Serpin-loaded extracellular vesicles promote tissue repair in a mouse model of impaired wound healing.

Chronic metabolic diseases such as diabetes are characterized by delayed wound healing and a dysregulation of the inflammatory phase of wound repair. Our study focuses on changes in the payload of extracellular vesicles (EVs) communicating between immune cells and stromal cells in the wound bed, which regulate the rate of wound closure. Adoptive transfer of EVs from genetically defined mouse models are used here to demonstrate a functional and molecular basis for differences in the pro-reparative biological activity of diabetic (db/db) vs. wildtype EVs in wound healing. We identify several members of the Serpin family of serine protease inhibitors that are absent in db/db EVs, then we overexpress Serpin A1, F2 and G1 in EVs to evaluate their effect on wound healing in db/db mice. Serpins have an important role in regulating levels of elastase, plasmin and complement factors that coordinate immune cell signaling in full thickness wounds in a diabetic model. Here, we establish a novel therapeutic approach by engineering the payload of EVs based on proteomic analysis. Serpin-loaded EVs were used to rescue the Serpin deficiency identified by proteomics and promote wound healing in db/db mice, as well as evaluated how EVs affected extracellular matrix remodeling and the resolution of tissue injury. Therefore, we propose that the identification of EV payloads that are downregulated in diabetic wounds can be systematically analyzed for their functional activity and potential as a therapeutic, based on whether their re-expression in engineered EVs restores normal kinetics of tissue repair in chronic wounds.

Osteogenesis Modulation: Induction of Mandibular Bone Growth in Adults by Electrical Field for Aesthetic Purposes.

BACKGROUND: A new technique in plastic surgery termed Osteogenesis Modulation is described. This technique uses a surgically implanted, battery-operated medical device to deliver customized electrical pulses to produce mandibular bone growth. This device was designed to be a temporary, nonpermanent implant. The purpose of this study was to review both the safety and efficacy of Osteogenesis Modulation. METHODS: This study comprises two phases. Phase I involved experimental technology development and animal experiments. Phase II included technology development for clinical use and a clinical trial. In Phase II, four patients with a diagnosis of mandibular hypoplasia and microgenia underwent surgical implantation of the novel medical device over the chin bone. Once a satisfactory change of contour of mandibular bone was achieved, the devices were removed. In all patients, the devices were left in place for 12 months, then surgically removed under local anesthesia. Preoperative and long-term postoperative cephalometric controls were done. RESULTS: In all patients, symmetrical mandibular bone growth was observed with good-to-excellent aesthetic results. The overall follow-up period was 39 months. Cephalometric controls taken 3 to 6 months after the device removal showed an average increase in mandible length of 5.26mm (range, 2.83-7.60mm) CONCLUSIONS: Preliminary clinical results suggest that Osteogenesis Modulation is a safe, minimally invasive, and effective alternative treatment for the correction of mandibular hypoplasia in selected cases. 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 .

Standardized Anatomic and Regenerative Facial Fat Grafting: Objective Photometric Evaluation 1 to 19 Months After Injectable Tissue Replacement and Regeneration.

BACKGROUND: A standardized technique for facial fat grafting, injectable tissue replacement and regeneration (ITR2), incorporating new regenerative approaches, was developed to address anatomic volume losses in superficial and deep fat compartments as well as skin aging. OBJECTIVES: The aim of this study was to track the short- and long-term effects of facial fat grafting by ITR2 in the midfacial zone over 19 months. METHODS: Twenty-nine females were analyzed for midfacial volume changes after autologous fat transfer with ITR2 with varying fat parcel sizes. Volumes were evaluated with an imaging system to calculate differences between a predefined, 3-dimensional midfacial zone measured preoperatively and after fat grafting. RESULTS: Patient data were analyzed collectively and by age (<55 and >55 years). Collective analysis revealed a trend of initial volume loss during Months 1 to 7 followed by an increase during Months 8 to 19, averaging 56.6% postoperative gain, and ending at an average of 52.3% gain in volume by 14 to 19 months. A similar trend was observed for patients <55 years of age, with a 54.1% average postoperative gain and a greater final average of 75.2%. Conversely, patients >55 years of age revealed a linear decay from 60.6% to 29.5%. Multiple regression analysis revealed no statistically significant influence of weight change throughout the study. CONCLUSIONS: A dynamic change in facial volume was observed, with an initial decrease in facial volume followed by a rebound effect, by 19 months after treatment, of improved facial volume regardless of the amount of fat injected. Volume improvement was greater in patients <55 years old, whereas in patients >55 years old, volume gradually decreased. This study represents the first time that progressive improvement in facial volume has been shown 19 months after treatment.

