Immediate breast reconstruction in the previously augmented patient.

BACKGROUND: Women who had undergone previous breast augmentation represent a unique subset of patients presenting for breast reconstruction. Much of the literature on breast augmentation and breast cancer has focused on cancer detection, prognosis, and recurrence. There is a paucity of data describing this patient population from a breast reconstruction standpoint. METHODS: A review of a prospective institutional database of all patients who had previous breast augmentation undergoing immediate breast reconstruction (IBR) from 1996 to 2010 was performed. Patient demographics, operative techniques, reconstructive methods, and breast cancer data were collected. Data were compared with a control group of 591 patients without previous augmentation undergoing IBR from 2005 to 2009. RESULTS: Thirty-five patients treated by total mastectomy and IBR who had previous breast augmentation were identified. The median patient age was 51 (range, 32-80) years in the augmented group versus 50.1 (range, 24-84) years in the control group. The mean body mass indices of the augmented and the control groups were 24.1 and 27.5, respectively (P < 0.05). Implant-based reconstruction was performed in 94.3% the augmented group versus 62.4% in the control group (P < 0.01). Stage 0 and I breast cancer occurred in 57.6% of patients in the augmented group and 46.6% of patients in control group (P < 0.05). CONCLUSIONS: Patients with previous augmentation mammoplasty are more likely to undergo implant-based reconstruction compared with nonaugmented women. The presence of implants does not delay the detection of breast cancer when compared with a control group of patients who do not have breast implants.

Silent sinus syndrome: a rare presentation after botulinum toxin injection.

Silent sinus syndrome is a unique diagnosis characterized by spontaneous enophthalmos and hypoglobus resulting from collapse of the orbital floor secondary to chronic subclinical sinusitis. Although reported in the ophthalmology and otolaryngology literature, there is no mention of silent sinus syndrome in the plastic surgery literature. The authors present a case report, along with a brief overview of silent sinus syndrome, so that knowledge of this rare but potentially devastating clinical entity may supplement plastic surgeons' differential to ensure proper diagnosis and treatment.

Is reduction mammaplasty a stimulus for weight loss and improved quality of life?

Reducing breast size for women with macromastia does more than provide symptomatic relief. The purpose of this study was to evaluate whether reduction mammaplasty was felt to be a stimulus for postoperative weight loss, subjective glucose control, and improved self-confidence. All patients who underwent reduction mammaplasty at Emory University Hospital by the senior author were reviewed. Patient demographics were queried, and a standardized questionnaire was devised to obtain information regarding postoperative weight, dress size, glucose control, and exercise. Forty-one women participated in the questionnaire. Mean follow-up was 2 years (range, 1-6). Patients were stratified according to whether they felt reduction mammaplasty was a stimulus for future weight loss; 63% stated yes (group A), 37% responded no (group B). Group A had significant postoperative weight loss (P < 0.001) and decreased dress size (P < 0.001). Group B had no change in weight (P = 0.239) or dress size (P = 0.735). There was 100% improvement of patient reported postoperative glucose control in group A and 50% improvement in group B. Sexual activity was improved in 85% of women in group A, and only 40% in group B. Group A patients had significantly increased postoperative exercise (P < 0.001); group B had no change. Reduction mammaplasty in motivated patients may be a stimulus for postoperative weight loss, and those patients were more physically active, had better glucose control and had an improved self-confidence.

Alginate microencapsulation technology for the percutaneous delivery of adipose-derived stem cells.

