Cancer Risk after Fat Transfer: A Multicenter Case-Cohort Study.

BACKGROUND: Fat transfer is an increasingly popular method for refining postmastectomy breast reconstructions. However, concern persists that fat transfer may promote disease recurrence. Adipocytes are derived from adipose-derived stem cells and express adipocytokines that can facilitate active breast cancer cells in laboratory models. The authors sought to evaluate the association between fat transfer to the reconstructed breast and cancer recurrence in patients diagnosed with local or regional invasive breast cancers. METHODS: A multicenter, case-cohort study was performed. Eligible patients from four centers (Memorial Sloan Kettering, M. D. Anderson Cancer Center, Alvin J. Siteman Cancer Center, and the University of Chicago) were identified by each site's institutional tumor registry or cancer data warehouse. Eligibility criteria were as follows: mastectomy with immediate breast reconstruction between 2006 and 2011, age older than 21 years, female sex, and incident diagnosis of invasive ductal carcinoma (stage I, II, or III). Cases consisted of all recurrences during the study period, and controls consisted of a 30 percent random sample of the study population. Cox proportional hazards regression was used to evaluate for association between fat transfer and time to recurrence in bivariate and multivariate models. RESULTS: The time to disease recurrence unadjusted hazard ratio for fat transfer was 0.99 (95 percent CI, 0.56 to 1.7). After adjustment for age, body mass index, stage, HER2/Neu receptor status, and estrogen receptor status, the hazard ratio was 0.97 (95 percent CI, 0.54 to 1.8). CONCLUSION: In this population of breast cancer patients who had mastectomy with immediate reconstruction, fat transfer was not associated with a higher risk of cancer recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Principles of nerve repair in complex wounds of the upper extremity.

Peripheral nerve injuries are common in the setting of complex upper extremity trauma. Early identification of nerve injuries and intervention is critical for maximizing return of function. In this review, the principles of nerve injury, patient evaluation, and surgical management are discussed. An evidence-based approach to nerve reconstruction is reviewed, including the benefits and limitations of direct repair and nerve gap reconstruction with the use of autografts, processed nerve allografts, and conduits. Further, the principles and indications of commonly used nerve transfers in proximal nerve injuries are also addressed.

A classification system for fat necrosis in autologous breast reconstruction.

PURPOSE: Fat necrosis (FN) is a common complication of autologous breast reconstruction, yet no classification system exists to describe it. We sought to develop and validate a tool for meaningful reporting, comparison of techniques, and treatment planning. Our hypothesis was that a valid classification system would demonstrate higher grades of FN for pedicled transverse rectus abdominus myocutaneous (pTRAM) flaps as compared to free flaps (FF). METHODS: A classification system for FN was developed: grade I, radiologic evidence only; grade II, palpable but not visible FN; grade III, palpable and visible FN; and grade IV, symptomatic FN. For validation, we applied this system to patients who had undergone pTRAM flaps from 2002 to 2006 and FF from 2006 to 2010 at our institution. RESULTS: We performed 93 pTRAM flaps in 69 patients and 102 FF in 69 patients. One patient had grade I FN and was observed. Of the 29 patients with grade II FN, 48% were observed, 17% had biopsy, and 35% underwent debridement. Of the 9 patients with grade III FN, 11% underwent biopsy and 89% had debridement. All patients with grade IV FN underwent debridement. The distribution of FN differed between pTRAM and FF. The mean FN grade for patients undergoing pTRAM was 1.4 versus 0.4 for those undergoing FF (P < 0.05). Fat necrosis requiring reoperation was more frequent in the pTRAM group (23.7% vs 5.9%, P < 0.05). CONCLUSIONS: Our validation study confirmed that FN grade was associated with the need for surgery and was higher for pedicled flaps as compared to FFs. As it is similar to the Baker grading system for capsular contracture, this classification system is familiar to all plastic surgeons. It is simple, easy to remember, clinically oriented, and could be readily incorporated into outcome studies of autologous breast reconstruction.

Bilateral accessory breast tissue of the vulva: a case report introducing a novel labiaplasty technique.

