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Background: The gender pay gap in medicine has been under intense scrutiny in recent years; female plastic surgeons reportedly earn 11% less than their male peers. "Hidden" pay in the form of industry-based transfers exposes compensation disparity not captured by traditional wage-gap estimations., Objectives: The aim of this study was to reveal the sex distribution of industry payments to board-certified plastic surgeons across all years covered by the Center for Medicare and Medicaid Services Open Payment Database (CMS OPD)., Methods: We obtained the National Provider Identifier (NPI) for each surgeon in the American Society of Plastic Surgeons (ASPS) member directory to record gender. Next, "General Payments" data points from annual files for all years present in the CMS OPD, 2013 to 2018, were aggregated and joined to provider details by Physician Profile ID before quantitative analysis was performed., Results: Of 4840 ASPS surgeons, 3864 (79.8%) reporting ≥1 industry payment were included with 3220 male (83.3%) and 644 female (16.7%). Over 2013 to 2018, females received mean [standard deviation] 56.01 [2.51] payments totaling $11,530.67 [$1461.45] each vs 65.70 [1.80] payments totaling $25,469.05 [$5412.60] for males. The yearly ratio of male-to-female payments in dollars was 2.36 in 2013, 2.69 in 2014, 2.53 in 2015, 2.31 in 2016, 1.72 in 2017, and most recently 1.96 in 2018., Conclusions: Individual male plastic surgeons received over twice the payment dollars given to their female counterparts, accepting both more frequent and higher-value transfers from industry partners. Payment inequity slightly declined in recent years, which may indicate shifting industry engagement gender preferences., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: The Aesthetic Surgery Journal (ASJ) is a world-renowned publication with valuable contributions from around the globe., Objectives: To better characterize the journal's evolving representation of global contributions to aesthetic surgery, the authors examined the author affiliations of all articles published in ASJ over the last decade., Methods: A PubMed search was performed for all journal articles published in ASJ from January 2008 to August 2018. For each article, the first author's primary affiliation as indexed in MEDLINE was recorded as the source country. Data were tabulated by source country and year. The authorless errata, corrigenda, and Cosmetic Surgery National Data Bank Statistics were excluded from analysis., Results: A total of 1746 articles were published during this period, contributed from 49 distinct countries. All continents other than Antarctica were represented. Higher income countries where aesthetic surgery is more prevalent produced 87% of published articles. The total number of published articles in ASJ has climbed from 77 annually in 2008 to 318 in 2018 as of August. In 2008, 27.3% of articles were from non-US countries, whereas in 2018 this increased to 43.7%. In particular, Turkey, the United Kingdom, Australia, Brazil, and Italy demonstrate steady increases in contributions over the 10-year period., Conclusions: Publications in ASJ have increased in number over the past decade, and the journal has become increasingly global in its network of contributing authors. The increased global contribution to the ASJ may enhance readers' experience both in the United States and in the world beyond., (© 2019 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com.)

Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The article processing charge for this abstract was paid for by the American Council of Academic Plastic Surgeons.

Background: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention., Methods: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level., Results: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician's assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution., Conclusions: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.

Background: This study is a 10-year follow-up to our previous publication reviewing the complication rates of tissue expansion in the pediatric burn population. The purpose of this study was to determine if our institutional experience with tissue expanders had remained stable during the subsequent 10 years., Methods: There were 240 patients who were identified at a major pediatric burn center who underwent reconstruction with a tissue expander (256 tissue expanders) from 1996 to 2006. Data were obtained retrospectively by reviewing patient medical records. Complications were categorized into absolute and relative complications., Results: Absolute complications occurred in 36 (14.1%) of 256 expanders placed and relative complications occurred in 26 (10.2%) of 256 expanders placed. There was no statistical difference between this study and our previous study for overall complication rates and complications for all sites. The highest complication rate occurred when the scalp was a surgical site. Betadine skin preparation was associated with a 10% reduction in infection-related complications compared to other skin preparations. The operating surgeon or age of patient was not found to be associated with increased complication rates., Conclusions: After changing our tissue expander protocol, the complication rates at our institution have remained stable during the 10-year follow-up period. Tissue expansion in the pediatric burn population continues to be a safe and effective reconstructive option with acceptable complication rates.