Disparity in Opportunities: Is It Harder to Match Into Plastic Surgery Residency Without a Home Plastic Surgery Division?

ABSTRACT: Medical students pursuing plastic surgery training must overcome multiple challenges to successfully match in such a highly coveted subspecialty. This adversity is amplified in applicants from medical schools without a home plastic surgery residency program and academic division. There is a paucity of data on the advantage of medical students applying from an institution with a home residency program. Applicant data from the past 5 years were accessed from the Association of American Medical Colleges Electronic Residency Application Services statistics form. Individual home programs of successfully matched applicants were collected from plastic surgery residency websites. A survey was distributed to 32 students pursuing specialty residencies from home medical schools without a plastic surgery residency. Evaluation of a subset of incoming plastic surgery interns revealed that 72% of matched applicants attended home medical institutions with plastic surgery residency programs. Seventy-seven percent of survey respondents felt strongly that students at institutions with home residency programs had a significant advantage. The current COVID pandemic is changing the landscape of subinternships and bringing to light the disadvantage students face without home residency programs. The development of virtual subinternships, online mentorship, and selection of students for subinternships from geographic areas without home programs may help address some disparities in educational opportunities. Continuing these virtual programs and offering preferential help to disadvantaged medical students permanently is an avenue for the field of plastic surgery to be a leader in diversity and inclusion.

Rectovaginal Fistula Repair 1 Year Later: Lessons Learned.

INTRODUCTION: Rectovaginal (RV) fistulas are notoriously difficult to treat. Various methods for repair exist, and refinements in techniques can lead to "successful" outcomes. Review of the literature demonstrates that outcomes studies are scarce and mostly limited to comments on closure rate. We have experienced "success" in our own series with 100% closure rate, regardless of fistula etiology and comorbidities (radiation, inflammation, etc). However, long-term outcomes, including various complications and quality of life changes, have previously been underreported. METHODS: Critical analysis of various outcomes after fistula repair in 14 patients was performed. Patients were surveyed and interviewed with regard to problems before and after fistula repair to obtain objective data focusing on their experience and outcomes. Conclusions are based on physician assessment and patient surveys 1 year after fistula repair and at least 6 months after ostomy reversal and are discussed within the context of data from the literature. RESULTS: Overall satisfaction rate after repairs was high. All patients would undergo attempt at repair again regardless of complications or functional changes (not present before repair). After repair, sexual dyspareunia affected 5 patients (36%); however, most abstained from sexual activity when their RV fistula became apparent. No patient admitted to dyspareunia before the development of their RV fistula. Anal sphincter and defecation function, as well as stool continence, were judged by surgeons and patients uniformly as adequate. However, 3 patients (21%) complained of intermittent problems with urination. A new/different type of pain affected 2 of 4 patients with Crohn disease. One of these patients subsequently developed a new postsphincteric RV fistula. Another patient noted new intermittent vaginal discharge after ostomy reversal, and magnetic resonance imaging suggested a residual fistula, which was not seen on follow-up sigmoidoscopy and "Blue Dye Test." CONCLUSIONS: We previously reported on algorithms for repair and refinements in techniques for "successful" repair of RV fistulas with zero recurrence rate. Long-term follow-up indicates, however, that although the overall satisfaction rate after surgery is high, true "success," defined as permanent fistula closure, is not necessarily problem free. Long-term morbidity and the management of other unique sequelae and problems are underreported.

Refining Approaches to Surgical Repair of Rectovaginal Fistulas.

