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ABSTRACT: Colonization of chronic wounds with methicillin-resistant Staphylococcus aureus continues to be an important healthcare concern. Aside from the morbidity associated with infections, colonization alone can contribute to outbreaks at long-term-care facilities and within hospitals. Despite the prevalence of pressure ulcers, the incidence of S aureus in these chronic wounds is unknown.
Advances in skin & wound care 11/2012; 25(11):509-12.
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ABSTRACT: The principles of bone biology and physiology permeate all subspecialty practices in plastic and reconstructive surgery, from hand surgery to aesthetic surgery. Despite its importance in our practices, these topics rarely surface within textbooks, literature reviews, or residency curricula. The authors present the second portion of a two-part review of the important concepts of bone biology and bone physiology relevant to plastic surgery, in an effort to ameliorate this educational gap.
Plastic and reconstructive surgery 06/2012; 129(6):950e-956e. · 2.74 Impact Factor
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ABSTRACT: The principles of bone biology and physiology permeate all subspecialty practices in plastic and reconstructive surgery from hand surgery to aesthetic surgery. Despite its importance in our practices, the biology of bone healing and bone physiology rarely surfaces within textbooks, literature reviews, or residency curricula. In this article, the authors present the first of a two-part series reviewing the important concepts of bone biology and bone physiology relevant to plastic surgery in an effort to ameliorate this educational gap.
Plastic and reconstructive surgery 06/2012; 129(6):1314-20. · 2.74 Impact Factor
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Plastic and reconstructive surgery 04/2012; 129(4):727e-8e. · 2.74 Impact Factor
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ABSTRACT: There are many products approved for aesthetic soft tissue augmentation. Despite this abundance, there is limited objective data regarding safety, longevity, and complication rates. Instead, most reports rely on subjective measures to report volume changes and outcomes, making product comparison difficult.
The authors developed and validated a mathematical model to prospectively calculate and analyze three-dimensional (3D) volumetric changes associated with nasolabial fold augmentation based on human acellular dermis.
Seven consecutive patients were included in this prospective review. The patients underwent nasolabial fold treatment with BellaDerm (Musculoskeletal Transplant Foundation, Edison, NJ), administered by a single surgeon. 3D photographs were obtained and analyzed with a novel mathematical model to determine absolute volumetric changes and objective longevity.
Mean preoperative nasolabial fold volume was 0.17 mL. The mean one-, three-, and six-month postoperative fill volumes were 0.35, 0.19, and 0.07 mL, respectively. Fill volumes and contour changes returned to baseline by 24 weeks postoperatively in the majority of patients.
The mathematical model utilized in this study provided prospective and objective data regarding longevity and volumetric changes associated with nasolabial fold augmentation. The analysis demonstrated minimal objective filler permanence beyond six months, with peak volume enhancement between one and three months. Adoption of objective 3D mathematical metrics into the assessment of soft tissue filler outcomes is critical to obtaining more accurate product-to-product comparisons.
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 03/2012; 32(4):488-94.
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ABSTRACT: Dermatofibrosarcoma protuberans (DFSP) is the most common cutaneous sarcoma. Tentacle-like extensions of neoplastic cells create a high incidence of local recurrence and pose challenges to resection and reconstruction.
Here we present a multidisciplinary approach to the management of DFSP incorporating the expertise of a Mohs micrographic surgeon, surgical oncologist, dermatopathologist, and plastic surgeon.
This was a single-institution, retrospective review of a prospectively maintained database of 19 consecutive patients who underwent resection and reconstruction of a DFSP from 1998 to 2010. All patients underwent Mohs micrographic surgery for mapping of peripheral margins (stage I excision), followed by wide local excision for delineation of the deep margin (stage II excision). Procedures were performed in consultation with a dermatopathologist who confirmed tumor-free margins, and a plastic surgeon who performed immediate reconstruction after the wide local excision (stage II reconstruction).
