Early Surgical Management of Medical Tourism Complications Improves Patient Outcomes.

BACKGROUND: Complications from medical tourism can be significant, requiring aggressive treatment at initial presentation. This study evaluates the effect of early surgical versus conservative management on readmission rates and costs. METHODS: A single-center retrospective review was conducted from May of 2013 to May of 2017 of patients presenting with soft-tissue infections after cosmetic surgery performed abroad. Patients were categorized into two groups based on their management at initial presentation as either conservative or surgical. Demographic information, the procedures performed abroad, and the severity of infection were included. The authors' primary outcome was the incidence of readmission in the two groups. International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; and CPT codes were used for direct-billed cost analysis. RESULTS: Fifty-three patients (one man and 52 women) presented with complications after procedures performed abroad, of which 37 were soft-tissue infections. Twenty-four patients with soft-tissue infections at initial presentation were managed conservatively, and 13 patients were treated surgically. The two groups were similar in patient demographics and type of procedure performed abroad. Patients who were managed conservatively at initial presentation had a higher rate of readmission despite having lower severity of infections (OR, 4.7; p = 0.037). A significantly lower total cost of treatment was shown with early surgical management of these complications (p = 0.003). CONCLUSIONS: Conservative management of complications from medical tourism has resulted in a high incidence of failure, leading to readmission and increased costs. This can contribute to poor outcomes in patients that are already having complications from cosmetic surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Uso de colgajos libres perforantes de la región abdominal tipo DIEP y SIEA para reconstrucción mamaria / Use of perforator flaps from the lower abdomen (DIEP and SIEA) for breast reconstruction

Introducción: El cáncer de mama es la neoplasia que afecta en forma más frecuente a las mujeres en el mundo. Posterior a una mastectomía, el uso de tejidos autógenos para la reconstrucción mamaria tiene mejores resultados a largo plazo. La utilización de colgajos libres obtenidos del abdomen se ha planteado como una alternativa adecuada. Objetivos: Se reportan una serie de casos con el uso de colgajos libres de vasos perforantes de la arteria epigástrica inferior profunda (DIEP) y vasos epigástricos inferiores superficiales (SIEA) en la reconstrucción de mama. Pacientes y método: Describimos 21 casos de reconstrucción mamaria utilizando el colgajo DIEP y 3 casos de colgajo SIEA en la Clínica Las Condes (CLC) entre el 2007 y 2015. Resultados: De un total de 24 pacientes con un rango de edad de entre 48 y 60 años, 18 de ellas fueron sometidas a reconstrucción unilateral, 3 a reconstrucción bilateral con DIEP, y 3 fueron sometidas a reconstrucción unilateral con colgajo SIEA. El tiempo operatorio promedio fue de 6,5 h y el tiempo de hospitalización, de 6 días. En una reconstrucción bilateral hubo pérdida del colgajo izquierdo por trombosis venosa, la cual se sometió a una segunda reconstrucción con colgajo libre. Discusión: En nuestra experiencia en la CLC, la reconstrucción mamaria con colgajos libres perforantes de la zona inferior del abdomen tiene una baja morbilidad. La literatura avala esta técnica como una alternativa válida en pacientes seleccionadas.

Introduction: Breast cancer is the most frequent neoplasia affecting women worldwide. After mastectomy for breast cancer, autologous tissue breast reconstruction offers better long-term results. The use of abdominal free flaps has shown to be an adequate option. Aim: We report a series of cases of deep inferior epigastric perforator flap (DIEP flap) and superficial inferior epigastric artery flap reconstructions. Patients and methods: We describe 21 patients with breast reconstruction using DIEP flap and 3 cases of SIEA flap in CLC between 2007 and 2012. Results: 24 patients underwent the procedure with an age range of 48 to 60 years; 18 patients underwent a unilateral reconstruction and 3 patients bilateral reconstructions with DIEP flaps; 3 patients underwent unilateral breast reconstruction with SIEA flap. Mean operative time was 6,5 h and mean hospitalization was 6 days. In one bilateral reconstruction the left flap was lost, which required a second free flap reconstruction. Discussion: In our experience, microvascular breast reconstruction using perforator flaps has a low morbidity. As described in the literature, this is a valid alternative in selected patients.

Cranial defect reconstruction in an experimental model using different mixtures of bioglass and autologous bone.

