Consensus-based Recommendations for Vibration Amplification of Sound Energy at Resonance Ultrasound-assisted Liposuction.

Ultrasound-assisted liposuction (UAL) is a popular and minimally invasive cosmetic procedure. Third-generation devices such as the vibration amplification of sound energy at resonance (VASER)lipo system are used for body contouring with enhanced tissue specificity. Despite the widespread use of VASER UAL, published guidelines and recent expert consensus recommendations are lacking. The objective of this study is to develop an expert consensus on the recommendations for use of VASER UAL. Methods: In a modified Delphi process, a panel of five US-based, expert plastic surgeons participated in three rounds of consensus building that spanned 4 months to align on guidance statements for the use of VASER as an adjunct to liposuction. Results: After the experts responded to an online questionnaire that assessed device settings, postoperative instructions, side effects or complications, and best practices, 32 initial consensus statements were developed. By round 3, these consensus statements for VASER UAL had been reduced and refined to a total of 18. Conclusions: To improve patient outcomes, clinicians must understand key factors and best practices when using VASER UAL, including device settings, provider technique, managing side effects, potential complications, and postoperative care. The consensus statements developed herein aim to provide clinicians with expert-backed recommendations for the use of VASER UAL.

Microvascular lifeboats: a stepwise approach to intraoperative venous congestion in DIEP flap breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap is becoming a widely practiced method of autologous breast reconstruction. Although it has been shown to be a safe and reliable technique with acceptable morbidity, disadvantages include a comparatively higher incidence of venous congestion and total flap loss compared with autologous reconstruction with a pedicled or free transverse rectus abdominis myocutaneous flap. Venous congestion is reported in up to one-third of cases of breast reconstruction with a DIEP flap. If venous congestion is detected and addressed intraoperatively compared with postoperatively, outcomes are significantly improved. A wide variety of techniques have been introduced to augment venous drainage to treat congestion and prevent flap failure. Here, the authors offer a comprehensive review of techniques available to address intraoperative venous congestion in DIEP flaps for breast reconstruction. From this review, the authors propose a stepwise, algorithmic approach to diagnosing and treating this potentially devastating complication.

The effect of prior abdominal surgery on abdominally based free flaps in breast reconstruction.

BACKGROUND: The abdomen has long remained the preferred donor site in breast reconstruction. Over time, the flap has evolved to limit morbidity with reduced muscular harvest. Previous abdominal operations, however, may limit the ability to perform a muscle- or fascia-sparing flap. The purpose of this study was to evaluate outcomes in women who had prior abdominal operations and underwent abdominally based autologous breast reconstruction. METHODS: All patients who underwent abdominally based breast free flap reconstruction between 2004 and 2009 were reviewed. A study group of patients with previous open abdominal surgery were compared to patients with no prior abdominal surgery. Patient demographics, operative details, and flap and donor-site complications were analyzed. RESULTS: A total of 539 patients underwent abdominally based breast free flap reconstruction. The study group consisted of 268 patients (341 flaps) and the control group consisted of 271 patients (351 flaps). Prior abdominal surgery led to greater muscular harvest, as 19.9 percent in the study group versus 12.0 percent required muscle-sparing 1-type harvest (p < 0.01). Both groups presented similar overall complications, with the exception of lower partial flap loss and increased wound healing complications in the study group (p < 0.05). Abdominal wall laxity became less frequent with increasing number of prior abdominal operations. CONCLUSIONS: Abdominally based flaps for breast reconstruction, including muscle-sparing 3 (deep inferior epigastric perforator) flaps, can be performed safely in patients with prior abdominal surgery. These patients should be informed, however, of an increased chance of muscular harvest and wound healing complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Factors influencing patient interest in plastic surgery and the process of selecting a surgeon.

