Consistent metacommunity structure despite inconsistent drivers of assembly at the continental scale.

A fundamental goal of community ecology is to understand the drivers of community assembly and diversity. Local factors acting on community assembly are typically related to environmental conditions while regional factors are typically related to dispersal. Previous research has not consistently demonstrated the importance of local or regional factors, but this is likely because these factors act in concert and not in isolation. Studies that simultaneously integrate local and regional factors into analyses of community assembly can be a useful avenue to further our understanding of this core concept in community ecology. Here, we aimed to identify metacommunity structure and diversity and the local and regional drivers of community assembly at the continental scale. We evaluated metacommunity structure and drivers of assembly of macroinvertebrate communities in 941 rivers and streams nested within nine ecoregions distributed across the conterminous United States. Pattern-based metacommunity analyses and boosted regression tree techniques were used to (a) assign metacommunity structures and (b) identify the environmental, landscape and network drivers of assembly. We also evaluated how biodiversity scaled across hierarchical levels and varied among ecoregions. Metacommunity structures were consistent for the conterminous United States and each of the nine ecoregion subsets, with each ecoregional metacommunity displaying a Clementsian structure. Environmental variables were the predominant drivers of assembly, suggesting the importance of species sorting and environmental filtering on community structure; however, the identity of the most influential environmental variables differed among ecoregions and suggested hierarchical filtering on assembly. Partitioned diversity was found to be lower at the local and ecoregional levels, but turnover in diversity among ecoregions was higher than expected. Our results demonstrate contingencies in community assembly, notwithstanding consistency in metacommunity structure and support the importance of environmental control over community assembly and biodiversity. Moreover, biodiversity at the continental scale is likely maintained through this inherent variation in the drivers of assembly and concomitant changes in community composition among ecoregions. We suggest that further work should evaluate the assembly of other facets of community structure and the underlying mechanisms of the contingency in assembly drivers.

Brief Report: Human Perivascular Stem Cells and Nel-Like Protein-1 Synergistically Enhance Spinal Fusion in Osteoporotic Rats.

Autologous bone grafts (ABGs) are considered as the gold standard for spinal fusion. However, osteoporotic patients are poor candidates for ABGs due to limited osteogenic stem cell numbers and function of the bone microenvironment. There is a need for stem cell-based spinal fusion of proven efficacy under either osteoporotic or nonosteoporotic conditions. The purpose of this study is to determine the efficacy of human perivascular stem cells (hPSCs), a population of mesenchymal stem cells isolated from adipose tissue, in the presence and absence of NELL-1, an osteogenic protein, for spinal fusion in the osteoporosis. Osteogenic differentiation of hPSCs with and without NELL-1 was tested in vitro. The results indicated that NELL-1 significantly increased the osteogenic potential of hPSCs in both osteoporotic and nonosteoporotic donors. Next, spinal fusion was performed by implanting scaffolds with regular or high doses of hPSCs, with or without NELL-1 in ovariectomized rats (n = 41). Regular doses of hPSCs or NELL-1 achieved the fusion rates of only 20%-37.5% by manual palpation. These regular doses had previously been shown to be effective in nonosteoporotic rat spinal fusion. Remarkably, the high dose of hPSCs+NELL-1 significantly improved the fusion rates among osteoporotic rats up to approximately 83.3%. Microcomputed tomography imaging and quantification further confirmed solid bony fusion with high dose hPSCs+NELL-1. Finally, histologically, direct in situ involvement of hPSCs in ossification was shown using undecalcified samples. To conclude, hPSCs combined with NELL-1 synergistically enhances spinal fusion in osteoporotic rats and has great potential as a novel therapeutic strategy for osteoporotic patients.

One-Stage Augmentation Mastopexy: A Review of 1192 Simultaneous Breast Augmentation and Mastopexy Procedures in 615 Consecutive Patients.

