Medium- and Long-Term Outcomes of Autologous Fat Grafting to Hands and Feet for Patients With Raynaud Phenomenon.

BACKGROUND: Autologous fat grafting (AFG) has emerged as a promising treatment option for Raynaud phenomenon. However, existing studies are limited by short follow-up, and there is little evidence regarding predictive factors for successful outcomes. METHODS: A retrospective chart review and standardized phone interviews were performed for all patients (n = 17, 65% response rate) treated with AFG to the hands or feet at our institution for primary or secondary Raynaud from 2010 to 2021. Each occurrence of AFG was defined as a separate surgery (n = 23), with an average follow-up of 3.7 years. RESULTS: At follow-up, patients reported a 31% reduction in cold attack frequency, a 45% reduction in the intensity of individual attacks, a 29% reduction in the duration of attacks, and a 40% improvement in overall Raynaud Condition Score (P < 0.01). Although initial AFG to an extremity significantly improved symptoms, subsequent attempts were not shown to statistically improve outcomes. Digital ulcers were present in 65% of cases, and AFG resulted in ulcer healing in 87% of those cases. Median duration of maximum symptom relief was 1 year postoperatively, with 74% of patients reporting diminishing symptom relief by 4 years postoperatively. Those with a BMI ≥25, with primary Raynaud phenomenon or without preoperative ulcers experienced significantly longer symptom relief (P < 0.05). Average patient satisfaction was 7.7 of 10, and 91% would recommend the procedure to others. CONCLUSIONS: Autologous fat grafting is an effective, albeit sometimes temporary, treatment for Raynaud and digital ulcers. Certain patients may be more likely to experience lasting symptom relief beyond 1 year.

Umbilical Ablation During Deep Inferior Epigastric Perforator Flap Harvest Decreases Donor Site Complications.

BACKGROUND: Donor site complications are a significant source of morbidity for patients undergoing abdominal-based free flap breast reconstruction, but there is a paucity of data regarding minimizing these postoperative complications. We hypothesize that selective ablation of the umbilicus at the time of deep inferior epigastric perforator (DIEP) harvest decreases the incidence of umbilical and abdominal wall complications in high-risk patients. METHODS: A retrospective review was performed of all patients (n = 117) who underwent DIEP harvest with concomitant umbilical ablation from 2010 to 2015. This cohort was paired with 117 patients who underwent DIEP harvest without umbilical ablation. Preoperative risk factors, intraoperative factors, and postoperative complications were compared. RESULTS: The umbilical ablation group had significantly higher body mass index (30.9 vs 27.4 kg/m, P < 0.001), presence of umbilical scar (20.9% vs 5.3%, P < 0.001), umbilical hernia (82.9% vs 8.5% P < 0.001), ventral hernia (23.9% vs 1.7%, P < 0.001), and rectus diastasis (10.3% vs 2.6%, P = 0.016). There were no significant differences of smoking, diabetes mellitus, hypertension, prior abdominal surgery, or midline abdominal scar. The umbilical ablation group had a significantly lower rate of postoperative abdominal wound dehiscence and skin loss (11.1% vs 22.2%, P = 0.023) and overall donor site complications (24.8% vs 39.3%, P = 0.017). There was no significant difference in incidence of cellulitis, seroma, or abscess. Mean follow-up time was 1.8 years. CONCLUSIONS: Selective umbilical ablation in high-risk patients at the time of abdominal flap harvest can result in significantly fewer donor site wound complications, even in the setting of increased risk factors for poor wound healing. This is likely due to avoidance of umbilical incisions and decreased upper abdominal skin undermining. We conclude that umbilical ablation is a viable option to minimize donor site complications, especially in high-risk patients.

The Chemistry of Cold: Mechanisms of Torpor Regulation in the Siberian Hamster.

Siberian hamsters use spontaneous daily torpor, a state of hypometabolism and hypothermia, to save energy during winter. Multiple neuroendocrine signals set the scene for spontaneous torpor to occur, and several brain areas have been identified as potential sites for torpor regulation. Here, we summarize the known mechanisms of a fascinating physiological state in the Siberian hamster.

Thyroid hormone status affects expression of daily torpor and gene transcription in Djungarian hamsters (Phodopus sungorus).

