Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy.

INTRODUCTION: We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT). STUDY DESIGN: Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications. RESULTS: 284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group. CONCLUSIONS: MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.

Better Results in Facial Rejuvenation with Fillers.

Facial rejuvenation is a rapidly advancing field in aesthetic medicine. Minimally invasive techniques represent a powerful tool for rejuvenation, and fillers are a popular modality with which to restore and optimize facial proportions. Currently, our filler armamentarium is characterized by products with an increasing variety of biochemical compositions warranting tailored injection approaches. An intimate knowledge of anatomy, product characteristics, and appropriate injection techniques is essential to achieve optimal results while maintaining patient safety. Here, we review facial anatomy, structural changes secondary to aging, appropriate filler selection, safe injection techniques, and complications.

A Novel Approach in the Surgical Management of Nasal Tip Hemangiomas: A 26-Year Experience.

Infantile hemangiomas are common benign tumors of infancy with a predilection for the face. Nasal-tip hemangiomas, termed the "Cyrano deformity," can have especially devastating psychological effects. The ideal surgical approach and timing for these patients is unclear, as numerous designs have been reported in the literature. The authors present a novel approach to nasal tip reconstruction involving an algorithmic approach to incision selection and leaving a thin rim of hemangioma tissue under the dermis after debulking to minimize skin envelope atrophy. Nineteen cases were treated with the senior author's preferred method, with a mean age of 3.3 years and follow-up of 2.5 years. At follow-up, 10 patients were deemed by the senior author to have a very good aesthetic result, and the remaining nine patients were deemed to have an excellent one. The results of this study suggest that surgical intervention as early as 3 to 4 years of age is safe and provides good aesthetic outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

National Survey of US Plastic Surgeon Experience with Female Genital Mutilation.

Female genital mutilation (FGM) is a growing problem in the United States, with the past few decades showing a dramatic increase in prevalence. This study aims to understand the plastic surgeon experience with FGM and inform preparedness for this rising problem. METHODS: A 26-question survey was developed and electronically distributed to a random cohort of 2,508 active American Society of Plastic Surgeons members. It was sent three times over a 3-week period in 2018. χ2 statistical tests were used to analyze outcomes, assuming a P < 0.05 level for statistical significance. RESULTS: There was a 7% survey response rate (n=180). Demographic profiles reflected a range of practice types, geographical distribution, and years of experience. Ninety-five percent of respondents had heard of FGM (n=169). Sixty-seven percent were aware that surgical reconstructive options exist for FGM (n=115), with only 5% reporting any formal training on the topic (n=10). Only 13.6% of those surveyed felt prepared to care for a woman with FGM (n=23). CONCLUSIONS: After surveying plastic surgeons, responses demonstrate that while the majority are familiar with FGM, very few are comfortable or prepared for the care and surgical management of this patient population. Although this study is limited by a low response rate, we believe that the results reflect an existing knowledge gap and demonstrate the need for formal training. This may help to bridge this gap and prepare surgeons to care for this population.

Retraction Note: The Role of Scleraxis in Fate Determination of Mesenchymal Stem Cells for Tenocyte Differentiation.

This paper has been retracted.

Female Genital Mutilation Reconstruction for Plastic Surgeons-A Call to Arms.

The practice of female genital mutilation (FGM) is performed for historically engrained cultural beliefs with no recognized health benefits. FGM continues to be practiced secondary to motivating factors based on cultural beliefs, the majority of which aim to maintain the "purity" of the female victim. The World Health Organization has classified FGM into 4 types ranging from partial clitoral resection to complete clitoral excision along with the majority of the vulva. The list of short and long-term complications is extensive and morbid, including injury to the patient's sexuality and feminine identity. Reconstructive surgery can be an important addition to psychotherapy for these women with the goal of correcting the appearance of the vulva to achieve a more normal appearance, and to restore clitoral function. We suggest that this represents an opportunity for plastic surgeons to use our wealth of reconstructive knowledge to provide restoration of form and function to FGM victims.

Heterotopic Ossification Encountered During a Complex Ventral Hernia Repair: Case Report and Literature Review.

