Delayed Postconditioning with External Volume Expansion Improves Survival of Adipose Tissue Grafts in a Murine Model.

BACKGROUND: External volume expansion improves the survival of adipose tissue grafts by preoperatively conditioning ("preconditioning") tissues that will receive the graft. External volume expansion's mechanisms of action (induction of angiogenesis and of adipogenesis) could improve graft survival also when applied postoperatively ("postconditioning"). METHODS: Fifty-six 8-week-old athymic (nu/nu) mice received dorsal subcutaneous grafts of human lipoaspirate (0.3 ml each) bilaterally before undergoing external volume expansion (left dorsum) or no treatment (right dorsum, controls). External volume expansion was started either on the same day of (immediate group), 2 days after (early group), or 1 week after surgery (delayed group). At follow-up, grafts were analyzed for tissue survival, remodeling, adipogenesis, and angiogenesis using histology. The authors subsequently assessed the effects of the delayed application of external volume expansion adopting a foam-shaped interface to deliver the treatment. RESULTS: At 28-day follow-up, delayed postconditioning with external volume expansion significantly improved the survival of grafts (18 percent) compared with controls (viable graft thickness ratio, 58 ± 15 percent versus 49 ± 13 percent) and increased the density of blood vessels within the graft (63 percent; blood vessels per 10× magnification field, 44 ± 12 versus 27 ± 11). Other groups did not experience significant changes. Adoption of external volume expansion with a foam-shaped interface similarly improved outcomes and further reduced fibrosis within the grafts. CONCLUSIONS: Postoperative delayed application of external volume expansion modestly improves the survival of adipose tissue grafts by inducing adipogenesis and angiogenesis. Use of a foam-shaped interface decreases the fibrosis induced in the grafts.

Plastic Surgery Complications from Medical Tourism Treated in a U.S. Academic Medical Center.

BACKGROUND: Medical tourism is a growing, multi-billion dollar industry fueled by improvements in the global transportation infrastructure. The authors studied patients living in the United States who travel to other countries for plastic surgical procedures and returned to have their complications treated in the authors' center. METHODS: A retrospective patient evaluation was performed. Patients who had presented to an urban tertiary academic hospital plastic surgery service with complications or complaints associated with plastic surgery performed in a developing country were studied. The authors collected demographic information, types of surgery performed, destinations, insurance coverage, and complications. RESULTS: Seventy-eight patients were identified over 7 years. Most commonly, complications were seen following abdominoplasty (n = 35), breast augmentation (n = 25), and foreign body injections (n = 15). Eighteen patients underwent multiple procedures in one operative setting. The most common destination country was the Dominican Republic (n = 59). Complications included surgical-site infections (n = 14), pain (n = 14), and wound healing complications (n = 12). Eighty-six percent of patients (n = 67) relied on their medical insurance to pay for their follow-up care or manage their complications, with the most common type of health insurance coverage being Massachusetts Medicaid (n = 48). CONCLUSIONS: Cosmetic surgery performed in developing countries can carry substantial risks of complications that can be challenging to patients, primary care providers, insurers, and plastic surgical teams not associated with the original surgery. These complications pose significant burdens on our public health systems.

The Role of Dermal Matrices in Treating Inflammatory and Diabetic Wounds.

BACKGROUND: Dermal matrices are used to improve healing in both acute and chronic wounds including diabetic and lower extremity wounds, burns, trauma, and surgical reconstruction. The use of dermal matrices for the closure of inflammatory ulcerations is less frequent but growing. Currently available products include decellularized dermis and semisynthetic matrices. METHODS: A review of the published literature was performed to identify reports that use acellular dermal matrices in diabetic and inflammatory wounds. Studies were evaluated for quality and outcomes, and a level of evidence was assigned according to the American Society of Plastic Surgeons' Rating Levels of Evidence. Case studies from the authors' experience are also presented. RESULTS: Seventeen primary studies evaluating the use of dermal matrices in diabetic ulcers were identified with 2 based on level I data. There are no prospective clinical trial reports of their use in atypical or inflammatory wounds, but there are several case studies. CONCLUSIONS: Treatment of diabetic and inflammatory wounds may include both medical and surgical modalities. The use of dermal matrices can be a useful adjunct, but their optimal use will require future clinical studies.

Global Patterns of QALY and DALY Use in Surgical Cost-Utility Analyses: A Systematic Review.

BACKGROUND: Surgical interventions are being increasingly recognized as cost-effective global priorities, the utility of which are frequently measured using either quality-adjusted (QALY) or disability-adjusted (DALY) life years. The objectives of this study were to: (1) identify surgical cost-effectiveness studies that utilized a formulation of the QALY or DALY as a summary measure, (2) report on global patterns of QALY and DALY use in surgery and the income characteristics of the countries and/or regions involved, and (3) assess for possible associations between national/regional-income levels and the relative prominence of either measure. STUDY DESIGN: PRISMA-guided systematic review of surgical cost-effectiveness studies indexed in PubMed or EMBASE prior to December 15, 2014, that used the DALY and/or QALY as a summary measure. National locations were used to classify publications based on the 2014 World Bank income stratification scheme into: low-, lower-middle-, upper-middle-, or high-income countries. Differences in QALY/DALY use were considered by income level as well as for differences in geographic location and year using descriptive statistics (two-sided Chi-squared tests, Fischer's exact tests in cell counts <5). RESULTS: A total of 540 publications from 128 countries met inclusion criteria, representing 825 "national studies" (regional publications included data from multiple countries). Data for 69.0% (569/825) were reported using QALYs (2.1% low-, 1.2% lower-middle-, 4.4% upper-middle-, and 92.3% high-income countries), compared to 31.0% (256/825) reported using DALYs (46.9% low-, 31.6% lower-middle-, 16.8% upper-middle-, and 4.7% high-income countries) (p<0.001). Studies from the US and the UK dominated the total number of QALY studies (49.9%) and were themselves almost exclusively QALY-based. DALY use, in contrast, was the most common in Africa and Asia. While prominent published use of QALYs (1990s) in surgical cost-effectiveness studies began approximately 10 years earlier than DALYs (2000s), the use of both measures continues to increase. CONCLUSION: As global prioritization of surgical interventions gains prominence, it will be important to consider the comparative implications of summary measure use. The results of this study demonstrate significant income- and geographic-based differences in the preferential utilization of the QALY and DALY for surgical cost-effectiveness studies. Such regional variation holds important implications for efforts to interpret and utilize global health policy research. PROSPERO registration number: CRD42015015991.