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Diabetes mellitus (DM) is a chronic disease that results in a variety of systemic complications. Recently, stem cell-based therapies have been proposed as potential modalities to manage DM related complications. Mesenchymal stem cell (MSC) based therapies are often considered as an ideal stem cell-based treatment for DM management due to their immunosuppressive characteristics, anti-inflammatory properties and differentiation potential. While MSCs show tremendous promise, the underlying functional deficits of MSCs in DM patients is not well understood. Using the MEDLINE database to define these functional deficits, our search yielded 1826 articles of which 33 met our inclusion criteria. This allowed us to review the topic and illuminate four major molecular categories by which MSCs are compromised in both Type 1 DM and Type II DM models which include: (1) changes in angiogenesis/vasculogenesis, (2) altered pro-inflammatory cytokine secretion, (3) increased oxidative stress markers and (4) impaired cellular differentiation and decreased proliferation. Knowledge of the deficits in MSC function will allow us to more clearly assess the efficacy of potential biologic therapies for reversing these dysfunctions when treating the complications of diabetic disease.

Rhinoplasty is a popular aesthetic and reconstructive surgical procedure. It is one of the top five surgical cosmetic procedures performed worldwide. To evaluate global trends in rhinoplasty research spanning 20 years between 1994 and 2013. The top 15 plastic surgery and otolaryngology journals containing rhinoplasty research were determined using impact factors (IF). A database of rhinoplasty articles from 1994 to 2013 was created to include the following classifications: IF, authors’ geographic location, study design, level of evidence (LOE), and pertinence to aesthetic or reconstructive rhinoplasty. Productivity index and productivity share were calculated for each region. A total of 1244 rhinoplasty articles were included in the database. The mean IF among the 15 journals increased from 0.75 in 1994 to 1.90 in 2013 (p

BackgroundTamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The pu

Since its introduction 20 years ago for the treatment of chronic wounds, negative pressure wound therapy use has expanded to a variety of other wound types. Various mechanisms of action for its efficacy in wound healing have been postulated, but no unifying theory exists. Proposed mechanisms include induction of perfusion changes, microdeformation, macrodeformation, exudate control and decreasing the bacterial load in the wound. We surmise that these different mechanisms have varying levels of dominance in each wound type. Specifically, negative pressure wound therapy is beneficial to acute open wounds because it induces perfusion changes and formation of granulation tissue. Post-surgical incisional wounds are positively affected by perfusion changes and exudate control. In the context of chronic wounds, negative pressure wound therapy removes harmful and corrosive substances within the wounds to affect healing. When skin grafts and dermal substitutes are used to close a wound, negative pressure wound therapy is effective in promoting granulation tissue formation, controlling exudate and decreasing the bacterial load in the wound. In this review, we elucidate some of the mechanisms behind the positive wound healing effects of negative pressure wound therapy, providing possible explanations for these effects in different wound types.

Scarring following burn injury and its accompanying aesthetic and functional sequelae still pose major challenges. Hypertrophic scarring (HTS) can greatly impact patients' quality of life related to appearance, pain, pruritus and even loss of function of the injured body region. The identification of molecular events occurring in the evolution of the burn scar has increased our knowledge; however, this information has not yet translated into effective treatment modalities. Although many of the pathophysiologic pathways that bring about exaggerated scarring have been identified, certain nuances in burn scar formation are starting to be recognized. These include the effects of neurogenic inflammation, mechanotransduction, and the unique interactions of burn wound fluid with fat tissue in the deeper dermal layers, all of which may influence scarring outcome. Tension on the healing scar, pruritus, and pain all induce signaling pathways that ultimately result in increased collagen formation and myofibroblast phenotypic changes. Exposure of the fat domes in the deep dermis is associated with increased HTS, possibly on the basis of altered interaction of adipose-derived stem cells and the deep burn exudate. These pathophysiologic patterns related to stem cell-cytokine interactions, mechanotransduction, and neurogenic inflammation can provide new avenues of exploration for possible therapeutic interventions.