The purpose of this study was to investigate bone healing in a rabbit cranial defect model using different mixtures of bioglass (NovaBone C/M; Porex Surgical, Inc., Newnan, GA) and autologous bone with and without an overlying absorbable plate (Lactosorb; Walter Lorenz Surgical, Jacksonville, FL). Twelve rabbits were divided into three groups, and a 2 cm diameter cranial defect was created in each rabbit. Group I defects were filled with 80% bioglass and 20% autologous bone, group II with 60% bioglass and 40% autologous bone, and group III with 60% bioglass and 40% autologous bone with the addition of an absorbable plate placed directly over the reconstructed defect to help separate it from the overlying soft tissues. Rabbits were euthanized 6 months postoperatively. Histologic examination was then performed. The size of the remaining bone gap, area of reossification within the defect, and percentage of fibrous tissue within the defect were measured. Histologic analyses revealed that group II animals had an increased cross-sectional area of bone formation and decreased bone gap when compared with group I and III animals (P < 0.05). There were no statistical differences between groups I and III with regard to bone formation. This study suggests that when combining bioactive glass and autologous bone for repairing cranial defects, a combination of 60% bioactive glass and 40% bone graft yields superior results to a combination of 80% bioactive glass and 20% bone graft. Placing an absorbable plate over a defect filled with 60% bioactive glass and 40% bone graft inhibits rather than promotes reossification.

Management of incidental fibrous dysplasia of the maxilla in a patient with facial fractures.

We present the case of a 53-year-old man who was involved in a motor vehicle accident. A maxillofacial computed tomography scan revealed a large tumor of the left maxilla as well as multiple facial fractures. The tumor extended from the palate to the orbital floor and from the medial to the lateral wall of the maxillary sinus. We describe the surgical approach as well as the operative management of incidental fibrous dysplasia of the maxilla in a patient with facial fractures.

Short-stay cleft palate surgery with intraoperative dexamethasone and marcaine.

The perioperative management of cleft palate surgery remains controversial. Early literature supported hospital stays of 2-5 days, but more recent reports have supported 24-hour admissions in carefully screened patients without congenital syndromes. We retrospectively reviewed 65 cleft palate repairs performed by the senior author from August 1992 through November 2003. Procedures included repairs of the soft palate (n = 25), hard palate (n = 4), or combined hard and soft palate (n = 36). All repairs were performed using a Furlow double, opposing Z-plasty technique. Nine patients (14%) had associated congenital syndromes. Prior to January 1995, patients (n = 15) received perioperative antibiotics and local injection of lidocaine with epinephrine prior to incision. The average operative time to first oral feeding was 13 hours, and the average length of stay in this group was 2.4 days. Previous oral surgery literature has demonstrated the reduction of pain, edema, and trismus with the use of dexamethasone. As part of our recent operative protocol, all patients (n = 50) after January 1995 received perioperative antibiotics, local injection of a 50/50 mixture of 1% lidocaine with epinephrine, and 0.5% Marcaine with epinephrine prior to incision and 4 mg of intravenous dexamethasone perioperatively. The average time to first feeding was 7 hours and the average length of stay was 1.1 days. Postoperatively, patients from both groups were maintained on a liquid or soft diet, depending on their age without the use of bottles. There were no differences in the use of antibiotics or pain management between the 2 groups. Patients were assessed by the surgical team for evaluation of the surgical site and oral intake prior to discharge. Patients in the steroid/Marcaine group had earlier oral intake (P < 0.05) and shorter length of stay (P < 0.05). Of those patients receiving dexamethasone and Marcaine, 43/50 (86%) were discharged within 24 hours. Patients requiring longer hospitalization had initially inadequate oral intake. One patient required readmission for dehydration secondary to rotavirus. In conclusion, short-stay cleft palate surgery is safe, given adequate oral intake, competent parents, and a safe home environment.

Repair of palatal bone defects using osteogenically differentiated fat-derived stem cells.

BACKGROUND: Although autogenous bone grafting remains the standard in the reconstruction of bone defects, disadvantages may include limited amount of bone and donor-site morbidity. Tissue engineering approaches can potentially obviate these problems. Fat contains a population of stem cells that can be isolated and differentiated into various cell lines, including osteocytes, adipocytes, and myocytes, depending on the culture conditions. In this study, the authors used osteogenically differentiated fat-derived stem cells to repair rat palatal bone defects. METHODS: Fat-derived stem cells were isolated, differentiated into osteocytes in osteogenic medium, and seeded onto poly-L-lactic acid scaffolds. Rat palatal bone defects were surgically made and animals divided into four groups according to the type of implant for bone repair: group I, empty defect; group II, poly-L-lactic acid without cells; group III, poly-L-lactic acid with undifferentiated fat-derived stem cells; and group IV, poly-L-lactic acid with osteogenically differentiated fat-derived stem cells. Palates were harvested at 6 or 12 weeks after implantation (n = 8 per group at each time interval). Hematoxylin and eosin staining, immunohistochemical staining for osteocalcin, and histomorphometric measurements of new bone were performed. RESULTS: Defects in groups I, II, and III had no bone and were primarily filled with fibrous tissue. In contrast, there was substantial bone regeneration in group IV, which was statistically significant by histomorphometry compared with groups I, II, and III. Newly formed bone in group IV stained positive for osteocalcin. CONCLUSIONS: The authors successfully reconstructed palatal bone defects using absorbable three-dimensional scaffolds seeded with osteogenically differentiated fat-derived stem cells. This study demonstrates the feasibility of reconstructing bony defects with fat-derived stem cells.

