Circulating angiotensin peptides levels in Acute Respiratory Distress Syndrome correlate with clinical outcomes: A pilot study.

RATIONALE: We propose renin angiotensin system (RAS) peptides are critical in wound reparative processes such as in acute respiratory distress syndrome (ARDS). Their role in predicting clinical outcomes in ARDS has been unexplored; thus, we used a targeted metabolomics approach to investigate them as potential predictors of outcomes. METHODS: Thirty-nine ARDS patients were enrolled within 24 hours of ARDS diagnosis. Plasma RAS peptide levels were quantified at study entry and 24, 48 and 72 hours using a liquid chromatography-mass spectrometry based metabolomics assay. RAS peptide concentrations were compared between survivors and non-survivors, and were correlated with clinical and pulmonary measures. MEASUREMENTS AND MAIN RESULTS: Angiotensin I (Ang-I or A(1-10)) levels were significantly higher in non-survivors at study entry and 72 hours. ARDS survival was associated with lower A(1-10) concentration (OR 0.36, 95% CI 0.18-0.72, p = 0.004) but higher A(1-9) concentration (OR 2.24, 95% CI 1.15-4.39, p = 0.018), a biologically active metabolite of A(1-10) and an agonist of angiotensin II receptor type 2. Survivors had significantly higher median A(1-9)/A(1-10) and A(1-7)/A(1-10) ratios than the non-survivors (p = 0.001). Increased A(1-9)/A(1-10) ratio suggests that angiotensin converting enzyme II (ACE2) activity is higher in patients who survived their ARDS insult while an increase in A(1-7)/A(1-10) ratio suggests that ACE activity is also higher in survivors. CONCLUSION: A(1-10) accumulation and reduced A(1-9) concentration in the non-survivor group suggest that ACE2 activities may be reduced in patients succumbing to ARDS. Plasma levels of both A(1-10) and A(1-9) and their ratio may serve as useful biomarkers for prognosis in ARDS patients.

Selective Thumb Carpometacarpal Joint Denervation for Painful Arthritis: Clinical Outcomes and Cadaveric Study.

PURPOSE: To determine the innervation pattern to the thumb carpometacarpal (CMC) joint and assess the safety and efficacy of selective joint denervation for the treatment of pain and impairment associated with thumb CMC arthritis. METHODS: Cadaveric dissections were performed in 10 fresh upper extremities to better define the innervation patterns to the CMC joint and guide the surgical approach for CMC joint denervation. Histologic confirmation of candidate nerves was performed with hematoxylin and eosin staining. Results from a series of 12 patients with symptomatic thumb CMC arthritis who underwent selective denervation were retrospectively evaluated to determine the safety and efficacy of this treatment approach. Differences in preoperative and postoperative measurements of grip and key-pinch strength as well as subjective reporting of symptoms were compared. RESULTS: Nerve branches to the thumb CMC joint were found to arise from the lateral antebrachial cutaneous nerve (10 of 10 specimens), the palmar cutaneous branch of the median nerve (7 of 10 specimens), and the radial sensory nerve (4 of 10 specimens). With an average follow-up time of 15 months, 11 of 12 patients (92%) reported complete or near-complete relief of pain. Average improvements in grip and lateral key-pinch strength were 4.1 ± 3.0 kg (18% ± 12% from baseline) and 1.7 ± 0.5 kg (37% ± 11% from baseline), respectively. One patient experienced the onset of new pain consistent with a neuroma that resolved with steroid injection. All patients were released to light activity at 1 week after surgery, and all activity restrictions were lifted by 6 weeks after surgery. CONCLUSIONS: Selective denervation of the CMC joint is an effective approach to treat pain and alleviate impairment associated with CMC arthritis. The procedure is well tolerated, with faster recovery as compared with trapeziectomy. Branches arising from the lateral antebrachial cutaneous nerve, palmar cutaneous branch of the median nerve, and radial sensory nerve can be identified and resected with a single-incision Wagner approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

Obstetric balloon for treatment of foreshortened vagina using the McIndoe technique.