This article provides an overview of current therapies for photodamaged facial skin and their efficacy, with particular focus on studies that use the objective, quantitative evaluation methods discussed in the previous article. The role of topically applied agents including prescription drugs and cosmetics is discussed. From this information, a schema for the relative effectiveness of therapeutic modalities in reducing perceived age is presented. This information assists the facial plastic surgeon in evaluating patient expectations and selecting the most effective program., (Copyright © 2013 Elsevier Inc. All rights reserved.)

UVB exposure is well known to induce skin photodamage and photoaging that correlates with qualitative and quantitative deterioration of the dermal extracellular matrix (ECM) because of the upregulation of matrix metalloproteinases (MMPs). Although inhibitory effects of tissue inhibitor of metalloproteinases (TIMPs) on most MMPs have been reported, the protective role of TIMP-1 against photodamage is poorly understood. To address this, TIMP-1 function was augmented or abolished in a human skin xenograft photodamage model after the confirmation of significantly diminished TIMP-1 expression both in photoaged and intrinsically aged skins. During a chronic UVB exposure regimen, pre-treatment with a lentiviral vector overexpressing TIMP-1 or concomitant administration of an anti-TIMP-1-neutralizing antibody (NAB) led to photoprotection or more severe photodamage, respectively. Overexpression of TIMP-1 resulted in significant inhibition of UVB-induced ECM degradation, as well as suppression of decreased skin elasticity and roughness, whereas the NAB-mediated inhibition of TIMP-1 had opposite effects. Furthermore, UVB-induced production of the pro-inflammatory cytokine, tumor necrosis factor α, was inhibited by TIMP-1 treatment of human keratinocytes. Taken together, these data shed light on the important role of TIMP-1 in protection and recovery from cutaneous photodamage because of its suppression of ECM degradation and inflammation.

Wounds often cannot be successfully closed by conventional means of closure such as sutures or staples. Our group developed the FiberSecure™ device to close soft tissue wounds reliably, surpassing native tissue strength. We closed cross-fiber muscle incisions, to evaluate (1) four different configurations of FiberSecure™ for 30 days, then (2) the resulting preferred configuration for 180 days. The four treatment groups each placed 21,504 polyester (PET) 12-μm fibers (cross-sectional area 1% of muscle) traversing the incision, in the form of (A) Four large (No.7 suture) non-textured bundles, (B) Eight small (No.2 suture) non-textured, (C) Four large textured, or (D) Eight small textured. Four incisions were closed in the external oblique muscle of 16 Sinclair minipigs. At 30 days, specimens were removed for biomechanics, histology, and total collagen content. Group (B) was selected for 180-day evaluations in the same wound model in eight animals, four closures each (n = 32), again with biomechanics and histology. In strength testing, every specimen tore through muscle remotely, while the repair region remained intact. Maximum forces were (A) 37.8 ± 3.9 N, (B) 37.1 ± 4.7 N, (C) 39.0 ± 5.3 N, and (D) 32.4 ± 3.4 N at 30 days, and 37.2 ± 11.3 N at 180 days (mean ± SEM). No significant difference was observed among the groups or time points (p > 0.05)., (Copyright © 2011 Wiley Periodicals, Inc.)