BACKGROUND: Autologous fat is the ideal soft-tissue filler; however, its widespread application is limited because of variable clinical results and poor survival. Engineered fillers have the potential to maximize survival. Alginate is a hydrogel copolymer that can be engineered into spheres of <200 µm, thus facilitating mass transfer, allowing for subcutaneous injection, and protecting cells from shearing forces. METHODS: Alginate powder was dissolved in saline, and adipose-derived stem cells (ADSCs) were encapsulated (1 million cells/mL) in alginate using an electrostatic bead generator. To assess effects of injection on cell viability, microspheres containing ADSCs were separated into 2 groups: the control group was decanted into culture wells and the injection group was mixed with basal media and injected through a 21-gauge needle into culture wells. Microbeads were cultured for 3 weeks, and cell number and viability were measured weekly using electron and confocal microscopy. To assess effects of percutaneous injection in vivo, twenty-four male nude mice were randomly separated into 2 groups and injected with either empty microcapsules or ADSC-laden microcapsules. Mice were harvested at 1 and 3 months, and the implants were examined microscopically to assess bead and cell viability. RESULTS: A flow rate of 5 mL/h and an electrostatic potential of 7 kV produced viable ADSC-laden microbeads of <200 µm. There were no differences in bead morphology and ADSC viability between microcapsules placed versus injected into tissue culture plates for up to 3 weeks. Microspheres implanted in a nude mouse model show durability up to 3 months with a host response around each individual sphere. ADSCs remained viable and showed signs of mitosis. CONCLUSIONS: ADSCs can be readily cultured, encapsulated, and injected in alginate microspheres. Stem cells suspended in alginate microspheres survive in vivo and are seen to replicate in vitro.

Use of hydroxyapatite cement in pediatric craniofacial reconstructive surgery: strategies for avoiding complications.

The emergence of powdered hydroxyapatite (HA) has dramatically expanded the repertoire of reconstructive tools for craniofacial surgeons. Although several groups have reported mixed success using HA powder, to date there have been few large series retrospective reviews of HA use in an exclusively pediatric population. The purpose of our study was to assess the incidence of complications using a single surgeon's experience in an entirely pediatric cohort of patients. We present 78 pediatric patients (mean age, 9 [SD, 5.1] years; 26 girls, 52 boys) who have undergone craniofacial reconstruction with HA powder in the form of Mimix or BoneSource (mean, 57.3 [SD, 27.9] g). From this cohort, we discuss in detail 7 patients who experienced complications after their reconstruction with HA. These complications were related to trauma, infection, and exposure. Of these 7 patients with problems, 6 required eventual HA removal. In addition, all 7 patients who had complications after HA reported having a traumatic event with respect to their cranial reconstruction before presenting with a complication. Our series concludes that HA powder is a safe and effective material for use in pediatric craniofacial reconstruction. When certain principles are not violated, meticulous hemostasis and surgical planning are of paramount importance to reduce the incidence of seroma, exposure, and infection of the overlying HA placement. However, should these complications arise, prompt removal of HA is usually necessary.

Renal epithelial cell-derived monocyte colony stimulating factor as a local informant of renal injury and means of monocyte activation.

Monocyte accumulation in renal allografts is associated with allograft dysfunction. As monocyte influx occurs acutely following reperfusion, we investigated the effect of ischemia-reperfusion injury (IRI) on monocyte colony stimulating factor (m-CSF), a key cytokine in monocyte recruitment. We hypothesized that renal tubule epithelial cells (RTECs) could produce m-CSF in response to IRI, which could in turn promote monocyte activation. Real time PCR was used to measure levels of intragraft m-CSF transcripts in patients during IRI and clinical rejection. Also, m-CSF production by RTECs following IRI simulation in vitro was measured using ELISA. Monocyte expression of CD40 and CD80 was then analyzed using flow cytometry following co-culture with supernatants of RTECs after IRI. Monocyte expression of CD40, CD80 and HLA-DR was then examined following treatment with rh-m-CSF (10, 36, and 100 ng/ml), as was monocyte size and granularity. We found that intragraft m-CSF transcription was significantly increased postreperfusion (P = 0.002) and during clinical rejection (P = 0.002). We also found that RTECs produced m-CSF in response to IRI in vitro (P = 0.036). Monocytes co-cultured with the supernatants of postischemic RTECs became activated as evidenced by increased expression of CD40 and CD80. Also, monocytes treated with recombinant m-CSF assumed an activated phenotype exhibiting increased size, granularity and expression of CD40, CD80, CD86, and HLA-DR, and demonstrating enhanced phagocytic activity. Taken together, we suggest that renal tubular cell derived m-CSF is a stimulus for monocyte activation and may be an important target for control of IRI-associated immune activation.

Additional benefits of reduction mammaplasty: a systematic review of the literature.