Nineteen patients were included in this study. The average number of Mohs stages required for clearance of peripheral margins was 2.7 ± 0.7. The mean time between stage I and II procedures was 16 ± 11 days. The average defect size after the stage II operation was 87.3 cm(2) (range, 9-300 cm(2)). There were no cases of tumor recurrence. Mean follow-up time was 17 months (range, 1-53 months).
This is a retrospective review of a single-institution experience.
A multidisciplinary approach to the management of DFSP optimizes both oncologic and reconstructive outcomes, minimizing the risk for local recurrence and limiting the functional and cosmetic morbidity associated with surgical resection.
Journal of the American Academy of Dermatology 03/2012; 67(5):861-6. · 3.99 Impact Factor
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Donald W Buck
Annals of plastic surgery 01/2012; 68(1):1-4. · 1.29 Impact Factor
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ABSTRACT: Adipose tissue contains various cells such as infiltrated monocytes/macrophages, endothelial cells, preadipocytes, and adipocytes. Adipocytes have an endocrine function by secreting adipokines such as interleukin (IL)-6, tumor necrosis factor (TNF)-α, leptin, and adiponectin. Dysregulation of adipokines in adipose tissues leads to a chronic low-grade inflammation which could result in atherosclerosis, hypertension, and type 2 diabetes. A sustained inflammatory state, which is characterized by prolonged persistence of macrophages and neutrophils, is found in diabetic wounds. In addition, subcutaneous adipocytes are enormously increased in amount clinically in type 2 diabetes. However, the function of subcutaneous adipocytes, which play an important role in injured tissue subjected to hypoxia, has not been well characterized in vitro due to the difficulty of maintaining mature adipocytes in culture using conventional methods because of their buoyancy. In this study, we established a novel in vitro culture method of mature adipocytes by enclosing them in a hyaluronan (HA) based hydrogel to study their role in response to stress such as hypoxia. BrdU labeling and Ki67 immunostaining experiments showed that hydrogel enclosed mature adipocytes proliferate in vitro. Both mRNA and protein expression analyses for hypoxia regulated genes, such as vascular endothelial growth factor (VEGF) and heme oxygenase 1 (HO1), showed that mature adipocytes of wild type mice respond to hypoxia. In contrast, mature adipocytes of diabetic db/db and TallyHo mice did not efficiently respond to hypoxia. Our studies suggest that mature adipocytes are functionally active cells, and their abnormal function to hypoxia can be one of underlining mechanisms in type 2 diabetes.
Experimental Cell Research 10/2011; 317(16):2299-307. · 3.58 Impact Factor
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ABSTRACT: Impairments in wound healing represent a significant source of morbidity and mortality in patients with diabetes. To help uncover the derangements associated with diabetic wound healing, murine animal models have been extensively used. In this article, the authors present results, and the accompanying wound healing implications, from experiments across three validated wound healing models using a newer polygenic strain of diabetes.
The authors investigated the wound healing impairments of the TallyHo/JnJ diabetic mouse strain, using three validated wound healing models: an incisional model, a splinted excisional model, and a cutaneous ischemia-reperfusion injury model. Appropriate control strain mice were used for comparison. Wounds were analyzed using gross, histologic, and molecular techniques.
TallyHo mice displayed deficits across all three wound healing models. There was a reduced resistance/response to oxidative stress and a global decrease in the initial inflammatory response to healing. In addition, there was a global decrease in the stimulus for angiogenesis and collagen formation, ultimately leading to reduced reepithelialization, granulation tissue formation, wound contraction, and wound tensile strength. Gross and histologic findings were corroborated with molecular data, which revealed a significant down-regulation of important cytokines, including vascular endothelial growth factor, neutrophilic attractant protein-2, monocyte chemoattractant protien-1, heme oxygenase-1, interleukin-1β, and interleukin-6, when normalized to the control strain (p<0.05).
The TallyHo polygenic mouse model of diabetes demonstrates predictable and clinically relevant wound healing impairments that offer important implications into the derangements of diabetic wound healing observed clinically. Therapeutics targeting these specific derangements could provide improvements in the care of diabetic wounds.
