Inferior pedicle breast reduction and long nipple-to-inframammary fold distance: How long is safe?

BACKGROUND: Free nipple grafting indications in breast reduction surgery are outdated. Safety of inferior pedicle technique for large resections and long pedicles has not been clearly defined. We evaluated patients who underwent inferior pedicle reduction mammoplasty to define the safety constraints of the inferior pedicle. METHODS: A retrospective review of patients who underwent inferior pedicle reduction mammoplasty due to symptomatic macromastia at Mayo Clinic over a six-year period was conducted. Patients with prior breast surgeries were excluded. Demographics, breast measurements, and surgical outcomes were collected. Univariate and multivariate analyses were performed to assess for predictors of necrosis. RESULTS: Overall, 288 patients (576 breasts) underwent inferior pedicle breast reduction from 2014 to 2019. The mean sternal notch-to-nipple (SNN) distance was 31.5 cm (standard deviation[SD]:4.2; range[r]:16-48), and the mean nipple-to-inframammary fold (N-IMF) distance was 14.8 cm (SD:4.0; r:7.5-27). The mean resection weight was 699.6 g (SD:310.4; r:125-2,385). The median follow-up was 3.9 months (interquartile range[IQR]:2.8-9.0). The overall skin or nipple areolar complex necrosis rate was 2.1%; the overall complication rate was 14.8%. On multivariate analysis, overall necrosis was not found to be associated with the N-IMF distance (adjusted odds ratio[aOR]:1.05, 95%-CI 0.88-1.16). Resection weight was statistically associated with an increased risk of overall necrosis (aOR:1.003, 95%-CI 1.001-1.005), adjusting for N-IMF and SNN distances. CONCLUSION: Inferior pedicle breast reduction offers low risk of necrosis and can be safely performed in patients regardless of the N-IMF distance. No association was found between N-IMF distance and overall necrosis in our cohort, including lengths >15 cm. However, large resections could increase the risk of necrosis.

Ocular tissue distribution in the State of São Paulo: analysis on corneal discarding reasons. / Distribuição do tecido ocular no Estado de São Paulo: análise por razões de descarte de córneas.

OBJECTIVE: to identify the reasons for refusal of corneas. METHOD: this was a cross-sectional, retrospective, descriptive and correlational study composed of 5,560 optical corneas. The information was taken from the notification, organ procurement and distribution centers database as well as donor records. Descriptive statistics were used for the analysis of categorical variables and specific tests with a significance level of 5% for assessing the associations between variables. This study met the ethical aspects of scientific research. RESULTS: 60% of the donors were male and 40% died by circulatory problems. The main reason for refusal as informed by transplant teams is the donor's age and the endothelial cell count. For each year added to the donor's age, there is a 1% decrease in the chance that this cornea will be used for transplantation, and the increase of 100 cells per mm2 increases the chances that this cornea will be used by 9%. CONCLUSION: the main cause of refusal in the acceptance of corneal tissue is related to the age and the endothelial cell count.

Fat Grafting for Improved Ileostomy Ostomy Device Fit: A Case Report.

For patients with an ostomy, a poor fitting appliance may cause leakage, peristomal dermatitis, and frequent appliance changes. PURPOSE: The purpose of this case study was to report the outcome of fat grafting to augment peristomal soft tissue and improve appliance fit. CASE STUDY: A 57-year-old woman with a history of Crohn's disease presented with soft-tissue deficiency and uneven contour around her ileostomy site. She was unable to properly fit an ostomy appliance, which resulted in leakage, chronic skin irritation, and frequent appliance changes. The patient underwent 2 rounds of fat grafting using fat harvested from her medial thighs and knees infused with dilute lidocaine with epinephrine. The patient noted immediate improvement after 34 cc of processed fat was injected in the first round. Appliance change frequency decreased from daily to every 3 to 4 days. A second graft of 32 cc provided 3 months later further improved appliance fit, reducing appliance change frequency to every 5 to 7 days and obviating the need to use adjustment rings and glue. Pre- and postoperative computed tomography showed increased thickness of abdominal wall subcutaneous tissues. CONCLUSION: Fat grafting around an ostomy site presents a viable option to improve contour and appliance fit with reduced skin irritation and leakage.