Lentiviral transfection with the PDGF-B gene improves diabetic wound healing.

BACKGROUND: The treatment of diabetic wounds remains a difficult challenge. The present study investigates whether platelet-derived growth factor (PDGF) lentiviral gene therapy can improve diabetic wound healing in the diabetic db/dbmouse. METHODS: PDGF cDNA was cloned and lentiviral vectors were constructed with either the PDGF-B or green fluorescence protein (GFP) gene. A 2 x 2-cm full-thickness dermal wound was made on each db/db mouse. Animals were divided into three groups, with eight animals in each group as follows: group I, empty wound; group II, lentiviral PDGF; and group III, lentiviral GFP. Lentiviral vectors were injected into the wounds and healing was assessed at 21 days. Harvested wounds were assessed for residual epithelial gap, granulation tissue area, PDGF expression, collagen formation (picrosirius red), and angiogenesis (CD31 staining). RESULTS: Lentiviral vectors were constructed and transfected dermal fibroblasts demonstrated in vitro production of PDGF mRNA as measured by reverse-transcriptase polymerase chain reaction. Immunohistochemistry for PDGF confirmed successful in vivo transfection of the PDGF gene. At 21 days, reepithelialization and granulation tissue area were similar in all groups. However, there was a statistically significant increase in angiogenesis and substantially thicker, more coherently aligned collagen fibers in the PDGF group compared with controls. CONCLUSIONS: PDGF lentiviral vectors were successfully transfected into the regenerated dermis in diabetic wounds. Although reepithelialization was similar among the groups, there was enhanced angiogenesis and collagen deposition in the lentiviral PDGF group. These results demonstrate that lentiviral PDGF transfection of the diabetic wound enhances PDGF production, improves vascularization and collagen organization, and has potential clinical applications in diabetic wound treatment.

Biological alchemy: engineering bone and fat from fat-derived stem cells.

Adipose tissue contains a population of pluripotent stem cells capable of differentiating along multiple mesenchymal cell lineages. In this study the authors isolated these fat-derived stem cells successfully from Lewis rats and induced differentiation along adipogenic and osteogenic lineages in vitro and in vivo. Induction was stimulated by exposing stem cells to lineage-specific induction factors. Adipocyte-inducing media contained dexamethasone, insulin, and isobutyl-methylxanthine. Osteoblast inducing media contained dexamethasone, beta-glycerophosphate, and ascorbic acid. Undifferentiated stem cells were maintained in minimal essential media alpha and fetal bovine serum. At 10 days, cells cultured in adipogenic media differentiated into adipocytes in vitro, as evidenced by positive Oil red O staining of lipid vacuoles. At 21 days, cells cultured in osteogenic media differentiated into osteoblasts in vitro as demonstrated by Alizarin red staining of a calcified extracellular matrix and immunohistochemical staining for osteocalcin. Differentiated cells were seeded at a density of 5 x 106 cells onto 15 x 15-mm polyglycolic acid grafts and implanted subcutaneously into three groups of Lewis rats: Group I contained undifferentiated stem cell grafts, group II contained adipocyte grafts, and group III contained osteoblast grafts. At weeks 4 and 8, in vivo fat formation was demonstrated in group II rats, as confirmed by Oil red O staining. At 8 weeks, group III rats demonstrated in vivo bone formation, as confirmed by the presence of osteocalcin on immunohistochemistry and the characteristic morphology of bone on hematoxylin-eosin staining. Group I rats demonstrated no in vivo bone or fat formation at either time interval. These results demonstrate the ability to isolate pluripotent stem cells from adipose tissue, to induce their differentiation into osteoblasts and adipocytes in vitro, and to form bone and fat subsequently in vivo. This is the first published report of in vivo bone formation from fat-derived stem cells. These cells may eventually serve as a readily available source of autologous stem cells for the engineering of bone and fat.