INTRODUCTION: Rectovaginal fistulas are notorious for both their morbidity and their difficulty to treat effectively. A variety of methods for repair has been described; however, there is no consensus on the ideal repair. A better understanding of the anatomical relationship of fistulas to the anal sphincter and detrusor muscles is one of the components necessary to develop an effective treatment plan for repair and preservation of sphincter mechanics. METHODS: A review of the literature was conducted to determine the types of methods typically used by reconstructive surgeons for repair of rectovaginal fistulas. A critical clinical analysis of our series of 10 patients was performed to determine optimal strategies for and pitfalls of repair in the context of recent reports in hopes of refining surgical techniques. RESULTS: Detailed anatomical understanding of the relationship of fistulas to the surrounding sphincter muscles is described. Etiology of the fistula and its anatomical relationship to the surrounding sphincter complex is used to help develop an algorithm for repair. Suprasphincteric fistulas will necessitate a laparotomy for repair, intersphincteric fistulas will often require muscle interposition with recreation of the vaginal and rectal walls, and low/transphincteric fistulas will require local flaps mostly for coverage and repair of the sphincter muscles. CONCLUSIONS: Complex rectovaginal fistulas are both debilitating for the patient and extremely difficult to manage. Plastic surgeons are often involved in such cases only after previous attempts at repair have failed. The success of surgery in treating these patients with rectovaginal fistulas depends on a variety of factors. Unfortunately, the available literature describing these repairs lacks uniform guidance regarding approach to repair. Herein, we attempt to detail the possible anatomical variations of fistulas in relationship to the sphincter muscles to begin the discussion necessary for the development of an algorithm for repair that considers preservation of sphincter mechanism function.

Subclinical Infection of the Silicone Breast Implant Surface as a Possible Cause of Capsular Contracture.

In order to reexamine the possible association between bacterial presence and capsular contracture, 55 silicone devices (mammary implants or tissue expanders) were cultured at the time of their removal from 40 patients. Special culture techniques were used in an attempt to recover bacteria adhering to the smooth-surfaced implant and encased in glycocalyx biofilm. Bacteria were detected on 56% (15 of 27) of implants surrounded by contracted capsules and on 18% (5 of 28) of those without capsular contracture (p < 0.05). Only three implants tested positive using routine plating techniques. The predominant isolate was Staphylococcus epidermidis. The concept that capsular contracture is associated with subclinical infection of silicone implants is supported by this study. With changes in the microbiological technique, bacterial recovery and growth occurs at a frequency greater than previously thought.

The Influence of Patient Exposure to Breast Reconstruction Approaches and Education on Patient Choices in Breast Cancer Treatment.

BACKGROUND: The landscape of surgical and medical management and patient choices for breast cancer treatment changes as breast reconstruction and oncoplastic approaches improve and diversify. Increased access to breast reconstruction, in addition to patient education, influences the breast cancer patient. Therefore, the examination of the possible impact of reconstructive surgery on all stages of the breast cancer management per se seemed timely. METHODS: Plastic surgery consults were arranged for 520 new patients diagnosed with breast cancer (2012-2016) including patients with noninvasive breast cancer but at high risk of further cancer development. To test the plastic surgery impact on patient choices regarding the management of the cancer, a subset of 90 patients was identified to test the plastic surgery impact on patient choices. These patients were referred to plastic surgery, following the first round of consultations by surgical and medical oncologists with only the preliminary oncological management plan defined. After a plastic surgery consultation, but prior to finalization of the overall oncological management plan, they were surveyed on the subject of modification of their personal choices and requests pertaining to their cancer management. RESULTS: In this subset of 90 patients 40 (44%) returned to their surgical or medical oncologist considering changes of the primary management plan after their plastic surgery consultation. Twenty-six (28%) ultimately altered their plan, and the following patient-driven changes were made: mastectomy as opposed to lumpectomy (18 patients [20%]), contralateral prophylactic mastectomy (11 patients [12%]), nipple/areola removal as opposed to nipple/areola sparing suggested by the oncologists (5 patients [6%]), oncoplastic breast reduction as part of lumpectomy (5 patients [6%]), and other modifications (3 patients [3%]). CONCLUSIONS: Decisions for altering the preliminary oncologic plan or choosing a specific alternative (eg, lumpectomy plus radiation vs mastectomy) resulted from patient education on (1) reconstructive options, (2) aesthetic pitfalls and results. and (3) their interfacing with the oncological outcomes. Ultimately, plastic surgeons influence the multispecialty breast cancer management and patient decision-making process. Therefore, oncological literacy for plastic surgeons is essential to provide state-of-the-art breast cancer care and avoidance of suboptimal patient decisions.