BACKGROUND: Despite the increasing popularity of the combined augmentation mastopexy procedure among patients, the safety and efficacy of this surgery have been questioned by many surgeons. OBJECTIVE: The authors investigated the safety and efficacy of the combined augmentation mastopexy procedure. METHODS: The authors retrospectively reviewed the medical records of 615 consecutive patients who underwent combined augmentation mastopexy procedures at a single outpatient surgery center from 1992 through 2011. Patient demographics, operative and implant details, and long-term outcomes were analyzed. Rates of complications and revisions were calculated. RESULTS: The most common complications were poor scarring (5.7%), wound-healing problems (2.9%), and deflation of saline implants (2.4%). Of the 615 patients evaluated, 104 (16.9%) elected to undergo revision surgery: 54 revision procedures were secondary to implant-related complications, and 50 were secondary to tissue-related complications. Our data compare favorably with previously reported revision rates for breast augmentation alone and mastopexy alone. CONCLUSIONS: With a skilled surgeon and proper patient selection, the combined augmentation mastopexy procedure can be safe and effective. LEVEL OF EVIDENCE: 4.

Epidemiological study of provision of cholecystectomy in England from 2000 to 2009: retrospective analysis of Hospital Episode Statistics.

BACKGROUND: The aim of this study was to report the trends in provision of cholecystectomy in the National Health System in England over the 9 year period from 2000 to 2009 and to determine the major risk factors associated with subsequent poor outcome. METHODS: The Hospital Episode Statistics database was interrogated to identify all cholecystectomy procedures for biliary stone disease in adult patients (>16 years). Multivariate regression analyses were used to identify independent predictors of in-patient death, 1 year death, conversion to open, major bile duct injury (BDI) requiring operative repair, and length of stay. RESULTS: A total of 418,214 cholecystectomy procedures for biliary stone disease were identified. Laparoscopic surgery was used in 348,311 (83.3%) cases and increased by 14.6% over the study period. The in-patient mortality rate (0.2%), 1 year mortality rate (1%), proportion of cases converted to open (5.0%), major BDI rate (0.4%), and mean length of stay (3 days) all decreased over the study period. 52,242 (12.5%) cases were carried out during an emergency admission and uptake has remained stable over the decade. Emergency surgery was more likely to be performed at high-volume centres (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.35-1.44) and specialist units (OR 1.32, 95% CI 1.30-1.35). High-volume centres were more likely to complete emergency cases laparoscopically (OR 1.11, 95% CI 1.05-1.18). Multivariate regression analysis demonstrated that patient- (male gender, increasing age, and comorbidity) and disease-specific (inflammatory pathology and emergency admission) factors rather than hospital institutional characteristics (annual cholecystectomy volume and presence of specialist surgical units) were associated with poorer outcomes. CONCLUSIONS: The provision of laparoscopic cholecystectomy in England has increased. This has been associated with improvements in outcomes such as mortality and length of stay. However, emergency cholecystectomy uptake remains sub-optimal and is more likely to be performed at high-volume or specialist hospitals without adverse outcomes. Further research into the routine provision of emergency cholecystectomy in England is needed in order to optimize patient outcomes.

Restoration and recognition of distant, blurry irises.

Raw iris images collected outdoors at standoff distances exceeding 25 m are susceptible to noise and atmospheric blur and even under ideal imaging conditions are too degraded to carry out recognition with high accuracy. Traditionally, atmospherically distorted images have been corrected through the use of unique hardware components such as adaptive optics. Here we apply a pure digital image restoration approach to correct for optical aberrations. Image restoration was applied to both single images and image sequences. We propose both a single-frame denoising and deblurring approach, and a multiframe fusion and deblurring approach. To compare performance of the proposed methods, iris recognitions were carried out using the approach of Daugman. Hamming distances (HDs) of computed binary iris codes were measured before and after the restoration. We found the HD decreased from >0.46 prior to a mean value of <0.39 for random single images. The multiframe fusion approach produced the most robust restoration and achieved a mean HD for all subjects in our data set of 0.33 while known false matches remained at 0.44. These results show that, when used properly, image restoration approaches do significantly increase recognition performance for known true positives with low increase in false positive detections, and irises can be recognized in turbulent atmospheric conditions.

The clonal origins of dysplasia from intestinal metaplasia in the human stomach.

