The Choice of Pulmonary Autograft in Aortic Valve Surgery: A State-of-the-Art Primer.

The Ross procedure has long been seen as an optimal operation for a select few. The detractors of it highlight the issue of an additional harvesting of the pulmonary artery, subjecting the native PA to systemic pressures and the need for reintervention as reasons to avoid it. However, the PA is a living tissue and capable of adapting and remodeling to growth. We therefore review the current evidence available to discuss the indications, contraindications, harvesting techniques, and modifications in a state-of-the-art narrative review of the PA as an aortic conduit. Due to the lack of substantial well-designed randomized controlled trials (RCTs), we also highlight the areas of need to reiterate the importance of the Ross procedure as part of the surgical armamentarium.

Hybrid Three-Dimensional-Printed Ear Tissue Scaffold With Autologous Cartilage Mitigates Soft Tissue Complications.

OBJECTIVES/HYPOTHESIS: To analyze the use of highly translatable three-dimensional (3D)-printed auricular scaffolds with and without novel cartilage tissue inserts in a rodent model. STUDY DESIGN: Preclinical rodent animal model. METHODS: This prospective study assessed a single-stage 3D-printed auricular bioscaffold with or without porcine cartilage tissue inserts in an athymic rodent model. Digital Imaging and Communications in Medicine computed tomography images of a human auricle were segmented to create an external anatomic envelope filled with orthogonally interconnected spherical pores. Scaffolds with and without tissue inset sites were 3D printed by laser sintering bioresorbable polycaprolactone, then implanted subcutaneously in five rats for each group. RESULTS: Ten athymic rats were studied to a goal of 24 weeks postoperatively. Precise anatomic similarity and scaffold integrity were maintained in both scaffold conditions throughout experimentation with grossly visible tissue ingrowth and angiogenesis upon explantation. Cartilage-seeded scaffolds had relatively lower rates of nonsurgical site complications compared to unseeded scaffolds with relatively increased surgical site ulceration, though neither met statistical significance. Histology revealed robust soft tissue infiltration and vascularization in both seeded and unseeded scaffolds, and demonstrated impressive maintenance of viable cartilage in cartilage-seeded scaffolds. Radiology confirmed soft tissue infiltration in all scaffolds, and biomechanical modeling suggested amelioration of stress in scaffolds implanted with cartilage. CONCLUSIONS: A hybrid approach incorporating cartilage insets into 3D-printed bioscaffolds suggests enhanced clinical and histological outcomes. These data demonstrate the potential to integrate point-of-care tissue engineering techniques into 3D printing to generate alternatives to current reconstructive surgery techniques and avoid the demands of traditional tissue engineering. LEVEL OF EVIDENCE: NA Laryngoscope, 131:1008-1015, 2021.

Follicular Unit Excision Punches and Devices.

BACKGROUND: Follicular unit excision (FUE) is used to harvest follicular units for hair transplantation using trephine punches. The characteristics of FUE punches can impact the success of this technique; thus, many innovative punch designs and devices have been developed. With many options available, it can be difficult for the hair restoration surgeon to know which punch best suits the needs of their patients. OBJECTIVE: To provide a comprehensive review of punch shapes and devices available. METHODS: Search of PubMed, reference mining of relevant publications, and hand searching trade publications. RESULTS: We examined FUE punches and devices and consolidated descriptive information for each to create textual and visual guides. No single punch shape or device may suit all cases; thus, it is important to know the best uses and limitations of each. CONCLUSION: The surgeon should have a comprehensive knowledge base of available punch shapes and devices and understand the advantages and disadvantages of each. It is also beneficial to have an in-depth knowledge of skin properties and follicular unit structure. Ultimately, understanding the dynamics behind punch excision will enhance the FUE technique.

Comparison of mitochondrial transplantation by using a stamp-type multineedle injector and platelet-rich plasma therapy for hair aging in naturally aging mice.

