases are represented by green plus signs in Figure 1 For these cases,
the criteria were not fully satisfied at the time of intervention. Therefore
these 3 cases are considered true positives.
**Positive Predictive Value
***Negative Predictive Value
|
Correlation between tissue oxygen saturation
(StO2) and hemoglobin (HbT): In venous hypertension there was a rise in
hemoglobin and a drop in the tissue oxygen saturation.
Conclusions:
Use of the new diagnostic algorithm with the
tissue oximeter monitor post-operatively was successful in predicting
complication within one hour of the onset of the occlusive event with high
diagnostic accuracy in 208 flap procedures.
The oximeter provided accurate quantitative
information that enabled the detection of vascular complications often before
they were noticeable through clinical observation.
Poster: Comparison of Functional Results of Prefabricated Nerve Graft, Autogenous Nerve Graft, and Vein Graft in Repair of Nerve Defects
Huseyin Karagoz, MD, Plastic Surgery, Maresal CAKMAK Military Hospital, Erzurum, Turkey
Ersin Ulkur, MD, Plastic Surgery, Gulhane Medical Military Academy, Haydarpasa Training Hospital, Istanbul, Turkey; Fatih Uygur, MD, Plastic Surgery, Gulhane Medical Military Academy, Haydarpasa Training Hospital, Istanbul, Turkey; Pinar Turan, MD, Department of Histology and Embriology, Marmara University, Medical School, Istanbul, Turkey; Mehmet Yapar, MD, Virology, Gulhane Military Medical Academy, School of Medicine,, Ankara, Turkey; Mehmet Guney Senol, MD, Neurology, GATA Haydarpasa Training Hospital, Istanbul, Turkey; Bahattin Celikoz, MD, Plastic Surgery, GATA Haydarpasa Training Hospital, Istanbul, Turkey
Background
Although there have used a lot of methods, autogenous nerve grafting has been the standart technique for repairing nerve defect, but it causes significant donor site morbidity. In a preliminary study, we thought that the alternative conduit material to avoid donor side morbidity should be as similar as the autogenous nerve graft. In that study, we carried out nerve prefabrication by using autogenous vein as conduit between two healthy nerves, in addition making partial incision on the nerves and performing VEGF gene therapy, thus we created a new alternative of autogenous nerve graft. The purpose of this current study was to evaluate the effectivity of prefabricated nerve grafts in the repairing nerve defect, and to compare them with the autogenous nerve graft and vein graft.
Material and Methods
Four groups were created, each containing 10 rats. Firstly, nerve prefabrication was carried out as described in our previously study during eight weeks in group I (partial incision group) and group II (gene therapy group), and then a 1 cm long nerve gap was created by sectioning on the peroneal nerve in all groups. Prefabricated nerve graft with partial incision sectioned from the right side was sutured to the peroneal nerve defect in group I. Prefabricated nerve graft with gene therapy sectioned from the right side was sutured to the peroneal nerve defect in group II. Nerve defect was repaired by using autogenous nerve graft sectioned from same localization on the peroneal nerve in group III (nerve group). Nerve defect was repaired by using jugular vein graft in group IV (vein group). Nerve conduction studies and histologic evaluation were performed for assessment of the results.
Results
According to electromyographic studies peak amplitude of the group I, II and III, were significantly higher than group IV. The latency of group I, II, and III were significantly shorter than group IV. According to microscopic evaluation of semithin sections, there were so many myelinated fibers had large diameters in group III (nerve group) as predicted (Figure 1A). The myelinated fibers of group IV (vein group) were less organized and fewer than other groups, while the results of microscopic evaluation in both group I (partial incision group) and group II (gene therapy group) were similar to group III (nerve group).
The electron microscopic evaluation of nerve, partial incision and gene therapy groups (group I, II, and III) showed that quite regularity in the myelin sheath, and no or mild lacuna formation in the axon. The electron microscopic results revealed large lacuna formation in the axons, and irregularity in the myelin sheath in the vein group (group IV).
Conclusions
We carried out nerve prefabrication by using autogenous vein as conduit between two healthy nerves, in addition making partial incision on the nerves and performing gene therapy, thus we created a new alternative of autogenous nerve graft. In addition, we showed that this prefabricated nerve grafts as effective as autogenous nerve graft but it doesn’t cause donor site morbidity.
Poster: Retinoic Acid Causes down-Regulation of Tbx1 Expression and Aberrant Morphogenesis in the Fetal Mouse Tongue
Junko Okano, MD, PhD, Anatomy and Developmental Biology, Kyoto University, Kyoto, Japan
Yasuo Sakai, MD, PhD, Plastic Surgery, Fujita Health University, Aichi, Japan; Kohei Shiota, MD, PhD, Anatomy and Developmental Biology, Kyoto University, Kyoto, Japan
Retinoic acid (RA) is essential for normal embryonic development, but excess RA during pregnancy can cause various congenital anomalies such as craniofacial and limb malformations both in humans and rodents. We reported in a previous study that exogenous RA might prevent tongue withdrawal and elevation of palatal shelves in mouse fetuses, resulting in cleft palate. In the present study, we observed the morphogenesis of the tongue and the differentiation of tongue intrinsic muscles in mouse fetuses exposed to exogenous RA in utero. The upper median surface of the tongue was depressed and notches were observed in the bilateral edges in RA-treated fetuses. Intrinsic muscle fibers of the tongue were also bent at the midline. Such aberrant morphogenesis of the tongue in RA-treated fetuses was never observed in control fetuses. Both RA-degrading enzymes (Cyp26a1 and Cyp26b1) and one of the RA-synthesizing enzymes (retinaldehyde dehydrogenase2: RALDH2) were expressed at early stages of normal tongue development, and RA caused remarkable up-regulation of Cyp26a1 and Cyp26b1. The expression of Cyp26a1 was hardly observed in the tongue primordia on early E11 by in situ hybridization on sections. However, in RA-treated fetuses, the robust expression of Cyp26a1 was observed in the epithelium of the tongue primordia as early as E11 and even in the tongue epithelium and mesenchyme ectopically at late E11. Cyp26b1, another isozyme of Cyp26s, began to be expressed early on E11 in the tongue of control fetuses, although its expression was restricted to the mesenchyme near the median sulcus of the tongue primordium. However, the expression of Cyp26b1 increased significantly in the mesenchyme, especially in that of the caudal part of the tongue in RA-treated fetuses at early E11 and its up-regulation continued until late E12. That is, Cyp26a1 is ectopically up-regulated in response to excess RA, while Cyp26b1 is up-regulated in response to excess RA in the region where it is expressed during normal development. RALDH2 expression in the fetal tongue was not affected by exogenous RA. We examined the RA distribution in the fetal tongue by b-galactosidase staining controlled by a sensitive RA response element (RARE), using RARE-hsplacZ reporter mice. RARE-hsplacZ positive cells was observed both in tongue intrinsic and extrinsic muscles in normal fetuses, but in RA-treated fetuses, it was not observed in tongue muscles but exhibited a diffuse distribution in the tongue mesenchyme. We also found that Tbx1, a candidate gene of DiGeorge/velocardiofacial syndrome (DGS/VCFS), was down-regulated in the fetal tongue in response to excess RA. Tbx1 was expressed in the genioglossus muscle primordium from E12.5 and down-regulated by excess RA. In the previous study Tbx1 was shown to regulate myogenesis in craniofacial development and clinically DGS/VCFS patients often have problems in feeding and swallowing, which may be due to poor coordination of the tongue, pharyngeal, and esophageal muscles. On the other hand, RA has been known to promote skeletal muscle development by stimulating myogenesis in myotomes in zebrafish. Therefore, our study strongly suggests that RA signaling plays an important role in tongue muscle development via regulation of Tbx1 and that its perturbation may induce abnormal tongue development. Because impaired tongue muscle development can result in various problems in feeding, swallowing and speech, further studies are surely needed to elucidate the molecular mechanism of normal and abnormal tongue development.
Poster: The Role of Body Mass in Body Contouring Complications
Devin Coon, BA, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
J. Peter Rubin, MD; Jeffrey Gusenoff, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
Background: An increasing number of patients are presenting for postbariatric reconstruction after massive weight loss. Some of these patients present with residual obesity which may compromise outcomes. We present a prospective registry analysis of the impact of body mass indices on the outcomes of body contouring surgery.
Methods: 449 body contouring patients were enrolled over 4 years. Measures included medical comorbidities and complications. Cases were analyzed in three groups: all cases, cases with one procedure (Group I), and those with multiple procedures (Group II).
Results: 449 patients (407 female, 42 male) with a mean age of 44.5 ± 10.3 underwent 511 separate operations. Mean pre-weight loss BMI (MaxBMI) was 51.6 ± 9.5, post-weight loss BMI (CurrentBMI) was 29.3 ± 5.0 and the ΔBMI was 22.4 ± 7.6. For all cases, the presence of a surgical complication was directly related to MaxBMI (p=0.003) and ΔBMI (p=0.002) but not CurrentBMI. MaxBMI (p=0.001) and ΔBMI (p=0.002) were related to infections. A MaxBMI > 50 led to an odds risk of 2.62 (95% CI 1.28-5.39) for infection.
Group I consisted of 194 single procedure cases. Complications in Group I were related to MaxBMI (p=0.008) and CurrentBMI (p=0.02) but not ΔBMI (p=0.06). MaxBMI impacted infections (p=0.001) while CurrentBMI impacted dehiscence (p=0.009) and infections (p=0.011). Group II consisted of 317 cases with only ΔBMI directly related to overall complications (p=0.02), specifically seroma (p=0.039).
Conclusions: Body mass indices influence complications in the postbariatric reconstructive patient. Current BMI impacts complications in single-procedure cases but may play less of a role in larger cases when multiple procedures are performed. Careful patient selection and assessment of surgical complexity can help to optimize outcomes in this patient population.
Poster: Using a Hydroquinone/Tretinoin-Based Skin Health System Before And After Electrodesiccation & Curettage of Superficial Truncal Basal Cell Carcinoma: A Multicenter, Randomized, Investigator-Blind, Controlled Study
David Pariser, MD, Eastern Virginia Medical School, Norfolk, VA
James Spencer, MD, Mt. Sinai School of Medicine, New York, NY; Kenneth Gross, MD, University of California, San Diego, CA; Suzanne Bruce, MD, Suzanne Bruce and Associates, PA, Houston, TX
Introduction: Superficial basal cell carcinomas (BCCs) may be treated using electrodesiccation and curettage (EDC) but aesthetically unpleasing scars can be a major disadvantage of this procedure. A hydroquinone/tretinoin-based skin health system is known to improve overall skin quality. In the treatment of photodamage, the system has been shown to significantly improve hyperpigmentation, tactile roughness, sallowness, laxity, wrinkling, and skin clarity. Tretinoin is also known to improve scar cosmesis. We sought to evaluate if scar cosmesis post-EDC can be improved through the use of the hydroquinone/tretinoin-based system before and after EDC. Methods: Patients were eligible for enrollment if they had 1-3 biopsy-proven superficial BCCs on the trunk, each with a diameter of > 0.5 cm and < 2.5 cm. The patients were randomly assigned (1:1) to twice-daily treatment with either the hydroquinone/tretinoin-based system or standard treatment with a cleanser and healing ointment—with each regimen to be used for 3 weeks before and after EDC. (Post-EDC therapy began once each lesion reached ≥ 75% re-epithelialization.) A modified version of the validated Beausang scale was used to evaluate indices of scar cosmesis. Results: Overall, 51 patients (with 59 lesions) enrolled in the study and 49 (96%) completed. Both patients who discontinued had received standard treatment and the discontinuations were due to malaise and voluntary withdrawal. At the end of the study, treatment success (i.e. an excellent or good wound appearance) according the investigator global assessments was reported in 72% of lesions receiving the hydroquinone/tretinoin system and 63% of lesions receiving standard treatment. Six masked expert graders reviewed the photos after the end of the study and they reported the mean incidence of treatment success to be 61% in lesions receiving the hydroquinone/tretinoin system and 29% in lesions receiving standard treatment. Overall, the proportion of lesions they reported as having achieved treatment success was significantly greater with the hydroquinone/tretinoin system than with standard treatment (P=.020). Both treatment regimens were similarly well tolerated.Conclusions: The photographic assessments show that use of the hydroquinone/tretinoin skin care system adjunctively with EDC resulted in superior aesthetic results post-procedure compared with standard treatment.
Poster: A Novel Approach for Promoting Bone Formation in the Hard Palate Utilizing Bone Morphogenetic Protein-2
Marcelo M. Ghersi, MD, Plastic Surgery, Cleveland Clinic Florida, Weston, FL
Eric J. Stelnicki, MD, Cleft and Craniofacial Center, Joe DiMaggio Children's Hospital, Hollywood, FL; Bindu Bahuleyan, MD, Cleft and Craniofacial Center, Joe DiMaggio Children's Hospital, Hollywood, FL; Christopher J.M. Brooks, MD, Cleft and Craniofacial Center, Joe DiMaggio Children's Hospital, Hollywood, FL
BACKGROUND Although numerous techniques have been described to address the cleft palate surgically, none has addressed the lack of bone in the anomalous hard palate. Unlike the soft palate, which is normally repaired in three layers, hard palate defects are usually covered with an unnatural and boneless soft tissue layer. The lack of bone puts children with cleft palates at risk of developing abnormal palatal growth, oronasal fisulization, and dento-alveolar collapse following primary palatoplasty. The ideal hard palate repair would provide not only soft tissue support, but also a bony scaffold layer to act as a buttress for the palatal arches to prevent hourglass deformities and other forms of collapse. A novel approach to cleft palate repair is hereby described, utilizing recombinant human bone morphogenetic protein-2 (rhBMP-2) at the time of primary palatoplasty. The aim of this technique is to promote bone formation in the hard palate after cleft surgery, to restore the natural intraoral architecture for a longer-lasting operative result.METHODS Five (n=5) patients with unilateral nonsyndromic cleft palates were selected from a patient database at Joe DiMaggio Children Hospital’s Cleft and Craniofacial Center. A retrospective chart review was conducted after obtaining institutional review board approval. All patients underwent one-stage palatoplasty using a modification of the Von Langenback technique. The procedure calls for placement of 3mg of rhBMP2 (Medtronic Sofamor Danek, Memphis, TN) and 1.5g of allogenic cancellous bone chips (Community Tissue Services, Dayton, OH) in the central hard palate, between the closed nasal mucosa suture line and bilateral mucoperiosteal flaps. The lateral donor-site defects are covered with Tisseal glue (Baxter Healthcare, Deerfield, IL). Patients were evaluated clinically at follow-up visits to determine the quality of the soft tissues. Additionally, computed tomography (CT) scans were obtained for all patients on postoperative day one as well as several months after surgery (range, 4-13 months). Volumetric quantification of osseous tissues between the superior alveolar ridges was performed on all images. Data from both sets of images were statistically compared utilizing paired t-test analysis. RESULTS All patients recuperated well from surgery and were discharged home within two days of their operation. Outpatient follow-up was conducted at regular intervals, with the longest visits done 4 to 10 months after surgery (mean, 7.6 months). Parents reported improved feeding and weight gain for all patients in the study. Oral examinations revealed oronasal fistulization rate of 0/5 (0%), infections in 0/5 (0%), and ectopic bone formation in 0/5 (0%) patients. Subjectively, all surgical wounds were found to be healing appropriately. Follow-up CT scans demonstrated increased bone generation across the hard palate defect when compared to initial CT images. Volumetric measurement data comparison revealed statistically significant hard palate ossification (p=0.015, CI=95%) and a 56% mean increase of palatal bone deposition (SD+/-12.7). New bone was detected on all images spanning the hard palate defect and bridging the superior alveolar ridges. No ectopic bone formation was appreciated.CONCLUSIONS This is the first report in the literature citing the use of rhBMP-2 with palatoplasty to address the cleft hard palate defect. Our observations indicate this novel approach produces significant bone growth in the hard palate with no adverse effects in the short term. This procedure aims to lessen the need for further interventions stemming from soft tissue breakdown or palatal arch collapse. It is our hope that normal restoration of the bony architecture of the hard palate will ensure proper growth and development over time. Despite our encouraging findings, this study is limited by the lack of long-term follow-up and a small study population. Prospective, randomized studies are necessary to determine the long-term repercussions rhBMP2 may have on maxillary growth and development; particularly in terms of ectopic bone formation, midface hypoplasia and speech formation.
Poster: Dermal Suspension, Parenchymal Reshaping Mastopexy after Massive Weight Loss: Statistical Analysis from a Prospective Registry
Jeffrey Gusenoff, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
Devin Coon, BA, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA; J. Peter Rubin, MD, Division of Plastic and Reconstructive Surgery, University of Pittsburgh, Pittsburgh, PA
Background: An increasing number of women are presenting for mastopexy after massive weight loss (MWL). We statistically analyzed data from a prospective registry of MWL patients who underwent the dermal suspension, parenchymal reshaping mastopexy alone or with concomitant operations to assess safety and efficacy.
Methods: 108 female MWL patients underwent mastopexy. Outcome measures included operative time, time since gastric bypass (GBP), pre-weight loss BMI, current BMI, delta BMI, revision, and complications such as seroma, dehiscence, hematoma, and infection. Univariate analyses were performed to assess outcome measures.
Results: 91 patients underwent mastopexy alone (mean age 43.7 yrs ± 9, mean intra-op time 8.5 hours ± 3, mean BMI 28.3 ± 3.9, mean time since GBP 27.5 months ± 13.4, mean follow-up 7.3 months) while 17 had augmentation/mastopexy. 93.4% (85/91) had multiple procedures performed. Wound dehiscence was the most common complication in 26 patients (29.2%); however, breast specific complications (delayed healing and seroma) occurred in only 8 patients (8.8%). BMI indices, operative time, and a cut-off BMI of 35 did not predict an increase in complication rates. Patients whom had an augment/mastopexy had lower current BMIs than those who had mastopexy alone (p=0.01).
Conclusion: Dermal suspension, parenchymal reshaping mastopexy is a safe, effective, and durable method of treating the deflated breast after MWL. Although patients with MWL are likely to present for longer procedures and have greater wound healing complications, these complications most frequently occur in areas other than the breasts.
Poster: Retrograde Internal Mammary Venous Anastomosis To Augment Outflow In DIEP Flap Breast Reconstruction
Mahlon A. Kerr-Valentic, MD, Division of Plastic Surgery, University of Utah, Salt Lake City, UT
Jayant P. Agarwal, MD, Division of Plastic and Reconstructive Surgery, University of Utah, Salt Lake City, UT
BackgroundThe deep inferior epigastric perforator flap (DIEP) has become an increasingly popular option for postmastectomy reconstruction because of decreased abdominal wall donor-site morbidity. Perforator flaps such as the DIEP flap may have a greater incidence of venous congestion, and several methods have been described to improve venous outflow. Salvage techniques such as venous supercharging and interconnection of the superficial and deep venous systems have been described by other authors. The concept of retrograde venous drainage has been described previously in reverse radial forearm flaps, but its use with DIEP flaps for breast reconstruction has not been reported. We present a new option for augmenting venous outflow in DIEP breast reconstruction by creating an anastomosis between a vena comitante of the deep inferior epigastric artery with the retrograde venous limb of the internal mammary vein (IMV).MethodsA series of fifteen DIEP flaps were prepared by anastomosing the deep inferior epigastric artery with the internal mammary artery and one vena comitante with the antegrade IMV. An additional venous anastomosis was then made between the second vena comitante and the remaining IMV in a retrograde direction. Venous congestion was assessed before releasing the antegrade IMV anastomosis after inflow had been established and outflow was based solely only on the retrograde system. Intraoperative duplex ultrasound was utilized to demonstrate the direction of venous blood flow away from the flap and into the retrograde IMV. Serial measurements of flap viability including color, temperature, turgor, and Doppler signal were then monitored throughout the patients hospital stay. ResultsFifteen consecutive DIEP flaps were created for breast reconstruction using the above described retrograde IMV over a three month period. Each flap had its venous outflow augmented with an anastomosis of a vena comitante to the retrograde limb of the IMV. After creating the arterial and retrograde venous anastomoses and establishing flow through the flap, no evidence of venous congestion was seen. Retrograde directional blood flow was demonstrated using intraoperative duplex imaging of the venous anastomosis with the retrograde IMV. All fifteen flaps were successful and displayed no evidence of venous congestion. ConclusionsThe clinical course of the retrograde augmented DIEP flaps was robust without development of venous congestion. Utilization of a venous anastomosis to the retrograde IMV provides a large caliber vessel which should improve venous outflow when compared to an antegrade IMV anastomosis alone. Intraoperatively we show that no significant venous congestion develops with flow which is limited to only a retrograde venous anastomosis. The combination of this outflow with an antegrade anastomosis should provide superior venous outflow when compared to single vein anastomoses. Intraoperative duplex ultrasound was used to confirm these findings, and supports the use of a retrograde venous IMV anastomosis to improve DIEP flap survivability. In addition to the method presented here, drainage of the superficial inferior epigastric venous system using a retrograde IMV anastomosis would also be possible.
Poster: The Use of Med-Por Implant for Augmentation of the Posterior Pharynx in the Elder Patients with Velopharyngeal Insufficiency
Ersin Ulkur, MD, Plastic Surgery, GATA Haydarpasa Training Hospital, Istanbul, Turkey
Huseyin Karagoz, MD, Plastic Surgery, Maresal CAKMAK Military Hospital, Erzurum, Turkey; Fatih Uygur, MD, Plastic Surgery, GATA Haydarpasa Training Hospital, Istanbul, Turkey; Bahattin Celikoz, MD, Plastic Surgery, GATA Haydarpasa Training Hospital, Istanbul, Turkey; Hakan Cincik, MD, ENT Surgery, GATA Haydarpasa Training Hospital, Istanbul, Turkey; Hakan Mutlu, MD, Radiology, GATA Haydarpasa Training Hospital, Istanbul, Turkey; Iclal Ertas, PhD, Ent, Gulhane Military Medical Academy, School of Medicine,, Istanbul, Turkey; Muzeyyen Ciyiltepe, PhD, Ent, Gulhane Military Medical Academy, School of Medicine,, Ankara, Turkey
BACKGROUND
Velopharyngeal insufficiency (VPI) occurs when the velum and lateral and posterior pharyngeal walls fail to separate the oral cavity from the nasal cavity during speech and deglutination. For cases with small insufficiencies, posterior pharyngeal wall implants may be the solution instead of flap surgery. In the present study, we evaluated the efficiency of using porous polyethylene implant to correct velopharyngeal insufficiency in adult patients.
MATERIAL and METHODS
Ten male patients with velopharyngeal insufficiency underwent posterior pharyngeal augmentation with porous polyethylene implant.The evaluations for VPI on all patients in the study included the following:
1. Speech evaluation of nasality and articulation was performed by speech pathologist author by using Multi Dimentional Voice Programme (MDVP).
2.Mirror test: Detecting nasal emission.
3.Nasopharyngoscopy: Direct visualization of the velopharyngeal sphincter during speech. The distance between lateral pharyngeal walls at rest and during phonation were measured, and the rate of the lateral pharyngeal wall movement to velopharyngeal gap was calculated.
R= a- b × 100
a
R: The rate of the pharyngeal wall movement (%)
a: The distance between lateral pharyngeal walls in the rest
b: The distance between lateral pharyngeal walls in the phonation
This value was used at determining the implant size during the operation.
4. Magnetic resonance imaging: Magnetic resonance imaging was taken in the sagittal, and axial planes at rest and during sustained ‘e’. The distance between posterior pharyngeal wall and velum was measured during phonation. Velopharyngeal orifices were drawn and the gap area was calculated in the axial views at rest and during sustained ‘e’.
The evaluation methods for VPI were done preoperatively and 6 months after surgery, and the results were compared.
At the operation the distance between the lateral pharyngeal walls were measured. Implant length was determined according to the rate of the lateral pharyngeal wall movement to the velopharyngeal gap calculated from nasopharyngoscopy.
L = D × (100-R)
100
L= Implant length (mm)
D= The distance between the lateral pharyngeal walls measured in the operation.
R= The rate of the lateral pharyngeal wall movement
Implant height determined with 2 mm plus to the distance between velum and posterior pharyngeal wall calculated in the sagittal plane MRI images.
The width of the all implants was approximately 10 mm.
The implant is inserted in the pocket prepared in the posterior pharyngeal wall.
RESULTS
According to preoperative speech evaluation, seven patients had severe and three patients had moderate hypernasal speech. Follow-up evaluations demonstrated that 7 patients had normal speech without hypernasal resonance. Two patients had mildly hypernasal speech, and one had moderate hypernasality.
While all of the patients had nasal escape on mirror test preoperatively, only two of them had postoperatively.
When the preoperative and the postoperative results of MDVP were analyzed, there was statistically significant improvement in all parameters (p < 0.05).The distance between posterior pharyngeal wall and velum during phonation observed preoperatively have been disappeared in the postoperative period in all of the patients` sagittal plane MRI.
In the axial views of MRI, velopharyngeal gap area calculated preoperatively was reduced postoperative period.
There were statistically significant differences between preoperative and postoperative velopharyngeal gap area in the axial views at rest and during phonation (p < 0.05).
CONCLUSION
We conclude that the posterior pharyngeal wall augmentation with porous polyethylene is an effective method in the adult patients for correction of mild velopharyngeal insufficiency.
Poster: A Retrospective Review of Initial Experience With Sternal Plate Fixation Following Sternal Dehiscence
Kannin Osei-Tutu, MD, MSc, Plastic Surgery, University of Toronto, Toronto, ON, Canada
James L. Mahoney, MD, Plastic Surgery, St. Michael's Hospital, Toronto, ON, Canada; Hosam Fawzy, MD, Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada; Lee Errett, MD, Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada; Daniel Bonneau, MD, Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada; David Latter, MD, cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
Introduction:
Open-heart surgery is one of the most common procedures performed in North America. Median sternotomy infection and bony nonunion are two commonly described complications which occur in 1-3 % of cardiac procedures. Although relatively infrequent, these complications can lead to significant morbidity and mortality. Timely reconstruction of the chest wall is required. Debridement of the sternum is critical in removing the infected tissue and bone. Several options have traditionally been used to reconstruct the wound. Sternal rewiring and closure, a variety of flaps, and more recently negative pressure therapy have been recommended as options. Recently a new technique of rigid fixation of the sternum has been introduced. Its potential advantage is the restoration of sternal stability following sternal debridement. This was not previously feasible with rewiring. To evaluate the effectiveness of this new technique, we reviewed our early experience of all patients who had their infections managed by plate fixation.
Methods:
We conducted a retrospective chart review on all adult cardiac patients who required sternal wound reconstruction by debridement, irrigation, sternal plate fixation, and bilateral myocutaneous advancement flaps for deep sternal infection between July 2004 and January 2008. Synthes 2.4-mm locking reconstruction plates were used in conjunction with bilateral pectoralis major advancement flaps. Data collected included patient demographics, complications, and length of stay.
