Nontopical Nitrates in Flap Perfusion and Delay Phenomenon.

Background: Topical nitrates have demonstrated efficacy in improving flap perfusion. However, evidence for nontopical nitrates in modulation of flap perfusion dynamics has yet to be consolidated. Here, we review evidence regarding the use of intravascular, sublingual, and oral nitrates in modulating flap perfusion. Methods: We performed a review of the literature for evidence linking nontopical nitrates and flap perfusion, and included clinical studies, animal studies, and in vitro studies. Results: Evidence suggests that intravascular, sublingual, and oral nitrates exert vasodilatory properties, which may be harnessed for identification of perforators and improved flap perfusion. We also found evidence suggesting nitrates may facilitate ischemic preconditioning while reducing ischemia-reperfusion injury. Conclusions: Nitrates delivered intravascularly, sublingually, or orally may increase flap perfusion and serve as a method for ischemic preconditioning, particularly in the intraoperative setting.

Using non-invasive behavioral and physiological data to measure biological age in wild baboons.

Biological aging is near-ubiquitous in the animal kingdom, but its timing and pace vary between individuals and over lifespans. Prospective, individual-based studies of wild animals-especially non-human primates-help identify the social and environmental drivers of this variation by indicating the conditions and exposure windows that affect aging processes. However, measuring individual biological age in wild primates is challenging because several of the most promising methods require invasive sampling. Here, we leverage observational data on behavior and physiology, collected non-invasively from 319 wild female baboons across 2402 female-years of study, to develop a composite predictor of age: the non-invasive physiology and behavior (NPB) clock. We found that age predictions from the NPB clock explained 51% of the variation in females' known ages. Further, deviations from the clock's age predictions predicted female survival: females predicted to be older than their known ages had higher adult mortality. Finally, females who experienced harsh early-life conditions were predicted to be about 6 months older than those who grew up in more benign conditions. While the relationship between early adversity and NPB age is noisy, this estimate translates to a predicted 2-3 year reduction in mean adult lifespan in our model. A constraint of our clock is that it is tailored to data collection approaches implemented in our study population. However, many of the clock's components have analogs in other populations, suggesting that non-invasive data can provide broadly applicable insight into heterogeneity in biological age in natural populations.

Modulation of Cellular Stemness for Enhanced Fat Grafting.

Low volumetric retention limits the utility of fat grafting. Although inclusion of stem cells and platelet-rich plasma have been proposed to enhance graft retention, accumulating evidence has failed to show a clear benefit. Here, we propose a strategy to pharmacologically enhance stemness of stem and progenitor cell populations in fat grafts to promote increased volume retention and tissue health. We also propose how to integrate stemness-promoting and differentiation-promoting therapies such as platelet-rich plasma, and viability promoting therapies within the common fat grafting workflow to achieve optimal fat grafting results.

Analysis of Major and Minor Pedicles in Flap Perfusion by Computational Fluid Dynamics.

Background: Type 2 muscle flaps are characterized by major and minor pedicles, such that the minor pedicle is unreliable, and the major pedicle is a requirement for the success of the flap. The role of the minor pedicle, beyond the decreased caliber and decreased vascular territory in comparison to the major pedicle, is poorly understood. We sought to model the fluid dynamics of a model flap containing a major and minor pedicle to understand differences between the pedicles and the implications on perfusion. Methods: We first generated a computer-assisted design model of a type 2 flap with a major and minor pedicle. We then performed computational fluid dynamics to analyze velocities and flow within the pedicles and flap. Results: In our investigation, we found that the flow velocity within the major pedicle was higher than the minor pedicle, indicative of decreased resistance to flow. Concomitantly, we found decreased pressures within the major pedicle, reflecting decreasing resistance to flow. Interestingly, we found increased kinematic viscosity in flap areas supplied by the minor pedicle, suggesting decreased flow rates and increased resistance. Conclusions: We identified that the major pedicle has increased flow velocity, decreased resistance, and decreased kinematic viscosity, suggesting its dominance in maintaining flap perfusion. Our study also identifies computational fluid dynamics as a powerful tool in studying flap perfusion dynamics.

Nasal Soft Tissue Triangle Large Composite Graft Take With Postoperative Hyperbaric Oxygen Therapy: A Case Report.

Background: Auricular composite grafts hold great potential for reconstructing the nasal soft tissue triangle with desired aesthetic results because there is ample tissue available for sufficient nasal ala projection and the natural curvature of the helical rim matches that of the alar rim. The use of auricular composite grafts also results in positive functional outcomes because of the cartilaginous airway support provided to widen the external nasal valve. Composite graft survival is highly dependent on graft size, as larger sized grafts have a higher metabolic demand.To improve graft viability and reliability, hyperbaric oxygen therapy can be employed to accommodate the increased metabolic demand seen with larger composite grafts. Conclusions: This report presents the survival of a large skin and cartilage composite graft for nasal soft tissue triangle reconstruction in conjunction with hyperbaric oxygen therapy to improve graft viability.