BACKGROUND: When conservative options such as the use of vaginal dilators fail, the McIndoe technique may be used in the surgical treatment of a foreshortened vagina. The McIndoe procedure, an approach commonly used for the treatment of vaginal agenesis, requires a mold over which a skin graft is sutured and placed inside the vagina. In most surgical descriptions, this mold is made from non-sterile foam, condoms, or gloves. Because makeshift molds can no longer be used in operating rooms owing to strict regulations, alternative methods must be employed. INSTRUMENT: The obstetric balloon is a good choice for use as a soft and adjustable vaginal mold for a modified McIndoe procedure because it is readily available as an approved device in hospitals that provide obstetric services. EXPERIENCE: This technique was successfully employed in a 54-year-old woman to treat foreshortened vagina. CONCLUSION: An obstetric balloon can be used effectively as a mold for vaginal reconstruction with the McIndoe technique.

Two-stage prosthetic breast reconstruction using AlloDerm including outcomes of different timings of radiotherapy.

BACKGROUND: The authors compared the outcomes of two-stage, acellular dermal matrix (AlloDerm)-assisted prosthetic breast reconstruction including different timings of radiotherapy. METHODS: A review of two-stage, AlloDerm-assisted, prosthetic breast reconstructions from 2004 to 2010 was performed. All data were recorded prospectively and the study population was stratified by the timing of radiotherapy. Complications were analyzed following first- and second-stage reconstruction. The Spear-Baker classification of capsular contracture was modified for irradiated devices. Reconstructive failure was defined as nonelective removal of a breast prosthesis. RESULTS: : AlloDerm-assisted prosthetic reconstruction was performed in 289 women (428 breasts). After first-stage reconstruction, clinically significant capsular contracture rates (grade III/IV) were higher in the radiation therapy during expansion group and in the radiation therapy before mastectomy group compared with the no-radiation therapy group. Three hundred fifty-three breasts (85.9 percent) successfully underwent second-stage reconstruction, with a median follow-up of 15.2 months. Of those 353 breasts, clinically significant capsular contracture (grade III/IV) was highest in the radiation therapy during expansion group. More often than in the other groups, the radiation therapy during expansion group failed two-stage reconstruction and required flaps in addition or as replacement. CONCLUSIONS: In AlloDerm-assisted prosthetic breast reconstruction, irradiated devices demonstrated higher rates of clinically significant capsular contracture following the first stage. These rates declined considerably on completion of reconstruction, with prostheses irradiated during expansion still having the highest frequency of clinically significant capsular contracture. With the follow-up reported, irradiated devices failed breast reconstruction less frequently and required autologous tissue less often than has been historically reported without acellular dermal matrix. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Unilateral failures in bilateral microvascular breast reconstruction.

BACKGROUND: As rates of bilateral prophylactic mastectomy and contralateral prophylactic mastectomy have increased over the past decade, bilateral microvascular breast reconstruction has played an increasing role in breast cancer care. Data on unilateral flap failure in bilateral microvascular breast reconstructions have been lacking, and strategies to address the challenges encountered in this situation are needed. METHODS: A retrospective review of all simultaneous bilateral microvascular breast reconstructions performed by the senior author (M.Y.N.) from July of 1999 to July of 2008 was conducted. Flap failures were identified and reviewed for operative parameters, causes of flap loss, and techniques used for secondary reconstruction. RESULTS: The authors identified 171 consecutive patients who underwent bilateral microvascular breast reconstruction between July of 1999 and July of 2008. In these patients, 342 flaps were attempted, including 108 free transverse rectus abdominis musculocutaneous flaps, 228 deep inferior epigastric artery perforator flaps, and six superior gluteal artery perforator flaps. Twelve flaps failed or were aborted intraoperatively, yielding an overall failure rate of 3.5 percent. The authors' unilateral microsurgical breast reconstruction failure rate over this period was 2.1 percent (eight of 386). No bilateral failures occurred. Causes of flap failure included venous insufficiency (six of 12), lack of adequate perforator anatomy (three of 12), and perforator injury during dissection (two of 12). Secondary reconstruction with tissue expanders and implants was performed in 11 of 12 patients who underwent an average of 2.25 additional procedures to complete reconstruction. CONCLUSIONS: Flap failure is more common in bilateral reconstructions than in unilateral reconstructions, largely secondary to the obligation to use both sides of the abdominal donor tissue. When flap failure does occur, techniques to optimize prosthetic reconstruction can ultimately result in successful bilateral reconstructions despite free flap failure.

Occupational injury in plastic surgeons.