Results:
(n = 40) patients (31 males, 9 females) were treated. Patients were elderly (69.7 yrs), overweight (BMI 30.4 kg/m2), hypertensive (75%), and had undergone a CABG with the left internal mammary artery (72.2%). The common presentation was sternal dehiscence (76.4%) and instability (67.6%). Coag –ve staph (39%) was the most common organism. Twenty-two percent of patients had biopsy confirmed osteomyelitis. Average length of ICU stay post reconstruction was 4.84 days and overall ICU was 14.4 days. The majority of patients (95%) were healed without further complications. The two patients that did not heal were severely immune-compromised and developed recurrent wound infection requiring VAC therapy. There was one mortality secondary to refractory septic shock from infected endocarditis.
Conclusion:
These findings confirm our initial impression that sternal plating, following sternal dehiscence and deep wound infection is superior to the standard muscle flap or wire reconstruction in terms of outcomes; better healing, reduced length of hospital stay and fewer complications.
Poster: Developmental, Behavioral and Speech Assessments in Children with Trigonocephaly
Joseph Bou-Merhi, MD, Plastic Surgery, ST-JUSTINE UNIVERSITY HOSPITAL, UNIVERSITY OF MONTREAL, Montreal, QC, Canada
Patricia Bortoluzzi, MD, FRCS, Plastic Surgery, ST-JUSTINE UNIVERSITY HOSPITAL, UNIVERSITY OF MONTREAL, Montreal, QC, Canada
Background: Trigonocephaly results from premature closure of the metopic suture. Recently, there has been increasing interest in cognitive, behavioral and speech problems associated with trigonocephaly. To date, there have been no prospective multidisciplinary evaluations to assess these issues in this patient population. This study was performed in order to establish the incidence of associated developmental, behavioral and speech anomalies in patients presenting with trigonocephaly.
Methods: Between 1990 and 2006, all patients presenting with trigonocephaly at St Justine University Hospital - Craniofacial Center, were prospectively assessed by a qualified specialized psychologist and speech therapist at two years of age, five to six years of age and eight to ten years of age. Medical charts of all these patients were retrospectively reviewed.
Results: Ninety two children with trigonocephaly were treated and followed between 1990 and 2006. Of these, twenty seven were excluded from the study because of incomplete assessments. Among the sixty five patients included (49 M, 16 F), 68% (44/65) were operated on and 32% (21/65) were observed. 83% (54/65) of the cases were isolated deformities, 6% (4/65) were syndromic, and 11% (7/65) had associated extra-cranial anomalies. The average age of patients at the time of last assessment was 6.7 years (ranging from 2 – 17 years). 29% (19/65) of patients had normal assessments, whilst 71 % (46/65) had documented developmental, behavioral, language or speech anomalies at some point in their course of follow-up. This incidence is significantly above that seen in the general population. Among the 44 operated children, normal assessments were seen in 25% (11/44), and abnormal in 75% (33/44). Among the 21 observed children, 38% (8/21) had normal assessments and 62% (13/21) had abnormal assessments. These results were not statistically significant (p > 0.05).
Conclusions: Trigonocephaly is associated with a higher incidence of developmental, behavioral, language and speech anomalies. Surgery does not seem to have an impact on this outcome. Early recognition, follow up, and appropriate specialized treatment is warranted in order to optimize long term development.
Poster: Reverse Skimming Technique: A New, Simple Method of Fat Separation in Fat Graft
Aisha White, MD, Plastic Surgery, University of Illinois at Chicago, Chicago, IL
Ramasamy Kalimuthu, MD, FACS, Plastic Surgery, Advocate Christ Hospital, Oak Lawn, IL
Many methods have been described for each of the stages of fat grafting with the hopes of developing a technique that will minimize graft resorption. We describe a new reverse skimming technique that is a fast, efficient, and easy way to refine fat prior to transfer.
Poster: The Usefulness of Transcatheter Arterial Embolization for Panfacial Injury
Hwan-Jun Choi, MD, Plastic & Reconstructive Surgery, SOONCHUNHYANG UNIVERSITY, Seoul, South Korea
Chang-Yong Choi, MD, Plastic & Reconstructive Surgery, SOONCHUNHYANG UNIVERSITY HOSPITAL, Seoul, South Korea
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Purpose : A life-threatening hemorrhage resulted from severe facial fracture is rare, but it needs a prompt and aggressive treatment. Especially, a massive oronasal bleeding combined with midfacial fracture may resulted from rupture of internal maxillary artery. As a radiologic intervention has developed recently, its use has increased for managing this case. We reviewed its usefullness with our experiences and literatures.
Method : A retrospective review was performed to determine the usefulness of transcatheter arterial embolization in patients with panfacial trauma. If the vital signs were unstable, cardiopulmonary resuscitation was performed. Then we did nasal packing and electrocautery for oronasal bleeding and checked all injured region by radiologic study including CT. If oronasal bleeding was persistent although primary management, radiologic intervention was performed. 10 patients got transcatheter arterial embolization and bleeding focus could be controlled by embolization with polyvinyl alcohol and gelfoam.
Result : After intervention, the vital signs became stable and there was no complications from embolization on follow-up for 6 months. Also patients could recover through appropriate operation.
Conclusion : Transcatheter arterial embolization for maxillofacial injury has many advantages for doctor and patient. First, it hurts less than a compression device or operation, which are other ways to treat oronasal bleeding. Second, it doesn't need a general anesthesia. And through a single procedure not only we can know an accurate bleeding point, but also we can stop bleeding by embolization.
Poster: A double-blind, placebo- and standard-care controlled, randomized, phase II trial evaluating the scar-improving efficacy and safety of intradermal avotermin (study RN1001-319-1011)
James Bush, MBChB, Clinical Trials Unit, Renovo, Manchester, United Kingdom
Jonathan Duncan, MBChB, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Jeremy Bond, MBChB, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Piyush Durani, MBBChir, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Karen So, MBBS, Clinical Trials Unit, Renovo, Manchester, United Kingdom; Tracey Mason, PhD, Vice President of Biometrics, Renovo, Manchester, United Kingdom; Sharon O'Kane, BSc, PhD, Executive Director, Research and Development, Renovo, Manchester, United Kingdom; Mark Ferguson, BDS, PhD, DMSci, Clinical Trials Unit, Renovo, Manchester, UK, United Kingdom
Background: There is a significant unmet medical need for effective treatments that reduce scarring following injury or surgery, with patients indicating that they value any improvement in scarring. Currently, there are no registered pharmaceuticals or universally accepted treatments for reducing scarring. Previous phase I/II trials have shown that avotermin (transforming growth factor β3) is a new class of prophylactic medicine that improves scar appearance, both macroscopically and microscopically at the tissue level. The objective of this trial was to compare the appearance of scars following one or two doses of avotermin (at two dose levels) versus within-subject placebo and standard-care controls. All treatments were administered to the approximated margins of acute incisional wounds.Methods: Healthy males, aged 18–45 years, were assigned to one of two treatments: avotermin 50ng or 200ng/100µL/linear cm/linear cm of wound margin. All subjects received three standardized 1cm incisional wounds on the inner aspect of each upper arm. Wounds were randomized to receive (into each wound margin): no injection (standard wound care only), a single intradermal injection of avotermin or placebo (immediately before surgery) or repeated doses of avotermin or placebo (immediately before surgery and 24 hours later). The study was powered to show treatment differences in the prespecified primary efficacy variable: the scoring of how closely scars resemble normal skin at Month 12. An Independent External Scar Assessment Panel (IESAP, Lay Panel) scored standardized, calibrated photographs of scars using a 100mm visual analogue scale (VAS). Within-subject differences in VAS scores between control- and avotermin-treated sites were analysed using a paired t-test (p<0.05 indicating significance). Results: 71 Caucasian males were recruited, with 32 randomised into the 50ng group and 39 into the 200ng group. Age, body mass index and medical history were similar across treatment groups. The primary efficacy analysis showed that avotermin 200ng/100mL/linear cm, administered once or twice, achieved statistically significant improvements in scar appearance compared with controls (p<0.02 for comparisons with Placebo and Standard Care). The 50ng dose also showed statistically significant improvements in scar appearance versus placebo (p=0.0425). Results with the 200ng dose were supported by secondary endpoints, including those that involved ‘on-the-subject’ scar assessment by investigators. The incidence and profile of site-specific adverse events (AEs) were similar with avotermin, placebo and standard wound care. No withdrawals due to AEs or serious AEs related to avotermin occurred.Conclusions: The primary objective was met. Compared with placebo and standard wound care, intradermal avotermin at 50 and 200ng/100µL/linear cm of wound margin produced statistically significant improvements in the appearance of scars resulting from acute incisional wounds with approximated margins and showed a favorable safety profile.
Poster: Does Size Matter? : Technical Considerations for Use of Alloderm in Reconstructive Surgery
Randall Craft, MD, Plastic Surgery, Mayo Clinic, Phoenix, AZ
Alanna Rebecca, MD, Plastic Surgery, Mayo Clinic, Phoenix, AZ; William J. Casey, III, MD, Mayo Clinic Arizona, Scottsdale, AZ; Amylou Dueck, PhD, Biostatistics, Mayo Clinic, Phoenix, AZ; Kristi L. Harold, MD, General Surgery, Mayo Clinic, Phoenix, AZ
62 individual sheets of Alloderm from distinct lot numbers were prospectively analyzed prior to use in reconstructive surgery. Size was recorded while dry, after hydration, and then following stretch. Percent change in size was recorded for each lot.
Poster: Role of Preoperative Multidetector-row Computed Tomographic Angiography on Free Anterolateral thigh Flap Transfer for Head & Neck Reconstruction
Chul Huh, MD, Plastic Surgery, Samsung Medical Center, Seoul, South Korea
Goo Hyun Mun, MD, Plastic Surgery, Samsung Medical Center, Seoul, South Korea; Sa Ik Bang, MD, Plastic Surgery, Samsung Medical Center, Seoul, South Korea
Background : Preoperative perforator localization of anterolateral thigh flap has been a challenge because of their topographic variation. However, as the more information of perforators can be obtained in the planning stage with the use of multidetector-row CT(MDCT), traditional techniques in perforator flap surgery would be changed and refined.
Methods : From November 2005 to August 2007, free anterolateral thigh(ALT) flap transfers were performed in 23 patients for reconstruction of the head and neck(23 cases). There were 17 male, 6 female patients with an average age of 50.1 (29-74). The mean BMI value of patients was 23.6 . Etioligies included 13 tongue cancer, 2 retromolar trigone cancer, 2 buccal cancer, 2 tonsilar cancer, 1 glottic cancer, 1 eyelid cancer. 1 lacrimal gland cancer, 1 malignant histiofibrocytoma . All patients underwent MDCT angiography for preoperative perforator mapping. In the axial view we studied the course of the lateral branch of lateral circumflex femoral artery from its origin. We identified the suitable perforators, marked them with an arrow. Then, locations of marked perforators were measured in 3-dimensional(3D) reconstruction image and transferred to the patient using anatomical landmarks. CT findings were compared with acoustic Doppler and intraoperative findings.
Results : Flap sizes ranged from 5x3cm to 16x9cm . One to two perforators(mean : 1.56) were marked on 3D CT image for each thigh, and the locations were in good correlation with hand-held Doppler examination. Intraoperatively, all perforators marked were confirmed and no additional perforators that were not identified on CT images were seen. All flaps survived completely. Donor site was primarily closed in 19 cases and Purse-string method was used in 4 cases. Mean length of donor site scar was 14.1cm (3.2-23cm). The average ratio of the long axis of the flap and the donor site scar was 1.95(0.81-3.09). Knowledge of the exact location and number of perforators allows minimized incision for flap harvest even in small flap and planned usage of multiple perforators for better perfusion or complex design.
Conclusions : Perforator mapping with preoperative MDCT angiography is valuable for the planning and executing the ALT flap transfer. By deciding preoperatively which perforators are most suitable, the surgeon can proceed directly to the chosen perforator with confidence and ligate other perforators safely and quickly. And the surgeon could select better donor site after comparing left and right thigh. Preoperatively, the surgeon can detect potent vascular disease and anatomic variation.Because the images of CT distribute from abdomen to whole legs, the surgeon also have informations about other possible flaps (DIEP flap, fibular osteocutaneous flap). Time saved in the operating room should be balanced with the extra cost of the investigation. Using the correct perforator topographic information allows safe, straightforward harvest and elegant reconstruction with leaving reduced donor site morbidity.
(Figure 1) Preoperative MDCT image of both thigh
(Figure 2) Intraoperative confirmed perforator of ALT free flap
(Figure 3) Donor site closed with Purse-String method.
Poster: Tissue-Engineered Scaffolds for Alveolar Bone Regeneration in a Gingivoperiosteoplasty Model
Phuong D. Nguyen, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY
Clarence D. Lin, MA, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Alexander C. Allori, MD, MPH, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Tom Reisler, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Jeffrey S. Schachar, BS, Institute of Reconstructive Plastic Surgery, New York University Langone Medical Center, New York, NY; Jamie P. Levine, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Pierre B. Saadeh, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Stephen M. Warren, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY
Intro: Primary alveolar cleft repair treating congenital
alveolar clefts with gingivoperiosteoplasty (GPP) has a 60% success rate. The
remaining 40% have persistent alveolar bony defects requiring secondary
grafting, which is associated with donor-site morbidity, graft resorption, and
infection, and bone or tooth loss. Herein, we describe a novel
critical-size defect GPP model using tissue-engineered scaffolds to improve
bone regeneration and circumvent secondary grafting.
Methods: A 7x4x3-mm complete alveolar defect was surgically
created in sixty 8-week old rats. Four scaffolds were tested within the defect:
absorbable collagen sponge (ACS), ACS+BMP, hydroxyapatite-tricalcium phosphate
(HA-TCP), HA-TCP+BMP, and no scaffold as control. Animals were sacrificed
at post-operative weeks 4, 8, and 12. New bone was assessed
histmorphometrically via micro CT. Decalcified sections were processed for
histology.
Results: Morphometric analysis demonstrated regeneration
in negative control groups to 43±10% at 4 weeks, but plateaued to 53±17%
at 8 weeks and 48±6% at 12 weeks . ACS groups showed 50±12%
at 4 weeks and 79±19% at 8 weeks and 69±12% at 12 weeks. ACS+BMP
regeneration was 49±4% and 71±13%, and 66±13%,
respectively. HA-TCP displayed 69±20% bone growth at 4 weeks and
plateaued to 86±6% (p<0.05) at 8 weeks and 87±25% at 12 weeks,
while adding BMP yielded 55±29%, 91±5% (p<0.05) and 90±1%
(p<0.05) at 12 weeks. Histologically, HA-TCP groups stimulated
appositional bone growth around scaffold granules. Four weeks showed
activated osteoblasts, osteoprogenitor cells, and nascent bone along leading
edges of bone spicules, while weeks 8 and 12 showed denser fibroblasts and
maturing bone in the form of well-formed osteocytes.
Conclusions: HA-TCP shows greater osteogenic capability
than ACS. BMP did not affect significant bone growth increases, perhaps
due to lack of a sustained release system. The inherent osteoconductive
properties of HA-TCP and its ability to provide for tissue guided regeneration
(as opposed to an absorbable matrix) may have contributed to defect healing.
Poster: Aging Impairs HIF-1á Stabilization Resulting in Poor Neovascularization in Wound Healing and Following Ischemic Injury
Edward . Chang, MD, Surgery, Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA
Michael G. Galvez, BA, Surgery, Division of Plastic Reconstructive Surgery, Stanford University, Stanford, CA; Samyra El-ftesi, BA, Surgery, Division of Plastic and Reconstructive Surgery, Stanford University, Stanford, CA; Geoffrey C. Gurtner, MD, Stanford University, Stanford, CA
Introduction: Aging is a known risk factor for poor wound healing, neovascularization, and tissue regeneration following an ischemic insult. The process of neovascularization is regulated by the transcription factor HIF-1α which is post-transcriptionally regulated through hydroxlase mediated degradation. We hypothesize that aging results in decreased HIF-1α stabilization resulting in reduced expression of the proangiogenic cytokines VEGF and SDF-1α leading to impaired wound healing and neovascularization.
Materials and Methods: Primary young and aged murine and human fibroblasts were exposed to normoxia and hypoxia and assessed for HIF-1α using Western blot. The downstream effectors VEGF and SDF-1α were analyzed using ELISA and real-time PCR. Prolyl hydroxylases (PHD1, 2, 3) and factor inhibiting HIF (FIH) were also analyzed using Western blot and real-time PCR. Excisional wounds and ischemic flaps were elevated on the dorsum of young and aged mice (n=4 per group) and analyzed for HIF-1α stabilization, VEGF expression, and neovascularization using CD31 staining. The known hydroxylase inhibitor, dimethyloxaloylglycine (DMOG) was administered in vitro and in vivo as rescue experiments.
Results: Aged murine and human fibroblasts demonstrated dramatically reduced HIF-1α stabilization in hypoxia compared to young controls. This correlated with decreased VEGF (25.30±5.30 versus 615.85±35.75 pg/mL, aged versus young, P<0.00001) and SDF-1α (fold induction: 1.90±0.21 versus 0.90±0.17, P<0.008) expression in response to hypoxia. Western blot and real-time PCR demonstrated significant upregulation of all PHDs and FIH in murine aged fibroblasts. Aged mice demonstrated significantly delayed wound healing and greater flap necrosis than young mice which corresponded with reduced HIF-1α stabilization, VEGF expression, and neovascularization. DMOG was able to increase HIF-1α stabilization and VEGF secretion in vitro, however, no differences were seen in PHD or FIH protein levels. In vivo, DMOG prevented flap necrosis in aged mice comparable to young controls with increased VEGF and SDF expression and neovascularization. DMOG also improved wound healing in aged mice.
Conclusions: Age associated defects in wound healing and the impaired response to ischemic injury result from increased HIF-1α degradation. Therapeutic strategies designed to augment the HIF response may represent a novel modality for treating wounds and ischemic damage in the aged population.
Poster: Endoscopic Technique for Breast Tissue Expander Capsulotomy Using Carpal Tunnel Release Kit
Laurence Yeung, MD, Plastic Surgery, Loma Linda University, Loma Linda, CA
Stephen West, MD, Plastic Surgery / Kaiser-Permanente Clinical Faculty, Loma Linda University, Fontana, CA
Title
Endoscopic Technique for Breast Tissue Expander Capsulotomy Using Carpal Tunnel
Release Kit
Introduction
During the process of tissue expansion in the breast, occasionally capsular
contracture or implant malposition will occur. Contracture may cause the
implant to change position or become difficult to expand. This usually
requires operative intervention to release or remove the capsule to allow
further expansion for breast reconstruction. We present a minimally
invasive technique for capsulotomy in the setting of breast tissue expander
capsular contracture or malposition.
Methods
The Carpal Tunnel Syndrome Relief Kit (Linvatec, Largo, FL) designed for the
Menon technique of endoscopic carpal tunnel release is used for the endoscopic
capsulotomy.
We remove 120ml to
240ml of saline from the expander prior to incisions. Short incisions are
made at the lateral and medial ends of the previous mastectomy scar overlying
the expander, each approximately 1.5cm long. We dissect with electrocautery
down to the capsule and enter it, taking care not to damage the expander.
The area of planned capsulotomy is bluntly dissected to create space between
the capsule and expander.
The D-shaped
slotted cannula is then inserted under the capsule with a standard 30 degree
angle 4mm arthroscope and the capsule is divided with the forward knife from
the kit. This is done under direct visualization with care to avoid
damage to the expander. To release the inferior capsule, we perform a
V-shaped capsulotomy from both medial and lateral incisions.
Blunt release of the capsule is performed and hemostasis is
obtained. The incisions are then closed in the standard fashion and
saline is replaced in the expander.
Results
By this technique we are able to perform a capsulotomy with minimal
incisions. The capsule is released and the implant repositioned
accordingly.
Discussion
The use of the endoscope in breast surgery has been reported in the literature
for many years. We present a new technique using the endoscopic forward
knife in conjunction with the endoscope for release of the breast tissue
expander capsule. This allows for smaller incisions and potentially less
discomfort after operative capsulotomy. For those already comfortable
with the endoscopic carpal tunnel release by Menon's technique, this can be a
simple translation of technique to breast surgery. The capsulotomy
technique may potentially be extended to other indications for capsulotomy such
as implant contracture or malposition.
Poster: Salvage of Difficult Chest Wall and Epigastric Defects Using the Intercostal Artery Perforator Flap
Aisha White, MD, Plastic Surgery, University of Illinois at Chicago, Chicago, IL
Ramasamy Kalimuthu, MD, FACS, Plastic Surgery, Advocate Christ Hospital, Oak Lawn, IL
Background: Primary closure of chest wall and epigastric defects is often difficult. Many muscle and musculocutaneous flaps have been described for management of these challenging wounds. Intercostal artery perforator island flaps have been previously described in the literature, mostly for reconstruction of inferior pole breast defects or upper back defects. However, they are not commonly used for reconstruction of anterior midline torso defects.
Methods: We present a retrospective review of the presentation, management, and outcomes of 6 consecutive cases of intercostal artery perforator flaps. We describe the indications, basic anatomical planning, and surgical procedure in a series of 6 consecutive patients who underwent intercostal artery perforator flap creation. The series of 6 patients consists of 5 females and 1 male. All 5 female patients required coverage of anterior chest wall defects resulting from resection of breast cancer and subsequent partial failure of TRAM or latissimus dorsi flaps complicated with postradiation changes. The male patient required coverage of an epigastric defect with an exposed left ventricular assist device (LVAD).
Results: Follow up for all patients ranged from 9 months to 3 years. Reconstructive efforts were successful in all patients. There was no flap loss in the series. Two patients did have superficial epidermolysis, which responded to treatment with local wound care; no surgical debridement was necessary.
Conclusions: Based on our successful experience, we believe that the intercostal artery perforator island flap can be used primarily to cover defects of the ipsilateral and contralateral chest wall and upper abdomen. It is also a reliable salvage flap for reconstructing difficult chest wall and epigastric defects.
Poster: Topical Gene Therapy Improves Diabetic Wound Healing
Vishal D. Thanik, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY
Christopher C. Chang, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY; Alexander M. Sailon, BA, Plastic Surgery, New York University Medical Center, New York, NY; Richard Zoumalan, MD, Institute of Reconstructive Plastic Surgery, New York University; Sanjeev Gupta, n/a, Institute of Reconstructive Plastic Surgery, New York University; Jamie P. Levine, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY; Stephen Warren, MD, Institute of Reconstructive Plastic Surgery, New York University, New York, NY; Pierre B. Saadeh, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY
IntroductionDiabetic wounds represent a common problem for the reconstructive surgeon. Although the etiopathogenesis is thought to relate to impaired blood flow, recent evidence implicates deranged molecular signaling in the development and persistence of these wounds. Specifically, these wounds are characterized by an increased rate of cell death (apoptosis), potentially mediated through hyperglycemic activation of p53 tumor suppressor. We targeted this pathway through a novel topical gene silencing delivery system to affect wound healing.MethodsA novel gel-based siRNA delivery system was developed to locally treat nondelimited cutaneous wounds. Paired four millimeter diameter wounds were created on the depilitated dorsum of a db/db mouse, stented with a twelve millimeter O-ring, and covered with a transparent sterile occlusive dressing. p53 siRNA (complexed with liposomal transfection reagent) was incorporated into an agarose matrix, applied onto the wound bed and allowed to gel. Reapplication was performed on day 5. Wounds were harvested every third day post-treatment for histologic and Western analysis. A second group was followed for time-to-closure with photodigital analysis of the wounds. Lung, liver, and spleen homogenates were examined for relative p53 suppression.ResultsLocal silencing of p53 in diabetic wounds yielded greatly improved wound healing, with closure at 18 days (± 1.3d) in treated wounds vs. 28 days (± 1d) in sham treated controls (p<0.05). Immunohistochemistry and Western blot analysis demonstrated near complete knockdown of p53 in the wound bed at 8 days. Immunohistochemistry one month after complete healing revealed normal levels of p53, an important finding in light of the potential mutagenicity of prolonged p53 suppression. There was no systemic suppression of p53.ConclusionTopical silencing of p53 markedly improved diabetic wound healing. Silencing is near-total yet entirely local and transient, suggesting near-term clinical applicability. Further elucidation of pathway dysregulation may help identify more specific downstream gene targets, improving both our molecular understanding of this clinical challenge and our therapeutic alternatives.
Poster: A lower cost alternative for managing hand fractures
Pirko Maguina, MD, Plastic Surgery, University of California Davis, Sacramento, CA
Karina L. Paulius, MD, Surgery, Mount Sinai Medical Center, Chicago, IL; Alfonso Mejia, MD, Orthopedic Surgery, University of Illinois Medical Center, Chicago, IL
Abstract: Introduction: Hand fractures are traditionally managed with fluoroscopic imaging for diagnosis and intraoperative imaging. The associated costs of the equipment including acquisition, maintenance, need for technicians, shielding and radiation precautions can be prohibitive for the solo practice plastic surgeon. Ultrasound has been used as a low cost alternative for diagnosis of hand fractures. We present our initial experience with ultrasound for treatment of hand fractures without need for fluoroscopy. Materials and Methods: A GE LOGIQ 7 (General Electric, Fairfield, CT) ultrasound machine, using a 10L 3.5 to 9.5 MHz probe was used to identify and reduce and percutaneously pin hand fractures. We started by practicing with in the anatomy laboratory with five cadavers before using this technique on a live patient. Results: Ultrasound imaging allowed us to clearly identify fractures in the fingers and metacarpals (84%-100% sensitivity), although we had some difficulty with carpal bone fractures (less than 50% sensitivity). Reduction of the fracture was easily confirmed with ultrasound imaging. The main advantage of ultrasound was seen in percutaneous pinning, where the images allowed for precise placement of the pins without the problem of skiving which may be seen with fluoroscopy. Conclusion: Ultrasound imaging can be used instead of fluoroscopy to diagnose and treat hand fractures. This can result in significantly lower costs and allows for precise imaging of K-wires during their placement.
