Prospective trial of adipose-derived regenerative cell (ADRC)-enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial.

AIMS: Women undergoing breast conservation therapy (BCT) for breast cancer are often left with contour defects and few acceptable reconstructive options. RESTORE-2 is the first prospective clinical trial using autologous adipose-derived regenerative cell (ADRC)-enriched fat grafting for reconstruction of such defects. This single-arm, prospective, multi-center clinical trial enrolled 71 patients post-BCT with defects ≤150 mL. METHODS: Adipose tissue was collected via syringe lipoharvest and then processed during the same surgical procedure using a closed automated system that isolates ADRCs and prepares an ADRC-enriched fat graft for immediate re-implantation. ADRC-enriched fat graft injections were performed in a fan-shaped pattern to prevent pooling of the injected fat. Overall procedure times were less than 4 h. The RESTORE-2 protocol allowed for up to two treatment sessions and 24 patients elected to undergo a second procedure following the six month follow-up visit. RESULTS: Of the 67 patients treated, 50 reported satisfaction with treatment results through 12 months. Using the same metric, investigators reported satisfaction with 57 out of 67 patients. Independent radiographic core laboratory assessment reported improvement in the breast contour of 54 out of 65 patients based on blinded assessment of MRI sequence. There were no serious adverse events associated with the ADRC-enriched fat graft injection procedure. There were no reported local cancer recurrences. Injection site cysts were reported as adverse events in ten patients. CONCLUSION: This prospective trial demonstrates the safety and efficacy of the treatment of BCT defects utilizing ADRC-enriched fat grafts.

Transplantation of a latissimus dorsi flap between identical twins.

We present a case of composite tissue transplantation of a latissimus dorsi flap between monozygotic twins. The recipient twin, a 19 year old male, suffered from a complex spinal kyphoscoliosis for which he had undergone multiple previous operations over many years. Soft tissue breakdown on his back causing metalwork exposure had necessitated the removal of his most recent spinal rod. This in turn led to rapid severe deterioration of his spinal deformity and consequent critical impairment of lung function. Robust soft tissue cover was required urgently in order to allow the insertion of a new spinal rod. His previous surgeries and body habitus precluded an adequate autologous reconstruction. Instead, reconstruction using composite tissue transplantation from his identical twin brother was successfully undertaken. We discuss the ethical, psychological and surgical issues involved in this case.

A comparison of the cosmetic and psychological outcome of breast reconstruction, breast conserving surgery and mastectomy without reconstruction.

METHOD: The cosmetic and psychological outcomes of patients who underwent reconstructive surgery, conservative surgery or simple mastectomy for breast cancer between 1995 and 2002 were compared. RESULTS: There was a significant correlation between good psychological adjustment and good cosmetic outcome scores (p=0.01-0.05). There was no difference in cosmetic outcome between different reconstruction methods. Reconstruction patients rated their cosmetic outcome better than conservative surgery patients, and conservative surgery patients better than mastectomy patients. There were no differences in psychological outcome between patient groups. CONCLUSION: Good perception of cosmetic outcome is associated with good psychological adjustment. There is no cosmetic advantage of one type of reconstruction over another. Reconstruction patients have a better body image compared with other treatment groups but there are no other psychological advantages of one type of treatment over another.

A novel imaging technique as an adjunct to the in vivo diagnosis of nonmelanoma skin cancer.

BACKGROUND: Spectrophotometric intracutaneous analysis (SIAscopy) is a light-based imaging system capable of producing rapid images of melanin, blood and collagen of the skin. Although the SIAscope has been investigated for melanoma diagnosis, no formal study has been conducted to determine its use in the diagnosis of nonmelanoma skin cancer (NMSC). OBJECTIVES: A prospective study was conducted to investigate the potential for the SIAscope to diagnose NMSC. METHODS: In total, 302 consecutive patients were recruited into the study, 363 lesions being scanned. Logistic regression analysis was used to construct a predictive model for NMSC diagnosis and receiver-operator characteristic curves were used to assess overall accuracy of the model. RESULTS: A sensitivity of 98.0%, specificity of 95.7% and overall accuracy of 98.2% was found for NMSC diagnosis by the SIAscope model. CONCLUSIONS: Results suggest that the SIAscope may be a useful adjunct in the diagnosis of NMSC.

Ocular contamination during lesional surgery-a hazard for the plastic surgeon.

UNLABELLED: Protective glasses reduce the risk of transconjunctival virus transmission although this has never been characterised for local anaesthetic skin lesion surgery. This study investigated the use of, and need for, protective eyewear during Plastic Surgery and the surgeons' attitude to risk. MATERIALS AND METHODS: Study 1. A multi-center questionnaire recorded the attitudes of Plastic Surgeons' regarding google use and ocular viral transmission. Study 2. A single surgeon performed local anaesthetic skin lesion surgery over 8 months whilst wearing clean goggles. After each procedure the goggles were inspected for macroscopic splashes ans a record made of whether the operator had been aware of the splash occurrence. RESULTS: Study 1. There were 36 respondents to the questionnaire (response rate of 84%). All grades recognised the risk of conjunctival contamination but most respondents did not wear goggles. Respondents changed their behavior, however, in 'high risk' cases. Study 2. 143 procedures resulted in 42 splashes. The surgeon was only aware of the splash in 6 cases. CONCLUSION: Despite widespread recognition of the importance of eye protection, goggle use is still infrequent. Our study stresses the frequency of potential splashes to the eye and need for routine use of goggles to prevent viral transmission.

Home oxygen therapy and cigarette smoking: a dangerous practice.