Distribuição do tecido ocular no Estado de São Paulo: análise por razões de descarte de córneas / Ocular tissue distribution in the State of São Paulo: analysis on corneal discarding reasons / Distribución del tejido ocular en el estado de Sao Paulo: análisis sobre razones de descarte corneal

Objetivo identificar os motivos da recusa de córneas. Método estudo transversal, retrospectivo, descritivo e correlacional, composto por 5.560 córneas ópticas. As informações foram extraídas do banco de dados da Central de Notificação, Captação e Doação de Órgãos (CNCDO), bem como de prontuários de doadores. A estatística descritiva foi utilizada para a análise das variáveis categóricas e testes específicos, com nível de significância de 5% para avaliar as associações entre as variáveis. Este estudo atendeu aos aspectos éticos da pesquisa científica. Resultados 60% dos doadores eram do sexo masculino e 40% morreram por problemas circulatórios. Os principais motivos de recusa informados pelas equipes de transplante são a idade do doador e a contagem de células endoteliais. Para cada ano adicionado à idade do doador, há uma redução de 1% na chance de que essa córnea seja usada para transplante, e para cada acréscimo de 100 células por mm2 aumenta as chances de que essa córnea seja usada em 9%. Conclusão a principal causa de recusa na aceitação do tecido corneano está relacionada à idade e à contagem de células endoteliais.

Objective to identify the reasons for refusal of corneas. Method this was a cross-sectional, retrospective, descriptive and correlational study composed of 5,560 optical corneas. The information was taken from the notification, organ procurement and distribution centers database as well as donor records. Descriptive statistics were used for the analysis of categorical variables and specific tests with a significance level of 5% for assessing the associations between variables. This study met the ethical aspects of scientific research. Results 60% of the donors were male and 40% died by circulatory problems. The main reason for refusal as informed by transplant teams is the donor's age and the endothelial cell count. For each year added to the donor's age, there is a 1% decrease in the chance that this cornea will be used for transplantation, and the increase of 100 cells per mm2 increases the chances that this cornea will be used by 9%. Conclusion the main cause of refusal in the acceptance of corneal tissue is related to the age and the endothelial cell count.

Objetivo identificar los motivos para el rechazo de córneas. Método estudio transversal, retrospectivo, descriptivo y correlacional, compuesto por 5.560 córneas ópticas. La información se obtuvo de la bases de datos de Centros de Notificación, Obtención de Órganos y Distribución, así como de los registros de los donantes. Se utilizaron estadísticas descriptivas para analizar las variables categóricas y pruebas específicas con un nivel de significación de 5%, para evaluar las asociaciones entre variables. Este estudio contempla los aspectos éticos de una investigación científica. Resultados el 60% de los donantes eran hombres y el 40% falleció por problemas circulatorios. La principal razón del rechazo, informada por los equipos de trasplante, es la edad del donante y el recuento de las células endoteliales. Por cada año agregado a la edad del donante, existe una disminución de 1% en la probabilidad de que la córnea pueda ser utilizada para trasplante; el aumento de 100 células por mm2 aumenta la posibilidad de que esta córnea será usada por 9%. Conclusión la principal causa de rechazo en la aceptación del tejido corneal está relacionada con la edad y el recuento de células endoteliales.

Efficacy and Safety of Cell-Assisted Lipotransfer: A Systematic Review and Meta-Analysis.

BACKGROUND: The main drawback of autologous fat grafting, which is commonly used for soft-tissue augmentation, is the high resorption rate. Cell-assisted lipotransfer has been used to improve fat graft survival; however, evidence for its efficacy and safety is still lacking. METHODS: The authors searched PubMed, Cochrane Library, EBSCO, and EMBASE for clinical studies on cell-assisted lipotransfer published from 2008 through 2014. A meta-analysis was conducted to pool the estimated fat survival rate. Incidence of complications and incidence of multiple operations were calculated. RESULTS: Seventeen articles involving 387 cases were included in the systematic review. The pooled fat survival rate was significantly higher in the cell-assisted lipotransfer group than in the nonlipotransfer group (60 percent versus 45 percent, p = 0.0096). Complication incidence was similar in the two groups. Cell-assisted lipotransfer significantly improved fat survival in the face (by 19 percent) and reduced the incidence of multiple operations (by 13.6 percent). In breast fat grafting, however, fat survival was improved by only 9 percent, which was not statistically significant. Meanwhile, lipotransfer in breast cases was associated with a higher complication incidence compared with face cases (p < 0.001). CONCLUSIONS: This study demonstrates that cell-assisted lipotransfer has better efficacy than conventional fat grafting (non-cell-assisted lipotransfer). It is more applicable to face cases than to breast cases. Until now, there has not been enough evidence of the superiority of cell-assisted lipotransfer over conventional fat grafting for reducing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Optimizing outcomes from ovarian tissue cryopreservation and transplantation; activation versus preservation.

