Use In Reconstructive Surgery Research Articles

In vivo characterization of the integration and vascularization of a silk-derived surgical scaffold

The application of acellular matrices, biomaterials, and polymeric scaffolds in reconstructive surgery facilitates postsurgical tissue remodeling and is increasingly used clinically in order to improve tissue healing and implant coverage. This study presents an invivo investigation of the integration of the knitted, silk-derived surgical scaffold, SERI(®) with regard to angiogenesis and wound healing. SERI(®) Surgical Scaffold was implanted into a full-thickness skin defect in male C57BL/6J mice (n=45) via the dorsal skinfold chamber (DSC). Skin tissue samples were collected for histology on days 2, 5, 7, 10, 14, and 21 (n=5 per time point) post implantation. Immunohistochemistry was performed for various angiogenic and inflammatory markers, as well as collagen deposition (CD31, VEGF, CD3, CD45, Desmin, and Sirius red). Vascular corrosion casting was used to assess the neovasculature within the silk and was visualized with scanning electron microscopy. We observed both early and late stages of inflammation during the healing process characterized by the infiltration of regenerating tissue by different subsets of leukocytes. Histological analysis displayed capillary-containing granulation tissue with full scaffold integration. In addition, collagen deposition within the scaffold and full skin defect was significantly increased over time. Qualitative analysis of the regenerated vasculature through corrosion casting and scanning electron microscopy revealed a complex, angiogenic network of capillaries originating from the wound bed. Based on these findings, SERI(®) displays the potential to be a promising resorbable bioengineered material for use in reconstructive surgery.

Comparative Role of Sonourethrography (SUG) and Magnetic Resonance Urethrography (MRU) in Anterior Male Urethral Strictures

Anterior urethral stricture is a common clinical condition encountered in day-to-day urological practice affecting predominantly males. Retrograde urethrography (RGU) is a common investigation done to determine the future course of management. But with increasing use of plastic surgery and other endoscopic procedures, information regarding presence of spongiofibrosis and other associated conditions, in addition to length of stricture is being demanded from radiologist for deciding the mode of management. Sonourethrography (SUG) has started gaining acceptance over RGU in last few decades for determining periurethral spongiofibrosis which at the same time obviates radiation to gonads. In recent years, magnetic resonance urethrography (MRU) has also been advocated for evaluation of anterior urethral strictures due to its excellent soft tissue contrast and lack of operator dependence. Besides, MRU can delineate posterior urethra simultaneously, affecting further management obviating the need for micturating cystourethrogram (MCU). Hence, in this article we evaluate the comparative role of SUG ad MRU in the evaluation of male anterior urethral strictures.

Assessing the Risks Associated with Antidepressant Use in Plastic Surgery: A Systematic Review.

Antidepressant use has increased dramatically over the past decade. Although there is no question about the benefits of these medications, uncertainty exists with regard to the implications of antidepressant treatment surrounding plastic surgery. This systematic review collates all of the available literature that evaluates the risks of patient antidepressant treatment, in relation to plastic surgery. A comprehensive literature review of the PubMed and Cochrane databases was conducted. Articles were assessed by two independent reviewers using predefined data fields and selected using specific inclusion criteria. The two authors independently reviewed the literature and extracted data from included reviews, and discrepancies were resolved by consensus. Twenty-six articles were included in the analysis and were categorized into five groups for comparison: risk of bleeding, risk of breast cancer, risk of breast cancer recurrence, breast enlargement, and miscellaneous (unique complications). Extracted information included study type, statistical analyses, conclusion, and limitations. This review does not support the cessation of antidepressants in patients before plastic surgery, as the numbers needed to harm are low and the implications of withdrawal may prove to be detrimental to postoperative management. However, the use of antidepressants for mental disorders may also implicate key patient risk factors for surgical complications, and sufficient exploration into the patient's indications for the prescription is crucial. Evidence so far does not suggest that antidepressants increase the risk of breast cancer or recurrence in general, but caution should be exercised for those specifically on concurrent tamoxifen and paroxetine treatment.