The mechanism of hair loss caused by aging is related to mitochondrial dysfunction. Pep-1-mediated mitochondrial transplantation is a potential therapeutic application for mitochondrial disorders, but its efficacy against hair aging remains unknown. This study compared platelet-rich plasma (PRP) therapy with mitochondrial transplantation for hair restoration and examined the related regulation in naturally aging mice. After dorsal hair removal, 100-week-old mice received weekly unilateral injections of 200 µg of allogeneic mitochondria-labeled 5-bromo-2'-deoxyuridine with (P-Mito) or without Pep-1 conjugation (Mito) or human PRP with a stamp-type electric injector for 1 month. The contralateral sides were used as corresponding sham controls. Compared with the control and corresponding sham groups, all treatments stimulated hair regrowth, and the effectiveness of P-Mito was equal to that of PRP. However, histology revealed that only P-Mito maintained hair length until day 28 and yielded more anagen follicles with abundant dermal collagen equivalent to that of the PRP group. Mitochondrial transplantation increased the thickness of subcutaneous fat compared with the control and PRP groups, and only P-Mito consistently increased mitochondria in the subcutaneous muscle and mitochondrial DNA copies in the skin layer. Therefore, P-Mito had a higher penetrating capacity than Mito did. Moreover, P-Mito treatment was as effective as PRP treatment in comprehensively reducing the expression of aging-associated gene markers, such as IGF1R and MRPS5, and increasing antiaging Klotho gene expression. This study validated the efficacy of mitochondrial therapy in the restoration of aging-related hair loss and demonstrated the distinct effects of PRP treatment.

Incorporating Fat Grafting with Facelift Surgery: When, How, and Where.

Facial aging is a multifactorial process with many articles over decades supporting various theories of varying causes. It is generally thought that aging occurs as a combination of changes in skin quality, gravitational descent of tissue with interaction of retaining ligaments on the ptotic tissue, and facial volume loss or the appearance of volume loss. The most significant cause of volume loss is skeletal remodeling and bone loss, which manifests as characteristic shadows and hollows on the face in conjunction with soft tissue changes that are yet to be completely elucidated.

Pedicle frozen autograft-prosthesis composite reconstructions for malignant bone tumors of the proximal femur.

BACKGROUND: Limb salvage surgery is becoming increasingly popular after tumor resection in the lower extremity. Biological reconstruction and use of megaprosthesis are main methods for malignant bone tumors of the proximal femur, which remain controversial due to short- and long-term complication in the proximal femur. Tumor-bearing bone treated by liquid nitrogen is one of biological reconstruction. This study aimed to evaluate the mid- and long-term functional outcomes and complications in patients treated with frozen autograft-prosthesis composite (FAPC) reconstructions in the proximal femur. METHODS: This retrospective study included 19 patients (10 women, 9 men) with malignant tumors of the proximal femur who underwent tumor-wide resection and FAPC reconstruction (mean age, 46 years; range, 9-77 years). The mean follow-up period of 69 months (range, 9-179 months). Functional outcomes, oncological outcome and complications were evaluated by Musculoskeletal Tumor Society score, clinical and radiological examinations. RESULTS: The overall survival rate was 68.4%, and the mean Musculoskeletal Tumor Society functional score was 26.4 points (88%). FAPC survival rates were 100 and 50% at 5 and 10 years, respectively. Five of the 19 patients (26%) had complications: 2 required prosthesis removal and 2 developed a deep infection around acetabular. Wear of the acetabulum occurred in 2 cases, while disease recurrence was occurred in 1 case. There were no cases of greater trochanter avulsion, obvious absorption around frozen bone, prosthesis loosening or leg length discrepancy. CONCLUSIONS: Due to without femoral osteotomy, this technique features satisfactory functional outcome and provide biomechanical stability that is comparable to those of other methods of biological reconstruction or megaprosthesis.

Dermatome-Induced Lacerations: An Unspoken Problem in Burn Surgery.

