[Show abstract][Hide abstract] ABSTRACT: Fat grafting is commonly employed by plastic and reconstructive surgeons to address contour abnormalities and soft-tissue defects; however, because retention rates and thus volume filling effects are unpredictable, there is a search for new and innovative approaches. Initial studies on the use of human decellularized adipose tissue extracellular matrix (hDAM) show promise for its use not only in tissue engineering, but also in fat grafting. In this review, we examine and analyze the literature for the preparation, characterization, and use of hDAM and its derivatives in tissue engineering and plastic surgery applications. All studies reviewed involve physical, chemical, and/or biological treatment stages for the preparation of hDAM; however a distinction should be made between detergent and nondetergent-based processing, the latter of which appears to preserve the native integrity of the hDAM while most-efficiently achieving complete decellularization. Methods of hDAM characterization vary among groups and included simple and immunohistochemical staining, biochemical assays, 3-dimensional (3D) imaging, and mechano-stress testing, all of which are necessary to achieve a comprehensive description of this novel tissue. Finally, we examine the various preclinical models utilized to optimize hDAM performance, which primarily include the addition of adipose-derived stem cells or cross-linking agents. Overall, hDAM appears to be a promising adjunct in fat-grafting applications or even possibly as a stand-alone soft-tissue filler with off-the-shelf potential for commercial applications.
Aesthetic Surgery Journal 09/2015; DOI:10.1093/asj/sjv170 · 2.03 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Combined procedures involving elective breast surgery at the time of abdominoplasty are frequently performed procedures in aesthetic plastic surgery. While found to be safe outpatient procedures, many surgeons elect to perform combined abdominoplasty/breast surgery as inpatient surgery. This study was performed to explore the practice of performing the combined procedure as an inpatient in the United States.
The Nationwide Inpatient Sample database was evaluated using ICD-9CM procedural codes to identify hospitalizations where patients underwent abdominoplasty combined with breast surgery. We trended the frequency of this combined procedure, and evaluated the rate of acute post-operative complications, length of inpatient hospitalization, and total hospital charges.
Between 2004 and 2011, 29,235 combined abdominoplasty/breast procedures were performed as inpatient in United States. The rate of major post-operative complications in the acute hospitalization period was 1.12% and included CVA (0.02%), respiratory failure (0.6%), pneumonia (0.3%), VTE (0.1%), and myocardial infarction (0.1%). Hospitalization averaged 1.8 days and resulted in $31,177 of hospital charges. The demographics of the combined procedure transitioned as i) frequency of inpatient surgeries decreased, ii) percent of patients >50 yr increased, and iii) hospital charges increased from 2004 to 2011.
A significant number of surgeons are performing combined abdominoplasty and elective breast surgery as inpatient procedures in United States. The combined surgery is safe but is associated with small risk of major post-operative complications. A short inpatient hospitalization may be beneficial for high-risk patients interested in combined procedures, but must be analyzed against the rising costs of inpatient surgery.
[Show abstract][Hide abstract] ABSTRACT: Acellular dermal matrices (ADMs) have been proposed to decrease the incidence of capsular contracture in implant-based breast reconstructions. The authors have modified ADMs with fenestrations in order to facilitate greater lower pole expansion and improve contour. The effect of fenestrations on the ability of ADMs to suppress capsule formation, however, has not been examined.
A retrospective review of all fenestrated ADM-assisted, implant-based breast reconstructions performed by the two senior authors with a minimum of one-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 the Baker grading scale and compared to those reported in the literature.
Thirty patients (50 breasts) underwent fenestrated ADM-assisted reconstruction with mean follow-up of 3.3 and 2.6 years after expander placement and implant exchange, respectively. Seven patients (23%) had a body mass index >30, 3 (10%) were active smokers, and 6 breasts (12%) were irradiated. Complications included 1 (2%) infection, 6 cases (12%) of incisional superficial skin necrosis and 1 (2%) tissue expander extrusion. Zero breasts had clinically significant Baker grade III/IV capsular contracture. The average Baker grade was 1.1.
Fenestrated ADMs decrease rates of capsular contracture similar to what is seen with non-fenestrated ADMs. Further research is necessary to determine whether this observation is a result of decreased need for inferolateral ADM coverage to achieve these effects or modified physical interaction of ADMs with surrounding soft tissues.