BACKGROUND & AIMS: Studies of the clonal architecture of gastric glands with intestinal metaplasia are important in our understanding of the progression from metaplasia to dysplasia. It is not clear if dysplasias are derived from intestinal metaplasia or how dysplasias expand. We investigated whether cells within a metaplastic gland share a common origin, whether glands clonally expand by fission, and determine if such metaplastic glands are genetically related to the associated dysplasia. We also examined the clonal architecture of entire dysplastic lesions and the genetic changes associated with progression within dysplasia. METHODS: Cytochrome c oxidase-deficient (CCO⁻) metaplastic glands were identified using a dual enzyme histochemical assay. Clonality was assessed by laser capture of multiple cells throughout CCO⁻ glands and polymerase chain reaction sequencing of the entire mitochondrial DNA (mtDNA) genome. Nuclear DNA abnormalities in individual glands were identified by laser capture microdissection polymerase chain reaction sequencing for mutation hot spots and microsatellite loss of heterozygosity analysis. RESULTS: Metaplastic glands were derived from the same clone-all lineages shared a common mtDNA mutation. Mutated glands were found in patches that had developed through gland fission. Metaplastic and dysplastic glands can be genetically related, indicating the clonal origin of dysplasia from metaplasia. Entire dysplastic fields contained a founder mutation from which multiple, distinct subclones developed. CONCLUSIONS: There is evidence for a distinct clonal evolution from metaplasia to dysplasia in the human stomach. By field cancerization, a single clone can expand to form an entire dysplastic lesion. Over time, this field appears to become genetically diverse, indicating that gastric cancer can arise from a subclone of the founder mutation.

Mechanisms of field cancerization in the human stomach: the expansion and spread of mutated gastric stem cells.

BACKGROUND & AIMS: How mutations are established and spread through the human stomach is unclear because the clonal structure of gastric mucosal units is unknown. Here we investigate, using mitochondrial DNA (mtDNA) mutations as a marker of clonal expansion, the clonality of the gastric unit and show how mutations expand in normal mucosa and gastric mucosa showing intestinal metaplasia. This has important implications in gastric carcinogenesis. METHODS: Mutated units were identified by a histochemical method to detect activity of cytochrome c oxidase. Negative units were laser-capture microdissected, and mutations were identified by polymerase chain reaction sequencing. Differentiated epithelial cells were identified by immunohistochemistry for lineage markers. RESULTS: We show that mtDNA mutations establish themselves in stem cells within normal human gastric body units, and are passed on to all their differentiated progeny, thereby providing evidence for clonal conversion to a new stem cell-derived unit-monoclonal conversion, encompassing all gastric epithelial lineages. The presence of partially mutated units indicates that more than one stem cell is present in each unit. Mutated units can divide by fission to form patches, with each unit sharing an indentical, mutant mtDNA genotype. Furthermore, we show that intestinal metaplastic crypts are clonal, possess multiple stem cells, and that fission is a mechanism by which intestinal metaplasia spreads. CONCLUSIONS: These data show that human gastric body units are clonal, contain multiple multipotential stem cells, and provide definitive evidence for how mutations spread within the human stomach, and show how field cancerization develops.

Patient retention and replacement trends after saline breast implants: are deflations inflationary?

BACKGROUND: This study aimed to examine serial operative trends with patients who have experienced surgical implant deflation. In addition, the economic impact of deflation on practice caseload was analyzed. METHODS: A retrospective review was conducted to examine patients who experienced deflation from 2000 to 2007. Patient demographics, implant data, and the presence of secondary (performed at explantation) or tertiary (performed later) procedures were examined. Financial information was tabulated to determine the economic multiplier effect (i.e. the expected value of revenue from secondary and tertiary procedures divided by explantation cost) of taking on deflation cases in a practice. RESULTS: For this study, 285 patients with an average age of 38.4 years were identified. The average time to explantation was 50 months. Slightly more than half of the patients (55%) had both implants replaced at the time of explantation, whereas 59% switched to silicone implants and 41% continued with saline implants. A larger implant was chosen by 54% of the patients (average increase, 82 ml), whereas 18% underwent secondary procedures at the time of explantation including mastopexy (n = 22), facial rejuvenation (n = 8), liposuction (n = 7), or a combination of the two (n = 8). Tertiary procedures were performed for 31% of the patients after their explantation/reimplantation (average time frame, 13 months). The tertiary procedures included replacement with silicone (33.7%), liposuction (24.7%), abdominoplasty (11.2%), facial rejuvenation (13.5%), or nonsurgical rejuvenation using Botox, Restylane, or laser procedure (33.7%). Economic multiplier analysis showed that the financial impact of revenue derived from implant deflation on downstream practice revenue is 1.02. CONCLUSION: At the time of explantation, replacement with silicone after saline deflation is common (59% of patients). In this study, patients who chose replacement with saline had a significant tendency to replace with silicone (33%) as a tertiary procedure. Saline deflation represents a substantial opportunity for practice development. In particular, it has a positive impact on patient retention for additional aesthetic surgical or nonsurgical procedures. Economic multiplier analysis can be used to quantify the financial impact of saline deflation.