Ovarian tissue cryopreservation and transplantation (OTCP) is gaining increasing traction in the field of fertility preservation as a result of accumulated successes. We now have a decade of experience with the technique, with tens of live births and greater than 90% return of ovarian function in graft recipients. Recently, a novel method of OTCP has been described, termed in vitro activated OTCP which proposes significant changes to the standard protocol. This method aims to stimulate activation of dormant follicles within the grafts prior to transplantation and ensure that mature oocytes can be generated in the immediate short term after transplantation. By contrast, conventional OTCP seeks to maintain dormancy and thus preserve the follicle reserve in the graft with the aim of maximizing graft lifespan. This opinion paper will compare the two methods of OTCP, highlighting their respective advantages and disadvantages, and provide suggestions as to when to apply either one of these methods in a clinical setting.

Intestinal transplant registry report: global activity and trends.

The Registry has gathered information on intestine transplantation (IT) since 1985. During this time, individual centers have reported progress but small case volumes potentially limit the generalizability of this information. The present study was undertaken to examine recent global IT activity. Activity was assessed with descriptive statistics, Kaplan-Meier survival curves and a multiple variable analysis. Eighty-two programs reported 2887 transplants in 2699 patients. Regional practices and outcomes are now similar worldwide. Current actuarial patient survival rates are 76%, 56% and 43% at 1, 5 and 10 years, respectively. Rates of graft loss beyond 1 year have not improved. Grafts that included a colon segment had better function. Waiting at home for IT, the use of induction immune-suppression therapy, inclusion of a liver component and maintenance therapy with rapamycin were associated with better graft survival. Outcomes of IT have modestly improved over the past decade. Case volumes have recently declined. Identifying the root reasons for late graft loss is difficult due to the low case volumes at most centers. The high participation rate in the Registry provides unique opportunities to study these issues.

Ovarian tissue cryopreservation: a committee opinion.

Ovarian tissue cryopreservation is an option to preserve reproductive potential in patients who must urgently undergo aggressive chemotherapy and/or radiotherapy or who have other medical conditions requiring treatment that may threaten ovarian function and subsequent fertility. Ovarian tissue cryopreservation may be the only option available to prepubertal girls undergoing such treatments. However, these techniques are still considered to be experimental. This document outlines the current technology, clinical outcomes, and risks of ovarian tissue cryopreservation and recommendations for clinical applications. This document and the document "Mature Oocyte Cryopreservation: A Guideline" published in 2013 (Fertil Steril 2013;99:37-43) replace the document "Ovarian Tissue and Oocyte Cryopreservation" last published in 2008 (Fertil Steril 2008;90:S241-6).

Importance of good manufacturing practices in microbiological monitoring in processing human tissues for transplant.

Skin allografts represent an important therapeutic resource in the treatment of severe skin loss. The risk associated with application of processed tissues in humans is very low, however, human material always carries the risk of disease transmission. To minimise the risk of contamination of grafts, processing is carried out in clean rooms where air quality is monitored. Procedures and quality control tests are performed to standardise the production process and to guarantee the final product for human use. Since we only validate and distribute aseptic tissues, we conducted a study to determine what type of quality controls for skin processing are the most suitable for detecting processing errors and intercurrent contamination, and for faithfully mapping the process without unduly increasing production costs. Two different methods for quality control were statistically compared using the Fisher exact test. On the basis of the current study we selected our quality control procedure based on pre- and post-processing tissue controls, operator and environmental controls. Evaluation of the predictability of our control methods showed that tissue control was the most reliable method of revealing microbial contamination of grafts. We obtained 100 % sensitivity by doubling tissue controls, while maintaining high specificity (77 %).

Vascularized composite allotransplantation: a member of the transplant family?

The definition of vascularized composite allograft (VCA) and the nomenclature require further attention and interaction with the competent authorities. When compared with solid organ transplantation, VCA donation and allocation imply additional elements such as donor identification, race, and bone constitution, which need to be worked into a scheme for VCA allocation. Furthermore, retrieval of limbs, faces, and possibly other body parts demands algorithms for the sequence of steps during the donor operation. Relevant aspects and criteria for any VCA allocation concept are addressed in this article.

A consolidated biovigilance system for blood, tissue and organs: one size does not fit all.

Biovigilance systems to assess and analyze risks for disease transmission through the transfer of organs, tissue, cells and blood between people is part of administrative oversight and has impact upon clinical practice and policy. In 2009, a formal recommendation by the Public Health Service requested that Health and Human Services fund and support efforts to consolidate national biovigilance efforts. There are differences in the biovigilance issues involved in organ and tissue donation/transplantation. If disease avoidance is made the dominant principle guiding organ donor testing, an unintended consequence may be an increase in deaths on the waiting list. We propose that overall benefit for the organ transplant recipient, tempered by patient informed awareness of limited organ availability and assessment processes, should be the guiding principle of such a system.

