Achieving Aesthetic Results in the Umbilical Float Mini-Abdominoplasty: Patient Selection and Surgical Technique.

BACKGROUND: The umbilical float mini-abdominoplasty has been criticized for low final umbilicus position and umbilical distortion. The authors believe that in the properly selected patient and with proper technique, the umbilical float can achieve superior aesthetic results in a subset of patients. METHODS: A retrospective review was performed of all umbilical floats performed by two surgeons (B.A.H. and H.S.B.) at the authors' institution. Postoperative photographs were reviewed by 20 blinded evaluators. RESULTS: Thirty-one female patients underwent umbilical float mini-abdominoplasty between 2010 and 2017. All patients had starting umbilicus position at or above the level of the iliac crest. The umbilicus was floated for a distance of 1 to 3.5 cm. Average umbilicus position was slightly above the midpoint between the xiphoid and pubis preoperatively, and slightly below the midpoint postoperatively. Final umbilicus was considered "too low" in five patients (18.5 percent), all of which were positioned at the level of the anterior superior iliac spine. CONCLUSIONS: Optimal candidates for the umbilical float mini-abdominoplasty are postpartum women with normal body mass index, mild to moderate infraumbilical skin excess, and minimal to mild supraumbilical excess. Starting umbilicus position should be at or above the level of iliac crests, or slightly above the mid torso. Final umbilicus position should remain above the anterior superior iliac spine. The umbilical base is reattached with multiple sutures to prevent distortion. At least 10 cm of hairless lower abdominal skin should be maintained between the final scar and navel to prevent a low-appearing umbilicus. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

IL-13 is produced by tumor cells in breast implant-associated anaplastic large cell lymphoma: implications for pathogenesis.

More than 500 women worldwide have developed a CD30+ T-cell lymphoma around breast implants, strongly suggesting a cause-and-effect relationship, and designated as breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). The mechanism of lymphomagenesis is unknown. Recently, a bacterial biofilm containing gram-negative bacilli was discovered on the surface of breast implants associated with ALCL. We and others have described overexpression of the proto-oncogene JUNB and mutations of JAK1/2, TP53 and STAT3 in BIA-ALCL. Here we report that BIA-ALCL cell lines and anaplastic lymphoma cells in clinical specimens produce IL-13, the signature cytokine of allergic inflammation. Supporting the link of BIA-ALCL to allergic inflammation, lymphoma cells were often surrounded by eosinophils and mast cells, features typically absent in systemic ALCL. Because of the link of IL-13 to allergy, we looked for IgE and found it decorating the surface of mast cells and antigen-presenting follicular dendritic cells in capsules and lymph nodes infiltrated by anaplastic lymphoma cells, but not uninvolved capsules. Plasma cells within capsules and regional lymph nodes were identified as a possible source of IgE. Together, these findings suggest the hypothesis that an amplified immune response with features of a chronic allergic reaction in a susceptible patient underlies the pathogenesis of BIA-ALCL.

Reversal of skin aging with topical retinoids.

Topical skin care and its place in plastic surgery today are often overlooked by clinicians formulating a plan for facial rejuvenation. Not only is it important to consider topical skin care as part of comprehensive care, but clinicians should also be educated with the data available in today's literature. This review aims to familiarize the reader with the biological processes of skin aging and evidence-based clinical outcomes afforded by various topical therapies. Furthermore, this review will focus on solar damage, the value of retinoids, and how they can be used in conjunction with forms of treatment such as chemical peel, dermabrasion, and lasers. Finally, guidelines will be provided to help the physician administer appropriate skin care based on the data presented.

Contractility of sphincter pharyngoplasty: Relevance to speech outcomes.