Plastic and reconstructive surgery 07/2011; 128(5):427e-437e. · 2.74 Impact Factor
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ABSTRACT: Human acellular dermal matrices help facilitate immediate tissue expander-implant breast reconstruction by providing support to the inferolateral pole, improving control of implant position, and enhancing early volume expansion. Although several freeze-dried human acellular dermal products have demonstrated reasonable safety and efficacy in immediate tissue expander-implant breast reconstruction, no dedicated studies have evaluated clinical outcomes of prehydrated human acellular dermal matrix (PHADM) in breast reconstruction.
The outcomes of 121 consecutive tissue expander reconstructions performed by the senior author using PHADM were evaluated.
Mean intraoperative tissue expander fill volume was 256.6 ± 133 mL, 60% of final expander volume. Patients required an average of 3.2 additional expansions prior to tissue expander-to-implant exchange. Mean follow-up period after reconstruction was 44 ± 26.5 weeks. Complications occurred in 20 (16.5%) breasts, including 9 (7.4%) soft-tissue infections, 8 (6.6%) partial mastectomy flap necroses, and 2 (1.7%) seromas. Eleven (9.1%) breasts ultimately required explantation. Patients receiving radiation demonstrated a strong trend toward greater complications (30.8% vs. 13.7%, P = 0.0749).
The outcomes and complication rates of PHADM tissue expander breast reconstruction are comparable to those reported with freeze-dried human acellular dermis.
Annals of plastic surgery 01/2011; 66(6):593-7. · 1.29 Impact Factor
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ABSTRACT: The indications for nipple-sparing mastectomy (NSM) are broadening as more breast surgeons appreciate the utility of preserving the nipple-areolar complex. A number of incision locations are available to the mastectomy surgeon, including inframammary, lateral and periareolar approaches. The present study investigated the effect of these three incisions on reconstructive outcomes; specifically, nipple necrosis.
A single-centre, retrospective review of 37 breast NSM reconstructions treated with immediate tissue expander reconstruction with acellular dermis between 2007 and 2008 was performed. The primary outcome was the incidence of nipple necrosis associated with periareolar, lateral and inframammary incisions. Secondary outcomes were the effects of radiation, chemotherapy and breast size on nipple necrosis.
Thirty-seven breast procedures performed on 20 patients were included in the present study. Periareolar incisions were used in 21 cases, lateral incisions in 14 and inframammary incisions in two. The periareolar incision was associated with a significantly higher incidence of nipple necrosis compared with lateral or inframammary incisions (38.1% versus 6.3%, P=0.028). Patients receiving breast radiation (45.5% versus 15.4%, P=0.066) and those with larger breast size (540.4 g versus 425.7 g, P=0.130) also demonstrated a modest trend toward an increased rate of nipple necrosis.
The periareolar incision results in a higher rate of nipple necrosis following NSM and immediate tissue expander breast reconstruction. Using the lateral or inframammary incision reduces the incidence of nipple necrosis and may help improve overall reconstructive and cosmetic outcomes.
The Canadian journal of plastic surgery, Journal canadien de chirurgie plastique 01/2011; 19(4):129-33. · 0.18 Impact Factor
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ABSTRACT: The advent of acellular dermis-based tissue expander breast reconstruction has placed an increased emphasis on optimizing intraoperative volume. Because skin preservation is a critical determinant of intraoperative volume expansion, a mathematical model was developed to capture the influence of incision dimension on subsequent tissue expander volumes.
A mathematical equation was developed to calculate breast volume via integration of a geometrically modelled breast cross-section. The equation calculates volume changes associated with excised skin during the mastectomy incision by reducing the arc length of the cross-section. The degree of volume loss is subsequently calculated based on excision dimensions ranging from 35 mm to 60 mm.
A quadratic relationship between breast volume and the vertical dimension of the mastectomy incision exists, such that incrementally larger incisions lead to a disproportionally greater amount of volume loss. The vertical dimension of the mastectomy incision - more so than the horizontal dimension - is of critical importance to maintain breast volume. Moreover, the predicted volume loss is more profound in smaller breasts and primarily occurs in areas that affect breast projection on ptosis.