BACKGROUND: Dermatome-induced lacerations are a known complication; however, there is a paucity of literature discussing the incidence and predisposing factors. The aim of this study was to determine the incidence and risk factors to develop a preventive algorithm. METHODS: An 18-question survey was sent to all US and Canadian burn unit directors. Surgeons were queried about type and location of their practices, average annual caseload of skin graft harvesting, and number of dermatome-induced lacerations. The survey also asked about donor site location, harvesting technique and equipment, laceration severity, and causative factors. An algorithm was developed based on the results. RESULTS: Fifty-six responses (42% response rate) were received from the burn unit directors. They reported an estimated 133 lacerations over the past 5 y. The overall incidence of dermatome-induced lacerations was approximately 0.1% per year (1.3 per 1000 cases). The most commonly attributed causes were excessive pressure (25.0%) and patient factors (18.4%). Most lacerations occurred when using air dermatomes (73.0%) with a 4-inch guard (63.5%), 0.010- to 0.015-inch thickness (78.4%), and 30°-45° angulation (47.3%); the most common brand was Zimmer (71.6%). The dermatome was typically set up by a scrub tech or nurse (48.6%), whereas the skin harvesting was performed by residents (39.2%) or attendings (35.1%). Lacerations typically extended to subcutaneous tissue (70.3%), with no neurovascular injury (86.5%). CONCLUSIONS: Our study showed that dermatome-induced lacerations are rare events and that certain factors predispose patients to injury. An algorithm was developed to provide guidance on risk factor identification and the set up and use of dermatomes.

Simulation of postoperative occlusion and direction in autotransplantation of teeth: application of computer-aided design and digital surgical templates.

Autotransplantation of teeth requires optimisation of both occlusion and direction to ensure minimal injury to the dental crown and the alveolar bone. We describe a method that could simulate postoperative occlusion and direction of the donor tooth by using CAD and digital surgical templates, and evaluate the postoperative effect in five patients who had teeth autotransplanted. Computed tomographic data were imported into ProPlan CMF 3.0 software, the donor tooth was simulated to replace the recipient site according to the position of the occlusion and alveolar bone, and a digital template was designed to guide preparation of the socket. A computer-aided, rapid prototyped, tooth was used to match the socket and, finally, an occlusal template was designed to ensure that the donor tooth was in the simulated position. We compared the position of the tooth in the simulation with its postoperative position using ProPlan CMF 3.0 software. In this way it was possible to simulate and guide the donor tooth accurately to the recipient site. At six-month follow up all teeth had survived successfully. Given the efficiency and precision of placement and the success, we conclude that CAD can successfully help to simulate occlusion and direction in autotransplantation of teeth while simplifying the procedure.

Therapeutic Role of Fat Injection in the Treatment of Recalcitrant Migraine Headaches.

BACKGROUND: This study was designed to assess the safety and efficacy of site-specific fat injection for the treatment of refractory migraine headaches following medical or surgical treatment. METHODS: A prospective cohort study was performed on consecutive patients who had migraine headaches with persistent symptoms after surgical decompression and were given therapeutic fat injections from September of 2012 to January of 2015 with 12 months' minimum follow-up. Clinical outcomes assessment included migraine frequency, intensity, duration, migraine headache index, and complications. A 50 percent or greater decrease in frequency, intensity, or duration was considered therapeutic success, whereas 10 percent or greater increase in migraine headache index was considered worsening of symptoms. Pairwise t tests were used to assess statistical significance (p < 0.05). RESULTS: Twenty-nine patients met inclusion criteria. All were female, with a mean age of 49.0 years (range, 21.5 to 72.5 years), and mean follow-up was 29.4 months (range, 12.3 to 49.5 months). Twenty patients (69.0 percent) experienced successful improvement; 12 (41.4 percent) experienced complete resolution. Five patients (17.2 percent) experienced subtherapeutic improvement, and four (13.8 percent) experienced worsening of symptoms. Mean improvement per patient at their last follow-up was 5.1 (39.3 percent) fewer attacks per month (p = 0.035); 3.1 (42.0 percent) lower intensity on a scale of 1 to 10 (p = 0.001); 31.8 (74.4 percent) fewer hours of duration (p = 0.219); and 52.8 percent lower migraine headache index (p = 0.012). There were no complications for any patient. CONCLUSIONS: Migraine headache symptoms were successfully reduced in the majority of cases with fat injection. A comprehensive surgical treatment algorithm including this novel procedure is presented. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Recombinant Human Bone Morphogenic Protein-2 Combined With Autogenous Bone Graft for Reconstruction of Alveolar Cleft.