Investigation of Hospital Pricing Information for Plastic Surgery Procedures Reveals Widespread Violation of the CMS Price Transparency Act.

BACKGROUND: Price transparency allows patients to estimate surgical procedure costs, which can affect where they elect to receive care and should theoretically result in hospitals setting lower and more uniform prices. To elucidate the traditionally opaque nature of health care pricing, the U.S. Centers for Medicare & Medicaid Services has mandated that hospitals publicly release their pricing information. The authors sought to investigate the utility of price transparency for plastic surgery patients, who are uniquely situated to benefit because of the dominance of elective procedures. METHODS: This study included 54 randomly chosen public and private hospitals. Pricing information for 15 common plastic surgery-related procedures was compiled from their websites. RESULTS: One year after the ruling went into effect, only 13% of hospitals were fully compliant with Centers for Medicare & Medicaid Services requirements for reporting standard charges. The most commonly reported plastic surgery procedures were adjacent tissue transfers (CPT codes 14000, 14001, 14301, and 14302), with an average of 32.4% of hospitals listing pricing data. The 25.9% of hospitals reporting the immediate insertion of breast implants (CPT code 19340) pricing presented a wide range of gross prices, from $2346.09 to $29,969.35. Free and pedicled flaps (CPT codes 19364, 19361, 19367, 19368, and 19369) were less commonly reported than autologous tissue transfer or nonflap breast procedures ( P = 0.00). CONCLUSIONS: A comparative analysis of published prices provides a starting point for surgeons to recommend facilities to patients based on price. However, significant variability was observed in data presentation, reported procedures, and listed prices. These inconsistencies in reporting and unrealistic ranges in price render the comparison of plastic surgery prices among hospitals impractical.

Smoking as a Risk Factor for Forehead Flap Wound Outcomes: An Analysis of 1030 Patients.

Background: The forehead flap is a local transposition flap based on a pedicled vessel commonly used to reconstruct facial defects. Often patients requiring reconstructions are smokers, yet the effects of smoking on forehead flaps are not well defined. Our study is aimed to examine smoking as a preoperative risk factor for complications following forehead flaps. Methods: This retrospective cohort study used data collected from the American College of Surgeons National Surgical Quality Improvement Program from 2005 to 2019. Multivariate logistic regression models were fitted to evaluate the association between smoking and development of wound complications. Results: A total of 1030 forehead flaps cases were analyzed and separated into 2 cohorts based on current smoking status: 789 (76.6%) nonsmokers versus 241 (23.4%) smokers. No significant differences in rates of wound complications were found for nonsmokers versus smokers (2.7% vs 4.1%; P = .0807), including when adjusted for comorbidities in a multivariate logistic regression model (adjusted odds ratio, 1.297 [95% confidence interval, 0.55-2.9]; P = .5174). Conclusions: Smoking has been demonstrated to be a risk factor for plastic surgery procedures. However, in our review of 1030 forehead flaps, smokers did not have worse outcomes compared with nonsmokers. Although it is still advised to recommend smoking cessation given multiple health benefits, smoking status should not preclude candidacy for facial reconstruction with a forehead flap based on complication risk.

Soft Tissue Expansion in Total Knee Arthroplasty Due to Extensive Scarring and Fibrosis in Multiple-Operated Knee.

Background: Inadequate wound closure is a feared complication following total knee arthroplasty (TKA). A knee with a multiple operative history, excessive scarring, and fibrosed surrounding soft tissue presents a significant challenge. In cases with preoperative uncertainty for sufficient soft tissue coverage because of ischemia and tension on closure, soft tissue expansion (STE) has been reported to be an effective tool for optimizing successful closure. Case Report: For the case in this report, STE was performed on a knee with multiple scars, potential ischemia, fibrosis, and soft tissue contractures prior to TKA. Conclusions: In cases of uncertain soft tissue coverage in TKA, the use of STE can be a useful method in creating adequate wound closure.

Treatment of Breast Animation Deformity in Implant-Based Reconstruction with Selective Nerve Ablation.