Introduction: Heterotopic ossification involves the formation of trabecular bone outside of its usual anatomic location. While it is a well-known entity in orthopedic and spinal injury literature, it has also been observed after midline laparotomy and severe burns. Methods/Case Report: We present a case of a 69-year-old man who presented for ventral hernia repair after a prolonged postoperative course following colectomy involving an open abdomen with eventual closure with skin grafting. Results: Two large calcified objects were encountered during the excision of the skin graft from the small intestine and during the component separation. They had grown into the anterior fascia and rectus muscle and interdigitated between loops of the small bowel. After careful resection of the 2 calcified objects, a ventral hernia repair with a component separation was successfully performed. Pathology was consistent with heterotopic ossification. After 18 months, there was no clinical evidence of recurrence. Discussion: Heterotopic ossification is not frequently encountered during ventral hernia repairs, but its presence can complicate repair. Resection is the only option in the context of hernia repair. If recognized preoperatively, waiting up to a year for the bone to mature before excision has been suggested, but there is minimal data to support this. Consultation with a general surgeon is also advised in case the calcified tissue involves the underlying viscera.

The Role of Scleraxis in Fate Determination of Mesenchymal Stem Cells for Tenocyte Differentiation.

Mesenchymal stem cells (MSCs) are pluripotent cells that primarily differentiate into osteocytes, chondrocytes, and adipocytes. Recent studies indicate that MSCs can also be induced to generate tenocyte-like cells; moreover, MSCs have been suggested to have great therapeutic potential for tendon pathologies. Yet the precise molecular cascades governing tenogenic differentiation of MSCs remain unclear. We demonstrate scleraxis, a transcription factor critically involved in embryonic tendon development and formation, plays a pivotal role in the fate determination of MSC towards tenocyte differentiation. Using murine C3H10T1/2 pluripotent stem cells as a model system, we show scleraxis is extensively expressed in the early phase of bone morphogenetic protein (BMP)-12-triggered tenocytic differentiation. Once induced, scleraxis directly transactivates tendon lineage-related genes such as tenomodulin and suppresses osteogenic, chondrogenic, and adipogenic capabilities, thus committing C3H10T1/2 cells to differentiate into the specific tenocyte-like lineage, while eliminating plasticity for other lineages. We also reveal that mechanical loading-mediated tenocytic differentiation follows a similar pathway and that BMP-12 and cyclic uniaxial strain act in an additive fashion to augment the maximal response by activating signal transducer Smad8. These results provide critical insights into the determination of multipotent stem cells to the tenocyte lineage induced by both chemical and physical signals.

Measuring quality of life in cleft lip and palate patients: currently available patient-reported outcomes measures.

BACKGROUND: Patient-reported outcomes in cleft lip and palate treatment are critical for patient care. Traditional surgical outcomes focused on objective measures, such as photographs, anatomic measurements, morbidity, and mortality. Although these remain important, they leave many questions unanswered. Surveys that include aesthetics, speech, functionality, self-image, and quality of life provide more thorough outcomes assessment. It is vital that reliable, valid, and comprehensive questionnaires are available to craniofacial surgeons. METHODS: The authors performed a literature review to identify questionnaires validated in cleft lip and palate patients. Qualifying instruments were assessed for adherence to guidelines for development and validation by the scientific advisory committee and for content. RESULTS: The authors identified 44 measures used in cleft lip and palate studies. After 15 ad hoc questionnaires, eight generic instruments, 11 psychiatric instruments, and one non-English language questionnaire were excluded, nine measures remained. Of these, four were never validated in the cleft population. Analysis revealed one craniofacial-specific measure (Youth Quality of Life-Facial Differences), two voice-related measures (Patient Voice-Related Quality of Life and Cleft Audit Protocol for Speech-Augmented), and two oral health-related measures (Child Oral Health Impact Profile and Child Oral Health Quality of Life). The Youth Quality of Life-Facial Differences, Child Oral Health Impact Profile, and Child Oral Health Quality of Life questionnaires were sufficiently validated. None was created specifically for clefts, resulting in content limitations. CONCLUSIONS: There is a lack of comprehensive, valid, and reliable questionnaires for cleft lip and palate surgery. For thorough assessment of satisfaction, further research to develop and validate cleft lip and palate surgery-specific instruments is needed.

BMP-12 treatment of adult mesenchymal stem cells in vitro augments tendon-like tissue formation and defect repair in vivo.