The hair follicle has a unique dynamic property to cyclically regenerate throughout life. Despite significant progress in hair structure and hair shape determination using animal models, the mechanisms controlling the architecture and the shape of the human hair remain largely unexplored. In this study, comparison of the genetic expression of several human genes, especially those involved in growth, development, and differentiation, between Caucasian curly hair and naturally straight hair was performed. Thereafter, analyses using human recombinant and lentiviral vector technologies were conducted to further dissect and elucidate a molecular mechanism that regulates hair growth and development, particularly in controlling the shape of the hair shaft. Overexpression of IGF-binding protein 5 (IGFBP-5) in the human hair xenografts obtained from straight- and curly-haired individuals was found to result in the decreased expression of several extracellular matrix proteins and disassembly of adhesional junctions, resulting in twisted hair shafts as well as an unusual deposition of hair cuticle that may be derived from the disturbance of normal proliferation and differentiation. This study provides evidence that IGFBP-5 has an effect on human hair shape, and that lentiviral transduction regimen can be used for functional analysis of genes involved in human hair morphogenesis.

UVB-induced cutaneous photodamage/photoaging is characterized by qualitative and quantitative deterioration in dermal extracellular matrix (ECM) components such as collagen and elastic fibers. Disappearance of microfibrillar-associated protein 4 (MFAP-4), a possible limiting factor for cutaneous elasticity, was documented in photoaged dermis, but its function is poorly understood. To characterize its possible contribution to photoprotection, MFAP-4 expression was either augmented or inhibited in a human skin xenograft photodamage murine model and human fibroblasts. Xenografted skin with enhanced MFAP-4 expression was protected from UVB-induced photodamage/photoaging accompanied by the prevention of ECM degradation and aggravated elasticity. Additionally, remarkably increased or decreased fibrillin-1-based microfibril development was observed when fibroblasts were treated with recombinant MFAP-4 or with MFAP-4-specific siRNA, respectively. Immunoprecipitation analysis confirmed direct interaction between MFAP-4 and fibrillin-1. Taken together, our findings reveal the essential role of MFAP-4 in photoprotection and offer new therapeutic opportunities to prevent skin-associated pathologies.

UVB irradiation has been reported to induce photoaging and suppress systemic immune function that could lead to photocarcinogenesis. However, because of the paucity of an UVB-induced photodamaged skin model, precise and temporal mechanism(s) underlying the deleterious effects of long-term UVB exposure on human skin have yet to be delineated. In this study, we established a model using human skin xenografted onto severe combined immunodeficient mice, which were subsequently challenged by repeated UVB irradiation for 6 weeks. Three-dimensional optical image analysis of skin replicas and noninvasive biophysical measurements illustrated a significant increase in skin surface roughness, similar to premature photoaging, and a significant loss of skin elasticity after long-term UVB exposure. Resembling authentically aged skin, UVB-exposed samples exhibited significant increases in epithelial keratins (K6, K16, K17), elastins, and matrix metalloproteinases (MMP-1, MMP-9, MMP-12) as well as degradation of collagens (I, IV, VII). The UVB-induced deterioration of fibrous keratin intermediate filaments was also observed in the stratum corneum. Additionally, similarities in gene expression patterns between our model and chronologically aged skin substantiated the plausible relationship between photodamage and chronological age. Furthermore, severe skin photodamage was observed when neutralizing antibodies against TIMP-1, an endogenous inhibitor of MMPs, were administered during the UVB exposure regimen. Taken together, these findings suggest that our skin xenograft model recapitulates premature photoaged skin and provides a comprehensive tool with which to assess the deleterious effects of UVB irradiation.

Background: Gynoid lipodystrophy (cellulite) affects most women, and many seek plastic surgery consultation to improve appearance. Various products are offered, but the literature on the cause and treatment is limited. Understanding the biological and biophysical factors that affect severity may facilitate the development of effective therapies. There has been a dramatic increase in the number of people who have lost significant weight as a result of bariatric surgery or medically supervised weight programs. The effect of weight loss on cellulite severity has not been systematically studied and remains a common patient concern. The authors hypothesized that cellulite severity would decrease with weight loss and subsequent decrease in subcutaneous fat in most subjects., Methods: The authors examined the cellulite changes in female subjects who were enrolled in medically supervised weight loss programs using quantitative surface roughness by three-dimensional laser surface scanning, tissue composition by dual energy x-ray absorptiometry, dermal-subcutaneous structure with three-dimensional ultrasound, and tissue elasticity with biomechanical measurements., Results: The majority of subjects had an improvement in cellulite with weight loss, but the condition worsened for others. Improvement was associated with significant reductions in weight and percentage of thigh fat, significantly higher starting body mass index, and significantly greater initial severity. Cellulite worsened with a significantly smaller starting body mass index, smaller reductions in weight accompanied by no change in percentage of thigh fat, and significant increases in tissue compliance., Conclusions: Cellulite is a complex condition, and treatments such as weight loss have variable effects on the improvement or worsening of this condition. Additional studies are required to understand how the factors that influence and modulate cellulite severity, particularly those at the level of the subcutaneous tissue septa, can be manipulated to improve this condition.