Introduction: The innovation of fenestrated allograft (acellular dermal matrix, ADM) has improved patient outcomes in two-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap and has enhanced the efficiency of the reconstructive experience. We present a follow-up study of one- and two-stage breast reconstruction with a more refined, standardized method of surgeon-designed fenestration of ADM. Methods: We conducted a retrospective review of 52 patients (91 breasts) having undergone one- and two-stage breast reconstruction using fenestrated ADM at our institution from 2013 to 2014. Results: Mean intra-operative fill volume (IOFV) measured 402cc (SD=118cc), and IOFV as a percent of tissue expander size averaged 79.1% (SD=16.7%). Ten breasts were expanded to 100% and completed reconstruction in one stage with implant placement. IOFV as a percentage of total fill volume at completion of expansion averaged 73.6% (SD=16.6%). Two-stage reconstruction patients underwent 1.8 post-operative expansions on average (range 0-4) and averaged 81.2cc (SD=29.3cc) per in-office expansion. Days to full expansion averaged 45.1 days, while days to exchange averaged 137.8 days (Table 1). Mean days to exchange between our first 24 breasts to complete reconstruction vs. our last 23 breasts to complete reconstruction differed significantly, with 205 ± 43.8 days vs. 137.7 ± 138.1 days, respectively (p=0.03). Table 1. Fill volume characteristics for 91 breasts after immediate reconstruction with fenestrated ADM. Data on tissue expander size was excluded.CharacteristicMinimumMaximumMeanSDTE size300700512.6108.3Intra-op fill (cc)150650402.1118Intra-op/TE size (%)44.1108.379.116.7Total fill (cc)31082537.6120.3Intra-op/Total fill (%)34.110073.616.6Total fill/TE size (%)76.9141.310813.2# of post-op expansions041.81.1Office fill per expansion (cc)31.322581.229.3Days to full expansion020445.141.8Days to exchange0554142117.9Implant size (cc)335800547.3126.9 The major complication rate requiring re-operation within 30 days post-operatively was 11.0%. Four breasts experienced partial mastectomy flap necrosis requiring re-operation with implant salvage (4.4%). Six breasts (6.6%) underwent explantation due to: infection (three), flap necrosis (two), and patient preference (one) (Table 2). Table 2. Complication rates in 91 breasts after immediate reconstruction with fenestrated ADM.Complicationsn%Minor 30-day complication22.2Major 30-day complication1011.030-Day take back for necrosis with salvage44.430-Day explant66.6Explant due to infection33.2Explant due to necrosis22.2Explant due to patient preference11.1Total 30-day complication1213.2 Conclusion: Our fenestrated technique is demonstrated to increase intra-operative fill volume, decrease number of post-operative expansions and time to full expansion, and improve expansion rate with subjectively less pain. We believe our patients benefited from improved cosmetic outcomes with better shape, maintenance of breast footprint, and enhanced comfort due to the decreased number of intra-office fills and increased intra-operative expansion. Citation Format: Daar DA, Bourgeois JM, Mowlds DS, Wirth GA, Paydar KZ. Acellular dermal allograft fenestrations decrease outpatient expander fills and increase direct to implant incidence in implant-based immediate breast reconstruction. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-13-06.

Adipose tissue is a rich source of cells with emerging promise for tissue engineering and regenerative medicine. The stromal vascular fraction (SVF), in particular, is an eclectic composite of cells with progenitor activity that includes preadipocytes, mesenchymal stem cells, pericytes, endothelial cells, and macrophages. SVF has enormous potential for therapeutic application and is being investigated for multiple clinical indications including lipotransfer, diabetes-related complications, nerve regeneration, burn wounds and numerous others. In Part 2 of our review, we explore the basic science behind the regenerative success of the SVF and discuss significant mechanisms that are at play. The existing literature suggests that angiogenesis, immunomodulation, differentiation, and extracellular matrix secretion are the main avenues through which regeneration and healing is achieved by the stromal vascular fraction.

Stromal Vascular Fraction (SVF) is a heterogeneous collection of cells contained within adipose tissue that is traditionally isolated using enzymes such as collagenase. With the removal of adipose cells, connective tissue and blood from lipoaspirate, comes the SVF, a mix including mesenchymal stem cells, endothelial precursor cells, T regulatory cells, macrophages, smooth muscle cells, pericytes and preadipocytes. In part 1 of our 2-part series, we review the literature with regards to the intensifying interest that has shifted toward this mixture of cells, particularly due to its component synergy and translational potential. Trials assessing the regenerative potential of cultured Adipose Derived Stem Cells (ADSCs) and SVF demonstrate that SVF is comparably effective in treating conditions ranging from radiation injuries, burn wounds and diabetes, amongst others. Aside from their use in chronic conditions, SVF enrichment of fat grafts has proven a major advance in maintaining fat graft volume and viability. Many SVF studies are currently in preclinical phases or are moving to human trials. Overall, regenerative cell therapy based on SVF is at an early investigative stage but its potential for clinical application is enormous.

BACKGROUND Poly-trauma patients often sustain complex head/neck injuries requiring prolonged hospitalizations and multiple operations. Few studies have evaluated the associated injury patterns and risk factors for poor clinical outcomes. METHODS Consecutive poly-trauma patients with operative maxillofacial fractures treated at a level 1 trauma medical center between 1995 and 2013 were evaluated. Concomitant head/neck injuries to identify potential injury patterns were numerated. Lastly, a multivariate analysis was performed to determine independent risk factors for complications during the acute hospitalization period. RESULTS Totally, 232 poly-trauma patients presented with operative maxillofacial fractures, while 38.8% of patients had a secondary maxillofacial fracture, 16.4% had intracranial hemorrhage, 23.7% had skull fractures, and 12.1% had spinal fractures. The rate of complication during admission was 28.3%. Multivariate analysis revealed advanced patient age and increased number of operations to predict the rate of complication. Patients requiring more than one operation had a 1.8-fold increase in complication rate (p