We characterized the differentiation of rat bone marrow-derived mesenchymal stem cells (BM-MSCs) into tenocyte-like cells in response to bone morphogenetic protein-12 (BMP-12). BM-MSCs were prepared from Sprague-Dawley rats and cultured as monolayers. Recombinant BMP-12 treatment (10 ng/ml) of BM-MSCs for 12 hours in vitro markedly increased expression of the tenocyte lineage markers scleraxis (Scx) and tenomodulin (Tnmd) over 14 days. Treatment with BMP-12 for a further 12-hour period had no additional effect. Colony formation assays revealed that ~80% of treated cells and their progeny were Scx- and Tnmd-positive. BM-MSCs seeded in collagen scaffolds and similarly treated with a single dose of BMP-12 also expressed high levels of Scx and Tnmd, as well as type I collagen and tenascin-c. Furthermore, when the treated BM-MSC-seeded scaffolds were implanted into surgically created tendon defects in vivo, robust formation of tendon-like tissue was observed after 21 days as evidenced by increased cell number, elongation and alignment along the tensile axis, greater matrix deposition and the elevated expression of tendon markers. These results indicate that brief stimulation with BMP-12 in vitro is sufficient to induce BM-MSC differentiation into tenocytes, and that this phenotype is sustained in vivo. This strategy of pretreating BM-MSCs with BMP-12 prior to in vivo transplantation may be useful in MSC-based tendon reconstruction or tissue engineering.

Tendon-derived stem/progenitor cell aging: defective self-renewal and altered fate.

Aging is a major risk factor for tendon injury and impaired tendon healing, but the basis for these relationships remains poorly understood. Here we show that rat tendon- derived stem / progenitor cells (TSPCs) differ in both self-renewal and differentiation capability with age. The frequency of TSPCs in tendon tissues of aged animals is markedly reduced based on colony formation assays. Proliferation rate is decreased, cell cycle progression is delayed and cell fate patterns are also altered in aged TSPCs. In particular, expression of tendon lineage marker genes is reduced while adipocytic differentiation increased. Cited2, a multi-stimuli responsive transactivator involved in cell growth and senescence, is also downregulated in aged TSPCs while CD44, a matrix assembling and organizing protein implicated in tendon healing, is upregulated, suggesting that these genes participate in the control of TSPC function.

Effects of visual force feedback on robot-assisted surgical task performance.

OBJECTIVE: Direct haptic (force or tactile) feedback is negligible in current surgical robotic systems. The relevance of haptic feedback in robot-assisted performances of surgical tasks is controversial. We studied the effects of visual force feedback, a haptic feedback surrogate, on tying surgical knots with fine sutures similar to those used in cardiovascular surgery. METHODS: By using a modified da Vinci robotic system (Intuitive Surgical, Inc, Sunnyvale, Calif) equipped with force-sensing instrument tips and real-time visual force feedback overlays in the console image, 10 surgeons each tied 10 knots with and 10 knots without visual force feedback. Four surgeons had significant prior da Vinci experience, and the remaining 6 surgeons did not. Performance parameters, including suture breakage and secure knots, peak and standard deviation of applied forces, and completion times using 5-0 silk sutures, were recorded. Chi-square and Student t test analyses determined the differences between groups. RESULTS: Among surgeon subjects with robotic experience, no differences in measured performance parameters were found between robot-assisted knot ties executed with and without visual force feedback. Among surgeons without robotic experience, however, visual force feedback was associated with lower suture breakage rates, peak applied forces, and standard deviations of applied forces. Visual force feedback did not impart differences in knot completion times or loose knots for either surgeon group. CONCLUSIONS: Visual force feedback resulted in reduced suture breakage, lower forces, and decreased force inconsistencies among novice robotic surgeons, although elapsed time and knot quality were unaffected. In contrast, visual force feedback did not affect these metrics among surgeons experienced with the da Vinci system. These results suggest that visual force feedback primarily benefits novice robot-assisted surgeons, with diminishing benefits among experienced surgeons.

Dynamic augmented reality for sensory substitution in robot-assisted surgical systems.

Teleoperated robot-assisted surgical systems provide surgeons with improved precision, dexterity, and visualization over traditional minimally invasive surgery. The addition of haptic (force and/or tactile) feedback has been proposed as a way to further enhance the performance of these systems. However, due to limitations in sensing and control technologies, implementing direct haptic feedback to the surgeon's hands remains impractical for clinical application. A new, intuitive augmented reality system for presentation of force information through sensory substitution has been developed and evaluated. The augmented reality system consists of force-sensing robotic instruments, a kinematic tool tracker, and a graphic display that overlays a visual representation of force levels on top of the moving instrument tips. The system is integrated with the da Vinci Surgical System (Intuitive Surgical, Inc.) and tested by several users in a phantom knot tying task. The augmented reality system decreases the number of broken sutures, decreases the number of loose knots, and results in more consistent application of forces.