Poster: Evaluation of Hemodyanamic and Intra Abdominal Pressure Changes in Patients with Burn Injury during Resuscitation
Surinder Makkar, MBBS, MS, MCh, Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Deepak Kalia, MBBS, MS, Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Ramesh Sharma, MBBS, MS, MCh, Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Madhu Khullar, MD, Experimental medicine and biotehnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
The purpose of this study was to observe the effects of fluid resuscitation on the intra abdominal pressure and monitoring the changes in the central venous pressure and cardiac output during initial resuscitation in burn patients. Twenty six burn patients admitted from July 2006 to June 2007, in the burn unit of Plastic Surgery in PGIMER, Chandigarh were included into prospective study extended over the initial three days of the burn injury .The patients were resuscitated according to the Parkland formula. For every patient the basal intra abdominal pressure(IAP) and the central venous pressure (CVP) were measured. The CVP and intra abdominal pressure were measured 8 hourly. The cardiac output(CO) was measured daily by the dye dilution method using Indocyanin Green dye. There were 15 male and 11 female patients. The TBSA in the study group ranged from 20 to 60%. It was found that with the increase in the burnt body surface area, the IAP also increased. There was non significant positive correlation between the CVP and the fluid infused. There was significant positive correlation between the CVP and IAP during initial burn resuscitation. The CVP was significantly negatively correlated with the cardiac output. The fluid infused was significant positively correlated with the IAP during initial burn resuscitation. There was significant negative correlation between the IAP and the cardiac output on all 3 days. The fluid infused was negatively correlated with the cardiac output on the initial two days of resuscitation but positively correlated on third post burn day. There was no case of abdominal compartment syndrome. There was positive correlation between urine output and cardiac output and negative correlation between urine output and CVP and IAP but all were not statistically significant.The data from our study suggest that the CVP during burn resuscitation is influenced more by the surrounding external intra-abdominal pressure than by the actual intra-vascular volume status of the patient. Thus CVP guided fluid therapy during burn shock may lead to an underestimation of fluid requirements of the patient. In major burns the increased amount of fluid infused can lead to increased intra abdominal pressure and one should be aware of abdominal compartment syndrome. More larger studies are needed to assess the results
Poster: Salvage of Exposed Left Ventricular Assist Devices
Aisha White, MD, Plastic Surgery, University of Illinois at Chicago, Chicago, IL
Ramasamy Kalimuthu, MD, FACS, Plastic Surgery, Advocate Christ Hospital, Oak Lawn, IL
Background: Left ventricular assist devices (LVADs) were initially designed to provide support to patients with end-stage heart failure who had failed medical therapy as they awaited heart transplant. These devices were considered temporary, as they were a “bridge to transplant.” More recently, however, they have been applied as a permanent alternative to heart transplant, “destination therapy”, in patients who are not candidates for heart transplant and who have failed medical therapy. With longstanding implantation of the device has come an increase in complications, most notably infections. These LVAD pocket infections and driveline infections often lead to subsequent wound breakdown and exposure of the device, creating an open cavity that is difficult to sterilize and close. Muscle flaps can provide well-vascularized tissue with bulky coverage that can help minimize re-infection rates and eliminate dead space around the device. Alternatively, perforator flaps and local abdominal wall flaps can be used to provide good, stable coverage in difficult areas, such as the epigastrium; they can also function as great salvage flaps after failure of other flaps.
Methods: A retrospective review of the presentation, management, and outcomes of 4 patients who underwent reconstruction of abdominal wall defects secondary to LVAD infections and erosion of the driveline exit site. One patient underwent an intercostal artery perforator flap for coverage of an epigastric defect. Another patient underwent a rectus abdominis musculocutaneous flap for coverage of a central abdominal defect and local fasciocutaneous flaps for revision of the driveline exit site. Two other patients underwent a three pedicle flap technique to eliminate contact between subcutaneous fat and the driveline in an effort to prevent subsequent driveline infections and erosion.
Results: Follow up for the patients ranged from 9 to 12 months. There was no flap loss in the series. Three patients had superficial epidermolysis of the flaps, which responded to treatment with local wound care. One patient had a recurrent wound infection at the driveline site, which was complicated by wound dehiscence in the area of the driveline; this patient refused any additional surgical intervention. The wound is stable, with no additional deterioration, and is managed by local wound care. One patient died 9 months postoperative of complications unrelated to the surgery.
Conclusions: We conclude that flap coverage is often necessary to provide stable wound closure and minimize recurrent infection following LVAD wound breakdown with device exposure. A variety of flaps can be used as long as well-vascularized, bulky tissue is used to eliminate dead space in the LVAD pocket and around the driveline. Perforator flaps and local abdominal wall flaps are important tools for challenging reconstructions where traditional options are limited.
Poster: Topographic and Microangiographic Anatomy of the Teres Major Muscle – a New Free Functional Muscle Flap?
Goetz Andreas Giessler, MD, Clinic for Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Clinic Ludwigshafen, Ludwigshafen, Germany
Sara Doll, BS, Department of Anatomy II, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany; Guenter Germann, MD, PhD, Clinic for Hand-, Plastic and Reconstructive Surgery, BG Trauma Clinic Ludwigshafen, Ludwigshafen, Germany
The teres major can be seen as an additional head of the latissimus dorsi muscle for extension, adduction and inward rotation of the arm. It gained importance in pedicled muscle transfers for the treatment of plexus palsies and shoulder instability. Its supplying vessels belong to the subscapular system and, according to the literature, the muscle was transferred only once as a free microvascular but nonfunctional graft. The detailed topographic and microangiographic anatomy was investigated to determine the potential use as a free functional muscle flap.
Eleven flaps from fresh cadavers were dissected and perfused with radiopaque media. Three different routes of access to the flap are possible. The mean length of the flap was 158 mm, the distal and proximal tendinous width 24 mm and 52 mm, respectively. A Taylor-type 1 nerve and Mathes-type-1 vessel distribution was found in all specimens. The pedicle is situated in the middle third of the superomedial border of the flap and derives almost exclusively from the circumflex scapular artery. No second pedicle was found in this study. Radioangiograms indicate possible splitting of the muscle both in transverse and longitudinal direction. The nerve could always be isolated to a considerable length (66 mm) before reaching the posterior cord.
This anatomical study indicates, that the teres major can be seen as a separate entity in the subscapular system and can be transferred as a free flap either alone or in combination. As from what is known from pedicled transfers, the donor site morbidity should be expectedly low, if the latissimus dorsi is left intact. According to its anatomical features, the flap may be interesting for upper extremity and plexus reconstructions as well as for tongue reconstruction.
Poster: A method of controlled closure: The use of Ligaclips© in the delayed primary closure of flaps
Alexander James Hills, BSc, (hons), Imperial college, London, United Kingdom
Bien-Keem Tan, MBBS, FRCS, Plastic, Reconstructive, Aesthetic Surgery, Singapore General Hospital, Singapore, Singapore
Abstract: Achieving primary closure of a flap may not always be possible initially. Current controlled closuretechniques exert uniform pressure across a wound, which is unsuitable for a flap, as it can induce ischemiain vulnerable areas. Using Ligaclips to secure tissue advancement along mattress sutures offers both theease of expansion, like running sutures, and the ability to moderate in tension in discrete areas, likeinterrupted sutures. The cases the poster highlight variations of how this technique can be applied to closewounds boarded by vulnerable tissues such as flaps. We concluded that the use of ligaclips in conjunctionwith mattress sutures in the controlled closure of defects around flaps is simple and fast, enabling greatercontrol over the forces exerted over discrete areas, minimising the risk of compromising vulnerable tissues.
Poster: Eyelid Ptosis: Late Results of Reconstruction with Modification of Frontal Muscle Flap Technique
Renato Fusaro Neto, MD, Plastic Surgery, Federal University of São Paulo, São Paulo, Brazil
Luis Eduardo F. Abla, MD, PhD, Plastic Surgery, Federal University of São Paulo, São Paulo, Brazil; Acary Souza Bulle Oliveira, MD, PhD, Clinical Neurology, Federal University of São Paulo, Brazil; Lydia Masako Ferreira, MD, PhD, Plastic Surgery, Federal University of São Paulo, Brazil
Eyelid
Ptosis: Late Results of Reconstruction with Modification of Frontal Muscle Flap
TechniqueIntroduction: Eyelid Ptosis is a congenital or
acquired condition characterized by a drooping of the upper eyelid below its
normal level and the eyelid levator muscle is not able to lift the lid. The
cases of severe ptosis (in which the levator function is equal or lesser than
4mm) are the most challenging reconstructive procedures. Most of those patients
do not have neither Bell's reflex or ocular movement that can cause,
postoperatively, corneal damage and diplopia. Most of the surgical procedures
available present a satisfactory result in mild to moderate ptosis. However, in
cases of severe ptosis only a few techniques can be accomplished, most of these
ones are static procedures or use alloplastic devices. In order to solve these
issues the authors used a large frontal muscle flap transferred to the upper
eyelid tarsus.
Method:
Surgical technique -
Eighteen subjects with severe ptosis and poor levator function were submitted
to this technique:
1. Two
musculocutaneous incisions are performed on the natural fold ( or 5mm from the
ciliary border if the fold is absent) and near the eyebrow, both 2,5cm long.
2. One
cutaneous incision, 3cm long, on the hairline.
3. A
musculocutaneous tunnel is fashioned between the inferior e superior palpebral
incisions.
4. Through
the hairline incision the forehead is undermined from the frontal muscle until
the superior palpebral incision is achieved.
5. Through
the superior palpebral incision, the frontal muscle flap is elevated laterally
to the supraorbitary pedicle.
6. The
freed flap extremity is passed under the palpebral musculocutaneous tunnel and sutured
on the tarsal plate.
7. A
relaxing incision is performed through the hairline incision to provide de
correct position of the eyelid. The relaxing incision must be parallel to the
tarsal pla
Patients - The Seven
patients with bilateral severe ptosis and 11 patients with unilateral severe
ptosis. In 3 patients the Bell's reflex was absent. The Follow-up period ranged
from 18 to 72 months. Aesthetic outcome and visual improvement were based on
the patients' opinion. The success of the surgery was measured by: presence of
orbitopalpebral fold, upper eyelid elevation as preoperatively planned (when
the frontal muscle is requested) and upper eyelid contour.
Results: All patients reported visual and
aesthetic improvement. One patient whose Bell's reflex was absent developed bilateral
corneal ulceration treated with ocular occlusion and eyedrops with no further
sequelae. Seventeen patients presented the visual axis freed, after the follow-up
period, most of them with the eyelid position near the preoperative proposal. One
patient present the visual axis covered, even 12 months after the surgery, frontal
muscle flap is still not working.
Discussion: The Modified Frontal Muscle Flap
Technique is a reliable procedure that can be used in severe ptosis with poor
or absent levator function. This technique provides outcomes comparable with
all others severe ptosis techniques. Furthermore, this muscle flap technique
does not use either synthetic or distant fascial grafts. Some modification
should be introduced to the Song's original technique, such as hairline
incision and the relaxing incision for either facilitate the dissection and
regulate the ptosis correction.
In early postoperative period of the
patients whom Bell's reflex is absent, extra care should be taken to avoid
corneal ulceration using Frost suture. Furthermore, ocular occlusion during
night should be used indefinitely.
Poster: Salvage of a Congested Dieap Flap with Subcutaneous Recombinant Tissue Plasminogen Activator Treatment
Safak Uygur, MD, Plastic Surgery, Gazi University, Ankara, Turkey
Suhan Ayhan, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Ismail Kucukoduk, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Ayse Sencan, MD, Plastic Surgery, Gazi University, Ankara, Turkey
PURPOSE Most common free flap failures are secondary to venous thrombosis. Thrombolytic agents have been used successfully to manage venous thrombosis. However, severe complications may occur when applied systemically. Recombinant tissue plasminogen activator (rtPA) in the treatment of no-reflow phenomenon in microvascular surgery was first used by Stassen et al. in two replanted fingers. Recently, Tran et al. presented a case of autogenous breast reconstruction with free TRAM flap, in which the flap was compromised by venous congestion, and salvaged by using subcutaneous rtPA. The purpose of this paper is to report and discuss another case with congested DIEAP flap, which was salvaged with subcutaneous recombinant tissue plasminogen activator treatment.CASE REPORTA forty-five-year-old woman underwent a delayed breast reconstruction with free deep inferior epigastric perforator flap. During surgery, dissection of the flap and the recipient vessels were uneventful. The superficial inferior epigastric vein (SIEV) was also dissected for a possible venous drainage route. We used the internal mammary artery and vein as recipient vessels. Following the anastomosis, flap color turned cyanotic, although there was no sign of venous thrombosis or kinking and twisting of the vessels. Patency of the vessels were tested and found positive. The SIEV was engorged, thus we opened the vessel and observed immediate relief and return of normal flap color. In order to be on the safe side, the anastomosis was renewed three times in a row; however we always ended up with venous congestion. We thought that the cause of venous congestion was most likely due to the dominance of superficial venous system. Since the SIEV was shortened, we were unable to do an extra venous anastomosis; and we decided to utilize leech therapy in the postoperative period along with continuous heparinization and oral aspirin. Leeches were employed for 36 hours. During this period, the flap color was still cyanotic, especially at the periphery of the flap and the capillary refill was faster than 1 second in the intervals of leech therapy. The flap temperature was low (32-33ºC), but the flap was alive, Doppler signals were audible although the flap looked compromised. At this point, we decided to try to improve the microcirculation by using rtPA as described by Tran et al . We used rtPA (ACTILYSE® 50mg, Boerhringer Ingelheim, Germany), in the dose of 2 mg in 2.2 ml distilled water, and we injected subcutaneously at multiple sites in the compromised flap.Several hours after the injection, capillary refill returned to normal levels and flap temperature progressively increased to 35-36ºC. Eventually, lateral marginal skin necrosis of 1,5 cm width and lateral fat necrosis of 3-4 cm extension settled and was debrided 2 weeks after the operation. The discoloration at the donor area ended up with a 3x3 cm full thickness necrosis of the skin. The patient was discharged from the hospital 1 week after the surgery. She has been followed for 3 months. The flap is alive with normal color and capillary refill.DISCUSSIONAdministering rtPA subcutaneously may have some beneficial effects, such as decreasing the need for additional operations, easy application, and bedside use. Although there is no study in literature comparing the efficacy of intravascular and subcutaneous administration of the rtPA, Lantieri et al. have recently demonstrated experimentally the value of topical application of recombinant tissue factor pathway inhibitor in the prevention of microvascular thrombosis. We believe that subcutaneous rtPA was responsible for salvaging this venous congested free DIEAP flap, given the return of capillary refill and the improvement of the skin color several hours later. Our experience is similar to Tran et al who used subcutaneous rtPA for free TRAM salvage. Further investigation is mandatory to explore the efficacy and the mechanism of function of subcutaneous rtPA, however it should be kept in mind that it works in venous congestive conditions.
Poster: Touch-up Needs Following Soft Tissue Filler Application with Hyaluronic Acid to the Face
M. Onur Cukurluoglu, M, D, Plastic surgery, Gazi University, Gazi Hospital, Ankara, Turkey
İsmail Kucukoduk, M, D, Plastic surgery, Gazi University, Gazi Hospital, Ankara, Turkey; Basar Kaya, M, D, Plastic surgery, Gazi University, Gazi Hospital, Ankara, Turkey; C. Reha Yavuzer, MD, Plastic surgery, Gazi University, Gazi Hospital, Ankara, Turkey; Osman Latifoglu, M, D, Plastic surgery, Gazi University, Gazi Hospital, Ankara, Turkey
Purpose: With the increasing interest of the media and developing
sociocultural architecture, the popularity of non-invasive procedures for facial
rejuvenation is rising. Among non-invasive procedures, soft tissue fillers,
especially hyaluronic acid derivates are leading with
their ability to be used alone or in combination with other procedure. The aim
of this study was to define the needs for touch-ups in different application
sites after facial rejuvenation procedures with hyaluronic
acid injections.
Material
and Method: 220 patients received hyaluronic acid derivates for facial rejuvenation between
the years 2004 and 2007 were studied retrospectively. On 220 patients 450 hyaluronic acid injections were used on 314 different localizations.
Injections were done under local or regional anesthesia after adequate antisepsis.
Superficial, mid-dermis and deep dermis injections were preferred according to the
anatomic localization and individual patient needs. Serial puncture and linear
threading methods were preferred for nasolabial sulcus and lips, whereas fanning was done in perioral and
malar areas. Total number of injections were as fallows; 110 nasolabial sulcus,
78 lips, 38 perioral, 37 malar, 16 tear
trough, 20 glabella, 8 nose, 6 mentum, 4 neck area.
Results: The most common complication was ecchymoses
at the injection site. No asymmetries or acute allergic reactions were observed.
Touch-up was needed in two groups.(Table 1) The first
group was consisted of patients who had insufficient augmentation due to
inadequate amount of injected material at the first session. In the second
group though the initial volume was satisfactory an early resorbtion
than expected was observed.
Insufficient augmentation 32 (%9.1)
| Early resorbtion 20 (%14.5)
|
Nasolabial sulcus 19 (%17,2)
|
Lips 9 (%11.5)
|
Malar 4 (%10,8)
|
Nasolabial sulcus 8 (%7.2)
|
Perioral 4 (%10,5)
|
Perioral 3 (%7.9)
|
Lips 5 (%6,4)
| |
Tble 1: Touch-up was needed in two groups
Conclusion: Hyaluronic acid fillers are
effective and reliable materials among soft tissue fillers. Touch up need for inadequate
amount of injection was seen mostly at the nasolabial sulcus and malar areas whereas
early resorbtion was the main reason for touch ups
for lips. As a result of these findings the patients must be informed for the
need of touch-ups before the procedure and certain areas are more prone to
require a staged application of the filler material. This is especially
important to mention to the patient in order not have any conflicts afterwards.
Poster: An Evaluation of Calcium Hydroxylapatite (Radiesse®) for Cosmetic Nasolabial Fold Correction: Meta-Analysis and Patient Centric Outcomes Study
G. Peter Fakhre, MD, General Surgery, Mayo Clinic Jacksonville, Jacksonville, FL
Galen Perdikis, MD, Mayo Clinic Jacksonville, Jacksonville, FL; Kyle Shaddix, MD, General Surgery, Mayo Clinic Jacksonville, Jacksonville, FL; James C. Waldorf, MD, Mayo Clinic Jacksonville, Jacksonville, FL; Sarvam P. TerKonda, MD, Mayo Clinic Jacksonville, Jacksonville, FL
BACKGROUND: The use of calcium hydroxylapatite (Radiesse®, BioForm Medical, San Mateo, California) for cosmetic soft tissue augmentation has increased significantly in recent years. Only a handful of authors have reported patient satisfaction data.
METHODS: A meta-analysis of published data was performed using a five-point scale for patient satisfaction to allow data comparison across studies. A patient-centric outcomes study was performed at our institution using a questionnaire.
RESULTS: Five usable studies were identified for meta-analysis. Patient satisfaction was 4.16 out of 5 in 324 patients at 3-6 months and 4.15 in 86 patients at one year. In our institutional patient-centric outcomes study, the early satisfaction rate was 3.7 out of 5. At one year the rate was only 2.3 out of 5.
CONCLUSION: Calcium hyroxylapatite remains a viable option for augmentation of facial soft tissue structures. However, this report shows that further, accurate, large population outcomes assessments are absolutely required.
Poster: Facial Reconstruction of a Multiple Malignant Melanoma in Xeroderma Pigmentosum Patient with Monoblock Full Thickness Skin Graft
Selahattin Ozmen, MD, Plastic Surgery, Gazi University, Ankara, Turkey
Safak Uygur, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Tolga Eryilmaz, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Betul Ak, MD, Plastic Surgery, Gazi University, Ankara, Turkey
PURPOSE
Xeroderma
pigmentosum is an autosomal recessive disease characterized by an endonuclease enzyme
defect and resulting in marked vulnerability of the skin to ultraviolet
radiation. Although conservative surgical resection the primary therapy for skin
tumors in patients with xeroderma pigmentosum, severe cases have been treated
by excision of large portions of facial surface and grafting with uninvolved
skin. The purpose of this paper is to report a xeroderma pigmentosum case with
multiple malignant melanoma on her face and radical excicion of total facial
skin followed by facial resurfacing with monoblock full- thickness skin graft
achieved by abdominoplasty material.
CASE REPORT
A
thirty-five-year-old woman was referred to our clinic with a multiple pigmented
lesion on her face. She had three brothers in good health and her family hisory
revealed neither xeroderma pigmentosum nor any other skin disease.
The
patient was 5 years old when freckling pigmentations first appeared on her
face. The first pigmented lesion on her face appeared two years ago and she had
had no treatment or had not been seen by a doctor until her admission to our
clinic. Sun exposed areas of her body showed multiple freckling pigmentations. Clinical
diagnosis was xeroderma pigmentosum.
Physical
examination of the patient revealed multiple pigmented lesions located on
bilateral malar region, dorsum of the nose, glabella, frontal region, right
half of the chin changing dimensions 0.5x0.5x1 cm to a maximum of 3.5x3x2 cm
(Figure 1)
Figure
1
We
performed multiple excisional biopsies and pathology revealed that multiple
invasive malignant melanoma. After pathological diagnosis excision of almost
whole facial skin and resurfacing with a monoblock full thickness skin graft was
planned given ubiguity of the invasive tumors the age of the patient.
There
was no sign of systemic metastases at physical examination and laboratory data.
The upper and lower eyelids , eyebrows, alar rim and vermillon were spared
because of challenges in reconstruction of these areas. Except these regions
the whole facial skin was excised under general anesthesia (Figure 2)
Figure
2
At
the same time we performed an abdominoplasty according to the pattern of the face
prepared preoperatively and we harvested monoblock skin graft from this
abdominoplasty excision material. The graft was adapted to the excised area of
the face (Figure 3,4,5).
Figure
3
Figure
4
Figure
5
The
donor area was primary repaired. Pressure bandages were applied to face and a
nasogastric catheter was applied for the immobilization of perioral region but
patient denied nasogastric catheter and we could not use this.
On
the first control examination during the fifth postoperative day graft on the
face was good but after 1 weeks, there was perioral necrosis (Figure 6).
Figure
6
We
performed debridment and full-thickness skin graft harvested form right
inguinal, left and right end of the abdominoplasty incision (Figure 7)
Figure
7
Postoperrative
there was no graft problem and achieved acceptable result. The patient has been
followed for three months and there has been no recurrence so far (Figure 8)
Figure
8
CONCLUSÝON
Face reconstruction is a challenging
procedure that there are many techniques including allotransplantation,
expanded skin flaps, split thickness skin grafting. Allotransplantation has
some difficulties that immunsupresion, total loss of transplanted face, technique details. Expanded flaps are limited
usage for total face reconstruction. Split thickness skin grafting has a poor
aesthetic results.
For xeroderma pigmentosum patients
who developed a large number of invasive tumors, complete resurfacing of
exposed skin with a full thickness skin grafting provides acceptable aesthetic
and reconstructive result. Monoblock full thickness skin graft achieved by
abdominoplasty material is a good donor choice for suitable cases.
.
.
Poster: Short Hospital Stay TRAM Flap Post-mastectomy Breast Reconstruction
Johan Lars Sandberg, MD, Surgery, Mercy Catholic Medical Center, Darby, PA
Patricia M. Bailey, MD, General Surgery, Chestnut Hill Hospital, Philadelphia, PA; Chris D. Tzarnas, MD, Plastic Surgery, Mercy Catholic Medical Center, Darby, PA
Healthcare financial concerns have increased administrative attention upon resource utilization and conservation by hospitals and physicians in providing surgical treatments to patients. Increased emphasis upon outcome metrics and healthcare economics has focused concerns upon in-hospital expenditures for surgical care. Hospitals have been more attentive to length-of-stay data in an attempt to reduce expenses and increase the contribution margin. Increased out-patient surgery has been a national trend as well as abbreviated in-hospital care in promoting medical resource conservation.
Autologous post-mastectomy breast reconstruction is a current standard for aesthetic outcomes of breast reconstruction. It is generally more resource intensive in hospital days compared to implant reconstruction. We have analyzed our experience with autologous post-mastectomy breast reconstruction using the transverse rectus abdominus flap over the past twenty years assessing changes in length-of-stay and the determinants of a shorter hospital course. Demographic, operative, and outcome data were gathered and analyzed on a consecutive series of 169 autologous post-mastectomy breast reconstructions performed using transverse rectus abdominus flaps. Length-of-stay has diminished from an average of seven days early in our experience to the current average length-of-stay of just three days over the past two years. Patient age did not correlate with length-of-stay. Post-operative pulmonary complications increased the length-of-stay.
Shorter length-of stay is attributed to 1) delineating patient expectations with pre-operative counseling, 2) improved post-operative pain management, and 3) changes of in-hospital nursing care. No differences in patient outcomes were identified following implementation of the shorter length-of-stay. Significant improved utilization was achieved with modest process changes which are easily implemented.
Poster: Trichilemmal Carcinoma: Surprising Surgical Challenges
Patrick W. Lappert, MD, Lappert Plastic Surgery, Decatur, AL
Monita Soni, MD, Pathology, Parkway Medical Center, Decatur, AL
Trichilemmal Carcinoma is characterized in the literature as a locally problematic skin-adnexal carcinoma that is entirely amenable to successful management by surgery alone, and that recurrences and metastatic lesions are not reported. 2 cases treated by the same surgeon are presented that demonstrated local recurrence in spite of agressive MOHS excision. The two patients are very different in demographics, and one patient demonstrated distant recurrence. Both patients required very extensive reconstruction.
The pathology of skin-adnexal carcinomas is discussed, and the literature reviewed.
Poster: An Unnamed First Rib Fibrous Band as a Cause of Thoracic Outlet Syndrome: A Cadaver Study
Carlos R. Medina, MD, Division of Plastic Surgery, Department of Surgery, Temple University Hospital, Philadelphia, PA
Michael Franco, MS IV; Tolulope Akinyemi, MD, Department of Surgery, Temple University Hospital, Philadelphia, PA; Carson Schneck, MD, PhD, Department of Anatomy and Cell Biology, Temple University School of Medicine, Philadelphia, PA; Julie Spears, MD, Division of Plastic Surgery, Hahnemann University Hospital, Philadelphia, PA; Amitabha Mitra, MD, Division of Plastic Surgery, Hahnemann University Hospital, Philadelphia, PA
Background: Thoracic Outlet Syndrome (TOS) is a clinical entity that develops due to compression against the shoulder girdle. Symptoms usually develop from compression of the brachial plexus and the subclavian vessels between the clavicle and the first rib. Despite of the patients’ vague symptoms, the clinical presentation of TOS is very consistent. Thoracic Outlet Syndrome is more common in women and the usual age distribution ranges from the second to the third decade. This syndrome has been associated to traumatic etiologies such as whiplash injuries from motor vehicle collisions, prolonged periods of upper extremity abduction, or the use of vibrating tools. Multiple hypotheses have attempted to explain the variety of symptoms observed in patients with TOS. Cumulative trauma disorders and muscle imbalance patterns with nerve compressions are some of the most prevalent theories regarding the pathogenesis of this controversial syndrome. Mild to moderate cases of TOS may benefit from conservative treatment while surgical interventions are reserved for severe cases. We propose that an adventitial fibrous band over the first rib is the etiology of the TOS. The purpose of our study is to identify the fibrous band of the first rib and describe its anatomic relationship to nerve roots and brachial plexus.
Material and Methods: One hundred first thoracic ribs were dissected from 70 embalmed cadavers. Thirty six cadavers were female and 34 were male. The age range was from 15 to 75 years with its majority in the 5th decade (mean of 54.3 years old). Twenty seven patients were African American, twenty two were Caucasian, twelve were Hispanics and 9 were Asian. The dissections were performed for evaluating for the presence of a congenital fibrous band within the first rib.