Cultured skin substitutes (CSS), prepared using keratinocytes, fibroblasts, and biopolymers, can facilitate closure of massive burn wounds by increasing the availability of autologous tissue for grafting. But because they contain only two cell types, skin substitutes cannot replace all of the functions of native human skin. To better understand the physiological and molecular differences between CSS and native skin, we undertook a comprehensive analysis of gene expression in native skin, cultured keratinocytes, cultured fibroblasts, and skin substitutes using Affymetrix gene chip microarrays. Hierarchical tree clustering identified six major clusters of coordinately regulated genes, using a list of 1030 genes that were the most differentially expressed between groups. These clusters correspond to biomarker pools representing expression signatures for native skin, fibroblasts, keratinocytes, and cultured skin. The expression analysis revealed that entire clusters of genes were either up- or downregulated upon combination of fibroblasts and keratinocytes in cultured skin grafts. Further, several categories of genes were overexpressed in CSS compared with native skin, including genes associated with hyperproliferative skin or activated keratinocytes. The observed pattern of expression indicates that CSS in vitro, which display a well-differentiated epidermal layer, exhibit a hyperproliferative phenotype similar to wounded native skin.

Gynoid lipodystrophy (cellulite) is the irregular, dimpled skin surface of the thighs, abdomen, and buttocks in 85% of post-adolescent women. The distinctive surface morphology is believed to result when subcutaneous adipose tissue protrudes into the lower reticular dermis, thereby creating irregularities at the surface. The biomechanical properties of epidermal and dermal tissue may also influence severity. Cellulite-affected thigh sites were measured in 51 females with varying degrees of cellulite, in 11 non-cellulite controls, and in 10 male controls. A non-contact high-resolution three-dimensional laser surface scanner was used to quantify the skin surface morphology and determine specific roughness values. The scans were evaluated by experts and naive judges (n=62). Body composition was evaluated via dual-energy x-ray absorptiometry; dermal thickness and the dermal-subcutaneous junction were evaluated via high-resolution 3D ultrasound and surface photography under compression. Biomechanical properties were also measured. The roughness parameters Svm (mean depth of the lowest valleys) and Sdr (ratio between the roughness surface area and the area of the xy plane) were highly correlated to the expert image grades and, therefore, designated as the quantitative measures of cellulite severity. The strength of the correlations among naive grades, expert grades, and roughness values confirmed that the data quantitatively evaluate the human perception of cellulite. Cellulite severity was correlated to BMI, thigh circumference, percent thigh fat, architecture of the dermal-subcutaneous border (ultrasound surface area, red-band SD from compressed images), compliance, and stiffness (negative correlation). Cellulite severity was predicted by the percent fat and the area of the dermal-subcutaneous border. The biomechanical properties did not significantly contribute to the prediction. Comparison of the parameters for females and males further suggest that percent thigh fat and surface area roughness deviation are the distinguishing features of cellulite.

