Contemporary Aspects of Burn Care.

The past one hundred years have seen tremendous improvements in burn care, allowing for decreased morbidity and mortality of this pathology. The more prominent advancements occurred in the period spanning 1930-1980; notably burn resuscitation, early tangential excision, and use of topical antibiotic dressings; and are well documented in burn literature. This article explores the advancements of the past 40 years and the areas of burn management that are presently topics of active discussion and research.

A Step Forward Toward the Understanding of the Long-Term Pathogenesis of Double Capsule Formation in Macrotextured Implants: A Prospective Histological Analysis.

BACKGROUND: Although increasingly reported in the literature, most plastic surgeons cannot define the etiology of double capsules. Often an incidental finding at implant exchange, double capsules are frequently associated with macrotextured devices. Several mechanisms have been proposed, including at the forefront that shearing causes a delamination of the periprosthetic capsule into a double capsule. OBJECTIVES: This study was designed to confirm the hypothesis that mechanical forces are involved in formation of double capsules by histological analysis. METHODS: A prospective analysis of consecutive implants with double capsules removed over 2 years was performed. Data collected at the time of surgery included Baker classification, reason for explant, implant manufacturer and style, and any presence of a seroma associated with the capsule. Specimens were sent for analysis by histology utilizing hematoxylin and eosin and alpha-smooth muscle actin staining techniques. RESULTS: Eight double capsules were collected for specimen analysis. All capsules demonstrated evidence of granulation tissue, alpha-smooth muscle actin positive myofibroblasts, and folds with embedded texture. Fibrosis surrounded weak areas with presence of layering and splitting, creating a potential space that is prone to separation. Tears and folds from granulomatous reaction are also present within the outer layer of the double capsule, which can only be explained by a mechanical shearing force as a pathogenic mechanism. CONCLUSIONS: Understanding the pathogenesis of double capsules may allow plastic surgeons to refine their indications for macrotextured implants while providing guidance to patients on avoidance of activities that produce shear-forces. The findings support the hypothesis that shearing forces delaminate the capsule into 2 separate distinct capsules.

Gynecomastia: Simultaneous Subcutaneous Mastectomy and Areolar Reduction with Minimal Inconspicuous Scarring.

Acceptable scar positioning on the anterior male chest is very limited. In Gynecomastia surgery, an obvious areolar incision is the most sensitive indicator of a previous operation; a less apparent scar is indispensable for the patient's psychological satisfaction. Whenever only areolar diameter reduction is required, the circumareolar incision must be performed in a position leaving the least conspicuous scar. Standard excision of an outer doughnut of areolar skin results in a visible and unnatural peri-areolar scar. The peri-nipple excision of areolar skin leaves the skin-areola junction undisturbed. When combined with a transverse areolar infra-nipple incision, access for subcutaneous mastectomy is facilitated. With this approach, risk of nipple vascular compromise is thought to be reduced, and necrosis of areolar pigmented skin virtually impossible. EBM LEVEL V: 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.

Staged Mastopexy Before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Implant-Based and Autologous Breast Reconstruction.

BACKGROUND: Breast reconstruction following nipple sparing mastectomy in patients with large or ptotic breasts remains challenging because of the risk of ischemic complications and the difficulty in managing the redundant skin envelope. Staged mastopexy or breast reduction before the mastectomy/reconstruction has been shown to decrease the risk of complications and improve clinical outcomes. METHODS: A retrospective analysis was conducted of patients with a genetic predisposition to breast cancer who underwent staged breast reduction/mastopexy before nipple sparing mastectomy and reconstruction in our institution. In patients with in situ disease or invasive cancer, the first stage consisted of lumpectomy and oncoplastic reduction/mastopexy. Breast reconstruction at the second stage was performed with free abdominal flaps or breast implants and acellular dermal matrix. Data regarding the ischemic complications were recorded. RESULTS: In total, 47 patients (84 breasts) underwent this staged approach. All patients had a genetic predisposition to breast cancer. The time interval between the two stages was 11.5 months (range, 1.3 to 23.6 months). Twelve breasts (14.3 percent) were reconstructed with free abdominal flaps, 6 (7.1 percent) with tissue expanders and 66 (78.6 percent) with permanent subpectoral implants and acellular dermal matrix. There was one postoperative superficial nipple areolar complex epidermolysis (1.2 percent), and two partial mastectomy skin flap necrosis (2.4 percent). The mean follow-up time after completion of reconstruction was 8.3 months. CONCLUSION: Mastopexy or breast reduction before nipple sparing mastectomy and reconstruction is a safe procedure with a low risk of ischemic complications.

Anatomical Study of the Penile Suspensory System: A Surgical Application to Micropenis.

Penile enlargement surgery is the second most desired cosmetic procedure in men worldwide. The mainstay of penile lengthening procedures is a partial release of the penile suspensory ligament system. Concerns regarding erect penis stability after this procedure have been raised by the surgical community. This study describes the anatomical features of the penile suspensory ligament system and explores the stability mechanisms of the penis. Methods: This study is subdivided in two parts: an anatomical analysis and a clinical analysis. The anatomical part consists of a dissection of eight male cadavers to describe the anatomy and test the stability after sectioning successively the suspensory ligaments. The clinical part consists of an analysis of 30 patients with micropenis operated on for penile lengthening by a penile suspensory ligament release and lipofilling. Results: The suspensory apparatus consists of four distinct ligamentous structures: fundiform, suspensory, dense vertical, and arcuate ligaments. These different structures are lax superficially but become firm and tense posteriorly. The section of the fundiform and suspensory ligaments did not destabilize the penis. Conclusion: Penile lengthening by way of cautious suspensory ligament release can be performed without erection instability.

Preliminary Results Supporting the Bacterial Hypothesis in Red Breast Syndrome following Postmastectomy Acellular Dermal Matrix- and Implant-Based Reconstructions.

Acellular dermal matrices have become a mandatory tool in reconstructive breast surgery. Since their introduction, they have been considered to be nonreactive and nonimmunogenic scaffolds. However, some patients who undergo implant-based breast reconstruction with acellular dermal matrices develop postoperative cutaneous erythema overlying their matrices, a condition commonly referred to as red breast syndrome. The aim of this study was to gain a better understanding of this phenomenon. An analysis was conducted on consecutive patients who underwent acellular dermal matrix- and implant-based breast reconstructions and developed red breast syndrome that was treated surgically between April of 2017 and June of 2018 at the authors' institution. During surgery, 1-cm specimens of acellular dermal matrix were sampled and analyzed by scanning electron microscopy. Observations were charted to score and record the presence and thickness of biofilm, and for identification of bacteria. These measurements were performed using Adobe Photoshop CS6 Extended software. Six postmastectomy breast reconstruction patients were included, all with AlloDerm Ready-to-Use-based reconstructions. All specimens were colonized by various bacteria ranging from Gram-negative bacilli to Gram-positive microorganisms. Biofilm was present in all studied specimens. The cause of skin erythema overlying acellular dermal matrix grafts, and the so-called red breast syndrome, may be related to contamination with various bacteria. Although contamination was omnipresent in analyzed samples, its clinical significance is variable. Even if acellular dermal matrix-based reconstructions are salvaged, this could come at the price of chronic local inflammation.