Thyroid hormones (TH) play a key role in regulation of seasonal as well as acute changes in metabolism. Djungarian hamsters (Phodopus sungorus) adapt to winter by multiple changes in behaviour and physiology including spontaneous daily torpor, a state of hypometabolism and hypothermia. We investigated effects of systemic TH administration and ablation on the torpor behaviour in Djungarian hamsters adapted to short photoperiod. Hyperthyroidism was induced by giving T4 or T3 and hypothyroidism by giving methimazole (MMI) and sodium perchlorate via drinking water. T3 treatment increased water, food intake and body mass, whereas MMI had the opposite effect. Continuous recording of body temperature revealed that low T3 serum concentrations increased torpor incidence, lowered Tb and duration, whereas high T3 serum concentrations inhibited torpor expression. Gene expression of deiodinases (dio) and uncoupling proteins (ucp) were analysed by qPCR in hypothalamus, brown adipose tissue (BAT) and skeletal muscle. Expression of dio2, the enzyme generating T3 by deiodination of T4, and ucps, involved in thermoregulation, indicated a tissue specific response to treatment. Torpor per se decreased dio2 expression irrespective of treatment or tissue, suggesting low intracellular T3 concentrations during torpor. Down regulation of ucp1 and ucp3 during torpor might be a factor for the inhibition of BAT thermogenesis. Hypothalamic gene expression of neuropeptide Y, propopiomelanocortin and somatostatin, involved in feeding behaviour and energy balance, were not affected by treatment. Taken together our data indicate a strong effect of thyroid hormones on torpor, suggesting that lowered intracellular T3 concentrations in peripheral tissues promote torpor.

Modification of the Labbé Procedure: Integration of the Deep Temporalis Fascia Turnover Flap.

Modification of the lengthening temporalis myoplasty for reanimation of facial paralysis is presented. A patient experienced traumatic laceration of the left facial nerve resulting in left hemifacial paralysis. Multiple attempts at nerve repair were unsuccessful. For smile restoration, a Labbé procedure was performed. Because of inadequate length, the temporalis tendon could not be directly secured to the modiolus. Therefore, an inferiorly based temporalis fascia flap was recruited from the deep temporal fascia and reflected inferiorly to provide additional length by which the tendon could be secured to the modiolus. This technique provided immediate smile restoration and required no additional donor site.

Torpor expression in juvenile and adult Djungarian hamsters (Phodopus sungorus) differs in frequency, duration and onset in response to a daily cycle in ambient temperature.

In addition to morphological and physiological traits of short-day acclimatisation, Djungarian hamsters (Phodopus sungorus) from Central Asia exhibit spontaneous daily torpor to decrease energy demands during winter. Environmental factors such as food scarcity and low temperatures have been shown to facilitate the use of this temporal reduction in metabolism and body temperature. We investigated the effect of a daily cycle in ambient temperature on short-day acclimation and torpor expression in juvenile and adult Djungarian hamsters. The animals were exposed to a cold dark phase (6°C) and a warmer light phase (18°C) and were compared with control hamsters kept at a constant ambient temperature of 18°C. Under constant conditions, torpor expression did not differ between adult and juvenile hamsters. Although the daily temperature cycle evoked an increased metabolic rate in adult and juvenile hamsters during the dark phase and strengthened the synchronization between torpor entrance and the beginning of the light phase, it did not induce the expected torpor facilitation. In adult hamsters, torpor expression profiles did not differ from those under constant conditions at all. In contrast, juvenile hamsters showed a delayed onset of torpor season, a decreased torpor frequency, depth and duration, as well as an increased number of early torpor terminations coinciding with the rise in ambient temperature after the beginning of the light phase. While the temperature challenge appeared to be of minor importance for energy balance and torpor expression in adult hamsters, it profoundly influenced the overall energy saving strategy of juvenile hamsters, promoting torpor-alleviating active foragers over torpor-prone energy-savers. In addition, our data suggest a more efficient acclimation in juvenile hamsters under additional energy challenges, which reduces the need for torpor expression.

Beyond the Breast: Body Contouring in the Context of Abdominally Based Microsurgical Breast Reconstruction.

With continued advances in abdominally based microsurgical breast reconstruction, the operative goal is no longer the creation of a simple breast mound but rather the formation of an aesthetically pleasing breast. While a substantial body of work has been dedicated to accomplishing this result, a similar progression has yet to be reflected in the literature with regard to the contour and shape of the abdominal donor site. Operative advances including muscle, fascial, and nerve preservation have been effective in minimizing the physiologic donor site morbidity of this procedure but have focused less on its cosmesis. Additionally, the published techniques aimed at the aesthetics of the abdomen have focused on the initial procedure and have not utilized the multistage process of breast reconstruction. In this paper, we will describe our approach to optimize the aesthetic result of the abdomen in abdominally based microsurgical breast reconstruction.

Economic analysis and review of the literature on implant-based breast reconstruction with and without the use of the acellular dermal matrix.

