How Fat Grafting Works.

Fat grafting has been shown to improve diseased soft issue. Although the mechanism behind fat grafting's regenerative properties is currently debated, published studies agree that there is an associated vasculogenic effect. A systematic literature review was conducted to elucidate the biochemical pathways responsible for establishing neo-vasculature to grafted fat. METHODS: A systematic literature review was conducted by searching PubMed for current basic science and clinical research relating to fat grafting. In total, 144 of 269 (54%) articles met the inclusion criteria for our literature review. These 144 articles were summarized, with 86 of them (60%) used to construct this article at the authors' discretion. RESULTS: Fat grafting-induced neovascularization can be divided into 3 parts. First, tissue trauma induced via fat injection activates a host inflammatory response necessary for cellular recruitment. Recruited cells promote the formation of connective tissue and neo-vasculature at the graft site. Second, cellular elements within the lipoaspirate contribute to neovascularization through a cytokine burst. Third, a synergistic relationship is established between recruited inflammatory cells and the cytokine burst of grafted fat. The end product of these processes is the differentiation of progenitor cells and the creation of neo-vasculature at the graft site. CONCLUSIONS: Establishing neovasculature is paramount for the survival of grafted fat. Fat graft take can be divided into 2 steps: imbibition and neovascularization. We believe this process occurs through 3 distinct concepts: host inflammation via graft injection, hypoxic response of lipoaspirate-derived cellular elements, and a synergistic relationship between host inflammation and grafted fat.

Warping Characteristics of Rib Allograft Cartilage.

When septal cartilage is lacking, commercially available costal cartilage allograft can be used. Such allografts have "off-the-shelf" accessibility, are available in multiple sizes, are aseptically processed to meet sterility, and are screened to minimize infectious risks. The purpose of this study was to evaluate the effect of donor age, storage temperature, and orientation of a bilayered construct on the degree of warping of a commercialized fresh frozen costal cartilage allograft in vitro over time. A total of 140 fresh frozen costal cartilage cadaveric specimens were separated into three donor age groups. These were allocated into three harvesting subgroups: group a, single pieces (cephalocaudal segments); group b, two laminated pieces of the same rib sutured together in anatomical position (laminated group); and group c, two pieces from the same rib reversed onto each other and sutured together (oppositional group). Photographs were examined and analyzed to determine the degree of cartilaginous warping. Decreased rates of warping were seen in commercially available, aseptically processed costal cartilage allografts procured from older cadavers. Warping was also decreased when oppositional suturing techniques were used as a way to address those intrinsic cartilage forces.

Full-thickness Skin Micro-columns within a Dermal Matrix: A Novel Method for "Donor-free" Skin Replacement.

Split-thickness skin graft has been the standard in the coverage of large full-thickness skin defects. However, donor sites can be associated with significant pain and scarring. Further, the recipient sites frequently lack some basic skin functions, such as temperature regulation, uniform texture, appropriate color, normal pliability, elasticity, and lubrication. Full-thickness skin grafts, while able to more adequately recapitulate skin function, have even greater donor site requirements. Implantation of full-thickness skin micro-columns is a relatively novel concept in which the skin is harvested orthogonally rather than tangentially. These micro-columns contain elements of full-thickness skin grafts, including reticular dermal fibroblasts, hair follicles, skin adnexa, and adipose tissue-all elements that contribute to skin function. Notably, it has been shown that the diameter of the skin micro-columns determine donor site morbidity; however, in most cases, full-thickness skin micro-column harvest results in a trivial donor site far less invasive or morbid than a traditional full-thickness skin graft or split-thickness skin graft harvest. Here, we present 2 cases in which full-thickness skin micro-columns were harvested and implanted into a bilayer dermal regeneration matrix (Integra) to achieve durable single-stage skin replacement with practically no donor site morbidity.

Use of a Titanium Microplate to Anchor Subunit Reconstruction at the Nasal-Cheek Junction.

Reconstruction of combined nose, cheek, and/or inferior eyelid defects is facilitated by stable anchorage at the nasal-cheek junction. The previously reported techniques of drill holes and Mitek anchors are not without disadvantages. The authors present a simple means of anchoring soft tissue flaps at the nasal-cheek junction: a titanium miniplate secured with a screw at each end. Our case report describes successful, lasting, and complication-free anchorage of cheek, forehead, and eyelid flaps to a single miniplate placed along the piriform aperture.

Patterns of node mapping differ for axial and extremity primary cutaneous melanoma: A case for a more selective use of pre-operative imaging.

PURPOSE: Preoperative lymphoscintigraphy for sentinel lymph node mapping in melanoma improves the ability to locate nodes. However, it still remains unclear whether this step is required for all patients. METHODS: Patients diagnosed with cutaneous melanoma from 1996 to 2012 were identified. Exclusion criteria were in situ disease, metastatic disease, or no SLN biopsy. RESULTS: 214 patients were evaluated. Median age was 57 years, the majority were male (59.8%), white (97.2%), and stage I (60.7%). SLN revealed metastatic disease in 14.5% of patients. The most common primary site was the trunk (43.4%) followed by head and neck (21%), upper extremity (19.2%), and lower extremity (16.4%). Multiple lymphatic basins were most common for head and neck lesions (66.7%) followed by those on the trunk (28.8%), with fewer identified when lower (11.4%), and upper extremities were involved (4.2%). When comparison was restricted to extremity vs. axial, a single basin was noted in 94.5% vs. 59.9% of patients, p < 0.0001. For all extremity lesions the SLN was located in the primary basin. Additional sites included in-transit (popliteal) and second tier basins. The only melanomas with bilateral or contralateral SLN were axial melanomas. CONCLUSIONS: Patients with axial melanomas benefit most from lymphoscintigraphy. This step may not be required for extremity melanoma.

The oblique mastectomy incision: advantages and outcomes.

Mastectomy has traditionally been performed using a transverse elliptical incision. The disadvantages of this approach are a potentially visible scar medially and poor subincisional soft-tissue coverage of implants laterally. A more natural and aesthetic result is obtained with an oblique incision running parallel to the pectoralis major muscle fibers. This approach offers women more freedom of choice in clothing as well as the potential for complete subincisional muscle coverage in alloplastic breast reconstruction, in addition to other functional advantages.