Acellular dermal matrices have been proposed to decrease the incidence of capsular contracture in implant-based breast reconstructions. The authors have modified acellular dermal matrices with fenestrations to facilitate greater lower pole expansion and improve contour. The effect of fenestrations on the ability of matrices to suppress capsule formation, however, has not been examined.A retrospective review of all fenestrated acellular dermal matrix-assisted, implant-based breast reconstructions performed by the two senior authors, with a minimum of 1-year follow-up after permanent implant placement, was completed. Patient demographics, details of extirpative and reconstructive procedures, and complications were examined. Capsular contractures were scored according to the Baker grading scale and compared to those reported in the literature.Thirty patients (50 breasts) underwent fenestrated acellular dermal matrix-assisted reconstruction, with mean follow-up times of 3.3 and 2.6 years after expander placement and implant exchange, respectively. Seven patients (23 percent) had a body mass index greater than 30 kg/m, three (10 percent) were active smokers, and six breasts (12 percent) were irradiated. Complications included one infection (2 percent), six cases (12 percent) of incisional superficial skin necrosis, and one (2 percent) tissue expander extrusion. Zero breasts had clinically significant Baker grade III/IV capsular contracture. The average Baker grade was 1.1.Fenestrated acellular dermal matrices decrease capsular contracture to rates similar to what is seen with nonfenestrated matrices. Further research is necessary to determine whether this observation is a result of decreased need for inferolateral acellular dermal matrix coverage to achieve these effects or modified physical interaction of acellular dermal matrices with surrounding soft tissues.Therapeutic, IV.

Acellular dermal matrices (ADMs) are increasingly being utilized in primary and secondary breast reconstruction as they confer several advantages, including soft tissue enhancement at the inferolateral pole of the breast. The senior authors have added fenestrations to ADMs to allow for more rapid expansion and improved breast aesthetics. The purpose of this study is to describe the benefits of ADM fenestration using a mathematical formula as a proof of concept for the effects of these modifications on breast shape. The aggregate effect of symmetrically arranged fenestrations on the ADM’s mechanical properties is explained by a uniform reduction in the effective Young’s modulus of the graft in a direction perpendicular to the chest wall in the area of graft fenestration. Asymmetric reduction of the Young’s modulus is achieved by concentration of the fenestrations at either the cephalic or caudal ends of the ADM. The relaxed Young’s modulus facilitates an increased deflection of the ADM from its resting, unaltered state under the weight of the implant or tissue expander and is modeled using a one-dimensional boundary equation. The reduced inferior pole tension allows for enhanced expansion under the weight of the implant or tissue expander. The effects of asymmetrically arranged fenestrations are similarly modeled and appear to afford the surgeon greater precision in controlling inferior pole characteristics. Acellular dermal matrix fenestration improves aesthetic outcome by facilitating greater inferior pole expansion. Mathematical models are provided to describe the modifications and elucidate the mechanism behind their effect on breast shape. Level of Evidence: Not ratable

BACKGROUND There are limited data regarding blood transfusion following abdominoplasty, especially in post-bariatric surgery patients. The purpose of this study was to evaluate (1) the frequency and outcomes of blood transfusion in post-bariatric surgery patients undergoing abdominoplasty and (2) the predictive risk factors of blood transfusion in this patient population. METHODS Using the Nationwide Inpatient Sample database, the authors examined the clinical data of patients with a history of bariatric surgery who underwent abdominoplasty from 2007 to 2011 in the United States. RESULTS A total of 20,130 post-bariatric surgery patients underwent abdominoplasty during this period. Overall, 1871 patients (9.3 percent) received blood transfusion. Chronic anemia patients had the highest rate of blood transfusion (25.6 percent). Post-bariatric surgery patients who received blood transfusion experienced a significantly higher complication rate (10.1 percent versus 4.8 percent; p < 0.01), longer mean hospital stay (4.0 days versus 2.4 days; p < 0.01), and higher mean total hospital charges ($49,116 versus $33,927; p < 0.01). Multivariate regression analysis showed that deficiency anemia (adjusted OR, 3.8), congestive heart failure (adjusted OR, 2.4), concurrent breast reduction (adjusted OR, 1.5), diabetes mellitus (adjusted OR, 1.4), coronary artery disease (adjusted OR, 1.4), African American race (adjusted OR, 1.4), Hispanic race (adjusted OR, 1.4), and female sex (adjusted OR, 1.3) were all independent risk factors for blood transfusion. CONCLUSIONS The blood transfusion rate in post-bariatric surgery abdominoplasty patients is not insignificant. Chronic anemia and congestive heart failure are the two major predictors of transfusion. Modifying risk factors such as anemia before abdominoplasty might significantly decrease the possibility of blood transfusion. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.

Although lipotransfer, or fat grafting, is a commonly used procedure in aesthetic and reconstructive surgery, there is still variability in graft survival and neoadipogenesis from one procedure to the next. A better understanding of the sequential molecular events occurring with grafting would allow us to strategize methods to improve the regenerative potency of the grafted tissue. These steps begin with an autophagic process, followed by the inclusion of stromal vascular fraction and matrix components. By tailoring and modifying each of these steps for a particular type of aesthetic or reconstructive procedure, strategic sequencing represents a dynamic approach to lipotransfer with the aim of maximizing adipocyte viability and growth. In the implementation of the strategic sequence, it remains important to consider the clinical viability of each step and its compliance with the US Food and Drug Administration regulations. This review highlights the basic science behind clinically translatable approaches to supplementing various fat grafting procedures.