BACKGROUND: Use of the acellular dermal matrix (ADM) in two-stage implant-based breast reconstruction has been widely adopted. Despite an increasing focus on health care costs, few reports have addressed the financial implications of ADM use. This study sought to examine the costs of the two-stage technique with and without ADM, concentrating on the direct variable costs of patient care during the expansion process. METHODS: A retrospective review of a prospectively maintained database was conducted. Data were collected on 132 cases resulting in a second-stage exchange for a permanent implant. The findings showed that AlloDerm was used in 61 reconstructions and Strattice in 23 reconstructions. The primary outcome was the number of fills required to achieve the final expander fill volume. The cost of subsequent patient encounters for expansion was estimated using institutional cost data. RESULTS: The number of fills required to achieve the final volume was higher in the non-ADM group (6.5 ± 1.7) than in the ADM group (3.6 ± 1.4) (p < 0.0001). No significant difference was found in the small fill volumes (<350 ml; 5.3 vs. 3.7; p > 0.05). The difference was significant in the larger fill volumes (>500 ml; 8.3 vs. 3.7; p < 0.05). Relative to non-ADM reconstruction, with AlloDerm at current prices, the cost increase ranged from $2,727.75 for large reconstructions to $3,290.25 for small reconstructions ($2,167.75-$2,739.25 with Strattice). CONCLUSION: The use of ADM in two-stage reconstruction reduces the number of visits required for reconstructions with 350 ml or more. However, at current pricings, the direct cost of ADM use does not offset the cost savings from the reduced number of visits. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Branding a Plastic Surgery Group Practice: A Case Study.

BACKGROUND: You only get one opportunity to make a first impression. In today's era, that first impression is frequently a digital one. The authors' old digital brand "face" was stale and not a true representation of how they view themselves as a practice. In an evolving arena of competition and surgical scope, the authors felt compelled to engage in rebranding their practice. METHODS: This article details the steps the authors took to launch a new website, generate collateral branded material, and execute a social media marketing plan. The authors attempt to keep the outline general enough to be applicable to the range of practice types of the Journal 's readership, and present relevant results of the process. RESULTS: Samples of "creative" products are shown. Quantifiable outcomes were direct website traffic (91% increase), website sessions (82% increase), unique users (55% increase), page views (118% increase), and time spent browsing (100% increase). The authors experienced a 21% increase in new patient volume and a similar increase in total cases performed. CONCLUSIONS: This article outlines steps the authors took to rebrand their practice in the face of current challenges in the plastic surgery landscape and how prospective patients seek surgeons. Benchmarking the steps of a successful branding process is crucial and informative to developing and executing a plan. Although there are many potential contributors to the growth of a practice, the impact of our branding appears to be a significant factor.

Post-Breast Surgery Pain Syndrome: Shifting a Surgical Paradigm.

Post-mastectomy pain syndrome and the less well-described post-breast surgery pain syndrome are long-term neuropathic pain conditions that may affect more than 50% of patients after mastectomy and breast surgery. While the etiology, risk factors, and management have been reviewed in our literature, we offer here a focused outline that will gear the plastic surgeon with tools to lead a multidisciplinary, algorithmic approach to the care of patients with post-mastectomy pain syndrome/post-breast surgery pain syndrome. After reading this article, we hope the reader will have improved awareness of post-mastectomy pain syndrome/post-breast surgery pain syndrome, and thus be able to incorporate appropriate treatments and preventative steps into their primary surgical routine.

Incidence, Impact, and Management of Incidentalomas on Preoperative Computed Tomographic Angiograms for Breast Cancer Patients with and without Genetic Mutations.

BACKGROUND: Preoperative abdominal computed tomographic angiograms for free flap breast reconstruction improve operative safety and efficiency, but incidental findings are common and potentially affect management. In addition, the authors hypothesized that patients with genetic mutations might have a higher rate of significant findings. The authors present the largest series of computed tomographic angiogram "incidentalomas" in these two populations and an evidence-based algorithm for managing common findings. METHODS: All patients undergoing free flap breast reconstruction at Northwell Health between 2009 and 2017 were eligible. Medical history, perioperative details, and radiology reports were examined with abnormal findings recorded. Published literature was reviewed with radiologists to develop standardized guidelines for incidentaloma management. RESULTS: Of 805 patients included, 733 patients had abdominal imaging. One hundred ninety-five (27 percent) had a completely negative examination. In the remaining 538 patients, benign hepatic (22 percent) and renal (17 percent) findings were most common. Sixteen patients (2.2 percent) required additional imaging (n = 15) or procedures (n = 5). One finding was concerning for malignancy-renal cell carcinoma-which interventional radiology ablated postoperatively. Seventy-nine patients (10.8 percent) had a genetic mutation but were not found to have a statistically significant higher rate of incidentalomas. CONCLUSIONS: The authors' rate of computed tomographic angiography incidental findings (73 percent) is consistent with previous studies, but the rate requiring further intervention (2.2 percent) is lower. Incidental findings were no more common or pathologic among genetic mutation carriers. The authors also introduce an evidence-based algorithm for the management of common incidentalomas. Using these guidelines, plastic surgeons can reassure patients, regardless of mutation status, that incidentalomas are most commonly benign and have minimal impact on their surgical plan.