Results: We performed 100 dissections on 70 embalmed cadavers, 60 cadavers having bilateral dissections. Twelve dissections involved the right first ribs and 28 left first ribs. The dissections demonstrated the presence of thirty five fibrous bands intrinsic to the first rib (35% incidence; 35/100). This band always originated from the concave surface of the first rib, lateral to the head of the rib (1.34 cm). Its insertion is lateral to the anterior scalene tubercle (0.59 cm). The width and length of the band were 0.27 cm and 3.45 cm, respectively. The band was found to be distinct to the scalene minimus muscle, but when both are present they fuse near its insertion. The scalene minimus muscle was found on 11 of the dissected first ribs (11% incidence; 11/100). The fibrous band consistently created a space through which the T1 nerve root passes. The interspace created by the band measured 0.60 cm.
Conclusion: Our dissections showed that this fibrous band always creates a space through which T1 nerve root passes. Contrary to previous reports, the T1 nerve root does not cross over this fibrous band. Since, costo-clavicular compression of the brachial plexus and the subclavian vessels seems to be main pathophysiologic mechanism responsible for this syndrome. It is possible that this intrinsic first rib band plays an important role in the TOS. We suggest that this fibrous band may be a potential site of nerve entrapment and causes symptoms related to the thoracic outlet syndrome. Knowledge of this band may change our clinical concept and surgical approach. We are presently evaluating this fibrous band by magnetic resonance imaging (MRI) in both cadaver and clinical settings.
Poster: Five-Year Prospective Outcome Study in 325 Cosmetic Breast Surgery Patients
Eric Swanson, MD, Swanson Center, Leawood, KS
PURPOSE: Although past
prospective outcome studies have evaluated breast augmentation or reduction,
there have been no previously published prospective outcome studies that
include mastopexy and augmentation/mastopexy patients. It is important to
evaluate these groups because mastopexy patients have been a source of
difficulty. Furthermore, concern has been raised about doing a mastopexy and
augmentation in combination and in treating patients secondarily.
Patients often ask about the amount of pain and recovery time. These questions
are important in terms of patient expectations and planning and need to be
answered specifically in terms of relevant activities of daily life and based
on patient-reported data. They have not been assessed in previous outcome studies.
This prospective study evaluates and compares 4 cosmetic breast procedures –
augmentation, mastopexy, augmentation/mastopexy, and reduction. This study is
part of a four-pronged evaluation of female cosmetic breast surgery patients,
which also includes a prospective clinical study, a photometric study of breast
morphology, and a photometric study of mastopexy/reduction publications.
METHODS: Over a 5-year
period, January, 2002 to September, 2007, 394 consecutive female patients
underwent 406 cosmetic breast procedures. A total of 331 interviews were
conducted with 325 patients for a response rate of 81.5 percent, using an
in-person interview conducted by one of the nurses. A vertical technique was
used for all mastopexies and breast reductions. Questions were asked in 6
categories: patient data, indications, recovery (including discomfort level),
results, complications, and psychological effects. A follow-up study was
included to determine duration of nipple numbness (fig. 1). Patients who
completed the breast augmentation survey were also asked to look at a page of
photographs of a patient who underwent a breast augmentation, before, one
month, and three months after surgery, to determine preferred breast
proportions
RESULTS: Patients
reported using prescription analgesics an average of 5.4 days, resumed driving
in 5.8 days, returned to work 7.5 days, and felt “back to normal” in 27.8
days. The mean length of time patients needed assistance after surgery was 3.1
days, help with their children 5.0 days, and return to full exercise, 36.9
days. Patients reported being able to sleep comfortably on average 19.5 days
after surgery.
Pain rating was moderate overall
(5.4/10), higher for breast augmentation (5.9) and lower for breast reduction
(3.3) (fig. 2) Both mastopexy and breast reduction patients reported a
significant reduction in physical symptoms after surgery (p <
0.001). Bra cup sizes are shown in figures 3 and 4. The mean results
rating was 9.2/10, similar (p > 0.05) for all procedures (fig. 5).
Almost all patients (326/329, 99.1 percent) would “do it again.” Breast
augmentation and reduction patients were most inclined to find the surgery
exceeded their expectations (p < 0.05). The complication rate
reported by patients was 40/331 (12.1 percent). All procedures reduced breast
self-consciousness after surgery (p < 0.001).
CONCLUSIONS: Almost all
patients desire an improvement in the appearance of their breasts, including
breast reduction patients. Results ratings were very high (9.2/10), with
comparable ratings for breast augmentation, mastopexy, augmentation/mastopexy
and reduction. Higher results ratings correlated with larger implant volumes
and a lack of complications. Primary versus secondary surgery and smoking
history did not correlate significantly with results rating. All four
procedures provided a high level of patient satisfaction, improvement in
self-esteem and quality of life. Symptomatic improvement was reported by both
mastopexy and reduction patients. Nipple numbness was common (42.9 percent)
but eventually resolved in 87.9 percent of patients who experienced it. Most
patients preferred a convex breast shape.
Fig. 1. Nipple
sensation follow-up study. Mean follow-up time was 29. 4 months (range 2.5
months – 67.9 months).
Fig. 2. Pain
rating. Scale of 1 (no pain) to 10 (most severe pain).
Fig. 3. Bra
cup size before surgery.
Fig. 4. Bra
cup size after surgery.
Fig. 5.
Results rating. Scale of 1 to 10.
Poster: Should bilateral latissimus dorsi myocutaneous flap be used as a first-line procedure for breast reconstruction?
Shayna L. Showalter, MD, General Surgery, Thomas Jefferson University, Philadelphia, PA
Neil Moudgill, MD, General Surgery, Thomas Jefferson University, Philadelphia, PA; Eric Hager, MD, General Surgery, Thomas Jefferson University, Philadelphia; Timothy K. Williams, MD, General Surgery, Thomas Jefferson University, Philadelphia; Kristin Brill, MD, General Surgery, Thomas Jefferson University, Philadelphia; Anne Rosenberg, MD, General Surgery, Thomas Jefferson University, Philadelphia, PA; Steven E. Copit, MD, Plastic Surgery, Jefferson Medical College, Thomas Jefferson University, Philadelphia, PA
Should bilateral latissimus dorsi myocutaneous flap be
used as a first-line procedure for breast reconstruction?
Shayna L. Showalter M.D.,
Neil Moudgill M.D., Eric Hager M.D., Timothy K. Williams M.D., Kristin Brill
M.D., Anne Rosenberg M.D., Steven E. Copit M.D.
Department
of Surgery, Division of Plastic and Reconstructive Surgery, Thomas Jefferson University, Philadelphia, PA
Purpose: To analyze a series of bilateral latissimus dorsi myocutaneous
flap (LDMF) breast reconstructions performed by a single surgeon (S.C.) and to
provide data supporting the use of LDMF as a first-line procedure for breast
reconstruction.
Methods: We reviewed outcomes of a prospective cohort of 121
patients who underwent bilateral mastectomy followed by bilateral LDMF. All
reconstructions were performed by a single surgeon between February 2000 and
August 2007. One-hundred and eight (89.3%) of the LDMF reconstructions were
immediate and 13 (10.7%) delayed. End points included average length of stay (LOS),
total operative time (mastectomy and LDMF reconstruction), operative time for LDMF
reconstruction alone, estimated blood loss (EBL), body mass index (BMI),
occurrence of post-operative hematoma or seroma, and incidence of necrosis or
flap loss.
Results: Mean age of the patient group at the time of
operation was 47.4y. (range 28y - 72 y). Mean BMI was 23.9. Mean total operative
time was 7.35 h (range 4.65h - 10.0h). Mean time of LDMF reconstruction was
5.53h (range 3.0h - 7.45h). Mean EBL was 300 cc. Three (2.5%) patients
received a blood transfusion of 1 unit. Mean LOS was 3.3 days. Forty-two
patients (34.7%) developed a donor site seroma, and required an average of 2.7
aspirations. Six patients (5.0 %) developed a donor site hematoma that
required reoperation. There was no incidence of flap necrosis or flap loss.
Conclusion: These data, representing a large consecutive series
of bilateral LDMF as a primary procedure for breast reconstruction, validate
the approach as one that provides excellent cosmetic results with low
morbidity. The technique is suggested as one to be considered routinely for
patients undergoing bilateral breast reconstruction.
Poster: Ultrasound Assisted Trigger finger release: is it really safe?
Karina L. Paulius, MD, Surgery, Mount Sinai Medical Center, Chicago, IL
Pirko Maguina, MD, Plastic Surgery, University of California Davis, Sacramento, CA
Abstract: Introduction: Trigger fingers can be treated by open or percutaneous division of the A1 pulley. The open approach allows for visualization of the pulley, as well as of the adjacent neurovascular bundles. The proponents of this technique argue that it allows a safer release of the trigger finger and ensures complete division of the A1 pulley. Many authors have advocated in favor of the percutaneous needle division, citing the lack of an incision as its biggest advantage. According to these reports, the percutaneous approach is safe and effective. Ultrasound imaging has been reported as an adjunct for guiding the needle during percutaneous trigger finger release, and advocates of this technique have reported good clinical outcomes with what they feel is increased safety. Materials and Methods: This study was designed to evaluate the safety and efficacy of needle trigger finger release with added ultrasound imaging. 18 cadaver A1 pulleys were divided percutaneously and then evaluated by converting to an open technique and examining the hands for completeness of the division and possible underlying tendon injury. The ultrasound was used to identify the position of the needle tip during the procedure. Results: The ultrasound images demonstrated repeated puncture of the tendon sheath and of the neurovascular bundle during percutaneous division. The subsequent dissection revealed 3/18 tendons with visible lacerations and 15/18 A1 pulleys with incomplete division as evidenced by persistence of transverse fibers across the area of the pulley. Conclusions: Percutaneous trigger finger division can be associated with puncturing of the flexor tendon and adjacent neurovascular bundles, as demonstrated by our ultrasound images. Additionally, it may lead to incomplete division of the A1 pulleys as seen on our cadaver dissections. While the clinical significance of these findings is unclear to us, it does raise skepticism towards the safety of percutaneous trigger finger release in our hands.
Poster: Improved Cosmetic Outcomes With Free Fat Transfer in Breast Reconstruction: A Review of 42 Procedures in 21 Patients
Gregory R. Scott, MD, Plastic Surgery, Kaiser Permanente San Diego Medical Center, San Diego, CA
Gregory L. Borah, MD, Plastic Surgery, UMDNJ-R. Wood Johnson, New Brunswick, NJ; Cynthia L. Carson, PA-C, Plastic Surgery, Kaiser Permanente San Diego Medical Center, San Diego, CA
Improved Cosmetic Outcomes with Free Fat Transfer in Breast Implant Reconstruction: A Review of 42 Procedures in 21 Patients
Introduction: Reconstruction of the postmastectomy breast with two stage biodimensional expanders and implants yields excellent results in most patients. However, disfiguring tissue contour deformities can result. Most common is thin tissue coverage superior to the implant reconstruction (superior perimeter defect) and wrinkling of the implant. The purpose of this study is to review our experience with treatment of these deformities using the "Coleman" free fat transfer system.
Methods: A retrospective review was undertaken of 21 patients with tissue contour deformities after two stage breast reconstruction with biodimensional expanders and implants. These deformities were corrected by free fat transfer using the Coleman system. All reconstructions and fat transfers were performed by a single surgeon.
Results: 21 patients underwent 42 procedures to correct post implant contour deformities 2003-2008. The average age was 52 years (range 25-71 years). Thirteen patients (62%)underwent bilateral fat transfers. Seven patients (33%)underwent a second fat transfer procedure. The average interval from implant placement to fat transfer was 9.9 months (range 2-44 months). The averge interval between the repeat fat transfer was 8.5 months. The indications for fat transfer was superior perimeter defects in 14 patients(67%); implant wrinkling and superior perimeter defects in 6 patients (29%); and contour deformity in 3 patients (14%). Four patient underwent simultaneous implant replacement for breast asymmetry. All procedures were performed in an outpatient surgery center under general anesthesia. The amount of fat transferred averaged 67 cc per breast (range 30-180cc). The fat was harvested from the abdomen in all cases. In 2 patients additional fat was harvested from the upper thighs. There were no reports of postop cellulitis or obvious fat necrosis. Four patients required a second fat transfer due to initial under correction.
Conclusions: Free fat transfer is a safe and effective means of correcting bothersome tissue contour deformities following postmastectomy implant reconstruction.
Poster: Shuttle Lifting of the Nose: A Minimal Invasive Method for Nose Reshaping
K. Tunc Tiryaki, MD, Plastic Surgery, Cellest Plastic Surgery Clinic, Istanbul, Turkey
Background: Suspension sutures are commonly used in numerous cosmetic surgical procedures. The use of such sutures as a part of classical rhinoplasty has been described by several authors. On the other hand, it is not uncommon to see patients seeking nasal surgery for only a minimal hump deformity combined with an under-rotated, under-projecting tip, which does not necessarily require a standard rhinoplasty. With the benefit of described suture suspension technique, this kind of nasal tip deformity can simply be reshaped via minimal incisions.
Method: In this study, the authors described an original technique based on the philosophy of vertical suspension lifts, achieving the suspension of the nasal tip with a percutaneous purse-string suture applied through small access punctures. All was obtained under local anesthesia with a double-sided needle or shuttle, smoothly anchoring the lower lateral cartilages in a vertical direction to the glabellar periosteum excluding the skin envelope.
Results: The technique was successfully applied under local anesthesia in carefully selected 62 patients between December 2005 and December 2007 with a follow-up changing from 8 months to 16 months. Five of the patients previously had a primary rhinoplasty operation. Outcomes were satisfactory in all but 6 cases, of which four found the result inadequate and two of them underwent a definitive rhinoplasty operation. Two patients requested the suture detached because of an over-exaggerated appearance. Operation time was very short in all patients followed by an uneventful rapid recovery.
Conclusion: As a minimally invasive nasal reshaping procedure, shuttle lifting technique is a very good choice to achieve long-lasting satisfactory results particularly in patients with minimal hump deformity and under-rotated tip.
Poster: Unrecognized Etiology of Asymmetric Prognathism and Novel Treatment with Lefort I Advancement and Unilateral Sagittal Split Rotation of the Mandible
Anand R. Kumar, MD, Plastic Surgery, National Naval Medical Center, Bethedsa, MD
Reza Jarrahy, MD, Plastic Surgery, UCLA, Los Angeles, CA; James P. Bradley, MD, Plastic Surgery, UCLA, Los Angeles, CA; Hurig Katchikian, BS, Plastic Surgery, UCLA, Los Angeles, CA; Mark Urata, MD, DDS, Los Angeles, CA; Henry Kawamoto, MD, DDS, UCLA, Los Angeles, CA
Introduction: Significant asymmetric
prognathism may be due to condylar hyperplasia or previous condylar trauma with
growth disturbance. Mild asymmetric prognathism with class II malocclusion is much
more common and the etiology is poorly understood. The traditional treatment to
these deformities involve a two-jaw orthognathic correction with or without
genioplasty. We investigated the etiology of this deformity with cranial
analysis and compared the traditional treatment to a novel treatment using only
a unilateral sagittal split mandibular osteotomy and final splint.
Methods: In part I, we obtained preoperative New Tom scans and 3D
photographic images of patients with asymmetric prognathism and measured neck
mobility to assess for unrecognized torticollis (n=30). In part II, we compared
patients treated for asymmetric prognathism with our novel approach of Le Fort
I advancement with unilateral sagittal split mandibular osteotomy using only a
final splint (Group 1) to the traditional 2 jaw method of a Le Fort I
advancement with bilateral sagittal split mandibular osteotomy with an
intermediate and final splint (Group 2) (n=60). Preoperative and postoperative
exams and cephalometric measurements were compared to determine the stability
of correction.
Results: Part I: Of all patients treated for prognathism in our
data bank 31% had asymmetric prognathism. All patients of thses patients had
restrictive measured neck range of motion and cranial base tilt on upward gaze;
based on these evaluations they were diagnosed with previously unrecognized
torticollis. These pateints had posterior lateral crossbite on the side of the
torticollis and deviation of the mandibular midline and chin point to the
contralateral side. Three-dimensional CT scan assessment revealed an asymmetic
cranial base in 85% of patients with slight anteriomedial displacement of the
glenoid fossa ipsilateral to the torticollis. Part II: In Group 1 (novel
unilateral split) Unilateral mandibular setback was performed ipsilateral to
the side of the torticollis in all patients. Intraoperatively, all cuts and
movements in both jaws were made and a final splint only was used to stabilize
the new occlusal relationship while osteofixation was obtained. When Group 1
(novel unilateral split) was compared to Group 2 (traditional 2 jaw surgery)
both were similar with regard to complications (infection 2-3%, bleeding 2%,
hardware failure 1%, need for revisionary surgery 2%). Operative time was
decreased in Gorup 1 by 15%. In Group I no patients complained of trismus, TMJ
clicking or popping, or lateral deviation with incisal opening. All patients
maintained a stable correction during a mean follow-up period of one year based
upon physical exam findings and cephalometric analyses.
Conclusions: Although a unilateral sagittal split solution may
seem to violate some principles of orthognathic surgery, for these patients
with asymmetric prognathism and unrecognized torticollis it provides successful
correction. We were able to obtain stable results using this technique in the
muscular torticollis patient while simultaneously decreasing morbidity and
without compromising function.
Poster: Internal Mammary Artery Perforator (IMAP) Based V-Y Advancement Flap for the Reconstruction of Soft Tissue Defects in the Sternal Region
Kwang Seog Kim, MD, PhD, Plastic and Reconstructive Surgery, Chonnam National University, Gwangju, South Korea
Sung In Yoo, MD, PhD, Plastic and Reconstructive Surgery, Chonnam National University, Gwangju, South Korea; Eui Sik Kim, MD, PhD, Plastic and Reconstructive Surgery, Chonnam National University, Gwangju, South Korea; Jae Ha Hwang, MD, PhD, Plastic and Reconstructive Surgery, Chonnam National University, Gwangju, South Korea; Sam Yong Lee, MD, PhD, Plastic and Reconstructive Surgery, Chonnam National University, Gwangju, South Korea
Background: The internal mammary artery perforator (IMAP) flap can be used to reconstruct small to medium sized defects in the neck or chest. The main advantage of the flap is its minimal donor site morbidity and superior aesthetic outcomes. However, if a larger flap is harvested, breast deformity may develop. In an attempt to resolve this problem, we modified the usual elliptical design of the IMAP flap in a V-Y manner.
Methods: Bilateral IMAP based V-Y advancement flaps were used to reconstruct an unstable wound in the lower sternal area in a male patient. After wide excision of the scar, an IMAP based flap is drawn triangularly and transversely on each side of the wound. The flaps were based on two intercostal perforators of the internal mammary vessels in the fourth and sixth intercostal spaces and measured 12 × 14 cm, respectively. The perforators of the internal mammary vessels were identified in the parasternal area and then the flaps were raised to the level of the pectoralis major fascia from lateral to medial. When the flaps were elevated, one perforator of the intercostal vessels in the sixth intercostal space was identified and preserved in each flap to enhance flap vascularity. The raised flaps were then advanced to the recipient site and the flap donor and recipient sites were closed primarily in a V-Y manner.
Results: Postoperative course was uneventful, and the flaps survived completely. Long-term follow-up showed good flap durability and elasticity.
Conclusions: The IMAP based V-Y advancement flap provides a convenient and reliable alternative for the reconstruction of soft tissue defects in the sternal region, particularly the lower sternal area.
Poster: Shuttle Lifting: A Percutaneous Purse-String Suture Suspension Method for Facial Rejuvenation
K. Tunc Tiryaki, MD, Plastic Surgery, Cellest Plastic Surgery Clinic, Istanbul, Turkey
Background: Thanks to the new concepts in face lifting surgery the attention of our efforts to restore youth of the face shifted from skin/SMAS traction to volume redistribution. S-lift or MACS lift are some examples of this effort to perform face lifts through shorter incisions due to the help of suspension sutures. The logical next step is to achieve comparable and durable results with minimal invasive methods. Methods: This paper describes a technique based on the same philosophy of volume redistribution, achieving the suspension of soft tissues with percutanous purse-string sutures through small access punctures. This is obtained through a double sided needle or shuttle, smoothly anchoring the subcutaneous tissues in a vertical direction to a more cranial periosteal point without drawing the skin. Results: The described shuttle suspension method was used on 266 patients in 384 different locations including the malar area, jowl, neck, eyebrows and nose, between December 2005 and December 2007 with satisfactory results and very low complication rate.Conclusions: The described technique might be significant in terms of using just punctures to gain access for tissue suspension and taking advantage of the inherent retraction capacity of the skin in order to deal with the non-excised skin excess in related localization. This simple percutaneous suspension method can be quickly and easily performed under local anesthesia with long term durability and high patient satisfaction rate.
Poster: Update on the Application of Laser-Assisted Indocyanine Green Fluorescent Dye Angiography in Microsurgical Breast Reconstruction
Martin I. Newman, MD, FACS, Department of Plastic Surgery, Cleveland Clinic Florida, Weston, FL
Michel C. Samson, MD, FRCSC, FACS, Cleveland Clinic Florida, Weston, FL
PURPOSE: Within the past 5 years, laser-assisted intraoperative indocyanine green fluorescent-dye angiography (LA-ICGA) has been successfully adopted by cardiac surgeons for its ability to provide unparalleled, real time vascular images. Recently, we described our experience with the application of this new technology for the purpose of evaluating arterial and venous flow as well as flap perfusion in microsurgical breast reconstruction. The purpose of this study is to update in the literature our experience with this outstanding imaging technique which serves to confirm anastomotic patency and tissue perfusion during microsurgical breast reconstruction procedures.
METHODS: Following IRB approval, LA-ICGA technology was introduced into our perforator flap protocol. To capture images, the SPY™ intra-operative imaging system (Novadaq, Toronto) was employed. In our practice, autologous breast reconstruction is performed with deep or superficial inferior epigastric perforator flaps or free TRAM using standard technique. In a prospective fashion, LA-ICGA was performed prior to harvest and following microsurgical anastomosis. Examined and imaged prior to harvest were the arterial and venous pedicles as well as the subdermal plexus of the flap. Examined and imaged following inset were the arterial and venous anastomoses, the vascular pedicles and the perfusion of the flaps through both adipose tissue and skin.
EXPERIENCE: Fifteen (15) female patients undergoing autologous breast reconstruction as outlined above were included in the study. Reconstructive techniques included eleven (11) DIEP flaps, three (3) SIEP flaps, and two (2) free TRAMs. Average age 46.3 years. (range 38 – 62 years of age). In 4 patients the anastomoses were performed using a mechanical coupler and in the remaining cases the anastomoses were performed by hand. In each case, intraoperative angiography was performed at several strategic points during the case. Following dissection of the flaps and the pedicles, but prior to actual flap harvest, ICG angiography was performed on the donor pedicles and on the skin and subcutaneous tissue comprising the flap. Following free tissue transfer and microsurgical anastomosis of both the artery and vein(s) LA-ICG angiography was again performed visualizing the post-anastomotic circulation through the artery and vein(s) as well as the skin and subcutaneous tissue of the flap. Finally, ICG imaging of the flaps, from the skin side, following inset was performed for each flap. Additional visualization of the mastectomy flaps was also obtained.
SUMMARY OF RESULTS: Flap survival was 100% and one flap (6.7%) required return to operating room for venous congestion. In 6 cases, imaging demonstrated flow or perfusion deemed “marginal or “poor” by the operating surgeons. In 2 of these cases, one involving poor arterial inflow, one of poor venous outflow, the intra-operative plan was adjusted accordingly by further dissection and follow up imaging demonstrated improvement. In the 3rd case, imaging demonstrated poor perfusion of a mastectomy flap and this was débrided guided by the pattern of subdermal perfusion on LA-ICGA imaging. In the 4th case, flow through a coupler used on an artery appeared “poor” by clinical assessment per the operating surgeon. However, LA-ICGA imaging confirmed excellent flow, and dissuaded us from performing re-anastomosis unnecessarily. In the 5th case clinically apparent “poor” flow, initially attributed to vasospasm, appeared adequate on imaging and allowed us to preserve a SIEP rather that dissecting a deep perforator. In the 6th case, clinically apparent “poor” flow was seen but no adjustment was made at operation. However this patient required return to the operating room for venous congestion of the flap which was corrected without sequela. Additionally it was found that flap perfusion was well visualized on African American skin where clinical exam is often confounded.
CONCLUSIONS: LA-ICGA appears to be a valuable adjunct in surgery involving microsurgical anastomoses. It can be used to evaluate arterial, venous and subdermal plexus perfusion prior to harvest of flaps and following anastomosis. As additional data is collected and analyzed, the ability to interpret findings will develop. A multicenter trial is recommended to evaluate the effect of this new technology on clinical outcome.
Poster: Investigator Global Evaluations of Efficacy with Injectable Poly-L-lactic Acid (PLLA) Versus Human Collagen in the Correction of Nasolabial Fold Wrinkles
Fredric S. Brandt, MD, Dermatology Research Institute, Coral Gables, FL
Purpose: Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible synthetic polymer currently approved in the United States as an injectable device for the treatment of facial fat loss (lipoatrophy) in people with human immunodeficiency virus. A cosmetic indication for the treatment of nasolabial fold wrinkles with PLLA is currently under review by the US Food and Drug Administration (FDA). The aim of this study was to investigate the efficacy of PLLA compared with that of commercially available human collagen implant (Cosmoplast™) in the treatment of dermal nasolabial fold wrinkles for 13 months. Efficacy was assessed by investigator evaluations of improvement following treatment. Methodology: The treatment phase in this randomized, parallel-group, multicenter clinical study consisted of one to four visits at 3-week intervals, during which eligible subjects received bilateral injections of either PLLA or human collagen in the left and right nasolabial fold wrinkles. Standardized photographs were taken at screening, at all treatment phase visits, and at all follow-up phase visits. Investigator evaluations of efficacy were collected at all visits beginning 3 weeks after the last injection of study treatment. Assessments were made by comparison to baseline (pretreatment) values, using the photograph at visit 1 (screening) as a reference. The treating investigator rated the subject’s nasolabial folds for global aesthetic improvement based on the following scale (one composite score for both the left and right nasolabial folds): 0 = worse; 1 = no change; 2 = improved; 3 = much improved; 4 = excellent improvement. The follow-up phase consisted of visits at week 3 and months 3, 6, 9 and 13 after the last treatment.Results: A total of 233 subjects comprising the intent-to-treat population were randomized to treatment with PLLA (n=116) or human collagen (n=117). Statistically significant differences (p<0.001) in the total investigator global evaluation assessments (including excellent improvement, much improved, improved, no change, and worse) were observed between the PLLA and human collagen treatment groups at the week 3, and month 3, 6, 9, and 13 visits after the final treatment. There was a consistently high level of investigator global evaluation scores for “overall improved” (excellent improvement, much improved, and improved) attributed to the PLLA group. In the PLLA group, the proportion of investigator global evaluation scores for “overall improved” remained above 88% during the entire 13-month follow-up period, whereas in the human collagen group the proportion of investigator global evaluation scores for “overall improved” decreased steadily from 95.7% at week 3 to 6.3% at month 13. For the human collagen group, the investigators initially gave a rating of much improved (49.6%) or excellent improvement (28.7%) at week 3; however, at the month 3 follow-up visit, nearly 83% of the investigators gave a rating of improved or no change. At month 6, most investigators (72.6%) scored the subjects receiving human collagen as showing no change from baseline. Overall, postinjection AEs were similar in both treatment groups; the majority of AEs were mild or moderate in intensity. Fewer subjects receiving PLLA had ≥1 AE (53.4% vs 63.2%; p=0.002). Fewer PLLA-treated subjects reported product-related (20.7% vs 35.9%; p<0.05) or injection-related AEs (20.7% vs 29.1%; p=0.005).The incidence of product-related application site papules (PLLA, 8.6%; human collagen, 3.4%) or nodules (6.9% and 6.0%, respectively) was low for both groups.Conclusions: Treatment with PLLA resulted in significantly higher investigators global evaluation scores of improvement from baseline at all follow-up visits through month 13, compared with treatment using human collagen. Investigators global evaluation of improvement following PLLA treatment remained consistently high, whereas investigators global evaluations of human collagen treatment were high at week 3 following the final treatment, but quickly declined at the month 3 follow-up visit. Treatment with PLLA or human collagen was well tolerated. In summary, injectable PLLA provided greater and sustained improvement in nasolabial fold wrinkles during the 13-month period than did human collagen.