Safe and consistent outcomes of successfully combining breast surgery and abdominoplasty: an update.

BACKGROUND: Combined cosmetic procedures have become increasingly popular. One of the most common combinations of cosmetic procedures includes abdominoplasty and cosmetic breast surgery. The shortened recovery and financial savings associated with combined surgery contribute to the increased demand for these combined surgeries. OBJECTIVE: The goal of this study was to evaluate the safety and efficacy of combined abdominoplasty and breast surgery at a single plastic surgery practice that performs a large volume of these cases. This is an update to a study published in 2006. METHODS: A retrospective review was performed for patients who underwent combined abdominoplasty and cosmetic breast surgery during the last 10 years at a single outpatient surgery center. Abdominoplasty inclusion criteria were defined as lower, mini, full, reverse, or circumferential abdominoplasty. Cosmetic breast surgery inclusion criteria were defined as augmentation, mastopexy, augmentation-mastopexy, reduction, or removal and replacement of implants. Pertinent preoperative and intraoperative data were recorded along with complications and revisions. RESULTS: There were 268 patients during the 10-year period between 1997 and 2007. There were no cases of death, pulmonary embolism, deep venous thrombosis, or other life-threatening complications. The overall complication rate was 34%. Abdominoplasty seroma and scars requiring revision comprised 68% (n = 74) of the complications. The total revision rate was 13%. CONCLUSIONS: Combined abdominoplasty and cosmetic breast surgery was safe and effective in this large series of cases performed at a single plastic surgery practice. The complication and revision rates of the combined surgery were similar to those reported for individually staged procedures.

Should the laparoscopic approach be the norm for appendicectomy in the third trimester of pregnancy?

Our case describes a pregnant woman with acute appendicitis who presented in the third trimester and underwent a laparoscopic appendicectomy. She made a rapid postoperative recovery and the pregnancy was otherwise uncomplicated, ending with a spontaneous vaginal birth at 41 weeks. The diagnosis of acute appendicitis can be unclear in pregnancy. Difficulty in establishing diagnosis due to atypical presentation often leads to delay in surgery, resulting in significant maternal and fetal morbidity and mortality. Surgical intervention should be prompt in cases of suspected appendicitis and the laparoscopic approach is advocated in the first two trimesters. In the third trimester (after 28 weeks), laparotomy is often performed due to the size of the uterus and the theoretical risk of inadvertent perforation with trocar placement. More recently, several authors have described successful outcomes following laparoscopic appendicectomy after 28 weeks and with increasing reassuring data, we suggest that this minimally invasive approach should be considered in managing appendicitis in the third trimester.

Outpatient reduction mammaplasty: an eleven-year experience.