Background: Chemical facial peels are common cosmetic procedures that have gained in popularity over the last decade., Objective: The aim of this study was to compare the efficacy and morbidity of a series of superficial glycolic acid (GA) peels with those of a midlevel trichloroacetic acid (TCA) peel., Methods: We conducted a split-face study of 7 female patients, comparing the benefits of a single 35% TCA peel with those of a series of 5 30% GA peels performed at monthly intervals. Throughout the study, we performed noninvasive biophysical measurements, optical imaging, and expert and naïve image evaluations and conducted subject-group discussions so that we might objectively quantify and compare the treatments over time. An additional objective of the research was to use quantitative objective measurements of skin condition and actinic damage to establish these techniques as biologically based standards for treatment evaluation., Results: Skin elasticity and hydration increased during the course of the study but were not significantly different between the 2 treatment modes. Overall improvement with both treatments was relatively small as judged by expert evaluations of digital images taken at baseline and 3 months after treatment. No important differences were perceived when naïve judges were asked to evaluate the images. Digital-image analysis of wrinkles in the cheek region revealed significantly greater improvement in wrinkles with the TCA peel. In patient-group discussions, TCA peels were associated with greater improvement but also with more discomfort; GA peels were associated with a high degree of satisfaction, although their effect on quantitative technical measures of actinic damage was not dramatic., Conclusions: Although a single TCA peel produced more improvement than a series of superficial peels, the differences were small, and the TCA peel was associated with significantly greater discomfort.

Background: Improvement in skin after laser resurfacing depends on treatment to a precise level. The target treatment level will depend on skin type, anatomic location, and severity of the presenting problem. The development of noninvasive skin measurements that correlate with histologic changes would provide a useful intraoperative guide for treatment., Objective: The relationship among different types of lasers and levels of applied energy; objective real-time noninvasive measures of the skin; and histologic condition were studied in an attempt to gain information that could aid in achieving safer and more predictable laser skin resurfacing., Methods: The paraspinal skin of Yorkshire hybrid pigs was used for the study. In pig 1, study sites were treated with the Ultrapulse CO(2) laser (Coherent, Inc, Santa Clara, CA) with the CP-G at 300 ml for 0 to 5 passes. The Sciton Contour erbium: YAG llaser (Contour, Sciton, Palo Alto, CA) set at 200 mum of pure ablation was used to treat a separate but adjacent area for 0 to 5 passes. Treated sites and control sites were evaluated by measurements of biomechanical properties, digital imaging, and barrier integrity. In pig 2, the study was repeated with the Sciton Contour erbium:YAG laser at 10 different energy levels. Full-thickness punch biopsy specimens were obtained immediately after treatment and correlated with the biomechanical measures., Results: After the third pass with the CO(2) laser, there was no additional tissue ablation or change in surface biophysical measurements. There was an apparent increase in inflammation in the lower dermis with passes 4 and 5 seen on day 2 biopsies that suggested deeper thermal effects. The erbium laser continued to ablate with increasing applied energy. The change in viscoelastic creep correlated with the laser energy applied and inversely correlated with the remaining dermal depth of the skin after laser treatment., Conclusions: The measurement of immediate changes in viscoelastic creep should be further studied as a means of guiding intraoperative erbium laser resurfacing. Histologic evaluation suggests that the erbium:YAG laser may be a more effective tool for dermal ablation than the CO(2) laser.

A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the "zone of injury." Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.

Facial skin treatments with laser resurfacing, dermabrasion, and chemical peels were responsible for a significant portion of the 2.7 million cosmetic procedures performed in 1998. Perioral wrinkles are a common problem for which plastic surgical consultation is obtained. The aim of this study was to compare and quantify the advantages and disadvantages of laser resurfacing versus dermabrasion in the treatment of perioral wrinkles. Twenty female patients provided informed consent and participated in the study. Half of the perioral area was treated with dermabrasion and half was treated with the UltraPulse CO2 laser. The two procedures were compared using high-quality photographs; a biophysical evaluation of skin color, hydration, and mechanical properties; and patient evaluation of outcomes. Photographs were evaluated by 10 board-certified plastic surgeons who were blinded to the treatment methods. The laser treatment had a significantly higher erythema score at 1 month and a small but significantly greater improvement in perioral wrinkles at 6 months. Thirteen subjects selected the laser treatment as producing the best result, despite the greater intraoperative pain for this procedure. Biomechanical measurements suggest that the laser treatment produced a skin state more similar to skin in younger patients, presumably with higher levels and/or greater organization of the collagen and elastin. Patient preference was inferred from the resurfacing method that they would recommend to a friend. Although the laser was selected as the best result in a majority of cases, patient preference was equally distributed between the two treatments. The authors think that by studying and quantifying the biophysical changes that occur as a result of CO2 laser resurfacing, greater improvements in restoring actinic damage (e.g., wrinkles) can be achieved. Patients consider more than the objective skin changes from a resurfacing technique when making a recommendation to a friend.