BACKGROUND: Sphincter pharyngoplasty has demonstrated time-tested results as a surgical treatment for velopharyngeal incompetence (VPI). However, controversy surrounding the contractility of the transposed muscles persists. Completely unaddressed in the literature is whether the dynamism of the sphincter affects speech outcomes. OBJECTIVE: To determine whether active sphincter contraction following sphincter pharyngoplasty influences velopharyngeal closure, nasal emission and hypernasality. METHODS: A prospective analysis of patients with VPI after cleft palate repair undergoing sphincter pharyngoplasty by a single surgeon was performed. Video nasendoscopy and videofluoroscopy were performed preoperatively and postoperatively at three and 12 months. Eighteen consecutive patients with cleft palate with or without cleft lip and VPI were reviewed. The average age of the patients at initial evaluation was 7.3 years, with a range of three to 19 years. Dynamicity of sphincter pharyngoplasty, velar closing ratio (VCR), and lateral wall movement (LWM) were assessed by nasendoscopy and videofluoroscopy. Nasal emission and hypernasality were assessed by perceptual speech examination. RESULTS: FOR LONGITUDINAL COMPARISON, THREE GROUPS WERE CREATED: dynamic at three and 12 months (n=12); adynamic at three months and dynamic at 12 months (n=4); and adynamic at three and 12 months (n=2). Perceived hypernasality scores significantly improved at three months (P=0.0001) and showed continued improvement at 12 months (P=0.03), despite no change in VCR and LWM from three to 12 months. There were no significant differences among the three groups at any time point. DISCUSSION: Sphincter pharyngoplasty effectively treats VPI in appropriately selected patients. Although the VCR and LWM remained stable between three months and one year, four of six adynamic sphincters became dynamic. Considering all patients, hypernasality showed continued improvement from three months to one year. CONCLUSIONS: There were no differences between dynamic and adynamic sphincters in terms of speech outcomes or the mechanical properties of velopharyngeal closure.

HISTORIQUE: La pharyngoplastie du sphincter est un traitement chirurgical de l'incompétence vélopharyngienne (IVP) qui a fait ses preuves. Cependant, une controverse persiste à l'égard de la contractilité des muscles transposés. Les publications n'abordent pas du tout l'influence du dynamisme du sphincter sur les issues du discours. OBJECTIF: Déterminer si la contraction active du sphincter après une pharyngoplastie du sphincter influe sur la fermeture vélopharyngienne, l'émission nasale et l'hypernasalité. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse prospective des patients présentant une IVP après la réparation d'une fente palatine qui ont subi une pharyngoplastie du sphincter exécutée par un seul chirurgien. Ils ont procédé à une nasendoscopie vidéo et à une vidéofluoroscopie avant l'opération, puis trois et 12 mois après l'opération. Ils ont examiné 18 patients consécutifs ayant une fente palatine, accompagnée ou non d'une fente labiale, et une IVP. Les patients de trois à 19 ans avaient un âge moyen de 7,3 ans au moment de la première évaluation. Les chercheurs ont évalué le dynamisme de la pharyngoplastie du sphincter, le ratio de fermeture vélaire (RFV) et le mouvement des parois latérales (MPL) par nasendoscopie et vidéofluoroscopie. Ils ont également évalué l'émission nasale et l'hypernasalité au moyen de l'examen du discours perceptuel. RÉSULTATS: Pour des besoins de comparaison longitudinale, les chercheurs ont créé trois groupes, soit un groupe dynamique à trois et 12 mois (n=12), un groupe adynamique à trois mois et dynamique à 12 mois (n=4) et un groupe adynamique à trois et 12 mois (n=2). Leurs indices d'hypernasalité perçus s'étaient considérablement améliorés à trois mois (P=0,0001) et avaient continué de s'améliorer à 12 mois (P=0,03), malgré l'absence de changement de l'IPV et du MPL entre trois et 12 mois. On ne constatait pas de différence significative à un moment ou à un autre entre les trois groupes. EXPOSÉ: La pharyngoplastie du sphincter traite l'IPV de manière efficace chez des patients bien sélectionnés. Même si le RFV et le MPL étaient demeurés stables entre trois mois et un an, quatre des six sphincters adynamiques sont devenus dynamiques. Chez l'ensemble des patients, l'hypernasalité s'est atténuée de manière continue entre trois mois et un an. CONCLUSIONS: On n'a constaté aucune différence entre les sphincters dynamiques et adynamiques sur les issues du discours ou les propriétés mécaniques de la fermeture vélopharyngienne.