BACKGROUND: In the last 15 years, reduction mammaplasty has been increasingly performed on an outpatient basis. Despite this evolution, few outcome studies have been published regarding outpatient breast reduction surgery. OBJECTIVE: The authors documented clinical outcomes of reduction mammaplasty performed in an outpatient setting over an 11-year period and compared these results with published normative values in the plastic surgery literature. METHODS: A retrospective review was undertaken of 884 reduction mammaplasties in 444 patients at a single outpatient surgical center performed by the senior author (W.G.S.) from 1995 through 2006. In all cases, a laser-assisted, inferior pedicle, Wise pattern, reduction mammaplasty was performed. In addition to demographic and surgical data, complication frequency and type were recorded. Complication data were further stratified into minor and major categories. Potential minor complications included seroma, hematoma, soft tissue infection, dog-ears requiring revision, and small incisional breakdowns or delayed healing of less than 2 cm. Potential major complications included large incisional breakdowns or delayed healing of greater than 2 cm, nipple/areolar necrosis, need for blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, and death. RESULTS: The mean patient age was 38 years (range, 16 to 73 years). Mean body-mass index was 27 (range 17 to 47). The reported preoperative brassiere cup sizes ranged from a 34 C to a 38 K, with a DD being the most common size. The mean preoperative sternal notch-to-nipple distance was 29 cm (range 22 to 54 cm). Forty patients smoked (9%). Mean clinical follow-up was 13 months. Mean total resection weight of breast tissue was 1228 g (range 100 to 5295 g). Mean operative time for reduction mammaplasty was 115 minutes (range 50 to 195 minutes). Nineteen percent of patients underwent multiple procedures, including abdominoplasty, lipoplasty, and facial procedures, with a mean operative time of 132 minutes (range 75 to 345 minutes). The overall complication rate was 14%, with 70 minor complications occurring in 62 patients. Specific minor complications included one seroma, four hematomas, eight soft tissue infections, two of which required a short course of intravenous antibiotics, one patient with dog-ears requiring surgical revision, and 56 small incisional wound breakdowns (< 2 cm). The small incisional breakdowns, which represented the largest group of complications, were further subdivided into 44 minor T-zone wounds, 3 nipple-areolar complex wounds, and 9 wounds of the vertical and horizontal incisions. Three major complications (0.67%) were recorded. Two patients had development of partial nipple/areolar necrosis. A third patient required anticoagulation for a pulmonary embolus diagnosed 10 days after surgery. Statistical analysis of the complication data revealed one significant relationship. Patients with a body mass index above the mean had a 21% complication rate as compared with a 12% rate for those below the mean. Of note, there was no increase in complication rate in the context of multiple procedures. CONCLUSIONS: This retrospective series is the largest to date involving outpatient reduction mammaplasty. Complication data derived from this series are comparable to previously published studies and thus support the safety and efficacy of outpatient reduction mammaplasty performed in an accredited facility.

Clinical experience with a fourth-generation textured silicone gel breast implant: a review of 1012 Mentor MemoryGel breast implants.

BACKGROUND: Since the introduction of fourth- and fifth-generation silicone gel implants, manufacturers have conducted several prospective, multicenter trials to examine their safety and efficacy. However, these studies were not standardized with regard to surgeon skill, pocket placement, operative technique, adjunct therapies, or postoperative management. OBJECTIVE: The purpose of this study was to examine the surgical outcomes of a single surgeon (WGS) in a consecutive series of breast augmentation cases using a fourth-generation cohesive silicone MemoryGel breast implant (Mentor, Santa Barbara, CA). METHODS: A retrospective chart review was conducted to identify all patients who underwent silicone breast augmentation within the Mentor Adjunct Silicone MemoryGel breast implant by a single surgeon (WGS) within a single free-standing outpatient surgical center over a 13-year period (1992 to 2006). For each patient, demographic information, comorbidities, and surgical information (implant size and concomitant surgery) were recorded. In addition, outcomes were analyzed to identify complications and the need for surgical revision. RESULTS: A total of 1012 fourth-generation, textured, cohesive silicone gel implants were placed in 511 patients during the 13-year study period. The overall complication rate per implant was 5.5% (n=56 implants in 43 patients). The most common complication was capsular contracture (n=26; 2.6 %) followed by abnormal scarring (n=11; 1.1%). The overall revision rates per patient and per implant were 8.0% (n = 41 patients) and 6.8% (n = 69 implants), respectively. The average time interval between initial implantation and revision was 18.5 months (range, 2 weeks to 26 months). The most common indication for surgical revision was patient desire for implant size change (n=15 patients) followed by Baker class III or IV capsular contracture (n=13 patients). The presence of previous surgery for capsular contracture was not statistically correlated to the need for revision (P= .326). Age (P= .568), previous history of breast surgery (P= .704), and history of smoking (P= .138) were also not statistically correlated to revision. Placement of the implant in the subglandular position (n=30 implants), however, was statistically correlated with need for revision (P< .01). CONCLUSIONS: Mentor fourth-generation cohesive silicone gel implants possess a complication and revision profile that is superior to earlier-generation silicone gel implants. Implantation with MemoryGel implants, when standardized with regard to surgeon and operative technique, can have significantly reduced complication and revision rates compared to the Mentor Core Data.