Hair transfer from split-thickness skin grafts harvested from the scalp is not a widely reported problem. The authors present their experience with hair transfer from scalp autografts in a pediatric burn population, with particular emphasis on hair transfer to the face. They retrospectively reviewed 3307 acute and reconstructive pediatric burn admissions over a 4-year period at a single institution and identified 109 cases in which the scalp had been used as a donor site and in which the patient survived the acute burn period. Data from 73 male and 36 female patients were analyzed with respect to age, race, sex, percent total body surface area burned, graft thickness, number of scalp harvests and time between harvests, and presence of donor site alopecia. Eighteen of the 109 patients had noticeable hair growth from their scalp grafts (17 percent). Fourteen of 18 cases of hair growth involved face or neck grafts (13 percent); the remaining 4 patients had hair growth elsewhere on the body. There was no difference between the two groups (hair growth versus no hair growth) when compared by age, sex, or graft thickness. There was a correlation between larger burn size and greater incidence of hair growth. Those who had multiple harvests of the same scalp donor site were more than twice as likely to have hair transfer (9 of 34 versus 9 of 75 patients), although time between harvests was not a significant variable. Caucasian children represented 77 percent of the study population yet 100 percent of the cases of problem hair growth. Thirty-three percent of the hair growth group (6 of 18 patients) and 4 percent of the remaining patients (4 of 91) had some degree of donor site alopecia. The scalp is a reliable and valuable donor site for skin grafting in children, particularly for facial burns. The authors note a moderate incidence of hair transfer (17 percent) and propose both suggestions for prevention and recommendations for management.

Traumatic amputation of the lip is a rare yet devastating event affecting both form and function. Considering the available methods for reconstruction, replantation may offer a reasonable solution. We sought to characterize the variables associated with lip replantation and to assess the outcome in a retrospective review of 13 lip replantations performed in 12 institutions utilizing a form database and clinical and photographic analysis. Lip replantation was successful in all 13 patients; partial flap loss occurred in one patient owing to iatrogenic injury. Follow-up averaged 3.1 years. Average patient age at the time of injury was 21.1 years. There were six male and seven female patients. Injuries in two patients were the result of a human bite, the remaining injuries resulted from dog bites. One patient had significant associated injuries. Average length of hospital stay was 11.9 days. Ten patients suffered amputations of the upper lip, and three suffered amputations of the lower lip. Average defect size was 10.6 cm2. Operative time averaged 5.7 hours (range 2.5 to 12 hours). Warm ischemia time averaged 2.9 hours, and cold ischemia time averaged 2.7 hours. Donor and recipient veins were often scarce; all patients had at least one arterial anastomosis, whereas no vein was available in 7 of 13 patients; vein grafts were required in one patient. Leech therapy was employed in 11 of 13 patients. Anticoagulant therapy was administered in the majority of patients. Systemic heparin was utilized in 10 of 13 patients, low molecular weight dextran was used in 7 of 13 patients, and aspirin was given to 7 of 13 patients. One bleeding complication was incurred. An average of 6.2 units of packed red blood cells was administered to 12 of 13 patients (adjusted to 250 cc/unit). Antispasmodic therapy was employed in six of eight patients intraoperatively and in two of eight patients postoperatively. Intraoperative complications included difficulty identifying veins in 7 of 13 patients, arterial spasm in 1 of 13 patients, and vessel diameter < 0.5 mm in 4 patients. Postoperatively, one patient suffered vein thrombosis requiring anastomotic revision. Broad spectrum antibiotics were administered to all patients, and there were no infections. Nearly one-third (4 of 13) patients suffered prolonged edema lasting > 4 months. Color match of the replanted lip segment was rated excellent in all cases. Hypertrophic scarring occurred in 6 of 13 patients. A total of 12 revision procedures was performed in six patients. Interestingly, leech therapy resulted in permanent visible scarring as a result of the leech bite in 6 of 11 patients treated. Ten patients demonstrated active orbicularis muscle contraction in the replanted lip segment. Stomal continence was present in all lips. Sensibility return in the replanted lip segment was quite good with 12 of 13 patients demonstrating at least protective moving two-point sensibility (> or = 10 mm). Partial replant necrosis in one patient resulted in significant scar and contraction that compromised the aesthetic appearance. Overall, however, all patients were uniformly pleased with their final results. This clinical study is one of the largest of its kind on lip replantation. Although this represents a multi-institutional experience, the data are remarkably consistent. Re-establishment of venous outflow seems to be the most problematic technical challenge. By incorporating the adjuncts of anticoagulation, leech therapy, and antispasmodics, a successful outcome can be expected despite the paucity of vessels and small vessel size. The risks of blood transfusion, lengthy operative time, and hospital stay must be weighed against the functional benefits.