Use with Tissue Expander Face, Scalp and Neck Reconstruction

The tissue expander has found widespread use in reconstructive surgery. The donor area is needed, the recipient site with similar characteristics (color, thickness, hair follicle) features, minimal scarring and leads to donor site morbidity. In our study, presented face, scalp and neck reconstruction results obtained with the use of expander. The face, scalp and neck areas expander was used to evaluate patients in the Plastic, Reconstructive and Aesthetic Surgery Department of Yuzuncu Yil University. Age, gender, expander indication, defect or scar area localization, expander residential area, expander shape, volume, valve location (internal-external), expansion time, major and minor complications were reviewed. 30 number expanders were used in 17 patients (8 male, 9 female patients). Expanders were used burn sequelae in 14 patients, tumor- related defects in 2 patients and due to giant hairy nevus in 1 patient. The expanders are scalp (19 cases), face (3 cases), supraclaviculer (7 cases) and the neck (1 case) has to be placed. In 4 of 17 patients (three major and one minor) complications were encountered. Use the expander is a good option especially in the reconstruction of soft tissue defects in the head and neck region.

Perforator Flaps: Anatomy, Technique and Clinical Applications

This extensive and highly detailed work comprises two volumes and provides a comprehensive account of perforator flaps and their use in reconstructive surgery. Perforator flaps have gained popularity in recent years in many aspects of reconstruction and the Initial chapter of the book provides a brief history of flap surgery, describing the relatively recent appreciation of the fact that perforating vessels were capable of sustaining a large variety of flaps. The first volume gives detailed accounts of flap types, anatomy and physiology and overall provides an excellent account of the basic principles underlying perforator flaps. This volume also includes chapters on planning and complications. The latter of these gives a very clear account of the main ‘golden rules’ for complication avoidance in this type of surgery. The remainder of this volume is divided into three sections dealing with flaps of the head and neck, upper extremity and trunk. The first section of the second volume deals with flaps of the lower extremity followed by a good account of the clinical applications of a wide range of perforator flaps for reconstruction in various sites of the body. The final part of the second volume is, in my view, one of the most interesting sections of the entire book. Entitled ‘Controversies and Future Directions’, this explores a number of newer concepts, including that of the ‘freestyle free flap’ (a flap harvested from any region of the body, based on a vessel identified by Doppler), ‘supermicrosurgery’ (vessels of 0.5–0.8 mm) and neurocutaneous perforator flaps. The quality of the presentation and illustration is high throughout. As with most multi-author texts there is invariably some overlap in the various chapters, but this is a minor criticism. I have no doubt that this two-volume set would be a significant asset to any individual or department involved in reconstructive surgery and I recommend it highly.

Paediatric ulcerative colitis surgery: Italian survey.

Recent epidemiological studies showed an increase in ulcerative colitis among children, especially in its aggressive form, requiring surgical treatment. Although medical therapeutic strategies are standardized, there is still no consensus regarding indications, timing and kind of surgery. This study aimed to define the surgical management of paediatric ulcerative colitis and describe attitudes to it among paediatric surgeons. This was a retrospective cohort study. All national gastroenterology units were invited to participate. From January 2009 to December 2013, data on paediatric patients diagnosed with ulcerative colitis that required surgery were collected. Seven units participated in the study. Seventy-one colectomies were performed (77.3% laparoscopically). Main surgical indications were a severe ulcerative colitis attack (33.8%) and no response to medical therapies (56.3%). A three-stage strategy was chosen in 71% of cases. Straight anastomosis was performed in 14% and J-pouch anastomosis in 86% of cases. A reconstructive laparoscopic approach was used in 58% of patients. Ileo-anal anastomosis was performed by the Knight-Griffen technique in 85.4% and by the pull-through technique in 9.1% of patients. Complications after colectomy, after reconstruction and after stoma closure were reported in 12.7, 19.3 and 35% of cases, respectively. This study shows that there is general consensus regarding indications for surgery. The ideal surgical technique remains under debate. Laparoscopy is a procedure widely adopted for colectomy but its use in reconstructive surgery remains limited. Longer follow-up must be planned to define the quality of life of these patients.

Is ketorolac safe to use in plastic surgery? A critical review.