Poster: Simultaneous Reconstruction of Total Loss of Both Lips – A Rare Challenge, Converting Ghastly to Socially Acceptable Female – A Case Report
Surinder Makkar, MBBS, MS, MCh, Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Simultaneous reconstruction of total loss of both lips is a challenge for reconstructive surgeon and is reported rarely in literature. The case being presented is a 18 year female reporting to outpatient with a ghastly appearance, having total loss of both lips extending to both cheeks. At the age of 8years, she had accidental blast injury from jaggery (eatable prepared from sugarcane juice) mixed with explosives placed unattended to kill animals. She couldn’t seek treatment due poverty and lack of awareness. Reconstruction of both the lips was done with microsurgical transfer of double neurosensory fasciocutaneous radial artery forearm flap with vascularised palmaris longus in first stage and vermilion reconstruction of both the lips was done with single tongue flap in subsequent stages. We could achieve satisfactory reconstruction of lip and vermilion with regard to height, sensations, color match, competence for solids, no drooling of saliva at rest. Shortcomings of reconstruction were lack of complete competence for liquids mainly at angle of mouth, mild restriction of mouth opening and fish mouth like appearance. There was no significant donor site morbidity of both forearms and tongue in terms of function. So, simultaneous reconstruction of complete loss of both lips is feasible by double free radial artery forearm flap. Using two flaps adequate amount of tissue is available and there is freedom to place the tissue in different anatomical location. One tongue flap can be used for reconstruction of both lips and it gives good color to vermilion. Satisfactory competence for solids and no drooling at rest can be achieved with neurosensory flap and palmaris longus sling used as static method of reconstruction.
Poster: Latissimus Dorsi Chimeric Free Flap Reconstruction in Complicated Scalp and Calvarial Defects
Iris Angela Seitz, MD, PhD, Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL
Neta Adler, MD, Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL; Eric Odessey, MD, Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL; Charles Y. Tseng, MD, Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL; Michael DeWolfe, MD, Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL; Russell Reid, MD, PhD, Section of Plastic and Reconstructive Surgery, University of Chicago, Chicago, IL; Lawrence J. Gottlieb, MD, Chicago, IL
Background: Adequate coverage of complex, composite scalp and cranial defects in
previously radiated, infected or otherwise compromised tissue represents a
challenge in reconstructive surgery. In order to provide wound closure with
bony protection to the brain, improved cranial contour, and prevention or
sealing of cerebrospinal fluid leaks, composite free tissue transfer is a
reliable and safe option. We report our experience with five latissimus dorsi/rib intercostal perforator myo-osseo-cutaneous free
flaps to reconstruct bony and soft tissue defects of the cranium and overlying
scalp.
Methods: The surgical technique, design and outcome of the latissimus dorsi/rib intercostal perforator myo-osseo-cutaneous free
flap reconstruction in five patients with cranial defects between 2003 and 2007
were retrospectively evaluated. Patient characteristics, defect size and
underlying cause, reconstructive details and complications were analyzed.
Results: All patients (age 43 to 81) had complex cranial defects, mean size
being 230cm2 (36-750cm2), two with cerebral spinal fluid (CSF) leak. Two
patients had cranial defects due to malignancy (squamous cell carcinoma of the
scalp, brain tumor with CSF leak), one patient had infiltrative cutaneous
mucormycosis with osteomyelitis, one patient had infection of a failed
cranioplasty after craniectomy for hemorrhagic stroke and one had continuous
CSF leak after craniectomy for hemorrhagic stroke. Follow up ranges from 7-26
months. Complications included vascular compromise of one flap salvaged by vein
graft, limited distal flap necrosis in three patients
that was treated with local debridement and topical antimicrobial agents. No
flap losses and no donor site complications were noted.
Conclusion: The latissimus dorsi chimeric free flap consisting of skin, muscle
and vascularized rib based of the thoracodorsal artery can successfully cover
large complex cranial defects, provide skeletal support, restore contour and
significantly improve functional outcome with limited donor site morbidity.
Image1: Preoperative pictures showing large
calvarial defect after failed cranioplasty with infection of cranial implant
Image 2: Intraoperative markings for latissimus dorsi/rib intercostal
perforator myo-osseo-cutaneous free flap and insetting of chimeric flap
into cranial defect
Image 3: postoperative cranial reconstruction
immediatly postoperative and at 3 month follow up
Poster: Slow Versus Rapid Fibrin Glue for the Prevention of Seroma in Abdominoplasty
Nidal Toman, MD, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany
Alexandra Buschmann, MD, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany; Thomas Muehlberger, MD, FRCS, DRK - Kliniken Berlin Westend (Humboldt University), Berlin
Backround
The formation of seroma is one of the most frequent complications following abdominoplasty. The effect of intraoperative fibrin sealant on the formation of seroma was investigated in patients who had an abdominoplasty. The relevance of slow versus accelerated fibrin polymerization was determined.
Material and Methods
Two different thrombin concentrations (4 IE vs 500 IE thrombin/ml) of the fibrin sealant were used in two groups of 40 patients. The control group consisted of 40 patients with abdominoplasties without fibrin glue adhesion.
Results
Patients in the group with the slow reacting fibrin sealant (4 IE) had a significantly lower rate of seroma formation when compared to the high concentration fibrin group and the control (p< 0.025 and p< 0.001, respectively). In addition, the amount of postoperative drainage was significantly lower in the low-dose group (p<0.000). Patients with seroma had a significantly higher weight of resected tissue (p<0.003). Smoking was found to be a significant risk factor for the development of seroma (p< 0.03). The amount of postoperative drainage, age and body-mass-index had no significant impact on the prevalence of complications.
Conclusion
The use of slow reacting, low-dose fibrin glue demonstrated a protective effect against the formation of seroma following abdominoplasty. The amount of postoperative drainage was significantly lower.
Poster: MRI Analysis of Breast Implant Deformities
Grant M. Kleiber, BS, Plastic Surgery, University of Southern California, Los Angeles, CA
Garry S. Brody, MD, Msc, USC Division of Plastic Surgery, Los Angeles, CA; Pulin Sheth, MD, Radiology, University of Southern California, Los Angeles, CA; Ruby Obaldo, MD, Radiology, University of Southern California, Los Angeles, CA
Background:
There is some debate within the plastic surgical community
as to whether the implant shapes the breast, or the breast, via the healing
scar envelope, shapes the implant.
Examination of breast implants explanted with their capsules intact has
shown a variety of bizarre shapes and contour deformities departing widely from
the original shape of the implant.
It is difficult to examine for implant contour deformities in vivo due to the overlying breast tissue's ability to
camouflage most implant deformities.
However, through the use of three dimensional reconstruction of breast
MR images, we have been able to recreate computerized models of implants as
they sit in the breast.
Surprisingly, most exhibit some degree of deformity.
Methods:
A retrospective review was
conducted of consecutive breast MRI reports until 50 patients with implants
were identified. Images of these
patients were obtained, and those with short TI inversion recovery (STIR)
images were included in the study.
All patients were scanned using the same 1.5 T dedicated breast coil in
the prone position with their breasts suspended uncompressed. Computerized three-dimensional
reconstructions of the implant were created using Osirix software (Geneva,
Switzerland). T2 image slices were
also used for confirmation and clarity.
These images were then reviewed for contour deformities by four
different reviewers: the primary author, a senior plastic surgeon, and two
radiologists trained in breast imaging. The implants were categorized as non-deformed, mildly
deformed, or significantly deformed.
Implants were grouped according to material and placement, and the rate
of distortion was calculated for each group.
Results:
23 patients with a total of 43
implants were included in the study.
There was some degree of distortion present in 31 implants (72.1%). Twelve implants were mildly distorted
(27.9%), and 19 were significantly distorted (44.2%). Only 3 implants had distortions that were evident in the
overlying skin (6.9%). Of the 24
saline implants, 5 were mildly distorted (20.1%), and 8 were significantly
distorted (33.3%). Of the 19
silicone implants, 3 were mildly distorted (15.8%) and 11 were significantly
distorted (58.9%). The overall
distortion rate was 54.2% of the saline implants and 73.7% of the
silicone. Of the 15 subpectoral
implants, 6 were mildly distorted (40%) and 3 were significantly distorted
(20%). Of the 28 subglandular implants,
7 were mildly distorted (25%) and 15 were significantly distorted (53.6%). The overall distortion rate was 60% for
subpectoral implants and 78.6% for subglandular implants.
Conclusions:
A significant majority of implants
included in this study expressed some degree of deformity. Implant distortions may be due to
extrinsic factors such as surgically inappropriate pocket, irregular
contraction of the capsule, or intrinsic factors such as implant folds. There was a higher overall rate of
distortion in silicone implants and subglandular implants. Of all the deformed implants in this study,
only three had any visible effect on the overlying skin, making deformed
implants difficult to detect through physical diagnosis or routine mammography. With adequate soft-tissue coverage,
deformed implants usually will have no effect on the external appearance of the
breast. This study sheds some
light upon the debate as to how round implants can perform like shaped devices
in mimicking an axillary tail.
Figure 1:
Significantly deformed right-sided silicone gel implant with inferior
flattening and medial angular distortion.
The external breast appeared normal with no contour deformities.
Figure 2:
Significantly deformed right-sided silicone gel implant with
anteromedial depression, and medial extension of the implant across the
sternum. The anteromedial
depression was reflected in the external breast.
Poster: Soft Tissue Changes of the Muscle, Nerve, and Vasculature of the Face Following Conventional Midface Distraction Osteogenesis
Shawkat Sati, MD, Plastic Surger, Lahey Clinic, Burlington, MA
Joyce Chen, MD, Plastic Surger, Lahey Clinic, Burlington, MA; Kip Panter, PhD; Qian Wu, MD, Pathology, University of Connecticut; M. Brandon Freeman, MD, Plastic Surgery, Brown University, Providence, RI; Jeffrey Weinzweig, MD, FACS, Plastic Surgery, Lahey Clinic, Burlington, MA
Purpose: Midface distraction offers the advantages of advancement without bone grafting, greater potential advancement, and lower relapse rates. Previous work of ours demonstrated adverse effects of immediate (intra-operative) distraction on the facial artery, zygomaticus muscle, and infraorbital nerve. The purpose of the present study was to determine if distraction affects these tissues when performed in delayed or conventional post-operative fashion The impact of distraction tensile forces on these tissues is poorly understood. Several studies have evaluated the impact of mandibular and long-bone lengthening on soft tissues; the present work is the first to evaluate all three soft tissue parameters following conventional midface distraction.
Methods: Using our congenital cleft palate model, midface distraction was performed on immature goats who had previously undergone cleft palate repair at 6 weeks of age. Unilateral harvesting of pre-distracted muscle, nerve and arteries was performed. Five days after surgery, distraction was initiated bilaterally (1mm/day) for 15 days. After 12 weeks of consolidation, contralateral soft tissue elements were harvested and studied.
Results: Light microscopy of distracted muscle demonstrated intermesial fibrosis, myotrophic atrophy, and intramuscular inflammation. Distracted arteries demonstrated hemosiderin deposition and tunical hemorrhage. Distracted nerves demonstrated myelin beading and staining heterogenecity with perineurial inflammatory infiltration. Electron microscopy corroborated these findings including vaso vasorum, nerve, and Schwann cell interruption.
Conclusion: The present work is the first to evaluate all three soft tissue elements following conventional midface distraction. Longitudinal distraction vector forces produced endoneurial and perineurial Wallerian degenerative nerve changes. Although nerve fibers are considered more vulnerable, reactive fibrous metaplasia and a paucity of elastin content and organization concentrated in the tunical media and intima represented demonstrative vascular susceptibility. Our findings support the adaptation cycle of muscle fibers to tensile forces beginning with hypertrophic, inflammatory and regenerative response pathways. Although bone receives the direct distractional force, soft tissue elements undergo significant stretching. The effect of these mechanical forces varies depending on the tissue's elastic, compensatory, and reparative properties. Thus, the process of distraction osteogenesis of the midface is not an innocuous one with significant adverse effects observed on adjacent important soft tissue structures. The consequences of these soft tissue changes remain to be determined.
Poster: Microarray and Immunohistochemical Characterization of Silicone Gel Occlusion in a Novel Murine Cutaneous Wound Model (Recipient of the Young Investigator's Award at the 2007 Wound Healing Society Meeting)
Clark Friedrich Schierle, MD, PhD, Division of Plastic Surgery, Northwestern University, Chicago, IL
Kristina O'Shaughnessy, MD, Northwestern University, Chicago, IL; Xian Zhong Ding, MD, PhD, Northwestern University; Robert D. Galiano, MD, Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL; Thomas A. Mustoe, MD
The efficacy of silicone gel
occlusion in the treatment of hypertrophic scarring has been well documented.
In vitro evidence has been reported suggesting that this effect is mediated
through normalization of epidermal hydration and a concomitant attenuation of
epidermal activation. Activated keratinocytes are characterized by altered
patterns of keratin expression, cytokine and growth factor signaling. In an
attempt to study this phenomenon in vivo, we have established a novel murine
cutaneous wound model which accurately recapitulates the proliferation of
epidermal keratinocytes and altered spectrum of cytokeratin expression
consistent with the activated keratinocyte phenotype. Introduction of silicone
gel occlusion in our model results in attenuation of keratinocyte activation as
well as modulation of cytokine and growth factor signaling pathways suggesting
accelerated restoration of the basal keratinocyte phenotype. We observe that
occlusion results in a marked downregulation of keratin-6 expression (a marker
of keratinocyte activation) and a decrease in JAK/STAT dependant cytokine
signaling activity. Conversely, occlusion appears to accelerate the TGF-beta
mediated restoration of the basal keratinocyte phenotype. Further we have developed a novel
technique which allows for the rapid, reproducible isolation of murine
epidermal cells from full thickness skin specimens resulting in epidermal
specificity (as measured by differential expression of keratin-14 and desmin)
comparable to digestion with dispase while better preserving RNA quality and
gene expression profiles. This technique makes possible the accurate profiling
of gene expression profiles arising specifically in the epidermal layer of
mouse skin. Analyzing differences in these expression patterns between occluded
and non-occluded skin allows detailed investigation into the modulation of
presumed signals between epidermal keratinocytes and dermal fibroblasts by
silicone gel occlusion or other interventions.
Cytokeratin 6 gene expression in nonoccluded mouse
skin
Poster: Sternal Plating for Primary and Secondary Sternal closure; Can it improve sternal stability?
James L. Mahoney, MD, Plastic Surgery, St. Michael's Hospital, Toronto, ON, Canada
Hosam Fouad Fawzy, MD, Cardiac Surgery, St. Michael's Hospital, Toronto, ON, Central African Republic; Mark Peterson, MD, St. Michael's Hospital, Toronto, ON, Canada; Daniel Bonneau, MD, Cardiovascular Surgery, St. Michael's Street, Toronto, ON, Canada; David Latter, MD, Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada; Alfons Marchie, MD, Plastic Surgery, St. Michael's Hospital, Toronto, ON, Canada; Alana M. Harrington, MSc, Anaesthiology, St. Michael's Hospital, Toronto, NU, Canada; Nasser AlHodaib, MD, Plastic Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Lee Errett, MD, Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada; David Mazer, MD, Anaesthesia, St. Michael's Hospital, Toronto, ON; Subodh Verma, MD, Cardiovascular Surgery, St. Michael's Hospital, Toronto, ON, Canada
Sternal Plating for Primary and Secondary Sternal closure; Can it improve sternal stability?
Background and Purpose: Sternal instability predisposes to post-operative mediastinitis. Biomechanical studies have shown the superiority of rigid plate fixation over wire cerclage in sternal healing. This study evaluates the mechanical stability of traditional or multifilament wire sternal closure compared to plate closure utilizing the Synthes Sternal Cable and Titanium Reconstruction Sternal Fixation System (West Chester, PA, USA) in a human cadaveric model.
Methods:Midline sternotomy was performed in 18 human cadavers. Two sternal closure techniques were tested: (1) approximation with six interrupted steel wires (size No.5) or six multifilament wire (2) the same closure technique reinforced with a transverse locking 12 hole sternal plate (4 screws/side) at the sixth rib (Synthes Titanium Sternal Fixation System, Synthes CMF, West Chester, PA, USA). (3) Closure using 4 sternal plates alone one at the manubrium and at ribs 3 through 5. Screws were inserted into sternal bone rib cartilage as recommended. Intrathoracic pressure was continuously measured using a calibrated pressure transducer as it was increased in a standardized fashion in all closure techniques using an inflatable rubber bladder placed beneath the anterior chest wall. Sternal separation was measured by three pairs of sonomicrometry crystals (Sonometrics Corporation, London, Ontario, Canada) fixed at the upper, middle and lower parts of the sternum. For the crystals, the accuracy is +/-0.04 mm (and the sampling rate is >1500/sec). Intrathoracic pressure in was increased until failure as defined by 2.0 mm of separation of any pair of crystals. Differences in distraction pressures were analysed using one-way repeated measures ANOVA and the Holm-Sidak test. Regression Coefficients were utilized to compare the groups.
Results:Intrathoracic pressure required to cause sternal separation of 2.0 mm was significantly improved with plate fixation both single and multiple plates compared to both monofilament and multifilament wiring. Data is summarized in Table 1.
Discussion:
Variability of the specimens led to variable absolute measurements of sternal distraction pressure. However, a similar improvement in sternal stability was demonstrated in all the specimens with plating. The sequence of wiring which is tested was designed to mimic the clinical situation with failure of the sternal wires to preserve sternal stability. Our clinical experience in dehisced cases utilizing plates has suggested that this form of plate fixation restores sternal stability reliably in this situation. An unexpected finding is the improvement in sternal stability with wiring and a plate only at rib 6. Adding a sternal plate to primary closure might help reduce the risk of sternal dehiscence in high risk patients.
Conclusion:Sternal stability is improved with sternal plating compared to wiring techniques. Adding a transverse plate to primary wire cerclage closure substantially improves stability of sternotomy closure in a human cadaver model.
Group | Mean ± SD | Median (IQR) | Unadjusted p value | Regression Coefficients (95% CI) |
Wires/Cables(n=18) | 180.1 ± 117.6 | 149.5 (117.0) | --------- | Reference Group (---) |
Wires/Cables + 1 Plate (n=18) | 301.3 ± 204.5* | 225.0 (95.0)* | P< .003 | 120.0 (47-194)** |
4 Plates (n=16) | 357.5 ± 209.8* | 325.0 (279.5)* | P= .0007 | 142.0 (66-219)** |
Table 1 . Summary Data. * - p<0.05 vs cables/wires ; SD = Standard Deviation; IQR = Interquartile Range; CI = Credible Intervals. * p< 0.05 when compared to cables/wires alone, ** Credible Intervals indicate significance when compared to cables/wires alone.For the mean and STD data, a One-way repeated measures ANOVA was used (F=8.740, p < 0.001). For the multiple pairwise comparisons the Holm-Sidak method was used (p-values in the table). For cables/wires +1 plate vs 4 plates the unadjusted p = 0.601.
Poster: Microscale Electrode Implantation during Nerve Repair: Effects on Recovery of Muscle Contractile Function, Nerve Conduction, and Nerve Morphology
Melanie G. Urbanchek, PhD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Thane E. Wolcott, BA, Plastic Surgery, University of Michigan, Ann Arbor, MI; Brent M. Egeland, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI; Daryl R. Kipke, PhD, Biomedical Engineering, University of Michigan, Ann Arbor, MI; William M. Kuzon, Jr, MD, PhD, University of Michigan, Ann Arbor, MI; Paul S. Cederna, MD, Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
Our purpose is to develop a flexible, multi-contact implant
to promote and enhance long-term stable peripheral nerve stimulation. Micro
scale implantable probe systems known as Micro-Electro-Mechanical Systems
(MEMS) contain multi-channel actuators, sensors, and electronics on a silicon probe.
We tested the null hypothesis that implantation of MEMS probes do not have a
detrimental effect on peripheral nerve function.
A rat hindlimb, peroneal nerve
model was utilized in all experimental groups: 1) No surgery (Control); 2)
Nerve division and repair (Rep); and 3) Nerve division, insertion of MEMS probe
in the distal end of the divided rat peroneal nerve, and repair (Rep+Probe). Extensor
digitorum longus (EDL) muscle contractile function, peroneal nerve electrophysiologic parameters, and nerve morphology were
measured following an 11 week recovery.
When compared with Control, Rep and Rep+Probe groups had
lower EDL muscle mass, smaller axon diameters, lower percent neural tissue in
the peroneal nerve, 12% reduction in nerve conduction velocity, 25% reduction
in relative action potential amplitude, and lower maximal muscle force. There
were no differences between any of the groups in muscle specific force, nerve
conduction latency, or number of axons (Table 1). Most importantly, Rep+Probe
did not vary from Rep group for any of the variables. Though there was some local fibrosis around
the MEMS probe, this did not lead to measurable detrimental effects.
The lack of a significant difference between repair group
muscle force, nerve conduction, and nerve morphology indicate that MEMS electrodes
are compatible with growing axons and show promise for establishing chemical
and electrical interfaces with peripheral nerves.
Table 1. Data
summary for muscle contractile function, nerve conduction, and nerve morphology
following recovery from micro scale electrode implantation during nerve repair.
Test
| Dependent Variable
| Peroneal Nerve Groups
|
Control
| Rep
| Rep+Probe
|
EDL Muscle Force
| Force (mN)
| 3868 ± 452 (n=9)
| 2025 ± 616* (n=6)
| 2348 ± 1024* (n=9)
|
Muscle mass (mg)
| 159 ± 13
| 104 ± 13*
| 111 ± 28*
|
Specific force (kN/m2)
| 324 ± 29 | 262 ± 62
| 277 ± 72
|
Body mass (grams)
| 403 ± 42 | 433 ± 20.5
| 428 ± 14
|
Post operative day (days)
| . | 76 ± 12
| 78 ± 9
|
Peroneal Nerve Conduction
| Conduction speed† (%)
| -22% (n=12)
| -34% (n=2)
| -34% (n=3)
|
Relative Compound Motor Action Potential (mV/mg) †
| 1.9%
| -1.2%
| -1.7%
|
Nerve Conduction Latency (ms, with Fibular head stimulation)
| 0.92 ± 0.21
| 0.78 ± 0.18
| 1.11 ± 0.55
|
Peroneal Nerve Morphology | Estimated Axon Count | 1958 ± 1027 (n=7)
| 2383 ± 1120 (n=5)
| 1710 ± 540 (n=4)
|
Average Axon Size (μm2)
| 48 ± 19 | 9.7 ± 4.1* | 12 ± 4.4* |
Average Non- Neural Area (%) | 57.8 ± 13.4 | 85.8 ± 4.1* | 81.7 ± 4.6* |
Values are means ± SD.
*Indicates different from the Control Nerve group, p < 0.05. †Nerve conduction values are the difference
between measurements made when the nerve was stimulated at the fibular head and
at the sciatic notch divided by the value when stimulated at the fibular head.
The views expressed in this
work are those of the authors and do not necessarily reflect official Army
policy. This work was supported by the Department of Defense Multidisciplinary
University Research Initiative (MURI) program administered by the Army Research
Office under grant W911NF0610218.
Poster: Successful Recovering of Almost Amputated Dorso-Nasal Flap
Osvaldo João Pereira-Filho, MD, Plastic Surgery, Clínica Jane - Hospital Florianópolis - UFSC, Florianópolis, Brazil
Dante Roberto Eickhoff, MD, Clínica Jane - Hospital Florianópolis - UFSC, Florianópolis, Brazil; Giovani Lobo, MD, Clínica Jane - Hospital Florianópolis - UFSC, Florianópolis, Brazil; Jorge Bins-Ely, MD, PhD, Clínica Jane - Hospital Florianópolis - UFSC, Florianópolis, Brazil; Alfredo Granemann, MD, Clínica Jane - Hospital Florianópolis - UFSC, Florianópolis, Brazil
In this
case-report, an almost complete amputation of the nasal- dorsum, tip and right
ala sub-units were successfully repositioned, recovering the original nasal
shape.
CASE REPORT
A 19-year-old
patient had a traumatic almost complete amputation of the nasal dorsum after
fell down during the bath. The injury result in avulsion the dorsum, tip, and
right ala sub-units. (Fig. 1) The flap was supplied by a small left ala
pedicle, which presented an small epidermal laceration. The upper part of the
mucosa and alar cartilages was connected with the avulsed cutaneous dermal
tissue. The dorsal nasal upper cartilage including pericondrium was intact
showing copious bleeding. A dermal pick with a 13x4.5 gauge needle over the
dorsal surface of the flap reveled capilar bleeding even at its cranial part,
although a cianosis nuance appeared when the flap was repositioned on its
original bed. (Fig 2, 2-a) Local anesthesic (xilocaine) 5cc without
epinephrine was infiltrated on the receptor site. The flap was then sutured
over its native bed with 6-0 separated monofilament stitches, despite the
discrepance between the pedicle pattern and flap size. The partial epidermal
laceration over the left ala-the site of the pedicle was untouched. Finally,
the anesthesiologist infiltrated the infra-orbital nerve bilaterally with 5cc
bupivacaine without vasoconstrictor. (Fig. 3)
The patient was
kept in warm room, in a 30o. elevated dorsal flexion position during five days.
Every 4 hours the nurse cleaned the surgical site with warm saline solution
and picked(stick) the cranial segment of the flap with a 13x4.5 needle to
facilitate the venous drainage. Antibiotics(cephazolin) 1g TID, AAS 100mg BID
and his regular anti-convulsivant drugs were continued.