The objectives of this study were to evaluate 1) the rate of immediate breast reconstruction; 2) the frequency of immediate tissue expander placement; and 3) to compare perioperative outcomes in patients who underwent breast reconstruction after mastectomy for breast cancer with immediate tissue expander placement (TE) with those with no reconstruction (NR). Using the Nationwide Inpatient Sample database, we examined the clinical data of patients with breast cancer who underwent mastectomy with or without immediate TE from 2006 to 2010 in the United States. A total of 344,253 patients with breast cancer underwent mastectomy in this period in the United States. Of these patients, 31 per cent had immediate breast reconstruction. We only included patients with mastectomy and no reconstruction (NR: 237,825 patients) and patients who underwent only TE placement with no other reconstruction combination (TE: 61,178 patients) to this study. Patients in the TE group had a lower overall postoperative complication rate (2.6 vs 5.5%; P < 0.01) and lower in-hospital mortality rate (0.01 vs 0.09%; P < 0.01) compared with the NR group. Fifty-three per cent of patients in the NR group were discharged the day of surgery compared with 36 per cent of patients in the TE group. Using multivariate regression analyses and adjusting patient characteristics and comorbidities, patients in the TE group had a significantly lower overall complication rate (adjusted odds ratio [AOR], 0.6) and lower in-hospital mortality (AOR, 0.2) compared with the NR group. The rate of immediate reconstruction is 31 per cent. TE alone is the most common type of immediate reconstruction (57%). There is a lower complication rate for the patients who underwent immediate TE versus the no-reconstruction cohort.

Treatment of hypertrophic scars and other fibrotic skin conditions with autologous fat injections shows promising clinical results; however, the underlying mechanisms of its antifibrotic action have not been comprehensively studied. Adipose-derived stem cells, or stromal cell-derived factors, inherent components of the transplanted fat tissue, seem to be responsible for its therapeutic effects on difficult scars. The mechanisms by which this therapeutic effect takes place are diverse and are mostly mediated by paracrine signaling, which switches on various antifibrotic molecular pathways, modulates the activity of the central profibrotic transforming growth factor β/Smad pathway, and normalizes functioning of fibroblasts and keratinocytes in the recipient site. Direct cell-to-cell communications and differentiation of cell types may also play a positive role in scar treatment, even though they have not been extensively studied in this context. A more thorough understanding of the fat tissue antifibrotic mechanisms of action will turn this treatment from an anecdotal remedy to a more controlled, timely administered technology.

BACKGROUND The aims of this study were (1) to evaluate the frequency of various reconstructive techniques for autologous breast reconstruction and (2) to compare perioperative outcomes of autologous breast reconstruction in teaching versus nonteaching hospitals. MATERIALS The authors analyzed clinical data of patients who underwent autologous breast reconstructive surgery from 2009 to 2010 using the Nationwide Inpatient Sample database. Autologous breast reconstruction operations included latissimus dorsi myocutaneous, pedicled transverse rectus abdominis myocutaneous (TRAM), free TRAM, free deep inferior epigastric artery perforator (DIEP), free superficial inferior epigastric artery, and free gluteal artery perforator flaps. RESULTS A total of 35,883 patients underwent autologous breast reconstructive surgery in that period. Most reconstructions were performed in teaching hospitals (74 percent). The two most common breast reconstruction types in teaching hospitals were latissimus dorsi myocutaneous (26 percent) and DIEP flaps (26 percent), compared with latissimus dorsi myocutaneous (39 percent) and pedicled TRAM flaps (22 percent) in nonteaching hospitals. In addition, the rate of free flap breast reconstruction was significantly higher in teaching hospitals (46 percent) compared with nonteaching hospitals (31 percent) (p < 0.01). There was no statistically significant difference for total in-hospital complication rate (teaching, 6.9 percent; nonteaching, 7.1 percent; p = 0.54) or total in-hospital mortality rate (teaching, 0.04 percent; nonteaching, 0.05 percent; p = 0.56). CONCLUSIONS Three-fourths of autologous breast reconstructions performed from 2009 to 2010 were performed in teaching hospitals, with free flaps also more likely to be performed in teaching hospitals. Despite more complex free flap breast reconstructions being performed in teaching hospitals, there was no statistically significant difference in perioperative outcomes (morbidity and mortality) between teaching and nonteaching hospitals. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, III.

Vascular thrombosis is one of the major postoperative complications of free flap microvascular breast reconstruction operations. It is associated with higher morbidity, higher cost, increased length of hospital stay, and potentially flap loss. Our purpose is to evaluate the rate of this complication and whether patient characteristics play a role. Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent free flap breast reconstruction between 2009 and 2010 in the United States. Multivariate and univariate regression analyses were performed to identify independent risk factors of flap thrombosis. A total of 15,211 patients underwent free flap breast reconstruction surgery (immediate reconstruction: 43%). The most common flap was the free deep inferior epigastric perforator (DIEP) flap (53.6%), followed by free transverse rectus abdominis myocutaneous (TRAM) flap (43.1%), free superficial inferior epigastric artery (SIEA) flap (2%), and free gluteal artery perforator (GAP) flap (1.3%). The overall rate of flap thrombosis was 2.4 %, with the highest rate seen in the SIEA group (11.4%) and the lowest in the TRAM group (1.7%). Peripheral vascular disease (adjusted odds ration [AOR] 10.61), SIEA flap (AOR, 4.76) and delayed reconstruction (AOR, 1.42) were found to be statistically significant risk factors for flap thrombosis. Other comorbidities were not linked. While the overall rate of flap thrombosis in free flap breast reconstruction was relatively low (2.4%), Plastic Surgeons should be aware that patients with peripheral vascular disease and those undergoing free SIEA flap are at higher risk of flap thrombosis and they should closely monitor flaps to increase the chance for early salvage.

