Avoiding Complications in Gigantomastia.

Gigantomastia is a disabling condition for patients and presents unique challenges to plastic surgeons. Presentation can occur throughout different phases of life, and treatment often begins with nonoperative measures; however, the most effective way to relieve symptoms is surgical breast reduction. Because of the large amount of tissue removed, surgeons can encounter different intraoperative and postoperative complications. By understanding this disease process and these complications, surgeons can attempt to minimize their occurrences. The authors present an overview of the cause, preoperative evaluation, techniques, and outcomes. Additionally, they present outcomes data from their center on 40 patients.

A Closer Look at the 2013 to 2014 Integrated Plastic Surgery Match.

BACKGROUND: Plastic surgery has become an increasingly competitive, yet limited information is available in the literature on successfully matched plastic surgery applicants. The goal of this study was to analyze which factors predicted a successful National Residency Match Program match during the 2013 to 2014 cycle. METHODS: An electronic questionnaire was distributed to successfully matched medical students in plastic surgery. Information obtained included (1) academic performance, (2) medical school criteria, (3) visiting subinternship rotation criteria, and (4) research performance. Match "success" was defined as matching into one of the applicant's top three ranked programs RESULTS: Data were available for 127 matched students. Average Step 1 score was 247.93 (95 percent CI, 244.3 to 251.56). Step 1 scores correlated with the number of interviews received (r(2) = 0.355; p = 0.039). An odds ratio of 2.2 was observed for residents who had a plastic surgery residency program affiliated with their medical school and match success. Step 1 score (r(2) = 0.045; p = 0.798), Step 2 score (r(2) = 0.131; p = 0.505), Alpha Omega Alpha membership (r(2) = 0.011; p = 0.905), and number of publications (r(2) = 0.121; p = 0.458) did not correlate significantly with match success. CONCLUSIONS: Successful applicants had a Step 1 score that was 1 SD greater than the U.S. mean. Having a plastic surgery residency program affiliated with an applicant's medical school was an important predictor of match success. Objective measures (step scores, Alpha Omega Alpha membership, and number of publications) were not predictive of match success.

Imaging the Stromal Vascular Fraction during Soft-Tissue Reconstruction.

BACKGROUND: Although fat grafting is an increasingly popular practice, suboptimal volume retention remains an obstacle. Graft enrichment with the stromal vascular fraction has gained attention as a method of increasing graft retention. However, few studies have assessed the fate and impact of transplanted stromal vascular fraction on fat grafts. In vivo imaging techniques can be used to help determine the influence stromal vascular fraction has on transplanted fat. METHODS: Stromal vascular fraction was labeled with 1,1'-dioctadecyl-3,3,3',3'-tetramethylindotricarbocyanine iodide (DiR), a near-infrared dye, and tracked in vivo. Proliferation and differentiation of labeled cells were assessed to confirm that labeling did not adversely affect cellular function. Different doses of labeled stromal vascular fraction were tracked within fat grafts over time using the in vivo imaging system. RESULTS: No significant differences in differentiation and proliferation were observed in labeled versus unlabeled cells (p > 0.05). A pilot study confirmed that stromal vascular fraction fluorescence was localized to fat grafts and different cell doses could be distinguished. A larger-scale in vivo study revealed that stromal vascular fraction fluorescence was statistically significant (p < 0.05) between different cell dose groups and this significance was maintained in higher doses (3 × 10(6) and 2 × 10(6) cells/ml of fat graft) for up to 41 days in vivo. CONCLUSIONS: DiR labeling allowed the authors to differentiate between cell doses and confirm localization. This article supports the use of DiR labeling in conjunction with in vivo imaging as a tool for imaging stromal vascular fraction within fat grafts.

Medial thigh lift in the massive weight loss population: outcomes and complications.

BACKGROUND: Complication profiles of medial thighplasty in the massive weight loss population are not well described. The authors present their experience with these procedures in the massive weight loss population. METHODS: Thighplasty patients from 2003 to 2012 were assessed. Variables included age, sex, body mass index, method of weight loss, comorbidities, and smoking status. Outcomes included seroma, dehiscence, infection, hematoma, edema, and revision. Statistical analysis was performed as appropriate. RESULTS: One hundred six subjects (90 women and 16 men) underwent thighplasty. Fourteen patients underwent horizontal thighplasty, with a complication rate of 43 percent; 24 underwent short-scar thighplasty, with a complication rate of 67 percent; and 68 underwent full-length vertical thighplasty, with a complication rate of 74 percent. Seventy-two subjects (68 percent) had at least one complication. Complications included dehiscence (51 percent), seroma (25 percent), infection (16 percent), and hematoma (6 percent). Overall, 25 patients (23 percent) developed edema, which did not resolve in two patients by 12 months. Hypertension was significantly associated with postoperative seroma (p = 0.02). Age (p = 0.01), hypothyroidism (p = 0.01), and liposuction outside the area of resection (p = 0.025) were associated with postoperative infections. A full-length vertical incision was associated with increased lower extremity edema (p = 0.007). CONCLUSIONS: Medial thighplasty has a high rate of minor wound healing problems. Full-length vertical thighplasty is associated with prolonged edema. Concomitant liposuction may also increase complications. Patients should be counseled appropriately about the potential for minor wound healing problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

A review of adipocyte lineage cells and dermal papilla cells in hair follicle regeneration.