At the fifth
post-operative day the flap appeared with satisfactory nutrition and the
patient was discharge to ambulatory follow-up. (Fig. 4) Two weeks later the
nasal anatomy was restored, with total integration of the pseudo-avulsed flap
and its sub-units. (Fig. 5, 6, 7)
DISCUSSION
Investigation
about the facial angiossomes demonstrated the abundant nutrition around the neck,
face, and the nose sub-units. Empiric experience along the time was reflected
by the numerous nasal flap patterns with random or axial nutrition. In this
case report the trauma energy was enough to almost amputated the dorso-nasal
tissue. Even the thin left ala pedicle presented a linear cut comprising the
epidermis. The lateral nasal artery branch of the angular , supplied the
avulsed flap. (Fig. 8) The first thought of the surgical team was to complete
the amputation and restore the lesion with the medio-frontalis flap. This idea
was refuted, when we observed satisfactory bleeding after picking the flap with
a 13x4.5 gauge needle. We just suture the flap over the native bed with 6-0 separated
stitches. The anesthesic block of the infra-orbitalis nerve was intended to
improve the vascular supply by simpathetic block of the region. Therefore, a
cianosis was present at the end of the surgery because of the insufficient
venous drenage. Probably, leches could be an alternative to improve the venous
drainage, but this facility was not at hand in our practice. So, We tried to
solve this issue keeping the patient in a warm room at a temperature around
28o.-30o.C. Every 4 hours the nurse picked the dermis with a 13x4,5 B-D® gauge
needle over the cranial flap site distal the pedicle area. After that, she
performed a smooth massage using cotton wetted with warm saline in order to
facilitate the flap venous capilar bleeding drainage. One week salicilic acid
100mg BID with its anti-plaquetary effect, helped to improve the vascular
turnover.
Finally, this case
demonstrates incredible vascular pattern over the nasal tissue that can guide
to possible flaps design considering the nose sub-units. It is also a witness
of the surgical team integration and that even in the challenging events, we
have to try with faith and talent.
Fig. 1
Fig. 2
Fig. 2-a
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Poster: Minimally Invasive Intrapleural Tissue Expander Placement In the Management Of Adult Post-Pneumonectomy Syndrome
Stephen Higuera, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Patrick Cole, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Jeffrey D. Friedman, MD, Plastic Surgery, The Methodist Hospital, Institute for Reconstructive Surgery, Houston, TX
Purpose: Although rare, pneumonectomy may result in severe,
late term mediastinal shift, bronchial obstruction, respiratory failure, and
eventual death collectively termed Post-Pneumonectomy Syndrome (PPS).1
Historically, a variety of treatments, such as muscle-flap transposition,
pericardial fixation, phrenectomy, filling of the empty hemithorax with saline/
albumin, and endoscopic bronchial stent insertion have been utilized to restore
intrapleural dimension. While these approaches have met with mild success,
they have generally been employed in children due to the higher incidence of
PPS in this particular population. 2 Management of this complex
problem in the adult population has only rarely been described, and no current
consensus exists on an optimal approach.3 Here, we describe
placement of tissue expanders within the empty intrapleural space to restore
hemithoracic volume, decompress the remaining bronchus, and substantially
improve respiratory function. Method: A 78 year old female who previously had
undergone a right pneumonectomy followed with radiation therapy for stage IIIA
non-small cell carcinoma developed postpneumonectomy syndrome with mediastinal
shift. The patient developed a progressive shift of the mediastinum to the
right hemithorax with significant narrowing of the left mainstem bronchus
causing dyspnea and stridor. Fig. 1 A right anterior minithoracotomy just
lateral to the pectoralis major muscle in the third intercostal space was
performed. The pleural cavity measured 9cm transversely to 7cm vertically. Two
round rigid base expanders 250ml and 200ml were positioned in the right
pneumonectomy cavity with the rigid back towards the bony thorax. Fig. 2
These were expanded to 240ml and 180ml along with methylene blue and radiopaque
fluid. The injectable ports were brought out and secured onto the underlying
pectoralis major muscle. The expandable prosthesis filled the right hemithorax
without any hemodynamic compromise. Results: The patient had immediate
postoperative relief of stridor along with radiographic evidence demonstrating
an improvement of her right mediastinal shift. She was discharged on
postoperative day 5 and her dyspnea has improved significantly. Fig. 3 Conclusion:
Pneumonectomy can, in rare cases, progress to a severe and life-threatening
condition (PPS) resulting from obstruction of residual bronchial structure. In
our experience, intrapleural placement of an expandable prosthesis using
minimally invasive access allowed for progressive mediastinal recentering,
decompression of remaining bronchial structure, and restoration of respiratory
function. Adequate intraoperative measurement of the hemithoracic cavity is
essential in establishing the size and possible use of more than one tissue
expander. Relative to more invasive procedures, such as pedicled flap use or
aortic arch repositioning, using a minithoracotomy for prosthetic application
provided a minimally invasive approach and negated more challenging operative
techniques that could have led to higher morbidity risk in the present case. In
our experience, TE placement proved the most conservative, effective means of
solving this challenging problem.
Figures
Fig. 1 Preoperative AP CXR demonstrating a right
mediastinal shift following right pneumonectomy.
Fig. 2 Right minithoracotomy with two round rigid back
expandable prosthesis.
Fig. 3 Postoperative AP CXR demonstrating an improvement of
previous right mediastinal shift.
References
Grillo H, Shepard J, Mathisen D, Kanarek D. Post-pneumonectomy syndrome. Diagnosis, management and results. Ann Thorac Surg. 1992;54:638-51
Rash DK, Grover FL, Schnapf BM, Clarke E, Pollard TG. Right pneumonectomy syndrome in infancy treated with an expandable prosthesis. Ann Thorac Surg. 1990;50:127-9
Audry G, Balquet P, Vazquez MP, Sorrel Dejerine E, Baculard A, Boulé M, et al. Expandable prosthesis in right postpneumonectomy syndrome in childhood and adolescence. Ann Thorac Surg. 1993;56:323-7
Poster: Superior Pedicle Autoaugmentation Mastopexy: A Review of 34 Consecutive Patients
Peter S. Kim, MD, Plastic Surgery, Northwestern University, Chicago, IL
Kenneth K. Kim, MD, Kaiser Permanente, Irvine, CA; Laurie A. Casas, MD, Glenview, IL
BACKGROUND: The ptotic breast deformity results from two opposing forces: involution of breast parenchyma leading to a loss of volume while, conversely, the skin envelope becomes progressively lax, inelastic, and accomodating. As the breast tissue descends inferiorly on the chest wall from gravity, there is an apparent volume loss in the upper pole and the central breast, while the lower pole becomes fuller and often wider. We propose a technique whereby the superior pedicle vertical mammaplasty technique originally described by Lassus is modified to include transposition of glandular tissue to restore central mound projection while simultaneously narrowing the lower breast base and raising the inframammary crease. Simply stated, the breast tissue that is usually retained in an inferior breast reduction is now elevated on a superior dermal pedicle blood supply and transposed into a prepectoral pocket under the central breast. The medial and lateral pillars are then sutured together to narrow the breast base.METHOD: From 2003 to 2007 thirty-four patients underwent a superior-pedicle autoaugmentation mammaplasty. Ages ranged from 22 to 47 years. The mean follow-up period was 24 months. Patients were selected pre-operatively based on presence of wide, low-lying breasts lacking central projection. In all cases, the patients expressed a desire to have a more youthful breast without the addition of an implant.RESULTS: All patients tolerated their procedure well. Two patients developed seromas that were drained in the office. Thirty-four of 34 patients stated they were satisfied with the shape and the size of their breasts post-operatively. No patient went on to desire breast augmentation.CONCLUSION: Using the vertical-scar mastopexy originally described by Lassus and later refined by Lejour, Hall-Findlay and Plaza, et al, we create a dermoglandular extension of the superior pedicle that can be transposed behind the nipple-area complex. This restores central mound projection while also narrowing the lower breast base and raising the inframammary crease. In carefully selected patients with low lying wide breasts who do not desire breast implant augmentation, this technique can be employed to reliably recreate a more youthful breast shape without the use of a prosthetic.
Poster: Multiple Layer Pseudomeningocoele Repair with Bilateral Paraspinous Muscle Flaps
Brandy Noelle Cross, BFA, MD, Plastic Surgery, Medical College of Georgia, Augusta, GA
Lawton Tang, MD, Medical College of Georgia, Augusta, GA; Edmond F. Ritter, MD, Medical College of Georgia, Augusta, GA
Background: Complex midline back wounds are usually not optimally treated with primary closure. There is a paucity of current literature on the management of pseudomeningocoeles. Although a number of techniques have been described, no current single technique is ideal. Primary layered closure of soft tissue over imbricated the pseudomeningocoele is the pre-eminently recommended method. When the patients condition is complicated by a cerebral spinal fluid (CSF) leak, the problem is more urgent, the patient is at risk for meningitis. In theory, it should be possible to provide a watertight closure of a dural leak and resolve the problem. However, due to technical difficulties, efforts to provide a truly cerebrospinal fluid tight closure falls short of being achieved.
Methods: The technique we describe includes meticulous dissection of pseudomeningocoele to its neck, opening the pseudomeningocoele, repair of dural defect with acellular dermal patch, resection of pseudomeningocoele leaving adequate residual tissue to make a two layer pants over vest closure, and wide mobilization of paraspinous muscle with importation of muscle into wound in overlapping fashion, thereby obliterating dead space and tamponading the dural repair. The vascularity is based on lateral row perforators after ligation of the medial row. Leaving the lateral row perforators intact provide excellent vascularity with adequate mobility. A dural patch and utilization of the myeolcoele remnant is incorporated into the layer, held in place with acellular dermis, and fibrin glue.
Results: We have demonstrated a one hundred percent success rate within this small series. These techniques were incorporated into the care of 9 patients between (3 male, 6 female) between January 2004 and July 2006. One patient’s defect was low cervical, one mid thoracic, and seven low lumbar. All wounds were closed in a single stage after careful flap section based on the wound's needs and anatomic location.
Conclusions: The technique presented d raws from the contributions of previous authors on the management of hostile back wounds permiting reliable back reconstruction for this difficult problem with minimal morbidity. Although our series is small, the technique appears to be safe and efficacious. While initially devised to treat pseudomeningocoeles it may be applied prophylactically for patients at risk of developing back wounds with CSF leaks.
Poster: Suture Suspension Technique for Mid Face and Neck Rejuvenation
Gloria Mabel Gamboa, MD, FACS, Medical College of Georgia, Augusta, GA
Luis O. Vasconez, MD, FACS, Division of Plastic Surgery, University of Alabama Birmingham, Birmingham, AL
Suture Suspension Technique for Mid Face and Neck
Rejuvenation
Purpose: The purpose of this study is to present a
new surgical technique using subcutaneous suture suspensions, with
polypropylene bio absorbable cones, and multiple point fixations (figure 1).
Methods: Anatomic study in fresh cadavers showing the
efficiency of suture lifting and safety with the branches of the facial nerve
(figure 2).
The surgical technique presented in video and photographic
documentation (figures 3-6). Microscopic illustration supports the accion of
the bio-absorbable cones with the surrounding tissue (figure 7). Two suspension
points each; nasolabial fold, commissure mandible line, all secure at the
temporal fascia with mesh. The neck procedure, sutures directed from
retro-auricular incisions to the mid line (figure 8). Performed in outpatient
setting, local anesthesia, 20-30 minutes.
Results: 11 surgical procedures, 9 patients, 6 months
follow up; Suture lift provides anterior projection of the cheek, elevates the
corner of the mouth and improves the jowls.
The complications are minimal temporary edema. Patients
return to work 3 to 4 days (figure 9-10).
Conclusion: Suture suspension technique with
polypropylene absorbable cones; multiple point fixations, safe and
aesthetically pleasing results, minimal down time and high patient
satisfaction.
Authors: G. Mabel Gamboa, M.D., Luis Vasconez, M.D.
Poster: Myoblast and Regenerating Nerve Compatibility with PEDOT, an Intrinsically Conductive Polymer
Melanie G. Urbanchek, PhD, Plastic Surgery, University of Michigan, Ann Arbor, MI
David C. Martin, PhD, Materials Science and Engineering, University of Michigan, Ann Arbor, MI; Lisa M. Larkin, PhD, Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI; Kristin M. Goble, MS, Biomedical Engineering, University of Michigan, Ann Arbor, MI; Brent Egeland, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI; Sarah M. Richardson-Burns, PhD, Biomedical Engineering, University of Michigan, ANn Arbor, MI; William M. Kuzon, Jr, MD, PhD, University of Michigan, Ann Arbor, MI; Paul S. Cederna, MD, Surgery, Section of Plastic Surgery, University of Michigan, Ann Arbor, MI
Introduction Our ultimate goal is to interface peripheral nerve and muscle
directly to electronics which power prosthetic devices. Existing electrode
interfaces lack durability, sensitivity, fidelity, and are cumbersome. We
envision a biological interface where an amputee nerve stump grows and synapses
with in vivo developing muscle contained in a porous multi channel
micro-electrode chamber treated with an intrinsically conductive polymer such
as poly (3,4-ethylenedioxythiophene), or PEDOT. That our electrode sites have
fuzzy coatings of PEDOT which is known
to decrease impedance by 5 times and increase conduction speed, affords many
benefits for recording from larger and more disperse muscle action potentials
rather then from small compact nerve fascicles.
Methods We measured myocyte growth in the presence of container conditions
and materials: 1) medium alone or 2) with: Biobrane, 3) smooth silicone
sheeting, 4) acellular muscle, or 5) acellular muscle polymerized with PEDOT.
We then also implanted acellular muscle with cultured muscle constructs into a
rat hind limb amputee model. The rat peroneal nerve was divided,
the proximal stump was sutured to an acellular muscle impregnated with PEDOT
that had myoblasts cultured on it. The PEDOT, myoblasts, and nerve ending were contained
in a 2 cm long BioBrane™.tube. The distal nerve stump was reflected and
tacked to gluteus muscle; the incision was closed. At post operative day 50,
the BioBrane™ container with nerve-muscle PEDOT
interface was removed and processed histologically. Biocompatibility
was confirmed if: robust myotube formation from mononuclear progenitor satellite cells occurred, cell proliferation was comparable
to cells grown in medium alone, and there was continued myoblast growth plus
nerve regeneration with in the implanted construct after 50 days.
Results Primary mixed cultures of myoblasts and fibroblasts were
grown from adult rat soleus muscles. At confluence (P1, Day 7) primary cultures
were passaged and cells were deposited on plates
holding test materials. Cell number
was determined at day 4 and day 7 after passage 2. Replicate plates were
completed 3-6 times. Cell counts on days 4 and 7 during passage 2 showed no
difference in cell viability (98%) across the 5 materials (power = 0.6) and
more live cells at day 7 (186%) than at day 4 (p<0.05). Multinucleated myocytes and fibroblasts were
observed on all plates. By day 14, myotubes were present as confirmed by desmin
staining for each material. For containers implanted in vivo, histology
verified nerve sprouts and small multinucleated muscles grew into the distal
end of the BioBrane™ tubes and both myofibers and nerves were in the immediate proximity of
PEDOT filled acellular muscle cytoskeltons.
Conclusion Biocompatibility of myoblasts growth and regenerating
nerve with PEDOT was confirmed. Myotube
formation from mononuclear progenitor
satellite cells and cell proliferation were as robust as seen in the
control for all other biomaterial cultures. After fifty days in vivo, the container
of PEDOT and myoblasts had developed muscle fibers and nerve sprouts in close
contact with the PEDOT. We conclude that PEDOT shows promise for incorporation
into a living nerve endoprosthesis interface. The intrinsically conductive
nature of this compatible PEDOT may prove advantageous to biologic interfaces
with electronic components.
The views expressed in this work are those of the authors
and do not necessarily reflect official Army policy. This work was supported by
the Department of Defense Multidisciplinary University Research Initiative
(MURI) program administered by the Army Research Office under grant
W911NF0610218
Poster: Temporomandibular Joint Located Odontogenic Keratocyst: An Unusual Location
Tolga Eryilmaz, MD, Plastic, Reconstructive and Aesthetic Surgery, Gazi University Medical School, Ankara, Turkey
Selahattin Ozmen, MD, Plastic, Reconstructive and Aesthetic Surgery, Gazi University Medical School, Ankara, Turkey; Mubin Aral, MD, Plastic, Reconstructive and Aesthetic Surgery, Gazi University Medical School, Ankara, Turkey; Kemal Findikcioglu, MD, Plastic, Reconstructive and Aesthetic Surgery, Gazi University Medical School, Ankara, Turkey; Sebahattin Kandal, MD, Plastic, Reconstructive and Aesthetic Surgery, Gazi University Medical School, Ankara, Turkey
IntroductionOdontogenic keratocyst is the most aggressive odontogenic cyst in the oral cavity. It is a significant clinical entity due to rapid growth and tendency for recurrence and extension into adjacent tissues including bone, which is typically occurring in the mandible and maxilla. In this study we present a case of odontogenic keratocyst which is unusually originated from temporomandibular joint. Case Report67-year-old female presented to our clinic for the evaluation of an enlarging mass in the left temporal region and discomfort at the temporomandibular joint during mouth opening. Maximal mouth opening was about one centimeter. She gave a history of undergoing surgery for three times for the same reason and the pathological diagnosis was odontogenic keratocyst. Clinical examination revealed a firm mass measuring 4 cm diameter and involving the left fossa temporalis and extending to the left temporomandibular joint. A cystic lesion 4.5 x 2.1 cm in size was detected in computerized tomography scanning. During the procedure, the lesion was found to be originated from the temporomandibular joint, which was the cause of the joint movement restriction. The pathological diagnosis was odontogenic keratocyst. The patient is at the first year of follow-up without any problem. Maximal mouth opening is about 4.5 centimeters.
DiscussionOdontogenic keratocyst is reported 70.16% in the mandible, 12.35% in the maxilla, 12.82% in the soft tissues and 4.66% in the maxillary sinuses. We did not found any report in such location of odontogenic keratocyst in the literature. They are known to have high recurrence rate ranging between 5 to 62%. Recurrence usually manifests itself within the first 5 to 10 years; however previous publications have reported recurrence as long as 41 years after treatment. Due to possible recurrences many years after initial treatment, a life-long follow-up schedule is suggested, regardless of the treatment given – every year for the first 5 years and every 2 years thereafter.
Poster: NOVEL Shape of a Manibular Cutaneous Flap to Repair Cheek and Labial Facial Units(MCP)
Osvaldo João Pereira-Filho, MD, Plastic Surgery, Clínica Jane, Florianópolis, Brazil
Dante Roberto Eickhoff, MD, Plastic Surgery, Clínica Jane, Florianópolis, Brazil
NOVEL SHAPE OF A MANIBULAR CUTANEOUS FLAP
TO REPAIR CHEEK AND LABIAL FACIAL UNITS(MCP)
The aim of this study is to demonstrate a
novel shape of a cutaneous flap, designed on the facial angiossome supplied by
the facial artery over the mandibular projection. The flap can replace soft
tissue in the cheek and labial facial sub-units at the same time. It was
indicated in the treatment of vascular malformation(3 cases) , complex pilousus
nevus(2 cases) and burn scars(2 cases).
Method: With the patient under sedation,
the MCP Flap is planned starting just 1.5cm from the auricular lobule running
parallel to the mandibular border superiorly until a point 1.5 cm from the oral
commissure. From this point, the line goes down to the mentum, returns 1cm
parallel the inferior border of the mandibular projection inferiorly until the
mandibular angle.(Fig 1) Tumescent infiltration using lidocaine 0,5% is utilized
to easy the undermining over the SMAS plane. The donor site is closed primarily
and the flap is rotated to the cheek and labial sub-unit as necessary. In 2
patients- 17 years-old and 22 years-old respectively, expander was indicated. (Fig
2,3) In the last ten years, 7 patients with ages varying from 17 to 50 years-old
underwent to the procedure. In the total: 7 MCP flaps was indicated to treat 10
facial units. The follow-up range from six months to five years. (Fig. 4)
Results: The MCP replaced successfully the
malar and labial units in six patients. In one case-a patient with a complex
vascular malformation-, the labial sub-unit was replaced with Abbé flap.(Fig. 5).
The post-operative period was uneventful. The first patient presented a
hematoma.
Discussion: The mandibular flap delineated
according the strategy of this study is located over the facial artery
angiossome. The MCP can provide satisfactory tissue to replace adequately the
malar and labial units. In selective cases, it is a better choice than the
multiple stages of cervical flap advancement, because in this case it is more
difficult to achieve a shape of facial unit, than with the MCP flap rotation. In
young patients or those with inelastic skin, a previous expansion can be
helpful. In those patients with good elasticity, a direct rotation without
expansion can be done in one or two stages procedure. We have to give special
attention during the flap design, preserving at a minimum 1.5cm from the labial
commissure, in order to allow primary closure of the donor site, avoiding displace
the oral angle. With the superior and inferior limit of the flap running 1cm
from mandibular border, the flap area can reach 9-10cm in length by 3.5 -4.5 cm
width. The indicaton of MCP flap is of importance in patients with vascular
malformation not responsible to laser therapy, as well as the complex nevus
involving two or more facial units. (Fig. 6, 7)
Conclusion:The mandibular cutaneous flap
with the parameters proposed by the authors, can provide enough tissue to
repair the homolateral malar and labial facial units, according preliminary
clinical investigation
.
Fig 1 – Design of the MCP Flap
Fig. 2a – Transoperative view of the MCP
flap before rotation to cheek and labial facial units
Fig. 2b – The MCP Flap at the receptor
site.
Fig. 3 – 5 year pos-operative view of the
patient of fig. 2
Fig. 4 – The MCP flap after repair of the
vascular malformation
Fig 5a – The planification of the MCP flap
to repair complex vascular malformation
Fig 5b – The flap at the receptor site
after the first stage
Fig. 6 – The MCP flap covering all the
cheek unit and the Abbé flap correcting the homolateral orbicular unit
Fig. 7a – Preoperative view of a complex
vascular malformation taking 3 facial subunits
Fig. 7b – 1 year postoperative view of the
MCP flap rotated to the cheek unit
Poster: ‘The use of Kaltostat with VAC dressings'
Amanda Isaac, MBChB, MRCS, Bristol Royal Infirmary, Bristol, United Kingdom
Marco Malahias, MBChB, MRCS, Plastic Surgery, Chelsea and Westminster Hospital, London, United Kingdom; Mohamed Jawad, FRCS, (Plast), Burns Unit, Plastic Surgery, Chelsea & Westminster Hospital, London, United Kingdom
We report a simple method to improve the quality of VAC dressings: Whilst applying the VAC dressing to promote wound healing¹ to an area which has been grafted/debrided the ooze from the raw bed, sometimes interferes with the clear adhesive film to seal off the area in question.Kaltostat consists of an absorbent fibrous alginic acid material. The dressing is presented as a flat sheet for application to surface wounds, which aids wound healing². By laying Kaltostat around the edges of the wound, this ooze is contained thus keeping the surrounding edges of skin dry and clean, allowing the adhesive film to stick properly. References: (¹) Banwell P, Withey S, Holten I. The use of negative pressure to promote healing. Br J Plast Surg 1998; 51(1): 79. (²) Attwood AI, Calcium alginate dressing accelerates split skin graft donor site healing, Br. J. Plast. Surg. 1989, 42, 373-379.
Poster: Nerve Graft Prefabrication: Preliminary Study
Ersin Ulkur, MD, Plastic Surgery, GATA Haydarpasa Training Hospital, Ýstanbul, Turkey
Hüseyin Karagöz, MD, Plastic Surgery, Maresal Cakmak Military Hospital, Erzurum, Turkey; Bahattin Celikoz, MD, Plastic Surgery, GATA Haydarpasa Training Hospital, Istanbul, Turkey; Pinar Turan, MD; Mehmet Yapar, MD, Virology, Gulhane Military Medical Academy, School of Medicine,, Ankara, Turkey; Serap Arbak, PhD, Department of Histology and Embriology, Marmara University, Medical School, Istanbul, Turkey
BACKGROUND
The most common surgical technique that used for repairing segmental nerve defects is using autolog nerve grafts. Although there are alternative tecniques, the results of these techniques are not successful. The morbidity of the donor site is a disadvantage of the nerve graft. In this study it was aimed to produce prefabricated nerve graft as effective as autolog nerve graft without donor site morbidity.
METHODS
Thirty adult Sprague-Dawley rats were used. One centimeter long jugular vein of the rats were excised and epineurial sheaths were excised in the related area. Rats were separeted into three groups each of them included ten rats. In the first group (epineural window group), vein graft excised from jugular vein was sutured to make a bridge between epineurial gaps of tibial and peroneal nerve. In the second group (partial incision group), ¼ of the nerve diameter was incised after excision of epineurial sheath, and vein graft excised from jugular vein was sutured to make a bridge between epineurial gaps of tibial and peroneal nerve. In the third group (gene therapy group), vein graft excised from jugular vein was sutured between epineurial gaps of tibial and peroneal nerve, and plasmid including VEGF gene were injected to muscle next to the nerve. At 2, 4, 6, and 8. weeks, functional assessment of nerve regenaration was realized by using “walking track analysis”. Morphological assessment was performed at the end of the eight weeks follow up period.
RESULTS:
Gene Therapy Results
The amount of VEGF was determined by test of quantitative ELISA from muscle samples preoperatively (0. day), 15 days postoperatively and 45 days postoperatively in gene therapy group (Group III) .
While increase of gene expression was seen at second week postoperatively in all samples, it was seen only in three samples until sixth week postoperatively. According to these results, gene therapy was succeeded in all samples, but its effect continued no more than six weeks.
Functional Assessment
According to peroneal function index, nerve injury signs were occurred initially in partial incision groups, but it improved gradually and got normal values at six week postoperatively. Peroneal function index values were changed with operation in neither epineural window group nor gene therapy groups. There were no statistical significant difference between the groups at eighth week (p>0.05).
Similarly, when tibial function index values were evaluated, we observed that nerve injury signs were occurred initially in partial incision group, but it improved gradually and got normal values at six week postoperatively. Tibial function index values were changed with operation in neither epineural window group nor gene therapy group. There were no statistical significant differences between groups at eighth week (p>0.05).
Histologic Results
The difference of the numbers of myelinated fibers between group II (partial incision group) and group III (gene therapy group) was not significant (p> 0.05); however, the differences of the other groups (group I-group II, group I-group III) were significant (p< 0.05).
The difference of the mean fiber diameters between group II (partial incision group) and group III (gene therapy group) was not significant (p> 0.05); however, the differences of the other groups (group I-group II, group I-group III) were significant (p< 0.05).
According to microscopic evaluation of semithin sections, there were myelinated fibers passed through vein graft in all groups. Although prefabricated grafts were included a few thinly myelinated axons in group I (epineural window group); there were so many myelinated fibers in group II (partial incision group) and group III (gene therapy group). The myelinated fibers of the group II and group III were better organized and thicker than group I.
The electron microscopic results were similar with semithin sections.
CONCLUSION
We prefabricated nerve graft by using autolog vein as a conduit material between two intact nerve and by gene therapy which increases the VEGF level in the medium.