The present study is the first to model the relationship between the vertical dimensions of the mastectomy incision and subsequent volume loss. These geometric principles will aid in optimizing intra-operative volume expansion during expander-based breast reconstruction.
The Canadian journal of plastic surgery, Journal canadien de chirurgie plastique 01/2011; 19(2):45-50. · 0.18 Impact Factor
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Plastic and reconstructive surgery 12/2010; 126(6):2189-95. · 2.74 Impact Factor
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ABSTRACT: Tissue expander breast reconstruction consists of three major surgical steps: placement of the expander after mastectomy, exchange of the expander for an implant, and nipple-areola complex reconstruction. The evolution of patient satisfaction throughout this process has not been evaluated. Here we performed a stratified analysis of patient-subjective cosmetic outcomes during the stages of breast reconstruction.
Twenty-eight consecutive tissue expander-implant reconstructions were performed by the senior author using human acellular dermis. Cosmetic outcomes were assessed after each reconstructive stage using a validated Breast Evaluation Questionnaire consisting of questions related to breast size, shape and firmness in three separate contexts: intimate or sexual activities, leisure or social activities, and professional or job-related activities.
Eighteen patients underwent unilateral reconstruction, while 10 underwent bilateral reconstruction. Satisfaction scores were statistically higher following Stage I and II procedures for bilateral reconstructions. For unilateral reconstructions, there was a statistically significant elevation in scores following Stage II. The addition of nipple-areola reconstruction resulted in the highest scores for both unilateral and bilateral reconstructions. These score elevations were significant (p < 0.05) in nearly every measured context for unilateral reconstructions and as such, the significant differences in scores between unilateral and bilateral cohorts after stages I and II were nearly eliminated after completion of the entire reconstructive process.
Satisfaction with tissue expander reconstruction is significantly affected by the patients' stage during the reconstructive process. Completion of all three stages, including nipple-areolar complex reconstruction, achieves maximal patient satisfaction. For unilateral reconstructions, completion of the entire reconstructive process, including contralateral symmetry procedures and nipple-areolar complex reconstruction, results in cosmesis scores that are similar to those in bilateral cases.
Breast (Edinburgh, Scotland) 12/2010; 19(6):521-6. · 2.09 Impact Factor
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ABSTRACT: LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the basic fundamentals of conscious sedation and deep sedation techniques. 2. Describe the basic principles of effective local anesthesia, as well as the "wide awake approach" and monitored anesthesia care. 3. Describe current methods for achieving postoperative pain control. 4. Evaluate and manage postoperative nausea and vomiting. SUMMARY: This article reviews the basic fundamentals of sedational anesthetic techniques. In addition, current concepts on local anesthesia administration are reviewed, including a description of newer techniques to allow for wide awake surgery. A brief review of postoperative pain management, and the management of postoperative nausea and vomiting, is also included.
Plastic and reconstructive surgery 10/2010; 126(4):165e-176e. · 2.74 Impact Factor
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ABSTRACT: The temporoparietal fascial flap is a thin, pliable, well-vascularized, locoregional flap that can be a reasonable alternative to traditional free flap reconstruction, but its utility for reconstruction of orbitomaxillary defects is often overlooked. The authors investigated the rationale for and benefits of the use of this flap over free tissue transfer in a well-defined subset of head and neck cancer cases.
The records of all patients who underwent temporoparietal fascial reconstruction for orbitomaxillectomy between 1993 and 2008 were reviewed. Demographic data, preoperative plans, operative details, and outcomes were assessed to (1) determine the overall outcomes for the temporoparietal fascial flap and (2) analyze preoperative and intraoperative factors that led to the choice of this flap instead of the originally planned free flap.