Splenic peliosis - a potentially fatal condition which can mimick malignancy.

Isolated splenic peliosis is an extremely rare occurrence, and this disease often manifests itself with spontaneous haemoperitoneum.We report a case where an otherwise healthy patient was found to have splenomegaly on clinical examination. On computerised tomography, a diagnosis of splenic malignancy was made, and the patient underwent a splenectomy. Histological examination gave the diagnosis of splenic peliosis, which had not been considered prior to the operation. In retrospect, splenectomy was the most prudent course of action, as the risk of spontaneous haemorrhage and fatality was eliminated. This case emphasises the need to retain an index of suspicion for this condition, even in otherwise healthy patients, and is a reminder of the usefulness of total splenectomy in the current era of minimally invasive diagnostic techniques.

Mastopexy revisited: a review of 150 consecutive cases for complication and revision rates.

BACKGROUND: Although there is an abundance of data in the literature regarding the safety of breast reduction and augmentation, nearly all of the literature concerning mastopexy describes techniques. There are few studies regarding revision and complication rates for mastopexy procedures. METHODS: A retrospective review was performed on a series of 150 consecutive patients who underwent a mastopexy procedure. Operations were performed by one of two surgeons (W.G.S. or D.A.S.) in an outpatient surgery center over a 6-year period (1999-2005), with an average follow-up of 36 months. Patients were identified as being either primary (no previous breast surgery) or secondary (history of at least one previous breast surgery). The type of mastopexy design was recorded (inverted-T or vertical), and trends were examined. Complication and revision rates were observed, and their rates were calculated. RESULTS: One hundred forty-eight women underwent bilateral and two underwent unilateral mastopexy for a total of 150 women and 298 breasts. There were 119 primary and 31 secondary patients. Mastopexy incision designs were as follows: 86% inverted-T and 14% vertical. There were no major complications. The most common complications were poor scarring (6%) and seroma formation (2.7%). The revision rate was 8.6%; 75% of revisions were for poor scarring. Some of these were performed with the patients under local anesthesia or at the time of a subsequent unrelated surgery. CONCLUSIONS: Our series of 150 consecutive patients, with no major complications and a revision rate of 8.6% over an average of 36 months, indicates that mastopexy may be considered a safe and effective procedure.

Ten years of outpatient abdominoplasties: safe and effective.

BACKGROUND: Abdominoplasty has traditionally been described in the literature as an operation that is performed in a hospital setting, although more recently it is likely that most procedures are performed on an outpatient basis. To date, there have been very few large series illustrating the safety and efficacy of abdominoplasty performed in outpatient surgery centers. OBJECTIVE: This study reports the complications and revisions of outpatient abdominoplasties in a large patient population. METHODS: The charts of 519 consecutive abdominoplasty procedures performed at a single outpatient surgical center over the past 10 years (1996-2006) were reviewed. Follow-up was 6 months to 10 years, with an average of 4.3 years. Mean age at the time of operation was 43 years; range 19 to 74 years. Gender, smoking history, American Society of Anesthesiologists risk score, body mass index, type of abdominoplasty, and concurrent procedures were recorded. Each patient's chart was reviewed to assess complication and revision rates, including deaths, venous thromboembolism events, wound dehiscence, infection, seroma, hematoma, and scarring unacceptable to the patient or surgeon. RESULTS: The most common complication was seroma (10.6%), followed by unacceptable scarring of the abdominal or umbilical incisions (7.9%). The most common reason for revision was abdominal scar revision (6.4%). Most patients had concurrent additional procedures at the time of abdominoplasty, most commonly lipoplasty (91%). There was no statistically significant difference in complications or revisions when comparing groups based on age, body mass index, operating room time, smoking status, full abdominoplasty versus a less complex procedure such as a "mini" or floating umbilical abdominoplasty or simultaneous procedures. Men were significantly less likely to have a complication when compared with women. CONCLUSIONS: This large retrospective study of 519 consecutive abdominoplasty procedures performed on an outpatient basis demonstrates that abdominoplasties may be performed safely and effectively at an accredited outpatient surgery facility.

A review of 100 consecutive secondary augmentation/mastopexies.