Poster: The Component Separation Index: a Standardized Biometric Identity in Abdominal Wall Reconstruction
Michael Christy, MD, Plastic and Reconstructive Surgery, The Johns Hopkins Hospital and The University of Maryland, Baltimore, MD
John Apostolides, MD, Plastic and Reconstructive Surgery, The Johns Hopkins Hospital and The University of Maryland, Baltimore, MD; Eduardo Rodriguez, MD, Plastic Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, MD; Paul N. Manson, MD, Plastic Surgery, The Johns Hopkins Hospital, Baltimore, MD; Thomas Scalea, MD, Surgery, The Shock Trauma Center, Baltimore, MD
Reconstruction of traumatic ventral hernias often requires not only the use of abdominal wall component separation, but also the use of interpositional reconstruction with an acellular dermal matrix or other mesh to bridge the defect. We have developed a new value termed the "Component Separation Index" or CSI, to evaluate ventral hernia defects. Choosing a fixed point on a preoperative axial CT scan (aorta) and the medial leading edges of the rectus abdominus muscles, we determined the angle of diastasis of the hernia. This angle is divided by 360 degrees giving a relative value of the transverse defect size as compared to the estimated circular body habitus for that specific patient. The value was then used as a predictor of the need for interpositional repair. A retrospective review of 30 cases of ventral hernia repairs was performed. The CSI was calculated from the pre-operative CT scans obtained prior to repair. Group I (n=15) required component separation for closure. Group II (n=15) required component separation and placement of interpositional mesh to span the hernia defect. The Mean CSI for Group I was .28 with SD of .08. The Mean CSI for Group II was .34 with SD of .05 (P=.019, CI=.33).
To our knowledge there has been no other study utilizing an indexed value for the evaluation of traumatic ventral hernia defects. With the CSI the defect size is translated to a value that corresponds to the patient’s own biometric identity and allows for a standardized method to compare and study ventral hernias and abdominal wall defects. As this value approaches 0.3 the likelihood of an interpositional repair with component separation becomes much greater. We believe this value will help guide the plan for reconstruction of ventral hernias. While there is no substitute for clinical acumen when evaluating these defects, objective measurements can provide a valuable additional tool for the surgeon facing these cases.
Poster: Optimization of Biomechanics in Flexor Tendon Engineering
Sepideh Saber, BS, Plastic and Reconstructive Surgery, Stanford University, Los Gatos, CA
Andrew Zhang, MD, Plastic Surgery, Stanford University, Mountain View, CA; Sae H. Ki, MD/PhD, Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA; Derek Lindsey, MS, Bone and Joint Center of Excellence, VA Palo Alto Heathcare System, Palo Alto, CA; Hung M. Pham, BS, VA Palo Alto Heathcare System, Palo Alto, CA; James Chang, MD, Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA
Purpose: Mutilating injuries of the hand and upper extremity result in tendon losses too great to be replaced by autologous grafts. Our goal is to use tissue engineering techniques to produce additional tendon material. In this study, we used a custom bioreactor to apply cyclic mechanical loading onto tissue engineered tendon constructs to study viability and ultimate tensile stress.
Methods: A custom LigaGen tissue bioreactor providing uniaxial tendon strain (DynaGen systems) was used for this study. Tendon constructs were subjected to a stretch force of 5N, exposing each construct to 1.25N over a 5 day course (n = 4). Constructs used were acellularized tendons reseeded with tenocytes or left unseeded. Actual tendon strain was measured linearly by comparing resting tendon length to tendon length under applied tension. Ultimate tensile stress and elastic modulus of the tendon constructs were compared after different cycle parameters (1cycle/min vs. 2cycles/min in alternating 1 hour periods of loading and rest) using a materials testing system (MTS 858, MTS Inc). Histologic appearances were examined for tendon architecture with specific emphasis on collagen organization. Finally, pairwise comparison of means across groups was assessed using the two-tailed unpaired Student T-test with the significance level set at p < 0.05.
Results & Conclusions: Seeded tendon constructs that were exposed to a 1 cycle/min load were found to have a significantly increased ultimate tensile stress and elastic modulus (UTS = 84.73N; λ = 1054.77MPa) compared to non-loaded controls (UTS = 38.90N, p = 0.002; λ = 699.98MPa, p = 0.03). Seeded tendon constructs exposed a 2 cycle/min load also had a significant yet less remarkable increase (UTS = 73.95N; λ = 1045.21MPa) compared to non-loaded controls (UTS = 38.90N, p = 0.01; λ = 699.98MPa, p = 0.02). Histologically, stressed tendons showed better alignment of collagen fibrils.
Relevance: This study shows that cyclic loading of tendon constructs increases the strength of seeded constructs and changes the constructs’ collagen architecture. The use of the bioreactor may therefore accelerate the in vitro production of strong, non-immunogenic tendon material that can potentially be used clinically to reconstruct significant tendon losses. The ultimate goal of this project is to produce tissue engineered tendon for clinical use in hand and upper extremity reconstruction.
Poster: The Composite Costochondral-Iliac Crest Bone Graft: A Novel Technique for Temporomandibular Joint (TMJ) Reconstruction
Patrick Cole, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Marcus Crawford, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Larry H. Hollier, Jr, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Terry Taylor, DDS, MS, Oral and Maxillofacial Surgery, Baylor College of Medicine, Houston, TX
The mandible and temporomandibular joint (TMJ) are critical to the functional integrity of the face. As a hinge for powerful mandibular structures, the TMJ allows for proper mastication, speech production, and facial expression. However, in severe cases of ankylosis, congenital disease, neoplasia or post-traumatic dysfunction, the TMJ may become significantly dysmorphic and nonfunctional.1, 2 In order to restore a proper environment for oral development, mastication, proper occlusion, and speech, early correction is necessary. Though the use of costochondral grafts for mandible and TMJ reconstruction is well-established particularly in children due to its growth potential, disadvantages include the relatively poor quality of bone, and suboptimal structural integrity.3 The inferior osteoinductive capacity and poor rigidity of this graft may contribute to screw loosening, hardware failure, and compromised graft integrity sometimes seen clinically. Prompted by a need for improved bone quality of the reconstructed region, we created a composite mandibular graft consisting of both costochodral and iliac graft material. In our experience, TMJ reconstructions utilizing this combination in conjunction with plate fixation improves structural stability and produces superior a clinical outcome.
Poster: Optimizing Cleft Lip Repair: An Anatomic Study of the Upper Lip, Philtrum, and Nasal Floor
Patrick Cole, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Kyle Gordley, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Yoav Kaufman, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX; Samuel Stal, MD, Plastic Surgery, Baylor College of Medicine, Houston, TX
Abstract: Cleft lip repair plays a prominent role in contemporary plastic surgery. Although the last century has seen remarkable progress in cleft reconstruction, a thorough description of musculature underlying the upper lip and associated structures remains obscure and highly debatable. In order to effectively restore local muscular equilibrium and provide optimal cosmetic outcome, a thorough understanding of musculature underlying the upper lip, philtrum, and nasal floor is imperative. Fine anatomic dissection of the upper lip, philtrum, and nasal floor in 5 adult cadavers provided several key insights. Most strikingly, tissues of the orbicularis oris from one side decussated immediately beneath the philtral groove before inserting into the skin of the contralateral philtral groove. Although the philtral groove immediately overlay this complex decussation, a relative paucity of muscular insertion to this area was readily apparent. At more inferior philtral levels, the levator labii superioris descended medially to insert along the philtral column and vermilion border. It is the complex anatomic relationship of this area which we feel is most responsible for the lateralization of nasal and midline cheek tissue in the setting of cleft lip/palate. Based on our experience, we suspect that cleft abnormalities are associated with a much more lateral insertion of this intersection. Here we present our findings from the gross dissection and anatomic study of adult peri-oral musculature, as well discuss these findings in the context of cleft lip and palate.
Poster: The Cost-Effectiveness of the Surgical Treatment of Migraine Headaches
Thomas Muehlberger, MD, FRCS, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany
Nidal Toman, MD, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany; Alexandra Buschmann, MD, Plastic Surgery and Hand Surgery, DRK - Kliniken Berlin Westend (Humboldt University), Berlin, Germany
Introduction The transpalpebral resection of the corrugator muscles is a novel approach of treating migraine which is based on the decompression of selective branches of the trigeminal nerve. In contrast to the traditional, conservative therapy with expensive acute medication which does not alter the character and frequency of the migraine attacks, the surgical intervention is a single procedure with lasting effects. 12%-15% of the population in the western world suffer from migraine entailing billions of costs per year in terms of medication, loss of work power and consequences of chronic abuse of analgesics. This study compared the direct and indirect costs of 70 patients during one year prior to the specific migraine surgery with the expenditures of the same time period one year postoperatively.
Material and Methods The corrugator muscles were chemically denervated with Botox® in 92 migraine patients after the identification of individual trigger points. 74 of these 90 patients experienced a significant symptomatic improvement. The surgical resection of the respective structures was performed on 70 of them. Data were collected retrospectively about the number and specialties of physicians consulted, diagnostic means, forms of treatment including triptans and prophylaxis, prescription-free medication, alternative regimen and individual sick-leave for a time period of one year. The same set of information was assembled prospectively for one year following the operation.
Results The average, cumulative cost of each migraineur was 6524 € in the year prior to surgery. The combination of direct and indirect cost in the postoperative year was 395 € per patient. 86% of the patients reported a significant and lasting improvement at the one-year follow-up. The number of days off work decreased by 91 %, thus diminishing the public economic burden by 95%. The consumption of triptans was reduced by 84 %. The individual costs, not covered by health care, decreased by 87%. The cost of the operation is 3462 €.
Conclusions Migraine patients who are suitable for the surgical treatment are not a representative sample. The operation is preceded by several months of tests and documentation. The patient selection is of crucial importance for the efficacy of the surgical intervention. In this particular sub-group the cost-effectiveness of the surgical treatment is clearly superior to conservative therapies which is reflected by the increasing willingness of german insurance companies to cover the one-time costs of the operation.
Poster: Osseous regeneration of the free fibula flap used for mandibula reconstruction resembling a firm mass
Selahattin Ozmen, MD, Plastic Surgery, Gazi University, Ankara, Turkey
Safak Uygur, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Tolga Eryilmaz, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Ismail Kucukoduk, MD, Plastic Surgery, Gazi University, Ankara, Turkey; Suhan Ayhan, MD, Plastic Surgery, Gazi University, Ankara, Turkey
AIM:
To discuss a case
with bony regeneration resembling a firm mass after reconstruction of the
mandibula with free fibula osteocutaneous flap
CASE REPORT:
Ten year old boy underwent
surgery for mandibula reconstruction with osteo-cutaneous free fibula flap
following a gun shot injury (Figure 1)
Figure 1
One year after a successful
reconstruction, he complained about a firm mass on the angle of the mandibula
at the reconstruction site. In 3-D tomography bony projection with 900 angle,
2x1x0,5 cm in size was seen at the posterior osteo-fibular
junction (Figure 2)
.
Figure 2
The bony segment
was excised and the bone was burred (Figure 3,4).
Figure 3
Figure 4
Histological
examinations showed bony regeneration. Four months later he admitted with the
same bony projection and he underwent re-excision and with a burr periosteum of
the fibula flap was degenerated around the bony segment. The histological specimens
corrected the bony regeneration
DISCUSSION:
Reconstruction of
the mandibula with a free fibula flap is a common procedure. According to most
head-neck surgeons because of the growth capacity, free fibula flap is the
first choice in the reconstruction of critical sized mandibula defects in
children. Bony projections are rare complications resulting from the
vascularized periosteum that separated from the bone during the reconstruction.
These bony projections may be very important in tumoral reconstructions by
resembling a firm mass. Although it is very rare, one must keep this
complication in mind. In the treatment, degeneration of the vascularized
periosteum around the bony segment is essential for complete recovery.
Poster: The Effect Of Obesity On Post-operative Body Image in Women Undergoing Breast Reconstruction
Anita Kulkarni, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Dunya Atisha, MD, University of Michigan, Ann Arbor, MI; Edwin G. Wilkins, MD, MS, Plastic Surgery, University of MIchigan, Ann Arbor, MI; Amy Alderman, MD, MPH, Plastic Surgery, U Michigan, Ann Arbor, MI
The Effect of Obesity on Post-operative Body Image in Women Undergoing
Breast Reconstruction
Kulkarni AR, Atisha D, Alderman AK, Wilkins EG
Purpose
Previous research by our group and others has shown that
breast reconstruction after mastectomy confers significant psychosocial
benefits to patients. However, previous
reports have also demonstrated relatively high complication rates in overweight
and obese patients undergoing these procedures. Despite the rising prevalence of obesity in America, many plastic
surgeons have expressed reluctance to offer breast reconstruction to these
patients due to potential for complications.
We sought to evaluate the impact of breast reconstruction on
post-operative body image in overweight and obese patients.
Methods and Materials
Women undergoing first-time breast reconstruction at 12
centers by 23 plastic surgeons were prospectively evaluated. Pre-operatively and at 1 year
postoperatively, study participants completed a questionnaire detailing health
status information. The post-operative
questionnaire included a subscale of 9 questions assessing body image. Patients were asked to respond to each item
using a 5-point Likert scale. A final
body image score was calculated with a range from 5 (lowest body image) to 45 (highest
body image). Based on Centers for
Disease Control criteria, patients were classified as normal weight (BMI
<25), overweight (BMI= 25-30), or obese (BMI>30). Each BMI category was evaluated for
differences in pre and post-operative body image scores with ANOVA
single-factor analysis. Logistic
regressions were used to analyze the effects of BMI category, age, timing of
surgery (immediate vs. delayed), type of reconstruction (implant vs
autogenous), and pre-operative body image scores on post-operative body image
scores.
Results
Our study population included 198 post-mastectomy
patients. Pre-operatively, there was a
significant difference between the body image scores of normal women when
compared to overweight and obese women.
Overweight women rated their pre-operative body image 11% lower than
normal women (p=0.01), while obese women rated their body image 22% lower than
normal women (p=0.0002). One year after
undergoing breast reconstruction, all patient cohorts experienced an
improvement in body image scores.
However, postoperatively there were no statistically significant
differences between normal, overweight, and obese women (p=0.5). Logistic regression analysis showed that
patient BMI had no significant effect on post-operative body image scores. Significant effects on post-operative body
image were noted for patient age, timing of surgery (immediate vs. delayed),
and pre-operative body image scores.
Conclusions
Obesity does not appear to limit improvements in body image
offered by post-mastectomy breast reconstruction. In our analysis, overweight and obese patients reported
postoperative body image scores on par with normal weight women, representing a
marked improvement from pre-operative status.
Despite the higher surgical complication rates among obese patients,
surgeons should be aware of the benefits of breast reconstruction in this
population and use these data for informed patient decision-making.
Poster: Outcome Assessment of Breast Distortion Following Subpectoral Breast Augmentation
Joseph Dayan, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC
Scott L. Spear, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC; Jaime Schwartz, MD, 2111 Wisconsin Ave Nw, 606, Jaime Schwartz MD, Washinton, DC; Mark Clemens, MD, Plastic Surgery, Georgetown University Hospital, Washington, DC
Introduction: Breast distortion during pectoralis muscle contraction following subpectoral breast augmentation is a known entity, however, its prevalence and significance are unclear in the literature. While there are a number of techniques that have been described to correct muscle-related implant distortion, a comprehensive review of this issue has not been done. While undoubtedly there are patients where distortion may be clinically significant, it is not clear how much this distortion bothers most patients. The purpose of this study is to propose a classification system for breast distortion, objectively measure distortion in an unselected consecutive group of patients, and quantify its significance on patient satisfaction.
Method: The first portion of this study involves proposing a four-point classification system for breast distortion. Twenty consecutive primary subpectoral breast augmentations performed by a single surgeon were evaluated by 9 plastic surgery residents with photos of the patients at rest and with pectoralis muscles aggressively contracted.
The second part of this study involves an IRB-approved questionnaire that was mailed out to 200 consecutive patients who underwent primary subpectoral breast augmentation by a single surgeon beginning in January 2000. All augmentations were performed using the dual-plane technique. The questionnaire focused on the possible adverse effects of muscle-related breast distortion and patient satisfaction with the results.
Results: Out of the twenty patient photographs that were evaluated by plastic surgery residents, 75% were scored as having none to minimal distortion. 10% were rated as having severe distortion.
Out of the 200 questionnaires there were 63 responses (32%). 79% of patients felt their distortion was none to mild, while 8% reported having severe distortion. However, only 1 patient reported being unsatisfied and 2 patients said they would not recommend subpectoral implants. The most common complaint was distortion related to lifting weights with 24% of patients reporting this as a problem.
Conclusion: As a result of this study, surgeons and patients should have accurate and reliable information regarding both the objective effect and subjective patient response to muscle-related distortion after subpectoral breast augmentation. While breast distortion can be significant, most patients remain satisfied with their results. The technique of dual-plane subpectoral breast augmentation will be briefly presented.
Poster: The Effect of Medical Co-Morbidities on Recurrence Using Prosthetic Materials with Component Separation for Complex Ventral Hernia Repair
Mazen S. Harake, MD, Plastic Surgery, University of Michigan, Ann Arbor, MI
Amy Shanks, MS, Anesthesiology, University of Michigan, Ann Arbor, MI; Melanie G. Urbanchek, PhD, Plastic Surgery, University of Michigan; Daniel J. Krochmal, MD, General Surgery, Mayo Clinic - Scotsdale; Laura Pressley, BA, Anesthesia, University of Michigan, Ann Arbor, MI; William M. Kuzon, Jr, MD, PhD, University of Michigan, Ann Arbor, MI; Michael G. Franz, MD, General Surgery, University of Michigan
Background: Medical co-morbidities affect complication and recurrence rates after ventral hernia repair. However, the relationship between co-morbid conditions and complication and recurrence rates after repair using the component separation technique with or without prosthetic implants is uncertain.Purpose: This retrospective study reviewed our series of patients at the University of Michigan, to determine the effect of medical co-morbidities on recurrence comparing complex incisional hernias repaired using the component separation technique (CST) without a prosthesis or CST with the addition of an underlay prosthesis.Methods: After receiving Institutional Review Board approval, one hundred and forty-four patients were identified that were treated between March 2002 and November 2007. In all patients, the surgical technique involved bilateral musculofascial release of the external oblique muscle lateral to the linea semilunaris line. In 66 of 144 patients, a single-layer prosthesis (alloplastic or biologic) was implanted beneath the fascial edges of the defect as an “underlay” with moderate tension. After bilateral midline advancement of musculofascial units, a tension-free midline fascial closure was performed. Patient demographics, preoperative risk factors, surgical indications, operative technique and details, and postoperative complications including recurrence rates were extracted from the clinical record. The co-morbidities examined included cardiovascular disease, diabetes, obesity, hypertension, renal dysfunction, cancer, alcohol and substance abuse, and smoking. Pearson Chi-Square, Fisher’s Exact Test, and Mann Whitney U Test were used for analysis using SPSS v. 15 as appropriate.Results CST was performed in 78 patients without a prosthesis and in 66 patients using an underlay Prosthesis. There were no significant differences between the groups in terms of average age (52 versus 57 years), Body Mass Index (33 versus 35 kg/m2), male ratio (50% versus 39%), average number of co-morbidities (1.5 versus 1.4), or history of previous surgeries (72% versus 76%). The average size of hernia defect in each group was not statistically different (318 cm2 versus 353 cm2). Postoperative complications including infection (37% versus 21%) and skin dehiscence (26% versus 9%) were increased in patients repaired using CST without prosthesis compared with CST and prosthesis (p £ 0.05). In the CST without prosthesis group compared to the CST with prosthesis group, the post-operative recurrence rate was 24% (n=19) versus 11% (n=7) (p = 0.03). Of the risk factors studied, only smoking was determined to be significantly higher in patients in the CST group without prosthesis. For the subset of patients that developed recurrence post-operatively, there was no significant difference between the two groups when comparing risk factors including obesity, elderly age, diabetes, smoking, hypertension, cancer, size of defect, or average number of co-morbidities.Conclusions: We conclude that co-morbid factors do not predict recurrence when comparing patients undergoing complex ventral hernia repair using component separation technique without prosthesis or component separation with prosthesis. Recurrence rate and postoperative complications decrease with the addition of a prosthetic implant to the component separation technique in incisional hernia repair. For optimal outcomes and decreased recurrence after ventral hernia repair, these data suggest that the use of a prosthetic implant underlay improves patient outcomes.
Poster: Outcomes of Abdominoplasty Performed in an Office-Based Surgical Setting
Mark M. Melendez, MD, MBA, Plastic Surgery, Stony Brook University Medical Center, Stony Brook, NY
Sami U. Khan, MD, Stony Brook University Medical Center, Stony Brook, NY; Michael E. Beasley, MD, Charlotte Plastic Surgery Center, P.A., Charlotte, NC; Alexander B. Dagum, MD, FRCS, FACS, Surgery-Division of Plastic and Reconstructive Surgery, Stony Brook University Medical Center, Stony Brook, NY
INTRODUCTION: Abdominoplasty is one of the most common aesthetic procedures performed in hospital operating rooms, ambulatory surgery centers and office-based facilities. Frequently, abdominoplasty is combined with other cosmetic procedures. Few studies have investigated the complications and outcomes after abdominoplasty. The purpose of this study was to determine the outcomes as well as complication rates of abdominoplasty in office-based surgery alone and in combination with another cosmetic procedure.
METHODS: A retrospective chart review using a database was performed on 2618 consecutive patients who underwent cosmetic procedures by a single group during a 5-year period (November 2000-December 2005). Formal abdominoplasties, and other cosmetic procedures (ultrasound assisted liposuction/suction assisted liposuction of abdomen, hips, flanks, knees and thigh, breast augmentation/mastopexy, bilateral implant exchange and capsulotomy , submental fat excision, facelift , brachioplasty/ medial thigh lift, endoscopic browlift, malar lift, lower blephorplasty, fat injection of lips lips, lower body lift, and umbilical hernia repair) were performed on 228 patients within this period. A database was reviewed for patient profile, types of procedures, multiple procedures, and complications. Two subgroups were evaluated. Group 1 included patients who underwent abdominoplasty and group 2 included those patients who had abdominoplasty in combination with other cosmetic procedures. Outcome measured included wound complications, hypertrophic scars, pulmonary embolism, deep venous thrombosis, deaths, seromas, and/or hematomas.
RESULTS: Patients included 96 (27.3 percent) females and 1 (.0003 percent) male for those who underwent abdominoplasty compared to 126 (20.8 percent) females and 7 (.002 percent) males who had abdominoplasty in combination with other cosmetic procedures. The mean age at the time of operation for each group was 40 years of age. The average amount of time it took for abdmoninoplasty was 119.4 minutes compared to 178 minutes for abdominoplasty in combination with other cosmetic procedures. The complication rate was (.013 percent) and (.022 percent) respectively. The most common complication was seroma formation, (9.7 percent) in patients with abdominoplasty alone, and (5.7 percent) in patients with abdominoplasty in combination with other procedures. The revision rates were not different significantly between the groups, (2.7 percent) and (3.9 percent) respectively. There were no deaths.
CONCLUSIONS: Abdominoplasty performed in an office-base setting can be safe and managed effectively by plastic surgeons. There is a low incidence of complications as well as re-operations for patients undergoing abdominoplasty alone or in conjunction with another cosmetic procedure.
Poster: Pain Relief and Restoration of Sensation for Diabetic Neuropathy
Huseyin Karagoz, MD, Plastic Surgery, Maresal CAKMAK Military Hospital, Erzurum, Turkey
Fuat Yuksel, MD, Plastic Surgery, Gulhane Medical Military Academy, Haydarpasa Training Hospital, Istanbul, Turkey; Ersin Ulkur, MD, Plastic Surgery, Gulhane Medical Military Academy, Haydarpasa Training Hospital, Istanbul, Turkey; Bahattin Celikoz, MD, Plastic Surgery, Gulhane Medical Military Academy, Haydarpasa Training Hospital, Istanbul, Turkey
BACKGROUND
In this current study, we intended to search the effect of nerve decompression procedures on diabetic neuropathy cases just in the following day after surgery as well as later in the 6th months.
MATERIAL AND METHODS
Twenty – four consecutive patients with symptomatic diabetic neuropathy who underwent surgical decompression of lower extremity were entered into this patient cohort. Each patient had been previously diagnosed and treated for diabetes mellitus with oral or parenteral hyperglycemic agents by their endocrinologists. All patients had been previously diagnosed with diabetic neuropathy and presented complaining of lower extremity symptoms related to their diabetes (pain, tingling, burning, numbness).
Using an 11-point visual analog scale (VAS), each patient was asked preoperatively to rate the greatest intensity of pain associated with their neuropathy. Absence of pain was rated as 0 and the worst possible pain as 10.
Patients were screened for surgery with neurosensory testing by using a Pressure-Specified Sensory Device (PSSD). Patients were graded by using numerical grading system according to physical exam, and their values of PSSD measurement from big toe plantar surface and heel.
The common peroneal nerve was decompressed distal to the fibular neck on the lateral calf. The posterior tibial nerve and its branches were decompressed by a technique that releases 4 medial ankle tunnels: the tarsal tunnel, the medial and lateral tunnels, and the medial calcaneal tunnel. The deep peroneal nerve at the dorsum of the foot was decompressed. At a mean postoperative follow-up of 8 months, the data was interpreted to evaluate pain relief and restoration of sensation in the operated foot. The results of the preoperative, postoperative first day and postoperative sixth month were compared.
RESULTS
We found pain relief rate 80% of the patients at postoperative first day and 85% of the patients at postoperative sixth month with a preoperative complaint of pain reported excellent to good levels of pain relief after surgery. For sensory assessment of each individual area, mean two-point discrimination length’s improvement rates was found as 72.6% at postoperative first day, and 89% at postoperative sixth month which mean excellent and good improvement. According to numerical grading system results, which helps us to compare clinical state of patients and sensory measurement values, while 45.9% of postoperative first day patients show significant grade improvement, this rate increases to 75% at postoperative sixth month.
CONCLUSIONS
The improvement in peripheral nerve function after complete regeneration period in the long time was essential in peripheral nerve surgery. Any improvements in the early periods were also very important for those patients as well. Those with diabetic neuropathy were suffering from their complaints for a long time and mostly depressed for that reason. That was why they became very excited after even minor improvements and their morales were recoverd. This concept was very important for diabetic patients because improvements reassured them they were getting better after all those bad days and made them hopeful for their future and made them more concordant with their treatment offered by their physicians The authors concluded that the peripheral nerve decompression can be used effectively in the treatment of symptomatic diabetic neuropathy patients.