Nineteen patients (mean age, 56 years) were included in this study. Ten (53 percent) were initially considered for free flap reconstruction. Among them, the principal reasons for electing the temporoparietal fascial flap were (1) smaller-than-anticipated extent of resection, (2) need for coverage of implant or bone or thin prosthesis support, and (3) patient comorbidities. Nine resections (47 percent) involved the orbit alone, two (11 percent) involved the maxilla alone, and eight (42 percent) involved a combination of the two. Five patients (26 percent) received neoadjuvant radiation. Four (21 percent) experienced complications (flap failure, ectropion, enophthalmos with intraoral mesh extrusion, and partial skin graft loss). Mean follow-up time was 36 +/- 27 months.
The temporoparietal fascial flap is a viable alternative to free flaps for orbitomaxillary defects when orbital resection is limited, when obturator reconstruction is desired, or when comorbidities preclude microvascular surgery.
Plastic and reconstructive surgery 09/2010; 126(3):880-8. · 2.74 Impact Factor
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ABSTRACT: Hernia patients with a history of recurrent bowel obstructions, chronic bowel dysmotility, and bowel distension have few options for return to a "normal" life. Return of the bowel and adhesiolysis seems the logical surgical solution, but the return of a swollen distended bowel into the abdominal cavity would put patients at a high risk for the development of abdominal compartment syndrome. Hernia repair with large pieces of mesh under tenuous skin flaps to incorporate the bowel into the abdominal cavity has its own set of devastating complications, including mesh infection, extrusion, and fistula formation.
Here we present 4 patients who underwent successful treatment with a combined small bowel resection for volume reduction and simultaneous components separation hernia repair for autogenous closure without mesh.
All patients had successful abdominal wall closure without major complications and were tolerating enteral feedings upon discharge.
A combined approach of small bowel resection and separation of parts hernia repair is a feasible and successful means for approaching challenging abdominal wall defects with chronically distended bowel. A vicious cycle in which postoperative elevation in intra-abdominal pressure leads to severe systemic consequences can be averted. Moreover, bowel function can be restored and excellent cosmesis achieved, leading to significant improvements in patients' quality of life.
American journal of surgery 08/2010; 200(2):258-64. · 2.36 Impact Factor
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Bulletin of the American College of Surgeons 07/2010; 95(7):21-6.
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Plastic and reconstructive surgery 07/2010; 126(1):48e-50e. · 2.74 Impact Factor
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ABSTRACT: Crescentric tissue expanders have the potential to improve postoperative aesthetic results via selective lower pole expansion; however, limited data are available on their efficacy.
The authors assess postoperative functional and cosmetic outcomes of acellular dermis-assisted breast reconstruction with crescentric tissue expansion.
This study is a single-institution, retrospective review of 40 consecutive patients who underwent acellular dermis-assisted breast reconstruction with crescentric tissue expansion. Demographic data, operative details, and procedural outcomes were recorded and assessed. Cosmetic outcomes were assessed using the Breast Evaluation Questionnaire.
Fifty-eight breasts representing 36 bilateral and 22 unilateral reconstructions were analyzed. Of these, 45 (78%) underwent tissue expander (TE) to implant exchange. The mean interval between stage 1 and stage 2 was 92 +/- 20 days, with a total follow-up time of 141 +/- 16 days. The average intraoperative expander fill volume was 213.5 mL, with an average final fill of 285 mL (range, 180-740 mL). The average number of expansions was 1.6. Overall, there were five complications (8.6%). Eighty-three percent of patients participated in the breast evaluation questionnaire. Answers to each question were reported using a qualitative five-point scale that ranged from 1 (very dissatisfied) to 5 (very satisfied). For the bilateral reconstructions, the average score in all contexts was 4.5 +/- 0.3, 4.33 +/- 0.5, and 4.36 +/- 0.33 for size, shape, and firmness, respectively. For unilateral reconstructions, the average scores were 4.0 +/- 0.58, 3.93 +/- 0.38, and 4.13 +/- 0.21, respectively.
Crescentric expander-based reconstruction with acellular dermis assistance is well tolerated, especially in smaller breasted women. Functional and cosmetic outcomes were acceptable and comparable to previous reports of traditional expander-based reconstructions.
Aesthetic surgery journal / the American Society for Aesthetic Plastic surgery 03/2010; 30(2):194-200.