BACKGROUND: Understanding patient interest in cosmetic surgery is an important tool in delineating the current market for aesthetic surgeons. Similarly, defining those factors that most influence surgeon selection is vital for optimizing marketing strategies. OBJECTIVE: The authors evaluate a general population sample's interest in cosmetic surgery and investigate which factors patients value when selecting their surgeon. METHODS: An anonymous questionnaire was distributed to 96 individuals in waiting rooms in nonsurgical clinics. Respondents were questioned on their ability to differentiate between a "plastic" surgeon and a "cosmetic" surgeon, their interest in having plastic surgery, and factors affecting surgeon and practice selection. Univariate and multivariate analyses were conducted to define any significant correlative relationships. RESULTS: Respondents consisted of 15 men and 81 women. Median age was 34.5 (range, 18-67) years. Overall, 20% were currently considering plastic surgery and 78% stated they would consider it in the future. The most common area of interest was a procedure for the face. The most important factors in selecting a surgeon were surgeon reputation and board certification. The least important were quality of advertising and surgeon age. The most cited factor preventing individuals from pursuing plastic surgery was fear of a poor result. Most (60%) patients would choose a private surgicenter-based practice. CONCLUSIONS: The level of importance for each studied attribute can help plastic surgeons understand the market for cosmetic surgery as well as what patients look for when selecting their surgeon. This study helps to define those attributes in a sample population.

Comparison of immediate implant placement versus the staged tissue expander technique in breast reconstruction.

BACKGROUND: Tissue expansion is currently the most common method used in prosthetic breast reconstruction. Skin-sparing mastectomy techniques have facilitated immediate placement of a permanent implant. Proposed benefits to immediate implants include less time and fewer operations to complete reconstruction. Whether it leads to poorer outcomes remains unknown. The authors compared immediate implant-based and staged tissue expander breast reconstruction. METHODS: Thirty-five consecutive immediate implant-based breast reconstruction patients (62 breasts) and a matched group of 50 tissue expander immediate reconstruction patients (89 breasts) were identified. Normative data, complication rates, revision rates, number of office visits, total reconstructive time, and aesthetic outcomes were compared. RESULTS: Demographic variables and surgical risk factors were similar in both groups. At a mean follow-up of 14 months, the overall complication rates were similar (p = 0.97), and the need for revision surgery was also similar (p = 0.94). Mean final implant volume did not differ between the two groups (397 ± 93 cc for implants and 386 ± 128 cc for expansion; p = 0.57). Mean number of office visits/time to nipple reconstruction was significantly different at 5.0 ± 4 versus 9.2 ± 3 visits (p < 0.001) and 22 ± 19 versus 43 ± 24 weeks (p < 0.001) in the implant versus tissue expander group, respectively. Aesthetic evaluation revealed no significant differences. CONCLUSIONS: Immediate implant-based breast reconstruction has similar complication rates, need for revision, and aesthetic outcomes but fewer office visits and less reconstructive time when compared with tissue expander immediate breast reconstruction. In the appropriately selected patient, it is a safe option that provides similar outcomes in less time compared with staged expander-based reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Portable PET probes are a novel tool for intraoperative localization of tumor deposits.

BACKGROUND: Positron emission tomography (PET) identifies cancer deposits by detecting sites of gamma emissions that are released from radioactively labeled molecules targeting tumor to formulate a PET image. Correlating preoperative PET scans with intraoperative findings remains a challenge. We investigated whether high-energy gamma emissions detected by a novel hand-held PET probe would detect tumors and offer a real-time method to localize tumor intraoperatively. Furthermore, we investigated the novel beta probe, which detects emissions at a shorter range than gamma emissions, making them undetectable by PET scanners, but potentially valuable for close range intraoperative detection of tumor deposits. METHODS: Six-to-eight-week-old athymic mice were injected with one of four possible tumor cell lines: gastric, pancreas, squamous cell and breast cancer. After tumors reached at least 1 cm in size, they were euthanized and imaged with a micro-PET imager. Hand-held gamma and beta probes were then used in vivo and ex vivo to measure high-energy gamma and beta emissions. RESULTS: The portable PET probes detected high-energy gamma and beta emissions from all tumors evaluated. These emissions were reproducible and we established that beta emissions correlate with high-energy gamma emissions and conventional PET scans. There was a strong positive correlation (R = 0.8) between gamma and beta counts. Beta emission showed a stronger correlation than gamma emission with overall tissue radioactivity. CONCLUSION: This study is the first to demonstrate that gamma emission detected by conventional PET imaging correlates with beta emissions. This study shows that compared to detection of gamma emissions, beta counts may offer superior real-time localization of tumor deposits. Intraoperative portable PET probe may become a useful way to exploit tumor biology and PET technology to guide real-time tissue characterization during surgery.

Regression of human pancreatic tumor xenografts in mice after a single systemic injection of recombinant vaccinia virus GLV-1h68.