BACKGROUND Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. METHODS Using the Nationwide Inpatient Sample (NIS) database, we examined the clinical data of patients who underwent autologous breast reconstructive surgery in 2009 to 2010 in the United States. Univariate and multivariate regression analyses were performed to identify factors predictive of in-hospital VTE. RESULTS A total of 35,883 patients underwent autologous breast reconstructive surgery during this period. Overall rate of VTE was 0.13%. The highest rate of VTE (0.26%) was observed in pedicled transverse rectus abdominis myocutaneous flap. Patients who experienced VTE had significantly longer mean hospital stay (11.6 vs 3.9 days; P < 0.001) and higher mean total hospital charges ($146,432 vs $61,794; P < 0.001) compared with non-VTE patients; however, there was no significant difference observed in mortality rate (VTE, 0.0% vs non-VTE, 0.04%; P = 0.886). Using multivariate regression analysis, immediate reconstruction after mastectomy (adjusted odds ratio [AOR], 5.4), older than 65 years (AOR, 4.2), obesity (AOR, 3.7), history of chemotherapy (AOR, 3.5), and chronic lung disease (AOR, 2.5) were associated with higher risk of VTE. There was no association between race, payer type, diabetes, hypertension, liver disease, congestive heart failure, peripheral vascular disease, chronic kidney disease, smoking, reconstruction type, radiation, or teaching status of hospital on VTE. CONCLUSIONS In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.

PURPOSE Although most patients with implants have an uneventful course, some will require explantation. Moreover, women's breasts and their perception of their body habitus change with time. This study covering greater than a 32-year period will address the reconstruction options available after breast implant explantation. METHODS Augmentation mammoplasty was performed on 42 patients who subsequently underwent explantation. The following data were recorded: age at time of implantation and explantation, length of implant, type, reason for explantation, and decision after explantation. Recommendations were made based on patient preferences, degree of ptosis, clinical history, opinions regarding scars, and breast contour. Reconstruction options were categorized into none, mastopexy, capsulectomy and reaugmentation with saline implants, and mastopexy with immediate or delayed augmentation. RESULTS The average age of patients at implantation was 32.3 years, 46.8 years at explantation, with a length of implantation of 14.4 years. Thirty-six (86%) of 42 patients received explantation for capsular contracture, 7 (17%) for negative publicity of silicone implants, 7 (17%) for change in body habitus and perception of implants, 6 (14%) for rupture, 5 (12%) for ptosis, and 1 (2.4%) each for synmastia, breast cancer, and painful implants. Sixteen (38%) patients underwent mastopexy after explantation, 15 (36%) underwent no reconstruction after explantation, 6 (14%) with mastopexy and reaugmentation (2 immediate and 4 delayed), 4 (9.5%) with implant exchange, and 1 (2.4%) with mastectomy and reconstruction. All patients demonstrated satisfactory to excellent results. CONCLUSIONS This study provides long-term results of augmentation mammoplasty by a single surgeon (G.P.G.) evaluating available options and reasonable expectations after explantation. Although most of the augmentation patients have a good outcome, some require removal of implants for a variety of reasons and long-term satisfactory options do exist after explantation.

Background Venous thromboembolic events result in significant morbidity, mortality, and costly therapeutic interventions. As medical resource allocation strategies are becoming more pervasive, appropriate risk stratification and prophylactic regimens are essential. Previous studies have shown a decreased incidence of perioperative venous thromboembolism in the chronic spinal cord injury population. The question remains of whether chronic spinal cord injury is protective against venous thromboembolism. Methods A retrospective review of all cases involving chronic spinal cord injury patients who underwent plastic and reconstructive surgery operations (n = 424) and general surgery patients (n = 777) with a primary outcome of deep venous thrombosis or pulmonary embolism within 90 days of surgery was performed. Results The incidence of postoperative deep venous thrombosis in the control and spinal cord injury groups was 1.7 percent and 0.2 percent, respectively (p = 0.027). However, such significance was not observed with regard to postoperative pulmonary embolism incidence (p = 0.070). Collectively, the incidence of postoperative venous thromboembolism-specifically, deep venous thrombosis or pulmonary embolism-was significantly greater in the general surgery population (p = 0.014). A nearly 10-fold increased risk of venous thromboembolism was seen among the control group (1.9 percent versus 0.2 percent) despite administration of optimal prophylaxis. Conclusions This study demonstrates a profoundly low incidence of venous thromboembolism among chronic spinal cord injury patients compared with general surgery patients. Future efforts to elucidate how chronic spinal cord injury confers a protective mechanism may potentially influence the evolution of venous thromboembolism prevention guidelines, and spark the development of alternative prophylactic agents or customized application of prevention efforts.