Breast animation deformity is a known complication of subpectoral implant placement that is usually corrected by repositioning the implant to the prepectoral position. Other less common treatment options include performing the muscle splitting biplanar technique, triple plane technique, neuromodulator injections, and secondary neurotomies via transection of the pectoral muscle. We report a patient with animation deformity successfully treated with direct identification and ablation of the medial and lateral pectoral nerves using selective bipolar electrocautery. The patient is a woman with a history of invasive ductal carcinoma who underwent bilateral mastectomy and breast reconstruction with subpectoral implant placement and autologous fat grafting. Within 1 year of her breast reconstruction, she developed hyperactive pectoralis muscle contraction with resulting distortion of both breasts. Given the disadvantages of repositioning the implant to the prepectoral position and transecting the pectoralis muscles via secondary neurotomy, we chose to directly identify and selectively ablate distal branches of the medial and lateral pectoral nerves. This offers a novel technique for correcting breast animation deformity without transecting the pectoralis muscles, causing muscle atrophy, and preserving the subpectoral implant position.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the table of contents or the online instructions to authors www.springer.com/00266 .

Gauze Impregnated With Quaternary Ammonium Salt Reduces Bacterial Colonization of Surgical Drains After Breast Reconstruction.

Surgical site infection after breast reconstruction is associated with increased length of hospital stay, readmission rates, cost, morbidity, and mortality. Identifying methods to reduce surgical site infection without the use of antibiotics may be beneficial at reducing antimicrobial resistance, reserving the use of antibiotics for more severe cases. Quaternary ammonium salts have previously been shown to be a safe and effective antimicrobial agent in the setting of in vitro and in vivo animal experiments. A retrospective study was conducted to investigate the antimicrobial properties of a quaternary ammonium salt, 3-trimethoxysilyl propyldimethyloctadecyl ammonium chloride (QAS-3PAC; Bio-spear), at reducing surgical drain site colonization and infection after breast reconstruction (deep inferior epigastric perforator flap reconstruction or tissue expander placement). Twenty patients were enrolled, with 14 surgical drains covered with nonimpregnated gauze and 17 surgical drains covered with QAS-3PAC impregnated gauze, for the purposes of investigating bacterial colonization. Antibiotic sensitivity analysis was also conducted when bacterial cultures were positive. The overall incidence of bacterial colonization of surgical drains was lower in the treatment group compared with the control group (17.6% vs 64.3%, respectively; P = 0.008). QAS-3PAC impregnated gauze reduced the incidence of bacterial colonization of surgical drains during the first (0.0% vs 33.3%) and second (33.3% vs 87.5%; P = 0.04) postoperative week. Furthermore, no enhanced antibiotic resistance was noted on drains treated with QAS-3PAC impregnated gauze. The results of this study suggest that QAS-3PAC impregnated gauze applied over surgical drains may be an effective method for reducing the incidence of bacterial colonization.

Exorcising Grice's ghost: an empirical approach to studying intentional communication in animals.

Language's intentional nature has been highlighted as a crucial feature distinguishing it from other communication systems. Specifically, language is often thought to depend on highly structured intentional action and mutual mindreading by a communicator and recipient. Whilst similar abilities in animals can shed light on the evolution of intentionality, they remain challenging to detect unambiguously. We revisit animal intentional communication and suggest that progress in identifying analogous capacities has been complicated by (i) the assumption that intentional (that is, voluntary) production of communicative acts requires mental-state attribution, and (ii) variation in approaches investigating communication across sensory modalities. To move forward, we argue that a framework fusing research across modalities and species is required. We structure intentional communication into a series of requirements, each of which can be operationalised, investigated empirically, and must be met for purposive, intentionally communicative acts to be demonstrated. Our unified approach helps elucidate the distribution of animal intentional communication and subsequently serves to clarify what is meant by attributions of intentional communication in animals and humans.

Refinements in the Techniques of 2-Stage Breast Reconstruction.

BACKGROUND: Two-stage breast reconstruction with tissue expanders is one of the most common plastic surgery procedures. Acellular dermal matrix (ADM) has become popular for its ability to improve expansion parameters and aesthetics, albeit with a higher complication profile. We present data that support redefining 2-stage reconstruction to include tissue expanders regardless of final reconstructive modality to act as a bridge. Furthermore, we show that cooperation with the ablative surgeon and technical refinements support ADM omission from the first stage of reconstruction. METHODS: We retrospectively reviewed charts from the senior author's (D.A.J.) private practice over a 10-year follow-up period. Inclusion criteria included all women over 18 years who underwent mastectomy and had a tissue expander placed immediately or in a delayed fashion and successfully completed tissue expansion and are finished with the second stage of reconstruction or awaiting second stage of reconstruction. Demographic data, tissue expander filling data, final reconstruction, aesthetic outcome, and complications were tabulated. RESULTS: A total of 118 women (165 breasts) met inclusion criteria. There were no statistically significant differences in initial fill volume (P = 0.094), number of visits until final expansion (P = 0.677), or final fill volume (P = 0.985) between the ADM and non-ADM cohorts. In addition, non-ADM patients had superior aesthetic scores with respect to defects other than scarring (P = 0.015), projection (P = 0.013), and inframammary fold quality (P = 0.009). Fifteen percent of women decided to change desired final reconstruction modality during the tissue expansion phase. CONCLUSIONS: This reconstructive algorithm emphasizes surgical cooperation between the ablative and reconstructive surgeon, improved technique, and patient education. This focus translates into maintained tissue expansion, aesthetically pleasing results, and allows for the omission of ADM from reconstruction.