Poster: Pediatric TMJ Disorders: Etiology, Epidemiology, Classification and Treatment
Alexander C. Allori, MD, MPH, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY
Christopher C. Chang, MD, Institute of Reconstructive Plastic Surgery, NYU Medical Center, New York, NY; Rodrigo Farina, MD; Barry H. Grayson, DDS; Stephen M. Warren, MD, New York University Medical Center, New York, NY; Joseph G. McCarthy, MD, Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY
Background: Pediatric temporomandibular joint (TMJ) dysfunction, resulting from either soft tissue or skeletal disorders, may be congenital, developmental, or post-traumatic in origin. Congenital TMJ dysfunction is the least common. Here, we review our experience with pediatric TMJ dysfunction and develop a new classification system.
Method: Records of all patients with trismus or restricted mandibular excursion treated at the Institute of Reconstructive Plastic Surgery between 1976 and 2006 were reviewed. Clinical records, cephalograms, computed tomography, magnetic resonance images, and pathologic specimens were reviewed. All cases were stratified according to soft tissue and/or skeletal pathology. Skeletal abnormalities were further characterized as intra-, peri-, or extra-capsular.
Results: Thirty-three patients (ranging in age from 2 days of life to 19 years at diagnosis; mean age 5.4 years) were identified with TMJ dysfunction. Nine cases (27%) were due exclusively to soft tissue pathology, including post-irradiation scarring, fibrosis, infection, and tumor. The remaining 24 cases (73%) were skeletal in origin and were evenly divided between acquired and congenital cases. Acquired skeletal deformities included 11 (91.7%) intracapsular ankyloses and 1 (8.3%) extracapsular ankylosis (coronoid process to zygoma); etiology included infection, trauma/surgery, and degenerative rheumatic disorders. In contrast, congenital skeletal deformities accounted for 2 intracapsular ankyloses (16.7%) and 10 (83.3%) extracapsular ankyloses or mechanically restrictive skeletal disorders (e.g., coronoid hypertrophy without ankylosis).
Conclusion: The data appear, at first, consistent with previously published population studies that principally attribute TMJ dysfunction to acquired pathology, specifically trauma (or surgery) and infection. However, in contradistinction to prior published reports, we observed a significantly higher percentage of congenital cases of TMJ skeletal disorders. Classification based upon joint involvement revealed that most of these cases involved extracapsular pathology, such as coronoid hypertrophy or zygomatic hypoplasia. Only a minority of congenital cases were intracapsular ankyloses characterized by gleno‑condylar fibro-osseous fusion. Because precise diagnosis and classification directs the choice of therapy, we provide a new classification scheme to differentiate between soft tissue and skeletal pathologies and to better characterize the extent of capsular involvement. Protocol-based preoperative CT is recommended to aid in classification and the selection of treatment modalities, which are discussed critically.
Poster: Plasma Skin Rejuvenation in Asians
Taro Kono, MD, PhD, Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
William Groff, DO, Cosmetic Dermatology, La Jolla Cosmetic Surgery Centre, La Jolla, CA; Yuji Kikuchi, MD, PhD, Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan; Hiroyuki Sakurai, MD, PhD, Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan; Takashi Yamaki, MD, PhD, Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan; Motohiro Nozaki, MD, PhD, Plastic and Reconstructive Surgery, Tokyo Women's Medical University, Tokyo, Japan
Objectives: Ablative laser resurfacing has been considered to be the most effective option for skin rejuvenation. However, the epidermis is significantly damaged during this process and this can be associated with potential adverse effects, especially in dark skin patients. Recently, plasma skin rejuvenation has been investigated. There are no reports on plasma treatment of patients with darker skin. The objective of our study is to evaluate the effectiveness and complications of plasma skin rejuvenation in Asian patients. Materials and Methods: Twenty female Asian patients were enrolled in the study. Three full face treatments were performed at monthly intervals with the plasma device, using energy settings of 1-1.5J. Patients were seen 1 week after and 3 months after the last treatment. A facial analysis system and melanin index were used to objectively evaluate each patient. The patients were also evaluated for any side effects from the treatment as well their degree of satisfaction with the procedure.Results: Skin tone was significantly improved after plasma treatment (p<0.01). The average VAS score was 3.7 +/- 1.4SD and all patients easily tolerated the treatments. The average re-epithelization time was 4.9 +/- 1.5SD days. The improvement of wrinkles and enlarged pores was observed and the average patient’s satisfaction was 5.4 +/- 1.9SD. Temporary and local hyperpigmentation was observed in two patients and this hyperpigmentation disappeared within three months. Hypopigmentation and scarring were not observed.Conclusions: Low energy plasma treatment is clinically effective and is associated with minimal complications in Asian patients. Ablative laser treatments are not common in the Asian population because of the high risk of side effects. However, plasma treatment seems to be a safe and effective option for skin rejuvenation in Asian skin patients.
Poster: Preoperative Patient Education for Breast Reconstruction: A Systematic Review of the Literature
Beth Aviva Preminger, MD, MPH, Division of Plastic Surgery, New York Presbyterian Hospital, New York, NY
Colleen McCarthy, MD, MS, Division of Plastic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY; Andrea L. Pusic, MD, MHS, Plastic and Reconstructive Surgery, Plastic & Reconstructive Surgery, New York, NY; Peter G. Cordeiro, MD, Plastic and Reconstructive Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
Background: Patient education is emerging as an increasingly important aspect of modern healthcare. Both immediate and delayed breast reconstruction have been shown to provide substantial psychosocial benefits for mastectomy patients. However, lack of knowledge about breast reconstruction has been cited as a major contributing factor in women’s reluctance to undergo breast reconstruction. Even a cursory overview of educational approaches for breast reconstruction patients reveals a wide variety of objectives, methods, intensity and duration, educators, and content. This variability suggests a lack of consensus on what works. The purpose of this study was to formally assess the current state of literature on plastic surgical educational materials for breast reconstruction.
Methods: A systematic review of the English-language literature was conducted between the years 1966-2006 of all studies pertaining to the use of educational materials for breast reconstruction. MEDLINE, CINAHAL, PsychINFO, EMBASE, SCOPUS, and the Science Citation Index were searched. The selection criteria were that the study must employ and evaluate an educational tool for breast reconstruction. Qualifying studies were assessed for study design, use of a needs assessment, sample size, content, teaching setting, and outcome measure.
Results: A total of 496 articles were retrieved from our systematic review. Of these, only six met criteria. These studies employed various educational media including written, visual, and audio materials. Three of the studies were conducted in the United States; two were Canadian in origin; one was conducted in the Netherlands. Only three of the five studies were randomized controlled trials. Detailed review revealed that only one study included a needs assessment. Outcome measures varied: knowledge gains (n=4), decision to undergo reconstruction (n=3), satisfaction with decision regarding reconstruction (n=1), decisional conflict (n=3), and type of reconstruction (n=3).
Conclusions: This review highlights the need for well-designed, methodologically sound research into patient education regarding breast reconstruction that incorporates patient satisfaction as an outcome measure. Such information is invaluable in developing patient education programs and decision aids that aim at patient empowerment.
Poster: Primary and Secondary Procedures in Functional and Aesthetic Reconstruction of Noma-associated Complex Facial Defects
Goetz A. Giessler, MD, Clinic for Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Clinic Ludwigshafen, Ludwigshafen, Germany
Andreas B. Schmidt, MD, Department for Plastic, Hand and Reconstructive Microsurgery, Burn Center, BG Trauma Clinic Murnau, Murnau, Germany; Carl-Peter Cornelius, MD, DMD, PhD, Department for Maxillofacial Surgery, Plastic Operations, Germany Armed Forces Hospital Ulm, Ulm, Germany; Helmut Fischer, MD, Clinic for Facial Plastic Surgery, Marienhospital Stuttgart, Stuttgart, Germany
Most defects resulting from noma involve the lateral and anterolateral aspects of the face and are often combined with severe functional deficits owing to impaired mandibular mobility up to full ankylosis. A subgroup, commonly called "central noma", comprises defects of the upper lip, maxillary soft tissues, the premaxilla, the nasal cartilaginous infrastructure and soft tissues. In contrast to unilateral involvement of the face, central noma does not affect jaw opening, still it results in severe mutilation with disfiguring three-dimensional defects erasing any individual traits from a face. The common surgical approach to centrofacial noma defects has been single stage reconstructive procedures using loco-regional flaps, however often leading to disappointing outcomes in complex cases.
Our concept for complex central noma defects is a staged approach using free flaps for soft tissue reconstruction of the upper lip and the maxillary vicinity serving as a versatile base to introduce loco-regional flaps for later functional and aesthetic refinements. Secondary surgery includes total nose reconstruction with a free cartilage framework and forehead flaps. We prefer to interpose vascularized flap tissue between any osteotomized surfaces, if preoperative ankylosis made resection arthroplasty for the temporomandibular joint necessary.
In our series (n=53) the free radial forearm (n=4), anterolateral thigh (ALT-) (n=1) and parascapular flap (n=7) proved suitable for the central face in terms of pedicle length, tissue pliability and bulk. All free flaps survived completely. Three total nose reconstructions by forehead flaps were done successfully as a secondary step. Free flap interposition seemed to be advantageous in prevention of "trismus" recurrence in at least two cases.
Being of limited use for a subtotal or total reconstruction of the outer nose, a microvascular tissue transfer as a first step preserves local and regional donor sites – in particular the forehead - for secondary reconstruction. In extensive cases, this approach may prevent the common pitfall of reconstructing the missing nose as the most disfiguring feature first without providing a solid tissue fundament to place it beforehand.
Poster: Question Mark Ear Treatment
Gabriel Salum D Alessandro, MD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil
Oscar Porto, MD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil; Denis Oksman, MD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil; Tatiana Nunes, MD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil; Marcelo Wulkan, MD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil; Paulo Godoy, MD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil; Marina Beirigo, MD, Plastic Surgery, Santo Amaro University, Sao Paulo, Brazil; Walter Pinto, MD, PhD, Plastic Surgery, Santo Amaro University, São Paulo, Brazil
Concise Purpose: Although rare, the
congenital external ear deformity with weakening of the medium segment of conch
and of scapha is usually denominated “question mark ear” because of the called
minor development of that segment and by its characteristic shape. Some authors
justify this deformity by embryological studies of auricular complex. The major
axis becomes smaller and in some patients the ear gap too. Some authors have
published their experiences to correct this kind of deformity using a
condrocutaneous flap of sliding, z-plasty, wedge resection and skin graft based
on their own choice. Our experience is based on three patients using a sliding
flap and a compensatory triangle of the conch to balance the reduction of the
major axis of the ear and support its shape as natural as possible.
Patients and methods: Three female patients were submitted to a surgical
procedure. They were 17, 19 and 20 years old; the youngest has a unilateral
deformity and the others, bilateral. The procedures were systematically done
using a sliding flap associated to resection of a compensatory triangle of the
conch, whose characteristics were modified by the extension of the ear defect.
The bilateral ones were asymmetrical and in the right ears the defect was less
seeming, so the youngest patient needed only the use of sliding scrap. The
major axis and the size of the defect were measured before and after the
surgery to be compared.
Summary of results: The surgical procedures were almost similar, however
the deformities were not. They were different even in the same patient.
Although the same technical principle of sliding flap and compensatory triangle
of the conch has been used, the extension of the defect determined minor or
major resection and suture lines different in position and extension.
International literature has showed that ear gaps around 20 mm produce greater
distortion of the ear shape and dimension after surgery. In our experience we
have not faced this problem. There was a 21 mm ear gap patient and the axis
reduction was about 4 mm; and, the others, with smaller defects, were about 2
mm. These smaller reductions could be considered aesthetically acceptable.
Conclusions: The described procedure is not technically difficult. It
can be performed under local anesthesia, ambulatory condition and in only one
operating time. It was developed to solve specifically the question mark ear
deformity.
Poster: Quilting Suture in the Donor Site of the Tram Flap in Breast Reconstruction
Elvio Bueno Garcia, MD, PhD, Departament of Plastic Surgery, FEDERAL UVIVERSITY FROM SÃO PAULO, São Paulo, Brazil
Luis Antonio Rossetto, MD, Departament of Plastic Surgery, FEDERAL UNIVERSITY FROM SÃO PAULO, São Paulo, Brazil; Luis Eduardo Felipe Abla, MD, PhD, FEDERAL UNIVERSITY FROM SÃO PAULO, São Paulo, Brazil; Lydia Masako Ferreira, MD, PhD, Departament of Plastic Surgery, FEDERAL UNIVERSITY FROM SÃO PAULO, São Paulo, Brazil
Background: This study is designed to evaluate the effects of the quilting suture in the donor site of the transverse rectus abdominis musculocutaneous (TRAM) flap in breast reconstruction. Methods: The use of the quilting suture in closing the abdominal flap causes a collapse of the dead space and allows flap rest, thus ameliorating the factors that interfere with their adherence and reducing complications. From January 2004 to March 2005, 30 breast reconstructions using a pedicled transverse rectus abdominis musculocutaneous flap were performed. The sample was randomly distributed into two groups: 15 patients with the quilting suture (Group A) and 15 patients without the quilting suture (Group B). The study focused on: daily drain output (ml), time to drain removal (days) and possible donor site complications (%).Results: Group A presented an average of 4.2 days to remove the drain and Group B, 6.93 days, with a statistically significant difference (p<0.001). As to total volume upon removal of the drain, Group A presented an average of 434.7 ml and Group B, 620.7 ml, with a statistically significant difference (p=0.002). Group A presented 13.3% of complications at the donor site and Group B, 53.3%, with a statistically significant difference (p=0.05). Conclusion: The results allow us to conclude that the use of the quilting suture in the transverse rectus abdominis musculocutaneous flap donor site reduces the permanence of drains, total volume of tissue fluids upon drain removal and complication rates.
Poster: Re-Defining Pseudoptosis from a 3D Perspective after Short Scar-Medial Pedicle Reduction Mammaplasty
Oren Tepper, MD, Plastic Surgery, NYU Medical Center, New York, NY
Kevin Small, BA, Plastic Surgery, NYU Medical Center, New York, NY; Jacob Unger, BA, Plastic Surgery, NYU Medical Center, New York, NY; Mihye Choi, MD, Plastic Surgery, NYU Medical Center, New York, NY; Nolan Karp, MD, Plastic Surgery, NYU Medical Center, New York, NY
Background: Bottoming out, or pseudoptosis, is a well-known phenomenon that is associated with all types of reduction mammaplasty (RM). Despite its clinical relevance, the evaluation of post-operative bottoming out remains an imprecise science. The following study is the first to report the application of three-dimensional (3D) photography to objectively investigate changes in breast morphology associated with bottoming out. Methods: From July 2006 to December 2006, patients undergoing medial pedicle RM had 3D photographs (Konica Minolta V910) taken during the early and late post-operative period (early = 60-120 days; late = 400-500 days). 3D images were analyzed using a Boolean operation and a standardized chest wall. Bottoming out was assessed with various 3D parameters and vectors including: total breast volume, volumetric tissue distribution above and below the inframammary fold (IMF) plane, distance of the IMF-plane to the lowest point of the breast, and maximum anterior-posterior projection from the chest wall. Results: A completed series of 3D images were obtained from 15 RM patients. The total breast volume decreased 20.6% from the early to late postoperative period. The percent of breast tissue below the inframammary fold significantly increased from the early to late postoperative scan. (24% to 31%, p<0.01) Further evidence to suggest bottoming out included a significant increase in the distance from a fixed IMF-plane to the bottom of the breast (9mm, p<0.01) as well as a decrease in AP projection (6.23mm; p<0.01) and a drop in the position of the lateral border of the IMF (6.27mm; p<0.01).IMF-plane to the lowest point of the breast, and maximum anterior-posterior projection from the chest wall.Conclusions: This study provides quantifiable data to support the occurrence of bottoming out, which to date has been limited to clinical observation and descriptive studies. We demonstrate that bottoming out occurs during the initial 18-month post-operative period and encompasses significant changes in volumetric distribution, surface topography and breast projection. This study also demonstrates, for the first time, that breast volume continues to decrease from the early to late postoperative period after RM. With the advent of 3D photography, it is now possible for plastic surgeons to perform an objective evaluation of breast transformation over time, which ultimately may help to better predict surgical outcomes.
Poster: Anatomical Variants Of The Distal Inferior Alveolar Nerve: Spatially Defining Nerve Course With 3D Computed Tomography
Linping Zhao, PhD, Plastic and Craniomaxillofacial Surgery, Shriners Hospitals for Children, Chicago, IL
Ivan Rakic, MD, The Craniofacial Center, University of Illinois Medical Center, Chicago, IL; Pravin K. Patel, MD, Plastic and Craniomaxillofacial Surgery, Shriners Hospital for Children, Chicago, IL; David E. Morris, MD, Plastic and Craniomaxillofacial Surgery, Shriners Hospital for Children, Chicago, IL
PURPOSE: Injury to the inferior alveolar nerve (IAN) is a
complication of both operative procedures and mandibular trauma. Numerous
studies have addressed the course of the IAN, however most have concentrated on
its posterior portion and were conducted on cadavers or on older patients. As
trauma and elective orthognathic procedures are common in young adults,
anatomical study of the anterior portion of the IAN in a younger population is
of practical value.
METHODS AND MATERIALS: 21 patients (15 to 21 years old)
underwent computed tomography (CT) of the skull and facial bones for reasons
other than mandibular pathology (42 hemi-mandibles). Images were reformatted
using Simplant/CMF software (Materialise, Leuven, Belgium) (Figure 1). Examination
focused on the coronal section marked by the largest diameter opening of the
mental foramen (MF). The three-dimensional course of the IAN was studied over
at least ten adjacent sections (Figure 2).
SUMMARY OF RESULTS: Three patterns (Types 1, 2, 3) in
course of the anterior portion of the IAN were observed (Figure 3). In all three
types the IAN descended while traveling anteriorly within the canal. Just proximal to the MF however its
course varied as follows: Type 1: after reaching its most inferior point, the
IAN curved superiorly at an acute angle to reach the MF, Type 2: the IAN
abruptly turned superiorly and coursed laterally before exiting the MF, Type 3:
the IAN reached its most inferior point anterior to the MF, turned superiorly
and laterally to reach the level of the MF, and then traveled posteriorly
before exiting the MF. The configuration was Type 1 in 62% of hemi-mandibles,
Type 2 in 9.5 %, and Type 3 in 28.5%. For each patient, the same configuration
was noted bilaterally.
CONCLUSIONS: Using CT and adequate software
support, demonstration of the 3D course of the IAN was relatively simple. The
course of the anterior portion of the IAN assumed one of three distinct
configurations prior to exiting the MF. Understanding these variations may be
of benefit in safely planning operative procedures in the anterior body of the
mandible.
ACKNOWLEDGEMENT: This study is supported by Shriners
Hospitals for Children (Grant #8510).
Figure 1
Figure 2
Figure 3
Poster: Reconstruction of Trochanteric Pressure Sores using Extended Double Folding Tensor Fascia Lata Flap
Ji Hoon Kim, MD, Plastic Surgery, Ewha Womans University, School of Medicine, Seoul, South Korea
Jin Sik Burm, MD, PhD, Plastic Surgery, Ewha Womans University, School of Medicine, Seoul, South Korea; So Ra Kang, MD, PhD, Plastic Surgery, Ewha Womans University, School of Medicine, Seoul, South Korea; Yang Woo Kim, MD, PhD, Plastic Surgery, Ewha Womans University, School of Medicine, Seoul, South Korea
Reconstruction of
Trochanteric Pressure Sores using Extended Double Folding Tensor Fascia Lata
Flap
Tensor fascia
lata (TFL) flap and its modifications are commonly used for trochanteric sore
coverage. TFL flap has a small volume of muscle on its proximal portion but is
just a thin fasciocutaneous flap on its distal
portion. If the TFL flap does not have a sufficient amount of soft tissue, the
pressure sore can recur because the covering flap will progressively atrophy.
The angiosome of the lateral femoral circumflex artery, which is the dominant
pedicle of TFL muscle and its fascia, is distributed up to several centimeters
above to the knee. Thus, the skin territory of the TFL flap could be safely
extended to the lateral condyle of the femur. Accordingly, we used an extended
double folding TFL flap in order to cover the sore with a large amount of soft
tissue.
We designed
the extended TFL flap in a V-shaped pattern (Fig.1). The anterior border of the
flap was marked by drawing a line from the anterior superior iliac spine to the
lateral condyle of the femur. The posterior border was marked from the center
of the greater trochanter to the lateral condyle of the femur. After
debridement of the sore, including ostectomy of the greater trochanter, a skin
incision was made along the anterior and posterior borders just above the
fascia lata in depth. The fascia lata was incised about 1 cm lateral to the
anterior or posterior border to widen the pedicle of the flap and to improve
the blood supply of the distal portion of the flap. The TFL flap was elevated
by undermining the subfascial plane. The entire
distal portion of the flap, except the proximal portion for covering the
defect, was de-epithelialized. The de-epithelialized distal tip was
tangentially removed until pin-point bleeding was shown on the bed of the flap
to ensure a rich blood supply. When the TFL flap was transposed into the
defect, the distal de-epithelialized portion was double folded to pad the
defect cavity. Finally, the trochanteric defect was covered with a thickness of
soft tissue comprising three layers of the flap. The dog-ear on the proximal
area of the flap was corrected by excising only the skin preserving the
subcutaneous tissue. The donor site was always closed primarily.
Eleven
trochanteric pressure sores of nine patients were reconstructed using this
method without any surgical complications. There were no recurrences during
follow-up (6-22 months). All flaps had a sufficient thickness of the soft
tissue over the previous greater trochanter, even as its bulkiness decreased
over time (Fig.2).
Thus,
the double folding TFL flap has sufficient soft tissue bulkiness and a reliable
blood supply. This method provides a good option for covering trochanteric
pressure sores.
Fig.1. Surgical procedure for extended double
folding Tensor Fascia Lata flap. (Above left) Flap
design in the V-shaped pattern. (Above right) Flap elevation after formation of
wide fascial pedicle and de-epithelialization
of the distal portion of the flap. (Below left) Covering the
defect with the three-layer structure made by double folding the flap. ( Below right) Postoperative view after
correcting the dog-ear deformity.
Fig. 2. Cases.
(Left) Preoperative view of trochanteric pressure sore in two
different patients (above and below). (Right) Postoperative
view. These flaps had a sufficient bulkiness even 8 months (above) and
22 months (below) after reconstruction.
Poster: The Impact of Postoperative Nausea and Vomiting on Patient Functioning After Major Plastic Surgery Procedures
Paul F. White, PhD, MD, Department of Anesthesiology & Pain Management, University of Texas Southwestern Medical Center, Dallas, TX
Michael B. Howie, MD, Anesthesiology, Ohio State University, Columbus, OH; Katja R. Turner, MD, Anesthesiology, Ohio State University Medical Center, Columbus, OH; Keith Candiotti, MD, Anesthesiology, University of Miami, Miami, FL; Jerome F. O'Hara, MD, Anesthesiology, Cleveland Clinic, Cleveland, OH; Rod J. Rohrich, MD, Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
PURPOSE: Despite widespread use of prophylactic antiemetics for preventing postoperative nausea and vomiting (PONV), many surgical patients undergoing general anesthesia still experience nausea and vomiting in the postanesthesia care unit, on the post-surgical ward, and at home after discharge.1,2 This study was designed to determine the incidence and time course of PONV symptoms, and the extent of interference with postoperative functioning in high risk patients undergoing elective surgical procedures.
METHODS: A prospective, multi-center, observational trial was conducted in patients undergoing elective surgical procedures. A subset of 63 patients undergoing major plastic surgery who had been screened for PONV risk factors3 were studied in a post hoc analysis. Female patients who had a history of PONV/motion sickness and/or were nonsmokers were eligible to participate in this study. The incidence and severity of nausea, number of episodes of vomiting, the need for rescue antiemetics, and interference with postoperative functioning due to PONV were documented at pre-determined intervals between 0 and 72 hours postoperatively using an interactive voice recording system. Complete response (CR), defined as no emesis and no use of rescue medications, and complete control (CC), defined as CR with no moderate-to-severe nausea, were evaluated. Interference with functioning, due to nausea and/or vomiting, was assessed using a 4-point Likert scale (1=not at all, 2=a little, 3=quite a bit, 4=very much) across 5 domains (i.e., appetite, sleep, physical activities, social life, enjoyment of life).
RESULTS: Despite the fact that prophylactic antiemetics were administered to 95% of these patients, the CR and CC rates were 51% and 46% during the 72 hour postoperative observation period. Forty-nine percent of the patients required a rescue antiemetic. Fourteen percent of patients vomited and 35% experienced moderate-to-severe nausea. Interference with patient functioning was reported as follows: appetite (56%), sleep (44%), physical activity (44%), social interactions (32%), and general ability to enjoy life (48%).
CONCLUSIONS: In these high-risk patients, PONV interfered with patient functioning for up to three days following major plastic surgery procedures despite the frequent use of multi-modal antiemetic therapy.REFERENCES: White PF. Prevention of postoperative nausea and vomiting: A multimodal solution to a persistent problem. N Engl J Med. 2004;350:2511-2512.Carroll NV, Miederhoff P, Cox FM, Hirsch JD. Postoperative nausea and vomiting after discharge from outpatient surgery centers. Anesth Analg.1995;80:903-909.Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology.1999;91:693-700.
Poster: Upregulation of leukocyte cell adhesion molecules in radiated tissues
Martin Halle, MD, Reconstructive Plastic Surgery, Karolinska Institute, Stockholm, Sweden
Filip Farnebo, MD, PhD, Reconstructive Plastic Surgery, Karolinska Institute, Stockholm, Sweden; Per Tornvall, MD, PhD, Cardiology, Karolinska Institute, Stockholm, Sweden
IntroductionSurgical wounds within previously irradiated tissues are subject to an increased incidence of postoperative complications including microvascular occlusion and impaired wound healing. The high radiation sensitivity of the vasculature has previously mainly been linked to endothelial dysfunction. However, the vascular biology behind the tissue damage is mot fully understood. In the present study, we have studied the gene expression of leukocyte adhesion molecules after irradiation.Material and MethodsRadiated cervical neck arteries were harvested during head and neck cancer resection in 13 preoperativelly radiated patients and analyzed together with 13 nonradiated controls. The age of the radiated patients ranged from 46 to 68 years with a mean of 56.9 years in 11 patients. In these patients, total preoperative dose of radiation averaged 60.4 Gy with a range of 50-68 Gy whereas the time elapsed from termination of radiotherapy to harvest of biopsy ranged from 4 to 500 weeks with a median of 6.5 weeks. Age, dose and time-point for radiation were unknown for two of the radiated patients. RT-PCR was used to investigate gene expression of leukocyte adhesion molecules. ResultsThe results obtained showed a significant upregulation of intercellular cell adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1) and E-selectin (SELE) in the radiated arteries compared to controls. There was an increase in upregulation between week 4 to 7, with a gradual decrease at later time points for both ICAM-1 and SELE, whereas a susitained high level was seen for VCAM-1. ConclusionWe conclude that there is a significant upregulation of ICAM-1, V-CAM and SELE in radiated tissues. It is known that the increased adhesion of leukocytes to endothelium can impair microcirculation and promote thrombosis. We therefor believe that the upregulation of adhesion molecules play an important role in the development of impaired vascular function and tissue damage in radiated tissues.