BACKGROUND: Little research to date has investigated musculoskeletal injury in the surgical workforce. This study estimates the prevalence and functional impact of work-related injury in plastic surgeons and other surgical specialists. METHODS: A validated self-assessment of work-related injury was administered to surgeons at various professional conferences, over the telephone, and via email. Prevalence rates for each injury were tabulated, and a regression analysis was conducted to identify potential associations between demographic risk factors and self-reported injury. RESULTS: Of 500 surveys administered, 339 (67.8 percent) were returned. Musculoskeletal symptoms were observed in 81.5 percent of surveyed surgeons. Of 17 injuries of interest, the most prevalent conditions were muscle strain, vision changes, cervical pain, lumbar pain, and shoulder arthritis/bursitis. Carpal tunnel syndrome and epicondylitis were reported by 15.1 and 13.5 percent of respondents, respectively, more than three times general population prevalence rates. Years in practice were associated with carpal tunnel syndrome. Microscope usage of 3 hours or more per week was associated with cervical and thoracic pain. Hand surgeons appeared to be more prone to thumb arthritis than other specialties. CONCLUSIONS: Self-reported injury is more prevalent in surgery than in previously described, labor-intensive populations. Sampled surgeons appear younger than the general surgery workforce, and as a result, this study may underestimate the prevalence of occupational injury, particularly carpal tunnel syndrome. This study underscores the need for a formal, multicenter assessment of occupational injury in surgeons.

Barbed suture tenorrhaphy: an ex vivo biomechanical analysis.

BACKGROUND: Using barbed suture for flexor tenorrhaphy could permit knotless repair with tendon-barb adherence along the suture's entire length. The purpose of this study was to evaluate the tensile strength and repair-site profile of a technique of barbed suture tenorrhaphy. METHODS: Thirty-eight cadaveric flexor digitorum profundus tendons were randomized to polypropylene barbed suture repair in a knotless three-strand or six-strand configuration, or to unbarbed four-strand cruciate repair. For each repair, the authors recorded the repair site cross-sectional area before and after tenorrhaphy. Tendons were distracted to failure, and data regarding load at failure and mode of failure were recorded. RESULTS: The mean cross-sectional area ratio of control repairs was 1.5 +/- 0.3, whereas that of three-strand and six-strand barbed repairs was 1.2 +/- 0.2 (p = 0.009) and 1.2 +/- 0.1 (p = 0.005), respectively. Mean load to failure of control repairs was 29 +/- 7 N, whereas that of three-strand and six-strand barbed repairs was 36 +/- 7 N (p = 0.32) and 88 +/- 4 N (p < 0.001), respectively. All cruciate repairs failed by knot rupture or suture pullout, whereas barbed repairs failed by suture breakage in 13 of 14 repairs (p < 0.001). CONCLUSIONS: In an ex vivo model of flexor tenorrhaphy, a three-strand barbed suture technique achieved tensile strength comparable to that of four-strand cruciate repairs and demonstrated significantly less repair-site bunching. A six-strand barbed suture technique demonstrated increased tensile strength compared with four-strand cruciate controls and significantly less repair-site bunching. Barbed suture repair may offer several advantages in flexor tenorrhaphy, and further in vivo testing is warranted.

Fistula after 2-flap palatoplasty: a 20-year review.

Oronasal fistula formation is a recalcitrant complication following palatoplasty, resulting in nasal emission during speech and deglutition. We review our series to identify factors associated with fistula incidence. A retrospective review of all children with nonsyndromic cleft palate who underwent 2-flap palatoplasty by the senior author from July 1983 to August 2004, was performed. Patient demographics, cleft characteristics, and operative techniques were recorded for each patient. The incidence rates of fistula, pharyngeal flap, and reoperation were used as primary outcomes. Statistical comparisons of frequencies were performed using Fisher exact test. Comparisons of means were performed using chi2 analysis. A total of 332 consecutive children met inclusion criteria. Mean age at palatoplasty was 10.8 months, and mean follow-up was 74.1 months. Eight children (2.4%) were found to have fistulae postoperatively, ranging in size from 2 to 15 mm. Four palatal fistulas occurred in the soft palate, 2 at the junction of the hard and soft palate, 1 in the hard palate, and 1 at the incisive foramen. Symptomatic nasal emission requiring reoperation occurred in 5 children. Two of these 5 children required a second operation to achieve fistula closure. Forty pharyngeal flaps were required for correction of velopharyngeal incompetence (12.0%). Two-flap palatoplasty remains a highly successful technique for closure of a variety of palatal clefts, with low fistula incidence. Surgical technique and experience are factors associated with low fistula incidence.

A "buttressed mesh" technique for fascial closure in complex abdominal wall reconstruction.