Oxygen as a therapeutic agent is an important form of home therapy for hypoxic chronic obstructive pulmonary disease (COPD) and improved survival has been demonstrated in hypoxic COPD patients receiving continuous oxygen. However, some patients, despite dissuasion, continue to smoke and we describe the case of a patient on home oxygen who sustained a partial-thickness facial flash burn whilst engaged in this habit. A review is made of the literature, as also a comparison of all discovered cases of burns in home oxygen users, followed by a discussion of the implications of this potentially hazardous form of therapy.

Effective treatment of chondrodermatitis nodularis chronica helicis using a conservative approach.

BACKGROUND: Chondrodermatitis nodularis chronica helicis (CNCH) is usually treated by surgical excision, but is prone to recurrence. OBJECTIVES: To examine whether CNCH could be treated nonsurgically using a home-made, pressure-relieving prosthesis. METHODS: A retrospective comparison was made of the outcome in 41 subjects treated surgically and 15 treated nonsurgically between 1999 and 2001. RESULTS: Thirteen of the 15 patients (87%) treated nonsurgically were healed at follow-up after 1 month of conservative treatment and so have avoided surgery to date. In contrast, the recurrence rate of the surgically treated group was 14 of 41 (34%) patients. CONCLUSIONS: As a result of this study, we recommend that patients presenting with CNCH be managed conservatively in the first instance.

Autologous free tissue breast reconstruction using the internal mammary perforators as recipient vessels.

Perforator flaps have become popular for autologous free tissue breast reconstruction because they reduce the donor site morbidity. It is possible to apply the this principle to the recipient site. We present our experience of using the perforating vessels from the internal mammary artery and vein as recipient vessels for autologous free tissue breast reconstruction flaps in 21 out of 54 consecutive cases (39%). We discuss the technique and its advantages.

A case report of cutis laxa in one of identical twins.

A 29-year-old man with cutis laxa presented requesting surgery to improve his appearance. The patient had an unaffected identical twin brother which allowed us to compare how he had changed over the years in relation to his sibling and this also provided us with a gold standard for any surgery performed. The patient underwent staged surgery including upper lid blepharoplasties and two facelifts.

Sweeping of membranes vs. intracervical prostaglandin E2 gel for cervical ripening. Randomized trial.

OBJECTIVE: To compare intracervical prostaglandin E2 gel and membrane sweeping for cervical ripening. STUDY DESIGN: Fifty patients were randomized to either intracervical prostaglandin E2 or membrane sweeping. A Bishop score was assigned by a blinded examiner prior to and 24 hours following the procedure. RESULTS: The Bishop scores assigned 24 hours after prostaglandin instillation and membrane sweeping were not significantly different (3.4, SE 0.42, vs. 3.3, SE 0.37, respectively; P > .05). The proportions of women entering active labor or delivering within 24 hours were similar in the prostaglandin and membrane groups (21% and 19%, respectively; P > .05). CONCLUSION: When both intracervical prostaglandin insertion and membrane sweeping are feasible, their salutary effects are comparable.

The current clinical presentation of complete molar pregnancy.

OBJECTIVE: To study the current clinical presentation of complete molar pregnancy. METHOD: Retrospective study of the clinical and ultrasonographic records of 41 patients with complete hydatidiform mole. RESULTS: 17 (41%) patients were asymptomatic. 24 patients (58%) presented with vaginal bleeding, 6 (15%) had excessive uterine size, 1 (2%) had anemia and 1 (2%) had hyperemesis. Non of the patients had any other systemic manifestation. Pre-evacuation ultrasound was performed in all cases and molar pregnancy was diagnosed in 36 (88%). CONCLUSIONS: Currently with routine first trimester ultrasonography a significant proportion of patients with molar pregnancy are asymptomatic at the time of diagnosis.

Salvage of a below knee amputation stump with a free sensate total sole flap preserving continuity of the posterior tibial nerve.

We illustrate the use of a free sole flap with intact posterior tibial nerve in the coverage of a below knee amputation 6 months after an explosive injury to a 12-year-old child. We discuss the indications for lower leg amputation in children, modalities of reconstruction of the amputation stump and possible reason for the observed change of colour of the flap persisting for 14 days.

Evaluation of breast stimulation for induction of labor in women with a prior cesarean section and in grandmultiparas.

BACKGROUND: Information on the efficacy of breast stimulation for inducing labor in grandmultiparas and in women with a previous cesarean section with or without premature rupture of membranes is limited. METHODS: Retrospective study of labor data from 135 women of grand multiparity or those with a previous section with or without premature rupture of the membranes in whom labor was induced by breast stimulation. RESULTS: The success rate in achieving vaginal delivery was 84%. The duration of breast stimulation, length of labor, vaginal delivery rate, and Apgar score did not differ significantly among the four groups studied. CONCLUSION: Breast stimulation in grandmultiparas and in women with a previous cesarean section is efficacious and safe.

Oral sustained-release ritodrine as a substitute for prolonged intravenous tocolysis.

Prolonged administration of intravenous ritodrine is necessary in some pregnant women with recurrent preterm labor as serum levels achieved by oral administration of ritodrine are insufficient to prevent recurrent contractions. New oral sustained-release ritodrine at 320 mg/day was given to 38 women with recurrent preterm labor. Serum levels of the drug at this dosage are considered comparable with levels achieved by i.v. treatment. The average duration of treatment was 8 days (range, 1-22). Patient tolerance was acceptable, and major maternal complications did not occur. We conclude that in selected cases, it may be possible to substitute oral sustained-release ritodrine at 320 mg/day for prolonged i.v. treatment.

Transverse lower segment uterine incision in cesarean sections for transverse lie. A retrospective survey.

A transverse lower uterine incision was made at cesarean section in 79 term patients with a singleton fetus in a transverse lie. The mean Apgar score was 9.5 (SD 0.8). One infant sustained a fractured femur, and another had a torticollis. In no case did the incision extend into the uterine vessels.