The Impact of Residents on Patient Satisfaction.

BACKGROUND: High-quality physician communication is the foundation for achieving high patient satisfaction. Increasing importance is placed on eliciting feedback from patients. However, there have been few studies looking at the impact of resident involvement on patient satisfaction. Our hospital system values the patient's likelihood to recommend the practice as the top marker for patient satisfaction. METHODS: Between May 2016 and December 2016 at University of California, San Diego, all outpatient appointments were randomly mailed Press-Ganey surveys or an eSurvey regarding their experience. The surveys were filtered based on resident participation, and an χ test was performed to assess the impact of residents. An additional aim was to determine the degree to which the impact of resident involvement differed between surgical specialties. Binomial probability was calculated for each specialty using the 'no resident' group as the reference percentage. RESULTS: A total of 73,834 surveys were mailed or sent electronically, and 17,653 surveys were returned (23.9% response rate). Overall, patients expressed high levels of satisfaction with the quality of physician communication. Patients who had residents involved in their care reported a decrease in satisfaction with physician communication and a decrease in the likelihood to recommend the practice (88.7% vs 90.4%, P < 0.001). In the analysis of resident impact by surgical specialty, 9 specialties qualified for analysis. Resident involvement was associated with lower physician communication scores in orthopedic surgery (P = 0.032), otolaryngology (P = 0.015), and vascular surgery (P = 0.01). In all other surgical subspecialties, there was no statistically significant difference between groups. CONCLUSIONS: Overall, patients expressed high levels of satisfaction with the quality of physician communication with and without resident involvement. Resident physician involvement in surgical clinic visits was associated with lower overall patient satisfaction and decreased likelihood of recommending the practice. In addition, we observed that resident involvement was not associated with lower communication scores in most surgical specialties, including Plastic Surgery.

Analysis of Surfing Injuries Presenting in the Acute Trauma Setting.

BACKGROUND AND PURPOSE: Surfing is a rapidly growing major worldwide sport; however, little is understood regarding severe injuries and resulting hospital admissions. This study explores surfing-related injuries in the major surfing hub of San Diego presenting in the acute trauma setting. The purpose of this study is to address the void of information regarding severe surfing injuries in the trauma setting, including injury patterns, associated hospitalization course, and risk factors. Understanding the injury patterns in surfing accidents is crucial for proper management of surfing injuries. METHODS: A retrospective analysis was performed of all surfing-related injuries in a Level 1 trauma center between 2000 and 2016. RESULTS: A total of 93 patients were identified. Body parts most commonly affected include the head (42, 46%), face (21, 22%), and spine (47, 51%). Twenty-eight (30%) patients required surgical intervention, including 19 for spinal injuries, 3 for facial injuries, 4 for upper extremity injuries, and 2 for lower extremity injuries. The distribution for most presentations (55, 59%) occurred in the summer months between July and September. The Injury Severity Score demonstrated strong positive correlation with the length of hospital stay, with a Pearson coefficient of 0.52 (P < 0.01). The average length of hospitalization was 5.8 days, with intensive care unit level care required in 49% (46) patients and average length of intensive care unit stay of 5.5 days. Alcohol content was tested in 84% (78) of patients and found positive in 10% (8) of tested patients. Drug screening was performed in 70% (64) patients and found positive in 38% (24) of tested patients. CONCLUSIONS: Surfing, although a relatively safe sport, is not without major risks. In contrast with other studies, we found a high proportion of head, face, and spine injuries in patients presenting with surfing injuries in the trauma setting, consistent with its presentation as a high velocity and high impact injury. With plastic surgeons often treating severe head and facial injuries, understanding the injury patterns in severe surfing accidents is crucial for proper management. High rates of positive alcohol and drug screening signal the importance to bring awareness to the dangers of surfing under the influence.