The last decade has ushered in a rapidly expanding global discussion regarding acellular dermal matrix (ADM) applications, economic analyses, technical considerations, benefits, and risks, with recent emphasis on ADM use in breast surgery. This study aims to evaluate global trends in ADM research using bibliometric analysis. The top nine Plastic Surgery journals were determined by impact factor (IF). Each issue of the nine journals between 1999 and 2013 was accessed to compile a database of articles discussing ADM. Publications were further classified by IF, authors’ geographic location, study design, and level of evidence (LOE, I-V). Productivity index and productivity share were calculated for each region. In total, 256 ADM articles were accessed. The annual global publication volume increased significantly by 4.2 (0.87) articles per year (p

Background: Optimization of fat grafting continues to gain increasing attention in the field of regenerative medicine. “Nanofat grafting” implements mechanical emulsification and injection of standard lipoaspirate for the correction of superficial rhytides and skin discoloration; however, little is known about the cellular constituents of the graft. Based on recent evidence that various stressors can induce progenitor activity, the authors hypothesized that the shear forces used in common fat grafting techniques may impact their regenerative capacities. Methods: Lipoaspirates were obtained from 10 patients undergoing elective procedures. Half of each sample was subjected to nanofat processing; the other half was left unchallenged. The viscosity of each sample was measured for computational analysis. The stromal vascular fraction of each sample was isolated, quantified, and analyzed by means of flow cytometry with two multicolor fluorescence antibody panels. Results: Standard lipoaspirate is ideally suited for mechanical stress induction. The mechanical emulsification involved in nanofat processing did not affect cell number; however, viability was greatly reduced when compared with the stromal vascular fraction of standard lipoaspirate. Interestingly, nanofat processing resulted in stress-induced stromal vascular fraction with a higher proportion of endothelial progenitor cells, mesenchymal stem cells, and multilineage differentiating stress-enduring cells. Single-parameter analysis also revealed significant increases in CD34, CD13, CD73, and CD146 of the stress-induced stromal vascular fraction, markers associated with mesenchymal stem cell activity. Conclusions: Mechanical processing used in techniques such as nanofat grafting induces the up-regulation of progenitor phenotypes consistent with multipotency and pluripotency. These data provide a first step in characterizing the potential regenerative benefits realized through stress induction in fat grafting. CLINCAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Background The purpose of this study was to investigate the incidence of postoperative venous thromboembolism in chronic spinal cord injury patients undergoing plastic and reconstructive surgery. Previous studies show a venous thromboembolism incidence of 9.3 percent; however, based on anecdotal evidence, the authors hypothesize that the incidence is actually much lower. As postoperative venous thromboembolism prophylaxis is becoming mandated by the Surgical Care Improvement Project, more data are necessary so that recommendations for chronic spinal cord injury patients can be given. Methods A retrospective chart review was undertaken using electronic medical records from a Veterans Affairs hospital from 2004 through 2009 in which the perioperative course of the chronic spinal cord injury cohort was evaluated for the primary endpoint of venous thromboembolism evolution. The Pearson correlation was used for statistical analysis. Results Of the 415 operative cases evaluated, 155 cases were excluded secondary to operative time under 1 hour, use of mechanical or chemical venous thromboembolism prophylaxis, unknown operative time, or unknown prophylaxis use. Of the 260 cases evaluated without venous thromboembolism prophylaxis, there were no cases where venous thromboembolism developed within a 2-month postoperative time period. Conclusions Postoperative venous thromboembolism is a common surgical complication with significant morbidity and mortality. This study demonstrates that in the chronic spinal cord injury patient cohort, the incidence of postoperative venous thromboembolism evolution is extremely low and that a benefit from perioperative mechanical or chemical prophylaxis is not evidence based. Further prospective studies are required to fully elucidate the true venous thromboembolism incidence in these patients and give recommendations on this issue. Clinical question/level of evidence Therapeutic, IV.

Supplemental Digital Content is available in the text., Summary: Fenestrated acellular dermal matrix (ADM) has improved patient outcomes in both direct-to-implant and 2-stage tissue expander/implant breast reconstruction. This technical alteration utilizes optimal fenestration overlap to enhance the breast reconstruction experience. We present a novel, surgeon-designed shaped fenestrated ADM, placed in the recently repopularized prepectoral pocket for anterior coverage of implants in direct-to-implant and 2-stage breast reconstruction. A retrospective review of 10 patients (18 breasts) who underwent direct-to-implant or 2-stage breast reconstruction utilizing fenestrated shaped ADM in the prepectoral plane at a major academic institution in 2016 was conducted. Sixteen breasts (88.9%) underwent direct-to-implant reconstruction, and 2 breasts (11.1%) received tissue expanders. All reconstructions were performed using FlexHD Pliable ADM with surgeon-designed shape and fenestrations. The average implant size was 544.4 cc (±137.2 cc). The average intraoperative tissue expander fill volume measured 450 cc (90% of tissue expander size). The single expander case utilized 1 office fill (day 21) for full expansion. Major complications requiring reoperation within 90 days postoperatively were observed in 22.2% (4 breasts) of reconstructions. Three breasts (16.7%) due to partial mastectomy flap necrosis, 1 breast (5.5%) explantation due to infection. There was no seroma or capsular contracture. Prepectoral reconstruction with shaped fenestrated ADM is safe with high intraoperative fill volumes and facilitates more direct-to-implant reconstructions. Patients undergo fewer postoperative expansions, experience less time to full expansion, and subjectively report less pain. Patients benefit from improved cosmetic outcomes with better shape and no functional loss or animation deformity.