Plastic and Reconstructive Surgery 06/2015; DOI:10.1097/PRS.0000000000001570 · 3.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There are a limited number of large-scale studies comparing multicenter perioperative outcomes among several different autologous breast reconstruction options.
Journal of Plastic Reconstructive & Aesthetic Surgery 05/2015; DOI:10.1016/j.bjps.2015.05.023 · 1.47 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background 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. Methods 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. Results 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. Conclusions 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
European Journal of Plastic Surgery 05/2015; DOI:10.1007/s00238-015-1090-5
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: 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.
The American surgeon 02/2015; 81(2):143-9. · 0.92 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Annals of Plastic Surgery 01/2015; 74(3). DOI:10.1097/SAP.0000000000000416 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
[Show abstract][Hide abstract] ABSTRACT: Goals/Purpose: Combined procedures involving elective breast surgery at the time of abdominoplasty are frequently performed procedures in aesthetic plastic surgery. To date, few studies have investigated the demographics and safety of this combined procedure. The purpose of this study was to explore the frequency, complications, and costs of the combined procedure in the United States
Methods/Technique: We evaluated the Nationwide Inpatient Sample (NIS) database from 2004-2011. We used ICD-9 CM procedural codes to identify hospitalizations where patients underwent abdominoplasty combined with an elective breast procedure (reduction mammoplasty, mastopexy, and/or augmentation mammoplasty). We trended the frequency of this combined procedure, and evaluated the rate of peri-operative complications, length of inpatient hospitalization, and total hospital charges.
Results/Complications: From 2004-2011, 29,235 combined abdominoplasty/breast procedures were performed. After peaking in 2005, the frequency of the combined procedure down-trended in subsequent years. Patients were most likely to be Caucasian (77.5%), privately insured (47%), and in the Southern United States (36.6%). Average patient age was 44 years; the portion of patients older than 50 years increased from 2004 (24.7%) to 2011 (32.7%). The majority of these procedures were performed in teaching hospitals (56.7%). The overall complication rate for the combined procedure was 3.6% (ranged from 2.4-5.6%), with the most frequent being hematoma (1.2%) followed by acute respiratory failure (0.6%). The combined procedure resulted in low rates of mortality (0.02%), VTE (0.1%), wound dehiscence (0.3%), wound infection (0.2%), and seroma (0.3%). The mean hospital stay was 1.8 days and the majority of these procedures were performed as an outpatient surgery. The mean total hospital charge was $31,177. The mean hospital stay demonstrated minimal variation (1.7 days to 1.9 days) during these years, however, the mean total hospital charges significantly increased each year from 2004 ($22,194) to 2011 ($44,302).
Conclusion: In the United States, combined abdominoplasty and elective breast surgery procedures are being performed in significant numbers. The combined abdominoplasty and elective breast surgery procedure appears to be a safe surgical option that is associated with a low mortality rate, low complication rate, and short inpatient hospitalization.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
These data will aid in planning breast reconstruction surgery and will enable patients to be more informed regarding the likelihood of multiple surgeries.
[Show abstract][Hide abstract] ABSTRACT: The burn wound exudate represents the burn tissue microenvironment. Extracting information from the exudate relating to cellular components, signaling mediators and protein content can provide much needed data relating to the local tissue damage, depth of the wound and probable systemic complications. This review examines the scientific data extracted from burn wound exudates over the years and proposes new investigations that will provide useful information from this underutilized resource.
Burns: journal of the International Society for Burn Injuries 06/2014; 41(1). DOI:10.1016/j.burns.2014.06.002 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: 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.
Plastic and Reconstructive Surgery 04/2014; 133(4 Suppl):981. DOI:10.1097/01.prs.0000445795.01903.e5 · 3.33 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The neck is the region of the body between the clavicle and the mandible. It contains several vital structures and serves to separate the head from the torso. A detailed discussion of surgical neck anatomy is presented, including comments relevant to aesthetic surgery. This discussion begins by describing the divisions of the neck and their contents. Subsequently, the layers of the neck are discussed and, finally, relevance with regards to surgery. Risks of complications are increased with secondary and tertiary surgeries.