Molecular characterization of exosome-like vesicles from breast cancer cells.

BACKGROUND: Membrane vesicles released by neoplastic cells into extracellular medium contain potential of carrying arrays of oncogenic molecules including proteins and microRNAs (miRNA). Extracellular (exosome-like) vesicles play a major role in cell-to-cell communication. Thus, the characterization of proteins and miRNAs of exosome-like vesicles is imperative in clarifying intercellular signaling as well as identifying disease markers. METHODS: Exosome-like vesicles were isolated using gradient centrifugation from MCF-7 and MDA-MB 231 cultures. Proteomic profiling of vesicles using liquid chromatography-mass spectrometry (LC-MS/MS) revealed different protein profiles of exosome-like vesicles derived from MCF-7 cells (MCF-Exo) than those from MDA-MB 231 cells (MDA-Exo). RESULTS: The protein database search has identified 88 proteins in MDA-Exo and 59 proteins from MCF-Exo. Analysis showed that among all, 27 proteins were common between the two exosome-like vesicle types. Additionally, MDA-Exo contains a higher amount of matrix-metalloproteinases, which might be linked to the enhanced metastatic property of MDA-MB 231 cells. In addition, microarray analysis identified several oncogenic miRNA between the two types vesicles. CONCLUSIONS: Identification of the oncogenic factors in exosome-like vesicles is important since such vesicles could convey signals to non-malignant cells and could have an implication in tumor progression and metastasis.

Segmental concatenation of individual signatures and context cues in banded mongoose (Mungos mungo) close calls.

BACKGROUND: All animals are anatomically constrained in the number of discrete call types they can produce. Recent studies suggest that by combining existing calls into meaningful sequences, animals can increase the information content of their vocal repertoire despite these constraints. Additionally, signalers can use vocal signatures or cues correlated to other individual traits or contexts to increase the information encoded in their vocalizations. However, encoding multiple vocal signatures or cues using the same components of vocalizations usually reduces the signals' reliability. Segregation of information could effectively circumvent this trade-off. In this study we investigate how banded mongooses (Mungos mungo) encode multiple vocal signatures or cues in their frequently emitted graded single syllable close calls. RESULTS: The data for this study were collected on a wild, but habituated, population of banded mongooses. Using behavioral observations and acoustical analysis we found that close calls contain two acoustically different segments. The first being stable and individually distinct, and the second being graded and correlating with the current behavior of the individual, whether it is digging, searching or moving. This provides evidence of Marler's hypothesis on temporal segregation of information within a single syllable call type. Additionally, our work represents an example of an identity cue integrated as a discrete segment within a single call that is independent from context. This likely functions to avoid ambiguity between individuals or receivers having to keep track of several context-specific identity cues. CONCLUSIONS: Our study provides the first evidence of segmental concatenation of information within a single syllable in non-human vocalizations. By reviewing descriptions of call structures in the literature, we suggest a general application of this mechanism. Our study indicates that temporal segregation and segmental concatenation of vocal signatures or cues is likely a common, but so far neglected, dimension of information coding in animal vocal communication. We argue that temporal segregation of vocal signatures and cues evolves in species where communication of multiple unambiguous signals is crucial, but is limited by the number of call types produced.

Intensive care unit course of infants and children after cranial vault reconstruction for craniosynostosis.