Alopecia is an exceedingly prevalent problem effecting men and women of all ages. The standard of care for alopecia involves either transplanting existing hair follicles to bald areas or attempting to stimulate existing follicles with topical and/or oral medication. Yet, these treatment options are fraught with problems of cost, side effects, and, most importantly, inadequate long-term hair coverage. Innovative cell-based therapies have focused on the dermal papilla cell as a way to grow new hair in previously bald areas. However, despite this attention, many obstacles exist, including retention of dermal papilla inducing ability and maintenance of dermal papilla productivity after several passages of culture. The use of adipocyte lineage cells, including adipose-derived stem cells, has shown promise as a cell-based solution to regulate hair regeneration and may help in maintaining or increasing dermal papilla cells inducing hair ability. In this review, we highlight recent advances in the understanding of the cellular contribution and regulation of dermal papilla cells and summarize adipocyte lineage cells in hair regeneration.

Risk factors for pannus formation in the post-bariatric surgery population.

BACKGROUND: Previous studies describe a relationship between pannus mass and panniculectomy-related complication rates. Patient management may be improved by elucidating the key factors influencing pannus formation. METHODS: A retrospective review was conducted of 135 patients who had undergone laparoscopic Roux-en-Y gastric bypass from 1996 to 2010 and subsequent panniculectomy. Outcome measures included age, sex, body mass index, time of surgery, resected pannus mass, comorbidities, and panniculectomy-related complications. Nonparametric continuous and nominal variables were assessed using Spearman rank-correlation and Mann-Whitney U tests, respectively. RESULTS: One hundred thirty-five patients (123 women and 12 men; mean age, 44.7 years) were included in analysis. All patients had body contouring surgery more than 1 year after bariatric surgery (median time interval, 2.1 years). Median body mass index at the time of bypass, 1 year after bypass, and at the time of body contouring surgery was 48.7, 30.0, and 29.4 kg/m, respectively. Median pannus mass was 2.2 kg. Larger pannus mass was associated with greater age at gastric bypass surgery (p = 0.034), higher pre-gastric bypass body mass index (p = 0.031), higher prepanniculectomy body mass index (p < 0.001), and longer time interval between gastric bypass and panniculectomy (p = 0.046). Female patients requiring blood transfusions had a significantly larger pannus mass than those who did not (p = 0.048). CONCLUSION: Performing bariatric surgery on patients at a younger age or having patients reduce body mass index as much as possible before bariatric surgery may be useful for minimizing symptomatic pannus formation and in turn may decrease rates of panniculectomy-related complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

The scope of plastic surgery according to 2434 allopathic medical students in the United States.

BACKGROUND: The general public and physicians often equate plastic surgery with cosmetic surgery. The authors investigate whether this perception is present in U.S. medical students. METHODS: A national survey of first- and second-year allopathic medical students was conducted. Students were asked to determine whether 46 specific procedures are performed by plastic surgeons: 12 aesthetic and 34 reconstructive procedures, which were further separated into three subgroups (general reconstruction and breast, craniofacial, and hand and lower extremity). RESULTS: Of the questionnaires sent out, 2434 from 44 medical schools were returned completed (23 percent response rate); 90.7 percent of aesthetic, 66.0 percent of general reconstruction and breast, 51.0 percent of craniofacial, and 33.4 percent of hand and lower extremity procedures were correctly identified. There was no relationship with self-reported interest in plastic surgery (1 = not at all interested to 10 = extremely interested) and the number of correctly identified aesthetic procedures. However, there was a nonlinear relationship with correctly identified reconstructive procedures; compared to those with an interest level of 1 to 5, those who chose 10 scored on average 6.5 points higher (14.2 versus 20.7) (p < 0.01). An anticipated career in surgery was associated with more correctly identified procedures across all sections but neither year (first versus second) nor region (Northeast, South, Central, West) with any section. CONCLUSIONS: U.S. medical students are unaware of the true scope of plastic surgery. Early exposure to basic aspects of plastic surgery could serve as a means of increasing interest and knowledge in the field and help educate future generations of referring physicians.

Particle size in fat graft retention: A review on the impact of harvesting technique in lipofilling surgical outcomes.

Fat grafting popularity continues to rise among plastic surgeons. As a soft tissue filler, adipose tissue had many desirable attributes: it is easy to obtain, autologous, and may reintegrate into recipient sites. However, fat grafting is clinically plagued by unpredictable resorption rates, thus there is much interest in optimizing the procedure of fat grafting for consistent graft volumes. Fat harvesting, a part of fat transfer surgery, involves the removal of adipose tissue from the donor site. Different harvest procedures, such as whole fat excision or liposuction cannulas, result in a range of fat particle volumes, which may play a role in the cellular stability of grafts. The ideal harvesting technique and fat particle diameter is not currently known. This study aims to review the literature on the impact of fat particle size and clinical fat grafting outcomes, to present overarching conclusions, and to provide future directions for study. Current evidence supports excisional methods and larger bore cannulas to minimize cellular damage, preserve the native architecture, and maximize the number of cells within fat particles.