Clinics in plastic surgery 01/2014; 41(1):1-6. DOI:10.1016/j.cps.2013.09.016 · 1.35 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Introduction
The burn wound exudate represents the burn tissue microenvironment. Extracting information from the exudate relating to cellular components, signaling mediators and protein content can provide much needed data relating to the local tissue damage, depth of the wound and probable systemic complications. This review examines the scientific data extracted from burn wound exudates over the years and proposes new investigations that will provide useful information from this underutilized resource.
A literature review was conducted using the electronic database PubMed to search for literature pertaining to burn wound or blister fluid analysis. Key words included burn exudate, blister fluid, wound exudate, cytokine burn fluid, subeschar fluid, cytokine burns, serum cytokines. 32 relevant articles were examined and 29 selected as relevant to the review. 3 papers were discarded due to questionable methodology or conclusions. The reports were assessed for their affect on management decisions and diagnostics. Furthermore, traditional blood level analysis of these mediators was made to compare the accuracy of blood versus exudate in burn wound management. Extrapolations are made for new possibilities of burn wound exudate analysis.
Studies pertaining to burn wound exudate, subeschar fluid and blister fluid analyses may have contributed to burn wound management decisions particularly related to escharectomies and early burn wound excision. In addition, information from these studies has the potential to impact on areas such as healing, scarring, burn wound conversion and burn wound depth analysis.
Burn wound exudate analysis has proven useful in burn wound management decisions. It appears to offer a far more accurate reflection of the burn wound pathophysiology than the traditional blood/serum investigations undertaken in the past. New approaches to diagnostics and treatment efficacy assessment are possible utilizing data from this fluid.
Burn wound exudate is a useful, currently under-utilized resource that is likely to take a more prominent role in burn wound management.
[Show abstract][Hide abstract] ABSTRACT: 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.
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.
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.
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.
Annals of plastic surgery 12/2013; 72(1). DOI:10.1097/SAP.0000000000000003 · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Optimal pressure settings have been suggested in the use of negative pressure wound therapy (NPWT) in wound dressings. When used as a bolster for skin grafting, an NPWT setting of 125 mm Hg was initially suggested, but not validated through studies. The objective of this study is to report findings on the effect of varied pressure settings on the incorporation of split thickness skin grafts when using an NPWT bolster.
From 2007 to 2010, 48 inpatients underwent split thickness skin grafting using a negative pressure system as a bolster under the care of 2 surgeons at 2 academic institutions. Twenty-two patients were evaluated retrospectively who were treated using NPWT bolsters at 75 mm Hg and 125 mm Hg based on the surgeon's discretion. Twenty-six patients were evaluated prospectively and were randomized to 50 mm Hg, 75 mm Hg, 100 mm Hg, and 125 mm Hg pressure settings. Graft incorporation was assessed at time of bolster removal, 2 weeks, and 4 weeks, per standard protocol.
At each assessment point, incorporation of each skin graft was > 95% in all study subjects, at all pressure settings.
Whereas initially postulated to be 125 mm Hg, ideal pressure settings for NPWT, when used as a bolster for split thickness skin grafts, may be lower. This study suggests that pressures as low as 50 mm Hg can be tolerated without compromise of skin graft incorporation. Study findings were presented at the Plastic Surgery Research Council Meeting in San Francisco, CA in April of 2010. .
[Show abstract][Hide abstract] ABSTRACT: Pyoderma gangrenosum is a great masquerader in wound diagnosis and management. Frequently misdiagnosed as a necrotizing infection, the elusive nature of its etiology and pathogenesis has thwarted the establishment of a standardized management algorithm, leaving immunosuppressant therapies as the mainstay of treatment. The present report describes a 61-year-old woman presenting with temporally discrete bilateral dorsal hand lesions successfully managed with distinctive multimodality therapies. The initial lesion was managed under the auspices of a necrotizing process using a combination of hyperbaric oxygen therapy and skin grafting with a negative-pressure dressing, both individually demonstrated to be effective for prompt wound stabilization and coverage. A subsequent contralateral hand lesion was similarly managed as a necrotizing infection before a diagnosis of pyoderma gangrenosum was considered. Stabilization and eventual resolution was achieved using intravenous and topical steroids followed by hyperbaric oxygen therapy, again highlighting the benefits of multimodality therapy in the setting of pyoderma gangrenosum.
The Canadian journal of plastic surgery, Journal canadien de chirurgie plastique 01/2013; 21(4):239-42. · 0.27 Impact Factor