Ketorolac tromethamine is a nonsteroidal anti-inflammatory drug (NSAID) that provides postoperative pain control and reduces narcotic requirements. However, concerns regarding postoperative hematoma have limited its use in plastic surgery. Our goal is to critically review the risk of bleeding with ketorolac in plastic surgery patients, with a focus on aesthetic surgery. A PubMed/Medline literature search of clinical trials using the keywords "surgery" and "NSAID" yielded 2574 results. Of these results, 1036 included ketorolac and twelve involved plastic surgery patients. Six studies reported postoperative hematoma rates: three prospective randomized trials, two retrospective reviews, and one case series. These were subjected to statistical analysis to determine if an association existed between ketorolac and postoperative hematomas. Six papers reported 981 cases. Ketorolac use resulted in similar hematoma rates when compared to control groups, 2.5% (12 of 483) versus 2.4% (12 of 498), respectively (P = .79). There were no reported hematomas associated with ketorolac in over 115 patients undergoing aesthetic facial procedures. Hematoma rates of those undergoing aesthetic breast surgery, including reduction and augmentation mammoplasties, were 4.3% (11 of 257) in the ketorolac group versus 2.2% (6 of 277) in controls (P = .59). Reduction in postoperative narcotic use and improved pain scores was also reported. Our literature review did not find a significant association between hematoma formation and ketorolac use in a variety of plastic surgery procedures. These findings are similar to those in other surgical subspecialties.

Palmaris longus tendon assisted temporalis muscle transfer for lagophthalmos

Dear Sir, I read with interest the article by Gupta et al.,[1] although it was just a chance encounter of the article and the journal. I recalled having been shown by my colleague (Dr. Ayyappa T-Personal Communication) a video CD recording of his leprosy patient who was unable to close his eye treated by a combination of the fleshy temporalis muscle and the palmaris longus tendon. The tendon was tied to some fibers of the temporalis muscle and was split into two parts which were passed through the eyelids to meet at the medial canthus of the eye where they were tied to the medial canthal ligament avoiding trauma to the lacrimal sac. Only a passing reference has been made to the use of the palmaris longus by Gupta et al. 2014.[2] The palmaris longus is one of the most variable muscles of the human body[3] and this fact must be kept in mind by any surgeon contemplating its use in reconstructive surgery. Temporalis muscle along with its fascia is a popular graft for interpositional arthroplasty in temporomandibular joint ankyloses;[4,5] this surgery may also lead to lagophthalmos. One purpose of any tendon is to allow a muscle to act at a distance without increasing the bulk of the muscle; this is well served by the combination of the palmaris longus tendon and the fleshy temporalis muscle. Use of this combination, however, poses one question: For how long the patient has to open and close the mouth to open and close the eye-is it possible to delink these two activities? Similar question may be asked for hypoglossal-facial and spinal accessory-facial anastomoses: For how long the patient has to move the tongue or to raise the shoulder to express? Anatomists (and other basic medical scientists) are always keenly interested in close interaction with their clinical counterparts particularly surgeons as their experiences and experiments benefit all the parties concerned including their patients and students.

The formation of the latissimus dorsi muscle flap in the dorsal decubitus position

DOI: 10.5935/2177-1235.2015RBCP0138 Institution: Hospital Universitario da Universidade Federal de Alagoas (HU/UFAL), Maceio, AL, Brazil. Introduction: The latissimus dorsi muscle is located on the lateral-posterior chest wall. The latissimus dorsi muscle flap (LDMF) has extensive applications due to its consistent anatomy, which contributes to its use in plastic surgery. This muscle can be dissected in the dorsal decubitus (DD) position; this removes the need for a change in patient position and enables microsurgical reconstruction to be performed. This study aimed to describe the technique used for the dissection and transfer of the LDMF in the DD position. Methods: We evaluated 10 cases of LDMF formation performed in the University Hospital of the Federal University of Alagoas. The surgical procedures of individualization of the flaps and their positioning in the receiver region were similar in all ten cases. The evaluation of the muscle and the demarcation of the flap were performed with the patient in the standing position. Then, with the patient in the DD position, anesthetic induction was initiated and the operating field prepared. The neurovascular pedicle was formed by incising the top edge of the ellipse that delimits the LDMF, dissecting the insertion tendon of the muscle, and removing the flap necessary for the reconstruction of the receiver area. Results: The patient was in the DD position during the intraoperative period, even during the dissection of muscle flaps, and the technique used had no surgical disadvantages. Conclusion: It is possible to perform the dissection and individualization of the LDMF with the patient in the DD position. ■ ABSTRACT