Surrogate human tissue temperatures resulting from misalignment of antenna and implant during recharging of a neuromodulation device.

OBJECTIVES: A synergistic experimental and numerical investigation has provided quantitative information on the response of surrogate human tissue temperatures to misalignment of the implant and antenna of neuromodulation devices during recharging. MATERIALS AND METHODS: The experimental phase of the work provided information on the rates of heat transfer from the implant and the antenna to their respective surroundings. The heat transfer data were used as input to a biothermal model from which tissue temperature distributions were obtained. RESULTS: It was found that misalignment increases tissue temperatures compared with those for the aligned case for all of the investigated devices. These increases ranged from 0.5°C to 5.3°C. CONCLUSION: Notwithstanding these increases, the lowest temperatures were attained by the Restore Ultra device for all operating conditions. The temperature levels achieved by the Precision Plus and Eon Mini devices were found to be greater than those for the Restore Ultra but their relative rankings depend on the thermal boundary conditions and the duration of the recharging period. The foregoing rank ordering was validated by a sensitivity study in which the heat transfer data inputted to the numerical simulation was varied systematically. The aforementioned comparisons correspond with identical recharging periods for all of the devices.

Free functional muscle transfer for the upper extremity.

Free functional muscle transfers are an excellent treatment option in patients when significant time has passed after a nerve injury. In addition, they are the treatment of choice for reconstruction of established Volkmann's ischemic contracture, muscle loss from trauma, or tumor resection, and in congenital muscle absence. In cases where there is both soft tissue and functional muscle loss, free functional muscle transfers can address these problems together. This article focuses on the key principles for functional reconstruction of the upper extremity with free functional muscle transfers.

Fascicular topography of the suprascapular nerve in the C5 root and upper trunk of the brachial plexus: a microanatomic study from a nerve surgeon's perspective.

BACKGROUND: In patients with supraclavicular injuries of the brachial plexus, the suprascapular nerve (SSN) is frequently reconstructed with a sural nerve graft coapted to C5. As the C5 cross-sectional diameter exceeds the graft diameter, inadequate positioning of the graft is possible. OBJECTIVE: To identify a specific area within the C5 proximal stump that contains the SSN axons and to determine how this area could be localized by the nerve surgeon, we conducted a microanatomic study of the intraplexal topography of the SSN. METHODS: The right-sided C5 and C6 roots, the upper trunk with its divisions, and the SSN of 20 adult nonfixed cadavers were removed and fixed. The position and area occupied by the SSN fibers inside C5 were assessed and registered under magnification. RESULTS: The SSN was monofascicular in all specimens and derived its fibers mainly from C5. Small contributions from C6 were found in 12 specimens (60%). The mean transverse area of C5 occupied by SSN fibers was 28.23%. In 16 specimens (80%), the SSN fibers were localized in the ventral (mainly the rostroventral) quadrants of C5, a cross-sectional area between 9 o'clock and 3 o'clock from the surgeon's intraoperative perspective. CONCLUSION: In reconstruction of the SSN with a sural nerve graft, coaptation should be performed in the rostroventral quadrant of C5 cross-sectional area (between 9 and 12 o'clock from the nerve surgeon's point of view in a right-sided brachial plexus exploration). This will minimize axonal misrouting and may improve outcome.

Coding and traceability for cells, tissues and organs for transplantation.

Modern transplantation of cells, tissues and organs has been practiced within the last century achieving both life saving and enhancing results. Associated risks have been recognized including infectious disease transmission, malignancy, immune mediated disease and graft failure. This has resulted in establishment of government regulation, professional standard setting and establishment of vigilance and surveillance systems for early detection and prevention and to improve patient safety. The increased transportation of grafts across national boundaries has made traceability difficult and sometimes impossible. Experience during the first Gulf War with mis-identification of blood units coming from multiple countries without standardized coding and labeling has led international organizations to develop standardized nomenclature and coding for blood. Following this example, cell therapy and tissue transplant practitioners have also moved to standardization of coding systems. Establishment of an international coding system has progressed rapidly and implementation for blood has demonstrated multiple advantages. WHO has held two global consultations on human cells and tissues for transplantation, which recognized the global circulation of cells and tissues and growing commercialization and the need for means of coding to identify tissues and cells used in transplantation, are essential for full traceability. There is currently a wide diversity in the identification and coding of tissue and cell products. For tissues, with a few exceptions, product terminology has not been standardized even at the national level. Progress has been made in blood and cell therapies with a slow and steady trend towards implementation of the international code ISBT 128. Across all fields, there are now 3,700 licensed facilities in 66 countries. Efforts are necessary to encourage the introduction of a standardized international coding system for donation identification numbers, such as ISBT 128, for all donated biologic products.