Trends in autologous fat grafting to the breast: a national survey of the american society of plastic surgeons.

BACKGROUND: Autologous fat grafting has been gaining popularity in recent years, although there remains concern regarding the safety and efficacy of the practice for breast surgery. The purpose of this study was to determine national trends for fat grafting to the breast and to establish the frequency and specific techniques of the procedure to provide more supportive data. METHODS: A questionnaire was e-mailed to 2584 members of the American Society of Plastic Surgeons. Variables included prevalence and applications of fat grafting to the breast. Components of the fat graft protocol were also assessed. RESULTS: Four hundred fifty-six of the 2584 questionnaires were completed. Sixty-two percent of all respondents reported currently using fat grafting for reconstructive breast surgery and 28% of all respondents reported currently using the practice for aesthetic breast surgery. The most common reason cited by respondents for using fat grafting to the breast was as an adjunctive therapy to implant or flap surgery. CONCLUSIONS: Fat grafting to the breast is a common procedure most often used in reconstructive operations. The increasing prevalence of fat grafting to the breast indicates a need for collection of clinical data and supports the establishment of a national prospective registry to track outcomes after aesthetic and reconstructive applications.

Prevalence of endogenous CD34+ adipose stem cells predicts human fat graft retention in a xenograft model.

BACKGROUND: Fat grafting is a promising technique for soft-tissue augmentation, although graft retention is highly unpredictable and factors that affect graft survival have not been well defined. Because of their capacity for differentiation and growth factor release, adipose-derived stem cells may have a key role in graft healing. The authors' objective was to determine whether biological properties of adipose-derived stem cells present within human fat would correlate with in vivo outcomes of graft volume retention. METHODS: Lipoaspirate from eight human subjects was processed using a standardized centrifugation technique and then injected subcutaneously into the flanks of 6-week-old athymic nude mice. Graft masses and volumes were measured, and histologic evaluation, including CD31+ staining for vessels, was performed 8 weeks after transplantation. Stromal vascular fraction isolated at the time of harvest from each subject was analyzed for surface markers by multiparameter flow cytometry, and also assessed for proliferation, differentiation capacity, and normoxic/hypoxic vascular endothelial growth factor secretion. RESULTS: Wide variation in percentage of CD34+ progenitors within the stromal vascular fraction was noted among subjects and averaged 21.3 ± 15 percent (mean ± SD). Proliferation rates and adipogenic potential among stromal vascular fraction cells demonstrated moderate interpatient variability. In mouse xenograft studies, retention volumes ranged from approximately 36 to 68 percent after 8 weeks, with an overall average of 52 ± 11 percent. A strong correlation (r = 0.78, slope = 0.76, p < 0.05) existed between stromal vascular fraction percentage of CD34+ progenitors and high graft retention. CONCLUSION: Inherent biological differences in adipose tissue exist between patients. In particular, concentration of CD34+ progenitor cells within the stromal vascular fraction may be one of the factors used to predict human fat graft retention.

Postoperative management of Dupuytren's disease with topical nitroglycerin.

Dupuytren's contracture remains a significant clinical challenge due to associated complications and a recurrence rate of up to 60%. Commonly, the operated skin tends to rebuild scar in the area of surgery. Assuming local ischemia as an etiological factor, two cases in which topical nitroglycerin was used following surgical treatment of Dupuytren's disease are presented. In these patients, no raised scar formation developed during healing. At least six months after surgery, disease recurrence was not noted and the patients and surgeon reported improved skin quality. In the present study, the use of topical nitroglycerin, a local vasodilator, appeared to prevent recurrent scar formation, possibly through prevention of local ischemia. Further study and follow-up is necessary.

La maladie de Dupuytren demeure un problème clinique important en raison des complications connexes et d'un taux de récurrence pouvant atteindre 60 %. La peau opérée a souvent tendance à former de nouvelles cicatrices. Les auteurs présentent deux cas pour lesquels ils ont utilisé de la nitroglycérine topique après le traitement chirurgical de la maladie de Dupuytren, selon l'hypothèse que l'ischémie locale représentait un facteur étiologique. Chez ces patients, aucune cicatrice surélevée ne s'est formée. Au moins six mois après l'opération, il n'y avait pas eu de récurrence de la maladie, et les patients et le chirurgien avaient fait état d'une meilleure qualité de la peau. Dans la présente étude, le recours à de la nitroglycérine topique, un vasodilatateur local, a semblé prévenir la formation de cicatrices récurrentes, peut-être en prévenant une ischémie locale. D'autres études et un suivi s'imposent.