Recombinant human bone morphogenic proteins (rhBMPs) have been introduced for reconstruction of alveolar defects. The volume of the bone formed at the cleft region may be related to rhBMP-2 dose. Greater side effects have been reported with increased doses of rhBMP-2. The aim of the present study was to assess the bone at the cleft area using low dose of rhBMP-2 combined with autogenous bone graft for reconstruction of the alveolar cleft. Patients with unilateral cleft lip and palate between the 11 to 14 years old were enrolled. After palatal expansion, autogenous graft was placed at the side of cleft in the control group (n = 6). In the BMP group, the rhBMP-2 was injected into the autogenous bone graft at the defect site (n = 5). Cone beam computed tomography (CBCT) images were taken of all patients immediately and 3 months after graft surgery to compare the density, thickness, and height of the bone graft between the 2 groups. Intermolar and interpremolar widths were also measured. The authors found less diminish of density and height of the bone graft 3 months postsurgery in patients with autogenous bone graft combined with rhBMP-2. However, significant difference in the relapse tendency of transverse dimension of the arch or thickness of the bone graft was not observed between the 2 groups. Thus, low dose rhBMP-2 combined with autogenous bone graft can be promising to reach predictable results after alveolar reconstruction in cleft lip and palate patients.

Anatomic double-bundle medial patellofemoral ligament reconstruction with aperture fixation using an adjustable-length loop device: a 2-year follow-up study.

BACKGROUND: To assess the clinical availability of an adjustable-length loop device for use in the double-bundle technique with aperture fixation at the patella and femur during anatomic double-bundle medial patellofemoral ligament reconstruction (DB-MPFLR) for recurrent patellar dislocation. METHODS: We retrospectively investigated 11 patients (12 knees) with recurrent patellar dislocation who underwent anatomic DB-MPFLR with an ipsilateral semitendinosus tendon autograft. The graft was folded in half, and its central portion was hanged using the adjustable-length loop device. Both free ends of the graft were fixed at the proximal and distal ends of the medial edge of the patella by using suture anchors, and the hanged graft loop was pulled into the femoral tunnel while maintaining equal tension on both bundles. Manual traction of the suture loops was applied to fix the graft appropriately in full range of motion (ROM) of the knee joint under arthroscopic guidance. Clinical outcomes such as re-dislocation, ROM, clinical scores (Kujala score, Lysholm score, and visual analogue scale score for anterior knee pain), and complications were assessed preoperatively and at 2 years postoperatively. Radiographic parameters indicating patellar position, including congruence angle and lateral patellofemoral angle, were measured at 4 different angles of knee flexion (30°, 45°, 60°, and 90°). RESULTS: At 4 different flexion angles of the knee joint, the preoperative congruence angle decreased significantly and the lateral patellofemoral angle increased significantly at the final follow-up (P <  0.001). Notably, the improvements in these angles were maintained with no significant differences at the 4 different flexion angles. None of the patients experienced subluxation or re-dislocation after surgery. The patellar instability symptoms improved, as confirmed on the basis of radiographic and other clinical outcomes. CONCLUSION: New DB technique with aperture fixation at the patella and femur by using an adjustable-length loop device offers high stability with full ROM of the knee joint, can be considered as a feasible procedure and technique for recurrent patellar dislocation.

Massive Traumatic Skin Defect Successfully Treated with Autologous, Bilayered, Tissue-Engineered MyDerm Skin Substitute: A Case Report.

CASE: A 22-year-old man sustained a laceration that measured 180 cm, after debridement, over the anterolateral aspect of the right leg following a road traffic accident. The wound was treated with MyDerm (Universiti Kebangsaan Malaysia), a cell-based, bilayered, bioengineered dermal substitute that contains no animal-derived components and is fully autologous. For its construction, only a small area of skin was harvested from the left groin, which was closed primarily with absorbable sutures. CONCLUSION: MyDerm is an alternative option for the treatment of a massive skin defect in patients who desire removal of only a negligible amount of skin from the donor site and when use of an autograft is insufficient.