The safest method of sternal wire extraction post-midsternotomy closure.

BACKGROUND: An incident of fatal pericardial bleeding immediately after the extraction of a sternal wire prompted a search for the most appropriate method for removing sternotomy wire sutures. A model sternum was devised to explore this problem, and several commonly used techniques for wire extraction were evaluated. METHODS: A wooden sternal model was constructed to simulate the dimensional properties of a sternum overlying the mediastinal cavity, and to imitate its tensile characteristics. A Monofil CrNi-316L (Johnson & Johnson, Brunswick, NJ, USA), No. 7 CCS, 9 metric, 4x45-cm wire was passed vertically through drilled holes. The suture was then crossed and pulled, thus joining the two boards and approximating the wire to their deep surface. A latex balloon filled with dye was placed inside under the boards. Wire holders were used to extract the wires, using a linear pulling technique and a coiling around the wire-holder tip technique. Sixty repetitions were performed for each method. RESULTS: In 60 trials of direct linear wire pulling, balloon rupture occurred in 33 (55%), whereas tearing was noted only 15 times out of 60 attempts (25%) when the tense coiling method was used. CONCLUSIONS: Sternotomy wire sutures should be extracted using a controlled technique that ensures safety to vital tissues in close proximity to the sternal bone. The tense coiling procedure offers superior safety when compared to the direct pulling process, demonstrated by a lower incidence of balloon rupture because of the lesser degree of wire flexure. This technique has become the method of choice in our medical center.

Detection of alpha1 integrin in urine of patients with immunoglobulin A nephropathy.

BACKGROUND: The alpha1beta1 integrin is a cell surface membrane heterodimer composed of noncovalently linked alpha1 and beta1 polypeptides that is up-regulated on activated and proliferating mesangial cells. METHODS: A double-sandwich enzyme-linked immunosorbent assay that detects alpha1 integrin in a specific and dose-dependent manner at concentrations greater than 150 ng/mL was used to evaluate whether intact alpha1 polypeptides are secreted in the urine samples of 29 patients with various kidney diseases and in those of 5 healthy individuals. RESULTS: alpha1 Integrin was detected in 8 of the 29 patients including 3 of 3 patients with biopsy-proven immunoglobulin A nephropathy and 3 of 3 clinically suspected but non-biopsy-proven immunoglobulin A nephropathy with evidence of active nephritis. No alpha1 integrins were found in samples of 5 healthy controls. CONCLUSIONS: alpha1 Integrin polypeptides can be detected in human urine, particularly in immunoglobulin A nephropathy. Further extensive studies are required to clarify the significance of secretion of alpha1 integrins in urine of patients with kidney disease.

Gene expression analysis and microdialysis suggest hypothalamic triiodothyronine (T3) gates daily torpor in Djungarian hamsters (Phodopus sungorus).

Thyroid hormones play an important role in regulating seasonal adaptations of mammals. Several studies suggested that reduced availability of 3,3',5-triiodothyronine (T3) in the hypothalamus is required for the physiological adaptation to winter in Djungarian hamsters. We have previously shown that T3 is involved in the regulation of daily torpor, but it remains unclear, whether T3 affects torpor by central or peripheral mechanisms. To determine the effect of T3 concentrations within the hypothalamus in regulating daily torpor, we tested the hypothesis that low hypothalamic T3 metabolism would favour torpor and high T3 concentrations would not. In experiment 1 gene expression in torpid hamsters was assessed for transporters carrying thyroid hormones between cerebrospinal fluid and hypothalamic cells and for deiodinases enzymes, activating or inactivating T3 within hypothalamic cells. Gene expression analysis suggests reduced T3 in hypothalamic cells during torpor. In experiment 2, hypothalamic T3 concentrations were altered via microdialysis and torpor behaviour was continuously monitored by implanted body temperature transmitters. Increased T3 concentrations in the hypothalamus reduced expression of torpor as well as torpor bout duration and depth. Subsequent analysis of gene expression in the ependymal layer of the third ventricle showed clear up-regulation of T3 inactivating deiodinase 3 but no changes in several other genes related to photoperiodic adaptations in hamsters. Finally, serum analysis revealed that increased total T3 serum concentrations were not necessary to inhibit torpor expression. Taken together, our results are consistent with the hypothesis that T3 availability within the hypothalamus significantly contributes to the regulation of daily torpor via a central pathway.