BACKGROUND: Reduction mammaplasty is commonly described with regard to its qualitative benefits. The authors sought to perform a systematic review of the literature focusing on functional outcomes after reduction mammaplasty with regard to physical and psychological symptom improvement, including weight-related effects, exercise, and eating behaviors, in addition to aesthetic outcomes. METHODS: A systematic review of the English literature was performed using the PubMed database to evaluate outcomes following reduction mammaplasty from 1977 to 2010. Studies were chosen that addressed the physical and psychological benefits of reduction mammaplasty using a validated questionnaire. RESULTS: Women who undergo reduction mammaplasty have a functional improvement in musculoskeletal pain, headaches, sleep, and breathing. Psychological benefits are vast and include improved self-esteem, sexual function, and quality of life, in addition to less anxiety and depression. After reduction mammaplasty, women appear to exercise more and have a reduction in eating disorders. CONCLUSION: The authors present a comprehensive review of the literature with regard to the physical and emotional concerns women with macromastia experience and the broad benefits reduction mammaplasty could have for their daily functions and quality of life postoperatively. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A new animal model for assessing cartilage repair and regeneration at a nonarticular site.

The aim of this study was to establish a critical-sized nonjoint chondral defect animal model and to evaluate its feasibility for testing cartilage regeneration strategies. Dermal biopsy punches 1-4 mm in diameter were used to create cylindrical full-thickness defects in the center of athymic rat xiphoids. The 3 and 4 mm defects remained unhealed 35 days postsurgery, with a large area in the center that had low proteoglycan content based on contrast-enhanced microCT (EPIC-microCT), radiographic, and histological analyses. In a second step, tissue-engineered cartilage was synthesized by culturing primary bovine articular chondrocytes on poly-L-lactic acid (PLA) scaffolds in a perfusion-shear bioreactor for 28 days. These chondrocyte/PLA constructs or primary bovine chondrocytes were implanted into 3-mm-diameter defects. Empty defects and defects implanted with empty PLA scaffolds were used as controls. Xiphoids were harvested 28 days after surgery and examined with faxitron, microCT, and histology using hematoxylin and eosin and safranin-O staining. Both chondrocyte/PLA constructs and chondrocytes alone formed neocartilage. The results indicate that a 3 mm cylindrical defect in a rat xiphoid is an economic, feasible, and reproductive model to evaluate the potential of various constructs for nonjoint cartilage repair.

Effects of traditional sit-up training versus core stabilization exercises on short-term musculoskeletal injuries in US Army soldiers: a cluster randomized trial.

BACKGROUND: The US Army has traditionally utilized bent-knee sit-ups as part of physical training and testing. It is unknown whether the short-term effects of a core stabilization exercise program without sit-up training may result in decreased musculoskeletal injury incidence and work restriction compared with traditional training. OBJECTIVE: The objective of this study was to explore the short-term effects of a core stabilization exercise program (CSEP) without sit-up training and a traditional exercise program (TEP) on musculoskeletal injury incidence and work restriction. DESIGN: The study was designed as a cluster randomized trial. SETTING: The setting was a 16-week training program at Fort Sam Houston (San Antonio, Texas). PARTICIPANTS: The study participants were soldiers with a mean age of 22.9 years (SD=4,7, range=18-35) for whom complete injury data were available for analysis (n=1,141). INTERVENTION: Twenty companies of soldiers were cluster randomized to complete the CSEP (10 companies of 542 soldiers) or the TEP (10 companies of 599 soldiers). The CSEP included exercises targeting the transversus abdominus and multifidus musculature. The TEP comprised exercises targeting the rectus abdominus, oblique abdominal, and hip flexor musculature. MEASUREMENTS: Research staff recorded all injuries resulting in the inability to complete full duty responsibilities. Differences in the percentages of musculoskeletal injuries were examined with chi-square analysis; independent sample t tests were used to examine differences in the numbers of days of work restriction. RESULTS: Of the 1,141 soldiers for whom complete injury data were available for analysis, 511 (44.8%) experienced musculoskeletal injuries during training that resulted in work restrictions. There were no differences in the percentages of soldiers with musculoskeletal injuries. There also were no differences in the numbers of days of work restriction for musculoskeletal injuries overall or specific to the upper extremity. However, soldiers who completed the TEP and experienced a low back injury had more days of work restriction: 8.3 days (SD=14.5) for the TEP group and 4.2 days (SD=8.0) for the CSEP group. LIMITATIONS: A limitation of this study was the inconsistent reporting of injuries during training. However, the rates of reporting were similar between the groups. CONCLUSIONS: The incidence of musculoskeletal injuries was similar between the groups. There was marginal evidence that the CSEP resulted in fewer days of work restriction for low back injuries.