Multiple Perspectives on Body Image Research

Representation of the body is a nuclear aspect of self-image. Body representation includes both subjective and intersubjective experiences. The importance of visual body representation in our social life is demonstrated by the time we spend to take care of our physical appearance, including use of plastic surgery, as well as by the severe mental disorders associated to its alteration, including eating disorders (EDs) and body dysmorphic disorders. In spite of these issues, (neuro)psychological research on body representation has so far mainly focused on the body as a motor device, devoted to the perception of and interaction with objects. The complexity of factors involved in the development, maintenance, and plasticity of body image representations requires an integrated approach that facilitates the evaluation and treatment of EDs with novel, evidence-based, and more efficacious protocols. This special issue of European Psychologist aims to advance such an integrative approach, with a collection of papers that gather different perspectives on the phenomenological, cognitive, (neuro)psychological, and cultural aspects of body representation disorders.

Photographic Estimation of Facial Height and Nasal Length of Bangladeshi Women

Context: Estimation of facial height and nasal length from digital photography is important to evaluate and planning surgical treatment of facial trauma, facial defect and post traumatic deformity. So facial height and nasal length values are of great use in plastic surgery and reconstructive surgery. These values are also important for identification of a person in forensic anthropology and archeology. The reliability of estimation of facial height from nasal length by using multiplication factor is high. The values of facial height and nasal length vary among populations. Materials and Method: This is a cross sectional, analytical type of study conducted in the Department of Anatomy, Sir Salimullah Medical College, Dhaka from January 2010 to June 2011. One hundred (100) Bangladeshi 25 to 45 years old women were selected for the study. Fourth class female employees of Sir Salimullah Medical College and Mitford Hospital and part time housemaids of Mitford area were selected by purposive sampling as study subjects. Results: The values of facial height and nasal length were 17.949 ± 1.3111cm and 5.179 ± 0.5349cm respectively. Multiplication factor for measuring facial height from nasal length was 3.49 ± 0.2864 (Mean ± SD). No significant difference was found between the measured and estimated facial height from nasal length. Conclusion: The anthropometric base line data of different facial dimensions might help the surgeons in diagnosing and treating reconstructive cases DOI: http://dx.doi.org/10.3329/bja.v11i2.20669 Bangladesh Journal of Anatomy, July 2013, Vol. 11 No. 2 pp 50-53

A study on proliferation and gene expression in normal human urothelial cells in culture.

Cultured human urothelial cells can be used in tissue engineering for reconstruction of urothelial defects. For safety reasons, a fine characterization of the cells is required before use in reconstructive surgery. For these reasons, we aimed to characterize the effect of in vitro propagation of urothelial cells on gene expression and proliferative capacity. Gene expression of urothelial cells in passage two and eight was captured by using a microarray chip covering the whole human genome. To find relationships in biological functions and pathways, differentially regulated genes were subjected to pathway analysis using the WEB-based Gene Set Analysis Toolkit (WebGestalt). Proliferative capacity was tested with population doubling time, efficiency in colony formation assays, and immunocytochemistry. In addition, senescence markers were evaluated. Bioinformatics analysis revealed gene expression profile differences. Downregulated genes at passage eight clustered in biological pathways of cell cycle and DNA repair processes; upregulated genes had no obvious association to any specific biological function or pathway according to WebGestalt analysis, but individual genes with extracellular matrix, apoptosis, and cell morphology. Data were supported by reverse transcription-polymerase chain reaction (RT-PCR) and in vitro growth experiments. Passage two urothelial cells had higher efficiency in colony formation and lower population doubling time. An increase in senescence markers was detected at passage eight. We conclude that pretransplantation quality controls are important and, for reconstructive purposes, cells should be transplanted back to the patient as soon as possible to procure good proliferative capacity also after transplantation.

Transplantation of pulmonary valve using a mouse model of heterotopic heart transplantation.