Expansion Vibration Lipofilling: A New Technique in Large-Volume Fat Transplantation.

BACKGROUND: Despite rapid growth, gluteal fat transplantation is an operation in search of science and a teachable technique. Long operating times, tedious syringe transfers, inability to shape the recipient site, and the risk of fat embolism all headline as impediments to clinical adoption of the procedure. Expansion vibration lipofilling is a syringe-free surgical strategy that is a logical extension of Separation, Aspiration, and Fat Equalization (SAFELipo). In expansion vibration lipofilling, there is simultaneous disruption of recipient-site connective tissue, internal expansion using exploded-tip cannulas, and backfilling of these spaces with roller pump-propelled fat. METHODS: Two thousand four hundred nineteen consecutive cases of expansion vibration lipofilling fat transplantation to the buttocks were reviewed. Average follow-up was 12 months. The technique of expansion vibration lipofilling is dependent on the use of larger caliber cannulas attached to a roller pump and to an oscillatory power-assisted liposuction device, which is less labor-intensive, potentially allowing for better knowledge of cannula-tip location at all times during the procedure. RESULTS: Operating times averaged 1 hour 40 minutes. The average volume of fat inserted was 1003 cc. Complications included donor-site seroma, infection, and one pulmonary embolism treated with anticoagulation. There were no cases of fat embolism or death. CONCLUSIONS: Expansion vibration lipofilling is a new method for large-volume fat transplantation. Avoidance of fatal fat emboli demands a surgeon's complete knowledge of cannula tip location at all times during the procedure. Syringe-free, larger caliber, and less flexible cannulas, combined with techniques requiring less operator upper extremity effort resulting in less fatigue, may contribute to avoidance of this dreadful complication. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Safest Practices for Autologous Buttock Augmentation With Fat Grafting Using a Roller Pump Injection Technique.

BACKGROUND: Autologous buttock augmentation with fat grafting has emerged as one of the preeminent modalities for body contouring employed by plastic surgeons today. Since 2009, we have used the roller pump injection technique. OBJECTIVES: This procedure can be performed safely without specialized equipment and eliminates the tasks of manual graft preparation and injection. We describe our technique and standard safety measures. The anatomy of and complications associated with liposuction and fat grafting were recorded and reviewed. METHODS: Retrospective chart review of 916 patients who underwent autologous buttock augmentation by this method from February 2009 to November 2016 was performed. All procedures were performed under general anesthesia at the same surgical center. Liposuction was performed and using a roller pump, the fat layer was propelled through an open-ended cannula into the recipient site. RESULTS: Mean volume of fat removed and fat grafted in each patient was 3156 mL and 1807 mL per patient, respectively. There were complications in 13 patients for a rate of 1.4% with 10 (1.1%) related to fat grafting. Fourteen patients (1.5%) had subsequent procedures for volume and four patients (0.44%) for asymmetry. There were no venous thrombolic events, fat embolic events, or deaths. CONCLUSIONS: The roller pump injection technique for buttock augmentation with fat grafting is safe and efficient. This technique minimizes preparatory effort and does not require additional equipment. We were unable to identify variables associated with complication risk due to the power of this study and the low percentage of complications.

A novel cytotherapy device for rapid screening, enriching and combining mesenchymal stem cells into a biomaterial for promoting bone regeneration.

Bone defects are a common challenge in clinic, usually warranting bone grafts. However, current strategies to obtain effective graft materials have many drawbacks. Mesenchymal stem cell (MSC)-based therapy is a promising alternative. We designed an innovative appliance named the stem cell screen-enrich-combine(-biomaterials) circulating system (SECCS). In this study, 42 patients who required bone graft underwent SECCS-based treatment. Their bone marrow samples and beta-tricalcium phosphate (ß-TCP) granules were processed in the SECCS for 10-15 minutes, to produce MSC/ß-TCP composites. These composites were grafted back into bone defect sites. The results showed 85.53% ± 7.95% autologous MSCs were successfully screened, enriched, and seeded on the ß-TCP scaffolds synchronously. The cell viability remained unchanged after SECCS processing. Clinically, all patients obtained satisfactory bone healing. Thus, without in vitro culture, the SECCS can produce bioactive MSC/ß-TCP composites for bone regeneration during surgery. The SECCS represents a convenient, rapid, low-cost, and safe method for bone regeneration.