Prenatal counseling's effect on rates of neonatal intensive care admission for feeding problems cleft lip/palate infants.

Prenatal counseling and feeding instruction is standard at our institution for parents of cleft lip and palate patients. We studied this intervention's effect on Neonatal Intensive Care Unit (NICU) admission solely for feeding. Ten percent (2/20) of patients whose parents received counseling were admitted to the NICU for feeding issues alone compared to 21% (5/24) of the non-counseling group. Prenatal counseling and feeding instruction appears to decrease NICU admission, duration and health care costs.

Unilateral frontosphenoidal craniosynostosis with achondroplasia: a case report.

Isolated, premature fusion of the frontosphenoidal suture is rare. This report describes an unusual combination of frontosphenoidal craniosynostosis and achondroplasia. Although craniosynostosis is known to occur in allelic conditions such as thanatophoric dysplasia, craniosynostosis in individuals with achondroplasia is exceedingly rare. Due to the distracting diagnosis of achondroplasia or inadequate knowledge of craniosynostosis, the abnormal head shape was initially treated by other physicians with helmet molding. Plastic surgery consultation was obtained at 2 years of age and surgical care was provided. An acceptable head shape was obtained, but the delay in appropriate evaluation was disconcerting. To our knowledge this is the first reported case of isolated frontosphenoidal craniosynostosis associated with achondroplasia.

Fine tuning lipoaspirate viability for fat grafting.

BACKGROUND: The efficient harvest of abundant viable adipocytes for grafting is of considerable interest. Hand aspiration, low-g-force, short-duration centrifugation, and harvest of the lower sublayer of fat centrifugate maximize viable adiopocytes, but this process is cumbersome with conventional equipment. The Lipose Corporation (Greenwich, Conn.) has produced special syringes, filters, and a low-g-force centrifuge (Viafill system) to facilitate this process. The adipocyte viability using this system is presented. METHODS: Six women underwent fat graft harvest using the Viafill system from the lower hips (n = 6) and/or upper hips (n = 3). After centrifugation for 2 minutes at 50 g, the lower, middle, and top sublayers of the adipose layer were analyzed for viable adipocyte counts using trypan blue vital staining. Additional samples from standard power-assisted liposuction were obtained and analyzed similarly. RESULTS: The mean difference in square-root transformation of cell counts between the bottom sublayer of centrifuged fat and the middle sublayer was 0.95 (95 percent CI, 0.61 to 1.3), and the difference between the middle and top sublayers was 0.67 (CI, 0.50 to 0.84). Thus, the bottom sublayer had approximately 2.5 to 3 times more cells than the top sublayer. The difference between the hand aspirate samples and the power-assisted liposuction samples was significant (1.62; CI, 1.35 to 1.90). CONCLUSIONS: This study reconfirms the authors' early findings that atraumatic harvest of lipoaspirate yields high cell counts and that adipocyte density is greatest at the lowest sublayer of centrifuged fat. The Viafill system provides a more efficient and user-friendly system for fat grafting while maintaining cell counts similar to the authors' technique using conventional equipment.

Adenoid involvement in velopharyngeal closure in children with cleft palate.