Tissue engineered heart valves, especially decellularized valves, are starting to gain momentum in clinical use of reconstructive surgery with mixed results. However, the cellular and molecular mechanisms of the neotissue development, valve thickening, and stenosis development are not researched extensively. To answer the above questions, we developed a murine heterotopic heart valve transplantation model. A heart valve was harvested from a valve donor mouse and transplanted to a heart donor mouse. The heart with a new valve was transplanted heterotopically to a recipient mouse. The transplanted heart showed its own heartbeat, independent of the recipient's heartbeat. The blood flow was quantified using a high frequency ultrasound system with a pulsed wave Doppler. The flow through the implanted pulmonary valve showed forward flow with minimal regurgitation and the peak flow was close to 100 mm/sec. This murine model of heart valve transplantation is highly versatile, so it can be modified and adapted to provide different hemodynamic environments and/or can be used with various transgenic mice to study neotissue development in a tissue engineered heart valve.

Antimicrobial activity and biocompatibility of Ag+- and Cu2+-doped biphasic hydroxyapatite/α-tricalcium phosphate obtained from hydrothermally synthesized Ag+- and Cu2+-doped hydroxyapatite

Abstract Hydroxyapatite (HAp) powders doped with Ag+ or Cu2+ were synthesized by a hydrothermal method in order to obtain biomaterial with an antimicrobial effect. The synthesis was performed with two contents of dopant (Ag+ or Cu2+) by considering both the antimicrobial activities and biocompatibility of the powders. The doped HAp was annealed at 1200 °C for 2 h with the intention of investigating the influence of doping with Ag+ and Cu2+ on the creation of the biphasic HAp/α-tricalcium phosphate (HAp/α-TCP) and determining the antimicrobial activity and biocompatibility of the obtained biphasic powders. Analyses of all powders, undoped and doped HAp and HAp/α-TCP, were performed by Field emission scanning electron microscopy (FESEM), X-ray diffraction (XRD), atomic absorption spectroscopy (AAS) and energy-dispersive X-ray spectroscopy (EDS). The in vitro antibacterial activities of the powders were evaluated against: Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa and Candida albicans. All powders showed good antimicrobial activity but generally the powders of doped HAp/α-TCP had more uniform results against all pathogenic microorganisms than the powders of doped HAp. In vitro biocompatibility tests, MTT and DET, were used to evaluate the biocompatibility of Ag+- and Cu2+-doped HAp/α-TCP with MRC-5 human fibroblast cells. These tests confirmed that powders do not have a cytotoxic effect. The HAp/α-TCP powders doped with the lower content of Ag+ and Cu2+ showed especially good biocompatibility. Antimicrobial and biocompatibility tests recommend the Ag+- and Cu2+-doped HAp/α-TCP as promising material for use in reconstructive surgery of bone.

ONE-stop clinic use in plastic surgery: our experience and the results of a UK-wide national survey

ONE-stop clinic use in plastic surgery: our experience and the results of a UK-wide national survey

Medical Specialty Society–Sponsored Data Registries

Clinical data registries are commonly used worldwide and are implemented for a variety of purposes ranging from physician or facility clinic logs for tracking patients, to collecting outcomes data, to measuring quality improvement or safety of medical devices. In the United States, the U.S. Food and Drug Administration has used data collected through registries to facilitate the drug and device regulatory process, for ongoing surveillance during the product life cycle, and for disease appraisals. Furthermore, the Centers for Medicare and Medicaid Services, in certain instances, bases registry participation and submitting data to registries as factors for reimbursement decisions. The purpose of this article is to discuss the use of clinical data registries; the role that medical specialty societies, in particular, the American Society of Plastic Surgeons and The Plastic Surgery Foundation, can have in the development and management of registries; and the opportunities for registry use in plastic surgery. As outcomes data are becoming essential measures of quality health care delivery, participation in registry development and centralized data collection has become a critical task for plastic surgery to engage in to proactively participate in the national quality and performance measurement agenda.

Acellular Dermal Matrices in Breast Surgery

Acellular dermal matrices (ADMs) have become increasingly popular for use in plastic surgery. There has been an increase in the number of products that have paralleled their usage in various clinical settings and specifically breast surgery. A direct comparison of the most common ADMs used in breast surgery was performed including physical characteristics, level of sterility, maximum load sustained (N), stiffness (N/mm), and tensile strength (N/cm). A comprehensive review of the literature was also performed, detailing known results and complications. The direct comparison of most common ADMs is detailed along with a review of 26 series of breast reconstruction manuscripts involving the usage of ADMs. Specifically, Strattice and Permacol had the highest values of maximum loads sustained, stiffness, and tensile strength. ADMs have a role in breast surgery that continues to be defined. Future long-term follow-up remains crucial to the identification of the optimal biologic mesh.