Accuracy of Computer-Assisted Template-Guided Autotransplantation of Teeth With Custom Three-Dimensional Designed/Printed Surgical Tooling: A Cadaveric Study.

PURPOSE: The aim of the present cadaveric study was to assess the accuracy of computer-assisted template-guided autotransplantation of teeth with custom 3-dimensional (3D) designed/printed surgical tooling. MATERIALS AND METHODS: Ten partially edentulous human mandibular cadavers were scanned using a cone-beam computed tomography (CBCT) system and an intraoral scanning system. The 3D data of these cadavers were imported to specialized software and used to analyze the region of the recipient sites, and the donor teeth were selected. Subsequently, congruent to the donor teeth, custom surgical tooling and surgical-guided templates were designed and 3D printed. The guided osteotomies were performed and the donor teeth transplanted. To evaluate the planned donor teeth positions compared with the transplanted donor teeth positions, the mandibles were scanned again using the CBCT system, and software matching was applied to measure the accuracy of the procedure. RESULTS: The mean angular deflection of the transplanted donor teeth with the planned donor teeth positions was 5.6 ± 5.4°. Comparing the 3D positions of the shoulders, a mean deviation of 3.15 ± 1.16 mm and a mean apical deviation of 2.61 ± 0.78 mm were found. CONCLUSIONS: The described method of computer-assisted template-guided autotransplantation of teeth with custom 3D designed/printed surgical tooling could potentially provide a relatively accurate alternative for the currently available treatment approaches. Further research should focus on improving the accuracy of this technique and evaluating the clinical success and advantages of this method.

Guided Autotransplantation of Teeth: A Novel Method Using Virtually Planned 3-dimensional Templates.

INTRODUCTION: The aim of this study was to introduce an innovative method for autotransplantation of teeth using 3-dimensional (3D) surgical templates for guided osteotomy preparation and donor tooth placement. METHODS: This report describes autotransplantation of immature premolars as treatment of an 11-year-old boy having suffered severe trauma with avulsion of permanent maxillary incisors. This approach uses modified methods from guided implant surgery by superimposition of Digital Imaging and Communications in Medicine files and 3D data sets of the jaws in order to predesign 3D printed templates with the aid of a fully digital workflow. RESULTS: The intervention in this complex case could successfully be accomplished by performing preplanned virtual transplantations with guided osteotomies to prevent bone loss and ensure accurate donor teeth placement in new recipient sites. Functional and esthetic restoration could be achieved by modifying methods used in guided implant surgery and prosthodontic rehabilitation. The 1-year follow-up showed vital natural teeth with physiological clinical and radiologic parameters. CONCLUSIONS: This innovative approach uses the latest diagnostic methods and techniques of guided implant surgery, enabling the planning and production of 3D printed surgical templates. These accurate virtually predesigned surgical templates could facilitate autotransplantation in the future by full implementation of recommended guidelines, ensuring an atraumatic surgical protocol.

Resultados clínicos de injertos óseos autólogos en bloque / Clinical results of autologous bone block grafts

Introducción: En muchas ocasiones, el sitio edéntulo del paciente no cuenta con el sufi ciente volumen óseo para albergar un implante. El injerto óseo autólogo en bloque (IOAB) es una opción para acondicionar al individuo y poder realizar la colocación del implante. Objetivo: Determinar el porcentaje de éxito y fracaso de los IOAB y sus factores relacionados...

Introduction: Very often, there is insufficient bone volume available in the edentulous site of a patient to allow dental implant placement. One way to prepare such patients for an implant placement is to usean autologous bone block (ABB) graft. Objective: To determine the success and failure rates of ABB grafts and their associated factors...