OBJECTIVE: To assess the role of the adenoid pad in velopharyngeal (VP) closure. DESIGN: A retrospective review of patients with cleft palate (CP) who underwent nasendoscopy and multiview videofluoroscopy during evaluation for VP insufficiency (VPI) from January 2006 to March 2008. PATIENTS: Thirty-two consecutive patients were identified. None of the patients were lost to follow-up. Five patients were excluded: two for advanced age, two due to mental disabilities and one with a submucous cleft. INTERVENTION: Video nasendoscopy and multiview videofluoroscopy were performed for evaluation of VPI. OUTCOME MEASURES: Adenoid size based on nasendoscopy studies, and adenoid involvement in VP closure based on videofluoroscopy were recorded. RESULTS: The average patient age was 6.6 years (range three to 13 years). Seventy-eight per cent of patients had small adenoid volumes (less than 50% obstruction of the choanae), and six patients (two unilateral cleft lip and palate patients, one bilateral cleft lip and palate patient, two isolated CP patients and one cleft of secondary palate patient) had large adenoid volumes (50% or greater obstruction of the choanae); the adenoid pads of these patients were almost always (five of six patients) involved in their VP closure patterns. Videofluoroscopy showed that 26% (95% CI 9% to 40%) of patients did not significantly use their adenoid pad in VP closure. Forty-three per cent of those not using their adenoids attempted contact with a Passavant's ridge. CONCLUSIONS: In general, the adenoid pad should be maintained in CP patients. However, not all CP patients in the present study used their adenoid pad in attempted VP closure. If adenoidectomy is medically indicated, a percentage of these patents might be considered to be at lower risk for the development of postadenoidectomy VPI.

Splinting after carpal tunnel release: current practice, scientific evidence, and trends.

BACKGROUND: Postoperative splinting is common after carpal tunnel release, despite a lack of scientific evidence supporting its value. The purpose of this study was to characterize postoperative splinting regimens among hand surgeons and to identify trends in splint use after this procedure. METHODS: Questionnaires were mailed to members of the American Society for Surgery of the Hand. Recipients were asked to record whether and for how long they use splints after carpal tunnel release. They were also asked to indicate their training (i.e., orthopedic, plastic, or general surgery). Results were compared with those of previously conducted surveys. RESULTS: One thousand ninety-one questionnaires were returned, for a response rate of 48 percent. Fifty-three percent of respondents use splinting postoperatively. Duration of splinting varied tremendously, from 1 to 42 days. Splinting patterns were similar across all training backgrounds. In comparison with related surveys conducted in 1987 and 1997, a trend is evident toward less use of splinting after carpal tunnel release. CONCLUSIONS: The use and duration of splinting after carpal tunnel release vary widely among hand surgeons. This divergence of practice implies that there is little therapeutic benefit to splinting after this procedure, a concept supported by substantial scientific evidence and by a trend away from splinting over the past 20 years.

Kinetics of cisplatin binding to cellular DNA and modulations by thiol-blocking agents and thiol drugs.

DNA platination by cisplatin (CDDP) was investigated in peripheral blood mononuclear cells and ovarian cancer cells using atomic absorption spectroscopy. Plots showing the amount of platinum (Pt) bound to DNA versus the molar concentration of cisplatin in the incubation medium ([CDDP]) were nonlinear. For [CDDP] < about 5 microM, the amount of Pt bound to DNA increased slowly with added drug. However, for larger [CDDP], the slope of the plot increased significantly. To study the role of thiols in affecting cisplatin binding to DNA, cells were treated with N-ethylmaleimide, which modifies thiol groups, rendering them incapable of binding cisplatin. Analysis using high-pressure liquid chromatography showed that approximately 99% of cellular glutathione was modified by N-ethylmaleimide. A plot of the amount of Pt bound to DNA versus [CDDP] for thiol-blocked cells is linear, with a slope similar to that of unblocked cells at high [CDDP]. Neither S-2-(3 aminopropylamino)ethanethiol (WR-1065) nor mesna, when added at clinically achievable concentrations (i.e., < approximately 300 microM), affected DNA platination. However, DNA platination was totally abolished by millimolar concentrations of the drug thiols (approximately 1.25 mM WR-1065 or approximately 5 mM mesna). Thus, the data show that endogenous thiols intercept cellular cisplatin, but this mechanism is less important at high [CDDP]. Moreover, therapeutic concentrations of drug thiols do not significantly affect DNA platination. A simple model that reproduces the experimental results of the amount of cisplatin binding to DNA as a function of [CDDP], time, and thiol content is proposed. The model takes into account passage of cisplatin and thiols through the cell membrane, binding of cisplatin to cellular thiols, and platination of DNA.