The effect of full-thickness burns of the abdomen during childhood on subsequent pregnancy was evaluated. Eight hundred female pediatric patients treated for acute burns during a 14-year period (1975-1989) at the Shriners Burns Institute were reviewed. Through a combination of clinical follow-up, questionnaires, or phone interviews, data were obtained regarding the histories of 31 pregnancies in 19 patients who had required excision and skin grafting of > or = 50% of their abdominal wall during management of their acute burns. These patients sustained a mean burn size of 59.8% total body surface area (TBSA; range, 23-87%) with a mean full-thickness burn of 43.8% TBSA (range, 10-78%). The mean age at the time of burn was 7.6 years (range, 1.5-15 years). Normal rates of vaginal and cesarean section deliveries, prematurity, and infant mortality were observed in these 31 pregnancies. Despite a subjective sensation of increased tension on the scar in 25% of the patients, no interference with these patients carrying a full-term pregnancy directly attributable to the burn scar was identified. Follow-up and examination during the third trimester of pregnancy demonstrated how the burned and unburned portion of the abdominal wall accommodated the enlarged uterus. This review demonstrates that after extensive burns to the abdomen, which have been treated with excision and skin grafting during childhood, the scarred abdominal wall accommodates full-term pregnancy without the need for surgical release.

This report of four patients (2 male, 2 female) presents preliminary results of treatment of chronic skin wounds with cultured skin substitutes prepared from allogeneic human skin cells and collagen substrates. The patients ranged in age from 64 to 73 years (mean: 67.25). The etiologies of their wounds were saphenous veinectomy, venous stasis, peripheral vascular disease, and venous stasis, with wound sizes 10cm2, 20cm2, 36cm2 and 184cm2. After the wounds were debrided, the cultured grafts, overlaid with a porous, non-adherent dressing, were stapled to the wounds. The procedure included frequent irrigations with essential nutrients containing broad spectrum antimicrobials, followed by dressing with antimicrobial ointments, and periodic examination of the wounds. Complete healing was obtained in two patients, partial healing in one with gradual recurrence due to poor patient compliance, and no healing in one. The two healed wounds did not recur after more than one year of observation and achieved closure in shorter periods of time than their duration before treatment with the skin substitutes. These results suggest that grafts of cultured allogeneic skin cells and collagen may accelerate healing of qualified chronic wounds. Qualifications include, but are not limited to, sufficient perfusion of the affected site and adequate debridement to viable tissue.