Metaphyseal bone formation induced by a new injectable β-TCP-based bone substitute: A controlled study in rabbits

Adequate filling of bone defects still poses a challenge in every day clinical work. As many bone defects are irregularly shaped the need for appropriate scaffolds reaching the complete defect surface are great. The purpose of this pre-clinical pilot study was to investigate the handling, biocompatibility, biodegradation and osteoconductivity of a new pasty bone substitute (pure phase β-TCP, hyaluronic acid, methylcellulose) in bone tissue. In an unilateral tibial defect model the peri-implant and bone tissue response to the new pasty bone substitute was tested in New Zealand white rabbits for up to 24 weeks compared to empty controls. Analysis included HR-pQCT scans, histomorphometric evaluation and quantification of vascularization of un-decalcified histological slices. After 1 week the experimental group presented significantly higher new bone volume fraction (p = 0.021) primarily consisting of immature bone matrix and higher vessel density compared to controls (p = 0.013). After 4 weeks bone formation was not significantly different to controls but was distributed more evenly throughout the defect. Bone matrix was now mineralized and trabeculae were thicker than in controls (p = 0.002) indicating faster intramedullary bone maturation. Controls presented extensive periosteal bone formation, major fibrous tissue influx and high vascularization. After 12 and 24 weeks there was no new bone detectable. There were no severe signs of inflammation at all time points. The substitute showed an early induction of bone formation. It promoted accelerated intramedullary bone repair and maturation and prevented periosteal bone formation indicating its potential use for reconstructive surgery of bone defects.

Autologous Fat Grafting for Correction of Unaesthetic Scars

Autologous fat grafting has many clinical applications, and its use in Plastic Surgery is increasing. Currently, autologous fat grafts are used in breast surgery, facial rejuvenation, and facial lipoatrophy secondary to antiretroviral therapy and as a treatment for liposuction sequelae, buttock augmentation, and congenital facial hemiatrophy. Their use is expanding rapidly, and their applications in other fields are an ever growing interest within the Plastic Surgery community. To introduce a new application of lipoinjection for the correction of unaesthetic, retracted, or sunken scars. The study consisted of a total of 8 patients (6 women and 2 men), with a mean age of 47 years old, all of whom presented retractile and dystrophic scars in the abdomen (n = 3), arm (n = 1), male breast (n = 1), and face (n = 3). They all received treatment with a fat injection using Coleman technique. General anesthesia was used in 3 patients; deep intravenous sedation plus local anesthesia was used in the remaining 5 patients. A COL-ASP15 cannula was used to harvest the fat and a blunt-tipped COL-19 cannula (Byron Medical) to release the fibrosis and retraction, and for the fat grafting injection. A 4-grade visual scale was use to evaluate the results. An improvement in the scar was achieved in all patients. One operation was required in 5 cases, and 2 operations in 3 cases. There were no complications in any patient and the results were lasting in all cases (the mean follow-up period was of 18 months). Autologous fat grafting is a good method for correction of retracted or sunken scars instead of the traditional scar surgical excision.

The Use of Reconstructive Surgery to Improve Quality of Life and Survival in Prenatal Hypoplastic Left Heart Syndrome

Outcomes for hypoplastic left heart syndrome have improved substantially in the era of prenatal diagnosis. Current stage 1 survival rates are in excess of 90% in the absence of risk factors. However, fetuses with an intact atrial septum continue to have poor postnatal survival. Accurate diagnosis of these fetuses with an intact atrial septum relies upon careful assessment of the patent foramen ovale, pulmonary venous Doppler flow patterns and branch pulmonary artery Doppler flow patterns. Prenatal and perinatal interventions, such as the placement of an atrial stent in utero or delivery at a center where a stent may be placed immediately after birth to relieve left atrial hypertension, may improve survival in this particularly high-risk group.