Radiofrequency ablation of Barrett's esophagus: short-term results.

BACKGROUND: The presence of Barrett's esophagus (BE) increases the risk of esophageal cancer. Total regression of BE is uncommon with medication or laparoscopic fundoplication, and endoscopic techniques to obliterate BE have varied results. This study evaluated the early results of a balloon-based catheter radiofrequency ablation (RFA) system in patients with medically refractory reflux symptoms and biopsy-proven BE. METHODS: The medical records of 27 consecutive patients who underwent RFA for BE from March 2005 through January 2007 were reviewed. Esophagogastroduodenoscopy was performed before ablation to document presence of BE and no cancer and at 8 weeks after the RFA to assess the presence of residual BE. RESULTS: Mean patient age was 53.6 +/- 12.5 years; 16 (59%) were men. The average length of the Barrett segment treated was 4.6 +/- 4.7 cm. Two patients (7.4%) had low-grade dysplasia. No patient had high-grade dysplasia and cancer. There was no periprocedural morbidity or at follow-up, no postprocedure dysphagia or stricture. In all patients, the BE was completely replaced with normal squamous epithelium. Symptoms regressed in 16 patients (60%) with RFA and proton pump inhibitor therapy. Eleven required an antireflux procedure for persistent symptoms. CONCLUSIONS: Short-term results show that RFA for BE is safe and achieves 100% replacement of intestinal metaplasia. RFA of BE combined with fundoplication may be offered to patients with BE and medically refractory reflux symptoms. Long-term endoscopic surveillance is needed to determine if the risk of cancer is reduced with this bimodality therapy.

Pseudoangiomatous stromal hyperplasia. A case for bilateral mastectomy in a 12-year-old girl.

Pseudoangiomatous stromal hyperplasia (PASH) is a benign proliferation of breast stromal cells with a complex pattern of interanastomosing spaces lined by myofibroblasts and is most commonly seen in women of child-bearing age. PASH is a frequent incidental microscopic finding in breast biopsies. Nodular PASH, however, resulting in a clinically appreciable mass and rapid growth is a rare entity, with only four such patients cited in the literature. Surgical excision results in a cure in the majority of cases, with a recurrence rate of approximately 7-22%. We report a case of a 12-year-old girl with nodular PASH who presented with bilateral breast enlargement refractory to surgical excisions, eventually requiring bilateral mastectomies. To our knowledge, our patient is the youngest patient to have nodular PASH and to undergo bilateral mastectomies.

Acute insulin-induced elevations of circulating leptin and feeding inhibition in lean but not obese rats.

Insulin has been shown to stimulate leptin mRNA expression acutely in rat adipose tissue, but its short-term effects on circulating leptin levels, and subsequent feeding behavior, have not been well described. We used 11-mo-old female selectively bred obesity-resistant (OR) and obesity-prone (OP) Sprague-Dawley rats maintained on laboratory chow to investigate this question. At testing, body weights and basal leptin levels of the OP rats were significantly elevated compared with the OR rats. In the 3-h fasted state, injection of 2.0 U insulin/kg ip resulted in significant elevations of plasma leptin at 4 h postinjection in both OP and OR groups (hour 4, +2.50 and +5.98 ng/ml, respectively). In separate feeding tests with the same groups, intake of laboratory chow pellets was significantly inhibited during hours 2-4 after 2.0 U/kg of insulin in the OR (-80.1%, P < 0.05), but not in the OP group, compared with intake after saline injections. In feeding tests with palatable moderately high-fat pellets after 2.0 and 3.0 U insulin/kg ip, significant decreases between hours 2 and 4 in intake were seen in the OR group only (-41.0 and -68.3%, respectively). Thus feeding inhibition coincides with insulin-induced elevations of plasma leptin in lean but not obese Sprague-Dawley rats. Our data suggest that elevations of leptin within the physiological range may contribute to short-term inhibition of food intake in rats and that this process may be stimulated by feeding-related insulin release.