Oncolytic virotherapy of tumors has shown promising results in both preclinical and clinical studies. Here, we investigated the therapeutic efficacy of a replication-competent vaccinia virus, GLV-1h68, against human pancreatic carcinomas in cell cultures and in nude mice. We found that GLV-1h68 was able to infect, replicate in, and lyse tumor cells in vitro. Virus-mediated marker gene expressions were readily detected. Moreover, s.c. PANC-1 pancreatic tumor xenografts were effectively treated by a single i.v. dose of GLV-1h68. Cancer killing was achieved with minimal toxicity. Viral titer analyses in homogenized organs and PANC-1 tumors showed that the mutant virus resides almost exclusively in the tumors and not in healthy organs. Except mild spleen enlargements, no histopathology changes were observed in any other organs 2 months after virus injection. Surprisingly, s.c. MIA PaCa-2 pancreatic tumors were treated with similar efficiency as PANC-1 tumors, although they differ significantly in sensitivity to viral lysis in cell cultures. When GLV-1h68 oncolytic viral therapy was used together with cisplatin or gemcitabine to treat PANC-1 tumors, the combination therapy resulted in enhanced and accelerated therapeutic results compared with the virus treatment alone. Profiling of proteins related to immune response revealed a significant proinflammatory immune response and marked activation of innate immunity in virus-colonized tumors. In conclusion, the GLV-1h68 strain showed outstanding therapeutic effects and a documented safety profile in mice, with great promise for future clinical development.

Myxoma virus is oncolytic for human pancreatic adenocarcinoma cells.

BACKGROUND: Viral oncolytic therapy, which seeks to exploit the use of live viruses to treat cancer, has shown promise in the treatment of cancers resistant to conventional anticancer therapies. Among the most difficult to treat cancers is advanced pancreatic adenocarcinoma. Our study investigates the ability of a novel oncolytic agent, myxoma virus, to infect, productively replicate in, and kill human pancreatic cancer cells in vitro. METHODS: The myxoma virus vMyxgfp was tested against a panel of human pancreatic adenocarcinoma cell lines. Infectivity, viral proliferation, and tumor cell kill were assessed. RESULTS: Infection of tumor cells was assessed by expression of the marker gene enhanced green fluorescent protein (e-GFP). vMyxgfp had the ability to infect all pancreatic cancer cell lines tested. Killing of tumor cells varied among the 6 cell lines tested, ranging from >90% cell kill at 7 days for the most sensitive Panc-1 cells, to 39% in the most resistant cell line Capan-2. Sensitivity correlated to replication of virus, and was found to maximally exhibit a four-log increase in foci-forming units for the most sensitive Panc-1 cells within 72 h. CONCLUSION: Our study demonstrates for the first time the ability of the myxoma virus to productively infect, replicate in, and lyse human pancreatic adenocarcinoma cells in vitro. These data encourage further investigation of this virus, which is pathogenic only in rabbits, for treatment of this nearly uniformly fatal cancer.

Detection of micrometastases in peritoneal washings of gastric cancer patients by the reverse transcriptase polymerase chain reaction.

BACKGROUND: Gastric cancer patients with positive (+) peritoneal cytology have a prognosis similar to stage IV patients. We studied the ability of quantitative reverse transcriptase polymerase chain reaction (RT-PCR) to detect peritoneal micrometastases in patients undergoing staging laparoscopy. METHODS: Peritoneal washings were obtained prospectively from 34 patients with gastric adenocarcinoma undergoing staging laparoscopy and 6 patients undergoing laparoscopy for benign disease. Each sample underwent cytologic and RT-PCR analysis for tumor markers: carcinoembryonic antigen (CEA), cytokeratin 20 (CK20), survivin, and MUC2. Markers were evaluated on the basis of their deviance from the ideal marker. RESULTS: Pathologic stages for the gastric cancer patients were: stage I, 9 (27%); stage II, 7 (21%); stage III, 15 (44%); and stage IV, 3 (9%). The four cytology (+) patients were: stage II, 1; stage III, 1; and stage IV, 2. Fifteen patients were RT-PCR (+), including all cytology (+) patients. The optimal threshold for cycle amplification was 35, based on a receiver operating characteristic curve. CEA had the smallest deviance. CONCLUSION: RT-PCR using a panel of tumor markers, including CEA, detects (+) cytology. The clinical significance of "false-positive" overexpression of CEA, survivin, or CK20 but cytology (-) remains to be defined. RT-PCR could represent a more sensitive method than cytology for detection of subclinical peritoneal tumor dissemination; this may be useful in improving patient selection for operative management and clinical trials.