BACKGROUND: Craniosynostosis (CSS) results from the premature closure of one or more cranial sutures, leading to deformed calvaria at birth. It is a common finding in children with an incidence of one in 2000 births. Surgery is required in order to release the synostotic constraint and promote normal calvaria growth. Cranial vault remodeling is the surgical approach to CSS repair at our institution and it involves excision of the frontal, parietal, and occipital bones. The purpose of this article is to describe the post-operative course of infants and children admitted to our PICU after undergoing cranial vault remodeling for primary CSS. FINDINGS: Complete data was available for analyses in only 82 patients, 44 males (M) and 38 females (F); M: F ratio was 1:1.2. Patients (pts) age in months (mo) ranged from 2 mo to 132 mo, mean 18.2 ±-24.9 mo and weights (wt) ranged from 4.7 kg to 31.4 kg, mean 10.24 ± 5.5 Kg.. Duration of surgery (DOS) ranged from 70 minutes to 573 minutes mean 331.6 ± 89.0 minutes. No significant correlation exist between duration of surgery, suture category, patient's age or use of blood products (P > 0.05). IOP blood loss was higher in older pts (P < 0.05) and it correlates with body temperature in the PICU (P < .0001). Post-op use of FFP correlated with intra-operative PRBC transfusion (P < 0.0001). More PRBC was transfused within 12 hrs-24 hrs in PICU compared to other time periods (P < 0.05). LOS in PICU was < 3 days in 68% and > 3 days in 32%. Pts with fever had prolonged LOS (P < 0. 05); re-intubation rate was 2.4% and MVD were 1.83 days. Repeat operation for poor cosmetic results occurred in 9.7% of pts. CONCLUSIONS: Post-op morbidities from increased use of blood products can be minimized if cranial vault remodeling is done at a younger age in patients with primary CSS. PICU length of stay is determined in part by post-op pyrexia and it can be reduced if extensive evaluations of post-op fever are avoided.

Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for facial soft-tissue augmentation.

BACKGROUND: Soft-tissue fillers have become increasingly prominent in the practice of facial aesthetic medicine. The authors sought to evaluate the long-term clinical efficacy and safety of a calcium hydroxylapatite-based filler (Radiesse) for facial soft-tissue augmentation. METHODS: A total of 609 subjects received calcium hydroxylapatite injections in several facial areas: the nasolabial folds, marionette lines, oral commissure, cheeks, chin, lips, and radial lip lines. Follow-up patient satisfaction surveys were conducted at 6 months and again between 12 and 24 months. Treatment satisfaction was based on a scale of 1 (least satisfied) to 5 (most satisfied) using subjective self-evaluation of preoperative photographs. Subjects were also asked whether they would use the treatment again. Adverse events were recorded immediately after treatment and at follow-up visits. RESULTS: Of the total number of survey requests, 155 subjects provided 6-month follow-up data and 112 subjects provided long-term 12- to 24-month data. The average satisfaction rating at 6 months was 3.94. A total of 138 of 155 subjects (89 percent) at 6 months and 83 of 112 (74 percent) at 12 to 24 months stated that they would use the treatment again. The only side effect observed was the development of easily treated nodules, reported by 42 of 338 of lip mucosa augmentation subjects (12.4 percent) and six of 163 of subjects (3.7 percent) who had treatment for radial lip lines. The proportion of subjects with lip nodules decreased to 8.8 percent when the implant volume was decreased. CONCLUSIONS: The calcium hydroxylapatite-based implant is a safe, long-lasting, highly effective, and well-tolerated agent for many areas of facial soft-tissue augmentation.

Extracorporeal bypass preserved composite anterior thigh free flap (periosteo-musculo-fascio-cutaneous) for hemipelvectomy reconstruction: utilizing the periosteal component for abdominal wall fascial reconstruction.

We present a case of a right external hemipelvectomy for chondroblastic osteosarcoma originating from the right ilium and reconstruction with salvage parts; cardiopulmonary bypass preserved anterior thigh free flap. The resection required sacrifice of the right common iliac artery and vein and the entire right gluteus maximus muscle. The first stage of the procedure was a high above-knee amputation on the ipsilateral leg. The amputated extremity was placed on extracorporeal bypass utilizing the common femoral artery and vein. This technique, previously unreported, supported the successful utilization of the anterior thigh free flap for both soft tissue and abdominal wall facial reconstruction.

Extracellular matrix substrata alter adipocyte yield and lipogenesis in primary cultures of stromal-vascular cells from human adipose.

The stromal-vascular fraction of human adipose was subjected to in vitro adipogenesis on different extracellular matrix substrata. Adipose tissue was harvested from the breast of 25 to 45 year-old female patients undergoing elective surgery. After 24 d, less than 5% of stromal-vascular cells had converted to adipocytes on fibronectin, 13% to 28% on tissue culture plastic and collagen I; and 59% +/- 7% on Matrigel. Lipid volume surpassed 4.5 x 10(3) microm3 cell(-1) for Matrigel and was 30% lower for the other substrata. Cell proliferation was evident for Matrigel and fibronectin, and cell spreading was most pronounced for fibronectin with a projected area exceeding 3 x 10(3) microm2 cell(-1). These results are relevant to the design of an adipose implant, providing insight into its feasibility and scaffold composition.