Free flap success depends on rapid identification and subsequent salvage of failing flaps. Conventional free flap monitoring techniques require an external component, whereas an implantable monitor readily indicates changes in free flap perfusion, especially in buried flaps used in head and neck reconstruction.This is a retrospective review of 169 consecutive head and neck free flaps reconstructed mostly for oncologic surgical defects in 155 patients from April of 2000 to December of 2006, all of which were monitored by an implantable venous Doppler device.There were 25 buried flaps, representing 14.8 percent of 169 flaps. Flap ischemia caused by thrombosis (n = 16), hematoma (n = 2), or tight closure (n = 1) occurred in 11.2 percent of the cases. The Doppler probe detected all of the failing free flaps, and we were able to salvage 18 of 19 ischemic flaps (94.7 percent). All Doppler-detected ischemic nonburied flaps (100 percent) and three of the four buried free flaps were salvaged (75 percent). There were 33 total complications (19.5 percent), with thrombosis occurring in 9.5 percent of the flaps, whereas 12 flaps required reoperation for vascular revision (7.1 percent). The mortality rate was less than 1 percent (0.6 percent). The overall success rate using the implantable Doppler probe was 98.2 percent, which was similar to that of the most recent reported cases of all free flaps in the literature, with significant improvement in the salvage rate for both buried and nonburied head and neck free flaps.The implantable Doppler probe is a useful monitoring device in buried free flaps and should be considered for use in head and neck reconstruction.

Impaired wound healing in diabetic patients is associated with deficiencies in the production of factors involved in cell proliferation and migration, such as vascular endothelial growth factor. However, it remains unclear how the transcriptional regulation of the genes encoding these factors is affected by the diabetic environment. Hypoxia-inducible factor-1alpha (Hif-1alpha), the regulatory subunit of the Hif-1 transcription factor, plays an important role in activating many of these genes. Therefore, we tested whether Hif-1alpha function is impaired in the diabetic wound environment and whether restoring Hif-1 function improves wound healing. Here, we show that Hif-1alpha protein levels are dramatically reduced in wounds of leptin receptor-deficient diabetic mice compared with nondiabetic littermates. Reduction in Hif-1alpha levels results in decreased DNA-binding activity and in decreased expression of several Hif-1 target genes, including vascular endothelial growth factor, heme oxygenase-1, and inducible nitric oxide synthase. Furthermore, we demonstrate that sustained expression of Hif-1alpha in leptin receptor-deficient diabetic wounds restores expression of these factors, enhances angiogenesis, and significantly accelerates wound healing. Taken together, these results suggest that Hif-1alpha function plays a significant role in wound healing and reduced levels of Hif-1alpha may contribute to impaired healing.

Background The use of nerve conduits to facilitate nerve regrowth after peripheral nerve injury is limited to defects less than 3 cm. The purpose of this study is to determine the capability of novel single and multi-lumen poly(ethylene glycol) (PEG) conduits manufactured by stereolithography to promote peripheral nerve regeneration. Materials and Methods Eight Sprague Dawley rats with sharp transection injuries of the sciatic nerve were randomly assigned to receive single-lumen or multi-lumen PEG conduits to bridge a 10-mm gap. Sciatic nerve and conduit samples were harvested after 5 weeks, and axon number, myelin thickness, fiber diameter, and g-ratio were analyzed. The contralateral intact nerve was also harvested for comparison. Results Partial nerve regeneration was observed in three out of four single-lumen conduits and one out of four multi-lumen conduits. Axon number in the single-lumen regenerated nerve approached that of the contralateral intact nerve at 4,492 ± 2,810.0 and 6,080 ± 627.9 fibers/mm2, respectively. The percentage of small fibers was greater in the single-lumen conduit compared with the intact nerve, whereas myelin thickness and g-ratio were consistently greater in the autologous nerve. Axon regrowth through the multi-lumen conduits was severely limited. Conclusion Single-lumen stereolithography-manufactured PEG nerve conduits promote nerve regeneration, with regenerating axon numbers approaching that of normal nerve. Multi-lumen conduits demonstrated significantly less nerve regeneration, possibly due to physical properties of the conduit inhibiting growth. Further studies are necessary to compare the efficacy of the two conduits for functional recovery and to elucidate the reasons underlying their differences in nerve regeneration potential.