BACKGROUND: Simultaneous breast augmentation and mastopexy has historically been a controversial topic, and it has been considered by some to be a difficult and unpredictable procedure. Secondary breast augmentation and mastopexy after previous breast surgery is rarely discussed in the literature, and little is known about the outcomes of these secondary procedures. OBJECTIVE: The authors present the indications, surgical techniques, and outcomes in a series of 100 consecutive secondary simultaneous breast augmentation and mastopexy cases. METHODS: One hundred consecutive patients who underwent secondary combined augmentation mammaplasty and mastopexy from 1992 to 2005 were retrospectively reviewed. The complications and revision rates in this group of patients were analyzed and compared with primary mastopexy alone, as well as with primary combined augmentation and mastopexy. Independent variables such as patient age, history of smoking, body mass index, type and size of implant, and type of mastopexy incision were analyzed for correlation with complication and revision rates. RESULTS: No major complications were noted in an average of 3.5 years follow-up (range 13 months to 13 years). Minor complications occurred in 13 patients, of whom 8 required revision surgery. The most common tissue-related complications were poor scarring (3%) and recurrent ptosis (3%). The most common implant-related complications were infection (3%) and capsular contracture (2%). In addition, 6 patients underwent reoperation for implant size exchange, and 1 patient underwent revision surgery to receive silicone implants. Patient age, history of smoking, body mass index, type and size of implant, type of mastopexy incision, type and number of previous breast surgeries, surgical time, concurrent non-breast operations, and preoperative ptosis grade were not statistically significant risks when correlated to the complication and revision rate. CONCLUSIONS: Simultaneous breast augmentation and mastopexy after previous breast surgery is a commonly performed procedure that is not adequately reported in the literature. Our study indicates that the procedure is safe and has complication and revision rates comparable to primary augmentation/mastopexy.

Is one-stage breast augmentation with mastopexy safe and effective? A review of 186 primary cases.

BACKGROUND: Although some authors have reported that 1-stage breast augmentation with mastopexy does not increase the risks of surgery, recent literature has raised the question of whether better results might be achieved by staging the procedures. OBJECTIVE: The authors evaluated the safety and efficacy of 1-stage breast augmentation with mastopexy in their own patients by analyzing long-term complication and revision rates. METHODS: A retrospective chart review was performed of 186 consecutive patients who underwent primary 1-stage breast augmentation with mastopexy at a single outpatient facility. Patient data recorded included age, body mass index, smoking status, degree of breast ptosis, and any preoperative asymmetry. Operation-related data recorded included type of mastopexy performed, operating surgeon, length of surgery, American Society of Anesthesiologists level, and concomitant procedures. Data on implant type, volume, and position were also collected. Complication and revision rates were recorded and calculated. RESULTS: Ninety-six patients (44%) received saline implants; 104 (56%) received silicone implants. In most cases, textured implants were placed in submuscular pockets. The mean implant volume was 320 cc. Inverted T mastopexy was performed in 60% of cases, circumareolar in 24% of cases, and vertical or crescent accounted for most of the remainder. No severe complications occurred, although 1 patient developed a late infection that required removal of the breast implant. The most common complication was saline implant deflation (5.9%), although saline implants were used in less than half of cases. Thirty-one patients (16.7%) underwent some form of revision surgery within the average 42-month follow-up period. CONCLUSIONS: Our review of 1-stage breast augmentation with mastopexy procedures revealed no severe complications. Although the overall revision rate of 16.7% is significant, it is comparable to rates for breast augmentation alone and is significantly lower than the 100% reoperation rate required for a staged procedure. In our experience, it is a safe and effective procedure, although one that is not easy to perform. Patients should be advised of the possibility that a second procedure may be necessary.

Laser-assisted breast reduction: a safe and effective alternative. A study of 367 patients.