INTRODUCTION: We present the case of a 23-year-old female with bilateral ectopic breast tissue of the vulva, the repair of which necessitated a novel labiaplasty technique. Labiaplasty is becoming an increasingly frequent cosmetic procedure, and the popularity of brief didactic labiaplasty courses has risen in response to consumer demand. There is a paucity of detailed anatomic description of female sensory innervation patterns to the clitoris and surrounding structures. This places patients at risk for denervation of clitoral structures during labiaplasty procedures. Our novel technique proposes a method of individualized patient neurosensory mapping preoperatively, which allows for surgical planning to avoid injury to the sensory branches of the dorsal clitoral nerve. METHODS: A 23-year-old female presented with bilateral vulvar masses that involved the clitoral complex, which had first become apparent during the second trimester of pregnancy, and failed to resolve in the postpartum period. We describe the preoperative planning and intraoperative approach and dissection to labiaplasty in this patient, which was complex given the size of the masses, and specifically designed to avoid injury to sensory branches of the dorsal clitoral nerve. DISCUSSION: As labiaplasty becomes more common, it is important to approach labiaplasty patients with a detailed understanding of the sensory innervation of the clitoris and surrounding structures, to avoid nerve injury and resultant sexual dysfunction. Traditional labiaplasty approaches may violate the sensory innervation patterns of the clitoral region, thus causing a sensory loss that affects patient sexual function. Our novel approach to preoperative clitoral nerve sensory mapping provides an alternative method of labiaplasty that may avoid denervation injury.

Obesity impairs wound closure through a vasculogenic mechanism.

Since obesity impairs wound healing and bone marrow (BM)-derived vasculogenic progenitor cells (PCs) are important for tissue repair, we hypothesize that obesity-impaired wound healing is due, in part, to impaired PC mobilization, trafficking, and function. Peripheral blood was obtained from nondiabetic, obese (BMI > 30, n = 25), and nonobese (BMI < 30, n = 17) subjects. Peripheral blood human (h)PCs were isolated, quantified, and functionally assessed. To corroborate the human experiments, 6-mm stented wounds were created on nondiabetic obese mice (TALLYHO/JngJ, n = 15) and nonobese mice (SWR/J, n = 15). Peripheral blood mouse (m)PCs were quantified and wounds were analyzed. There was no difference in the number of baseline circulating hPCs in nondiabetic, obese (hPC-ob), and nonobese (hPC-nl) subjects, but hPC-ob had impaired adhesion (p < 0.05), migration (p < 0.01), and proliferation (p < 0.001). Nondiabetic obese mice had a significant decrease in the number of circulating PCs (mPC-ob) at 7 (p = 0.008) and 14 days (p = 0.003) after wounding. The impaired circulating mPC-ob response correlated with significantly impaired wound closure at days 14 (p < 0.001) and 21 (p < 0.001) as well as significantly fewer new blood vessels in the wounds (p < 0.001). Our results suggest that obesity impairs the BM-derived vasculogenic PC response to peripheral injury and this, in turn, impairs wound closure.

Nutritional support of surgical patients with inflammatory bowel disease.

Patients with inflammatory bowel disease (IBD) in need of surgery are often malnourished, which in turn increases the risk for postoperative complications. Malnutrition in IBD patients who must undergo surgery is due to the disordered activity of the diseased intestine, decreased dietary intake, and adverse effects of potent medications. IBD operations predispose patients to both macronutrient and micronutrient deficiencies. If the gut can be used safely it is the preferential route for feeding, though preoperative and postoperative parenteral nutrition remains a viable alternative for severely malnourished patients. New nutrient therapies include immunonutrition, fish oils, and probiotics.

Augmenting neovascularization accelerates distraction osteogenesis.

BACKGROUND: Distraction osteogenesis has revolutionized the treatment of craniofacial deformities, but it is limited by lengthy consolidation periods and tenuous healing in certain clinical settings, such as irradiated tissue. In this study, the authors aim to investigate whether increasing neovascularization by progenitor cell mobilization accelerates bone formation during distraction. METHODS: Sprague-Dawley rats aged 8 weeks (n = 36) were subjected to unilateral mandibular distraction with 3-day latency, 7-day activation (0.25 mm twice daily), and 21-day consolidation periods. From the beginning of the consolidation period, animals received daily injections of either AMD3100 (bone marrow progenitor cell mobilizing agent) or sterile saline. Animals were euthanized on postoperative day 31; mandibles were harvested; and bone regeneration was assessed using micro-computed tomography, immunohistochemistry, bone morphogenetic protein-2 enzyme-linked immunosorbent assay, and mechanical testing. RESULTS: Immunohistochemistry demonstrated that AMD3100 treatment increased vascular density and bone formation. Micro-computed tomography and dual-emission x-ray absorptiometry demonstrated that AMD3100-treated animals had improved bone generation compared with sham-treated controls. Greater force was required on three-point testing to break AMD3100-treated bone. Bone morphogenetic protein-2 expression was up-regulated with AMD3100. Interestingly, the nondistracted contralateral hemimandibles treated with AMD3100 were also stronger than sham-treated counterparts. CONCLUSIONS: Progenitor cell mobilization improves bone regeneration in a rat distraction model. Furthermore, because this effect is seen in healthy bone and in ischemic bone healing during distraction, the mechanism is not merely related to oxygenation, but could be a phenomenon of fluid flow.