The authors present a new technique of alteration of the acellular dermal matrix through strategically placed fenestrations, improving the reconstructive experience and overall cosmetic outcome. The authors present a retrospective chart review following two surgeons' experience at the University of California, Irvine, Department of Plastic Surgery using surgeon-designed fenestrated acellular dermal matrices in two-stage tissue expander breast reconstruction. The authors found that this leads to improved intraoperative fill volume, decreased number of postoperative expansions, increased expansion rate with subjectively less pain, decreased time to full expansion, and subjectively improved cosmetic outcome.Therapeutic, III.

Background: Breast reconstruction often requires multiple surgeries, which demands additional expense and time and is often contrary to the patient’s expectation. The aim of this study was to review the number of operations that were needed for completion of breast reconstruction and to determine patient and clinical factors that influenced this number. Methods: We retrospectively reviewed the medical records of 254 cases of breast reconstructions (in 185 patients) that were performed between February 2005 and August 2009. We investigated the numbers of operations that were performed for individual case of breast reconstruction and analyzed the influence of variable factors. The purpose of the additional operations was also analyzed. Results: The mean number of operations per breast was 2.37 (range, 1–9). The mean number of operations for mound creation was 2.24. Factors associated with an increased number of operation were use of an implant, contralateral symmetrization, complications, and nipple reconstruction. Considering the reconstruction method, either the use of a primary implant or the use of free abdominal tissue transfer demonstrated fewer surgeries than the use of an expander implant, and the number of operations using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps was less than the number of operations using pedicled transverse rectus abdominis musculocutaneous flaps. Conclusions: These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.

Aim: Reconstruction of the anterior skull base offers an especially complex challenge as the impermeable separation of the dural space and the upper aerodigestive tract must be maintained. We propose the use of the radial forearm free flaps (RFFF) as a superb method of re-establishing integrity in anterior skull base defects. Methods: Literature review and retrospective analysis of 4 single-institution cases of anterior skull base defects reconstructed with a RFFF. Data were collected on successful and unsuccessful defect repairs, complication rates, and length of hospitalization. Results: The indications for surgery were pneumocephalus, recurrent brain abscesses, recurrent frontal sinus mucoceles, and cerebrospinal fluid leak. Of the 4 cases, 1 was complicated by a small dehiscence of the craniotomy site, 1 developed infection, and 2 required further surgery. Conclusion: The use of RFFF is an excellent option for reconstruction of defects in the anterior skull base, especially those complicated by radiation, prior surgery, or infections. Patients with skull base defects are inherently at high risk for post-surgical complications. The RFFF transfers healthy, viable, well-vascularized tissue to prevent further infections and provides a reliable barrier between the dural and sinonasal spaces. This can reduce the need for repeat neurosurgical operations and hospitalizations.

Peripheral nerve injuries are a serious health concern and leave many patients with lifelong disabilities. There is little information about incidences, current practice, outcomes, and type of research that may help delineate new strategies. A questionnaire was designed to determine characteristics of peripheral nerve injuries and the need for alternative strategies and sent to 889 plastic, hand, trauma, and orthopedic surgeons in 49 countries; 324 completed surveys were collected and analyzed (total response rate of 36.45%). The majority of institutions treat more than 3000 patients annually. Trauma was the leading cause of injury with the majority located on the upper extremity. In most cases, a primary repair was achieved, but 2.52% were unrepairable. The overall outcome was linked to their Sunderland classification (SCL). A grade 1 nerve injury (SCL-1) reached a maximum outcome after 7.15 months. SCL-2, -3, -4, and -5 needed 10.69, 14.08, 17.66, and 19.03 months, respectively. Tissue engineering was considered the most important research field, resulting in a visual analogue scale of 8.6. Despite marked advances in the treatment of peripheral nerve injuries, clinical outcomes still appear unsatisfactory. The importance of research in the field of tissue engineering should be emphasized as a pathway toward improving these outcomes.

Hypothesis Many soft tissue infections treated with surgical drainage resolve even when treated with antibiotics not active against the organism isolated from the infection. Design Retrospective. Setting Integrated Soft Tissue Infection Services clinic. Patients All patients treated from July 19, 2000, to August 1, 2001, who underwent surgical drainage of a soft tissue infection and had microbiological culture results. Main Outcome Measures Documented resolution of the infection with drainage of the abscess and antibiotic therapy alone was deemed a cure. An infection resulting in death or other surgical therapy was deemed a failure. Therapy was appropriate when the organism was sensitive to prescribed antibiotics and was inappropriate when the organism was insensitive. Results The study included 376 patients with 450 infections. Staphylococcus aureus as the primary organism was isolated from 441 of the cultures. Methicillin sodium–sensitive S aureus and methicillin-resistant S aureus were found in 157 and 284 of these isolates, respectively. Appropriate antibiotics were prescribed in 153 infections with methicillin-sensitive S aureus and in 25 with methicillin-resistant S aureus . Of 441 episodes, 408 were clinically evaluated for cure. Three patients failed treatment, 2 in the appropriately treated group (resulting in death and amputation) and 1 patient with osteomyelitis in the inappropriately treated group. The cure rate for infections treated appropriately or inappropriately was the same. Conclusions Treatment of soft tissue infections after surgical drainage, even with inappropriate antibiotics, has a high cure rate. Further studies to evaluate the efficacy of treating these infections without antibiotics are needed.