Detection of micrometastases in peritoneal washings of pancreatic cancer patients by the reverse transcriptase polymerase chain reaction.

OBJECTIVE: Pancreatic cancer patients with positive (+) peritoneal cytology have a prognosis similar to stage IV patients. We studied the ability of quantitative real time-polymerase chain reaction (RT-PCR) to detect micrometastases in patients undergoing staging laparoscopy. METHODS: Peritoneal washes were obtained prospectively from 35 consecutive patients with pancreatic adenocarcinoma undergoing staging laparoscopy and 16 patients undergoing laparoscopy for benign disease. Each sample was assessed by cytologic examination and RT-PCR analysis for tumor markers: CEA, CK7, Kras2, and MUC1. Markers and their combinations were evaluated on the basis of their deviance from the ideal marker. RESULTS: Pathologic stages for pancreatic cancer patients were: 1A-1 (3%), IB-1 (3%), IIA-5 (15%), IIB-13 (38%), III-5 (15%), IV-9 (26%). Eight patients were cytology (+) and stages IIA-1, IIB-2, IV-5. Twenty-five patients were RT-PCR (+). The optimal threshold for cycle amplification was 35 based on a receiver operating characteristic curve. CEA had the best profile of sensitivity, specificity, PPV, NPV, and the smallest deviance. CONCLUSION: RT-PCR using a panel of tumor markers, including CEA, was comparable in sensitivity, specificity, PPV, and NPV to cytology. RT-PCR could represent a more sensitive method for detection of subclinical peritoneal tumor dissemination; this may be useful in patient selection for operative management and clinical trials.

Resected serous cystic neoplasms of the pancreas: a review of 158 patients with recommendations for treatment.

BACKGROUND: Serous cystic neoplasms of the pancreas are regarded as a benign entity with rare malignant potential. Surgical resection is generally considered curative. OBJECTIVE: To perform the largest single institution review of patients who underwent surgical resection for serous cystic neoplasms of the pancreas in the hopes of guiding future management. METHODS: Between June 1988 and January 2005, 158 patients with serous cystic neoplasms of the pancreas underwent surgical resection. A retrospective analysis was performed. Univariate and multivariate models were used to determine factors influencing perioperative morbidity and mortality. Major complications were defined as pancreatic fistula or anastomotic leak, postoperative bleed, retained operative material, or death. Minor complications were defined as wound infection, postoperative obstruction/ileus requiring total parenteral nutrition (TPN), delayed gastric emptying, arrhythmia, or other infection. RESULTS: The mean age of the patients was 62.1 years, with 75% being female. The majority of patients were symptomatic at presentation (63%), with abdominal pain as the most common symptom. Of the 158 patients, 75 underwent distal pancreatectomy, 65 underwent pancreaticoduodenectomy, nine underwent central pancreatectomy, five underwent local resection or enucleation, and four underwent total pancreatectomy. Mean tumor diameter was 5.1 cm. Mean operative time was 277 min. Mean postoperative length of hospital stay was 11 days. One patient was diagnosed at presentation with serous cystadenocarcinoma. The remaining 157 patients were initially diagnosed with benign serous cystadenoma. One of three patients with locally aggressive benign disease later presented with metastatic disease. Resection margins for all 158 patients were negative for tumor, and only one (0.6%) showed lymph node involvement. There was one intraoperative death. The incidence of major perioperative complications was 18%, whereas the incidence of minor complications was 33%. Men were significantly more likely to experience minor perioperative complications (OR = 3.74, P = 0.008), whereas patients greater than 65 years showed a trend toward fewer major complications (OR = 0.36, P = 0.09). CONCLUSIONS: Surgically resected serous cystic neoplasms of the pancreas are typically seen in asymptomatic women as 5 cm neoplasms and are predominantly benign. Most are resected via either a left- or right-sided pancreatectomy with low mortality risk, but with notable major or minor morbidity. Cystadenocarcinoma is a rare finding on initial resection of serous cystic neoplasms. However, initial pathology specimens exhibiting benign but locally aggressive neoplasia may indicate an increased likelihood of recurrence or metachronous metastasis, although this claim is limited by a small patient subpopulation in this study and warrants further review.