BACKGROUND: Although several studies have been published documenting the safety of laser-assisted breast reduction, they have involved only small numbers of patients. OBJECTIVE: The authors conducted a retrospective chart review of a series of 367 consecutive patients who underwent inferior pedicle laser-assisted breast reduction surgery at a single outpatient facility from 1995 through 2004. METHODS: All patients received appropriate preoperative intravenous antibiotics and had sequential compression devices placed on their lower extremities before induction of anesthesia. Pedicle deepithelialization was performed using a carbon dioxide laser in continuous mode. Following deepithelialization, an inferior pedicle Wise-pattern breast reduction was performed in standard fashion. In approximately 20% of cases, breast reduction was combined with lipoplasty, facial aesthetic surgery, or abdominoplasty. Minor complications assessed included seroma, hematoma, infection, dog-ear, and incisional wound breakdown. Major complications were defined as >25% nipple/areola necrosis, blood transfusion, deep vein thrombosis, pulmonary embolus, myocardial infarction, or death. RESULTS: No major complications were noted in our series. Two patients with infections required short-term hospitalization for administration of intravenous antibiotics. A total of 47 minor complications occurred in 42 patients (11%), including 36 incisional wound breakdowns, 6 infections, 3 hematomas, 1 seroma, and 1 dog-ear revison. The incisional breakdowns included 25 minor T-zone wounds, 2 nipple-areolar complex wounds, and 9 wounds of the vertical and transverse incisions. No inclusion cysts were noted in any patients. CONCLUSIONS: Complication rates for our series of patients who underwent laser-assisted breast reduction surgery were consistent with those reported for non-laser-assisted procedures. These results, combined with the benefits and efficient operating time afforded by laser deepithelialization, indicate that laser-assisted breast reduction surgery can provide an alternative to standard methods of deepithelialization for those surgeons with access to a carbon dioxide laser.

Acceleration of textured saline breast implant deflation rate: results and analysis of 645 implants.

BACKGROUND: Although inflatable saline implants have been in use since 1965, few studies have examined their deflation rates over time. OBJECTIVE: We conducted a retrospective study to analyze the deflation rate for Mentor inflatable Siltex saline implants (Mentor Corp., Santa Barbara, CA) for a period of 5 years following implantation. METHODS: The study group included 645 Siltex inflatable implants placed in 324 patients for primary breast augmentation between 1992 and 1997. The implants were placed by a single surgeon using the same surgical technique. Implant data were obtained from the operative log and patient charts for a 6-year period from 1992 to 1997. All patients were followed for 5 years. RESULTS: The deflation rate of the implants was 0.3% within the first year of implantation, 2.2% within the first 3 years, and 5.3% over 5 years. The rate of spontaneous deflation per implant year was 0.3% at 1 year, 0.7% at 3 years, and 1.0% at 5 years. The deflation rate was lower than the expected deflation rate reported in the manufacturer's product insert data sheet. CONCLUSIONS: The rate of spontaneous implant deflation per year was demonstrated to increase with time. Further studies are needed to ascertain the long-term deflation rates for each type of breast implant.

Does lipoplasty really add morbidity to abdominoplasty? Revisiting the controversy with a series of 406 cases.

BACKGROUND: The popularity of plastic surgery "makeover" television programs has increased interest among the public and the medical community in both the positive and negative aspects of combined surgery procedures. In particular, the safety of combining abdominoplasty with lipoplasty became a matter of concern following multiple deaths in Florida and the consequent moratorium on simultaneous abdominoplasty and lipoplasty enacted by the Florida Board of Medicine. OBJECTIVE: The goal of this study was to evaluate the morbidity of abdominoplasty combined with suction-assisted lipoplasty (SAL) compared to the morbidity of abdominoplasty alone. METHODS: A retrospective review of 406 consecutive abdominoplasty procedures performed by the senior author (W.G.S.) at a single outpatient surgery center was conducted. Cases were sorted into 2 groups: those that had abdominoplasty only and those that had abdominoplasty with SAL. The SAL group was further subdivided into 4 groups based on the volumes of aspirate removed. The primary groups and subgroups were compared with regard to morbidity. In addition, the location of SAL, age, body mass index (BMI) and surgery time of each patient were evaluated as contributing factors to morbidity. RESULTS: No statistically significant differences in complication rates were found when comparing abdominoplasty with SAL to abdominoplasty alone. Additionally, the amount and location of lipoplasty, age, BMI and surgery times did not significantly affect patient morbidity. The prevalence of morbidity in all groups compared favorably to parameters established in previous studies of abdominoplasty and SAL. CONCLUSIONS: This extensive retrospective study provides further evidence that combining abdominoplasty with SAL does not increase patient morbidity compared to abdominoplasty alone.