Today, plastic surgeons are increasingly faced with the problem of complex abdominal wall reconstruction. Obesity, bariatric surgery, and failed prior herniorrhaphy contribute to high rates of hernia recurrence in these difficult tertiary cases. We reviewed 50 consecutive complex abdominal wall reconstructions to identify the roles of 3 technical variables in successful outcomes: use of mesh, use of a flap buttress to reinforce the fascial repair, and the use of concomitant body-contouring techniques. Six groups were identified based on the presence or absence of each of these variables. Incidence of hernia recurrence and incidence of complications were compared for each group. Patient satisfaction with reconstructive outcome was assessed at follow-up using a 5-point scale. At a mean follow-up of 24 months, we observed an overall hernia recurrence rate of 4.0%, and an overall complication rate of 34%. Tension-free primary fascial repair and mesh repair of tension defects had equivalent recurrence rates (3.3% vs. 5%) and complication rates (40% vs. 25%). Repairs buttressed with flaps and repairs without buttressing had equivalent recurrence rates (3% vs. 6%) and complication rates (38% vs 28%). Repairs with and without body contouring techniques as part of the reconstructive plan had equivalent recurrence rates (7.7% vs. 0%) and complication rates (31.7% vs. 53%). Mean patient satisfaction was 4.8 of 5. Reconstruction of complex and recurrent hernias can be successfully performed. When tension-free primary fascial closure is not possible, an inlay mesh with a soft-tissue buttress leads to a 10-fold reduction in hernia recurrence as compared to historical norms. Concomitant body contouring surgery does not impact recurrence or complication rates and may contribute to reconstructive success.

History of breast implants and the food and drug administration.

Over the past 30 years, silicone-gel breast implants and their manufacturers have experienced a tumultuous relationship with the FDA and the public, which has changed the modern climate of industry oversight and the field of plastic surgery. We present an account of the events leading up to and resulting from the 1992 FDA moratorium on silicone implants. We highlight the involvement of the manufacturers, the scientific and legal communities, regulators, the plastic surgery community, and others as they strive to come to terms with a fearful public opinion shaped by the influence of the media. Finally, we describe how these past events will help the field of plastic surgery grow and continue to push the bounds of medicine.

External fixators as an adjunct to wound healing.

Complex foot and ankle wounds present multiple challenges for the reconstructive surgeon. Soft tissue deficits must be closed to protect underlying structures from infection and to provide a stable environment for healing. Surgical options commonly used include healing by secondary intention, local flap closure, skin grafts, pedicled flaps, and free tissue transfer. Despite a surgeon's best operative efforts, these strategies may fail because of postoperative shear forces created by premature joint motion or pressure (either weight bearing or decubitus). In the properly selected patient population, external fixators serve as an indispensable adjunct to wound healing by providing temporary offloading or immobilization of joints.

Imaging-guided percutaneous radiofrequency ablation of solid renal masses: techniques and outcomes of 38 treatment sessions in 32 consecutive patients.

OBJECTIVE: The purpose of this study was to describe the treatment techniques and results of 38 consecutive imaging-guided percutaneous radiofrequency ablations of solid renal masses performed in 32 patients. MATERIALS AND METHODS: Solid renal masses in 32 patients underwent 38 treatment sessions using imaging-guided percutaneous radiofrequency ablation. During 36 sessions, radiofrequency ablation was performed using CT guidance, and two, using sonographic guidance. The average patient age was 76 years (range, 52-87 years), and the average renal mass size was 2.6 cm (range, 1-5 cm). The average number of radiofrequency treatments per solid mass at each session was 2.4 (range, 1-6 treatments), and the average time per treatment was 9.2 min (range, 3-14 min). A single electrode was used in 12 sessions, and a cluster electrode was used in 26 sessions. The average follow-up time was 9 months (range, 1-36 months). RESULTS: Twenty-six of 32 patients had successful treatment of the solid renal mass using percutaneous imaging-guided radiofrequency ablation after one treatment session. Successful treatment was defined as lack of enhancement of the treated region on follow-up CT. Six of 32 patients had residual enhancing tissue after the first treatment session and returned for a second session. Five of these six retreatments were successful. Masses requiring a second treatment session were significantly larger than masses treated in a single session (3.5 vs 2.4 cm, respectively; p = 0.0013). Two patients had perinephric hematomas (which did not require transfusion), and one patient developed a 5-mm skin metastasis at the electrode insertion site, which was resected without recurrence. CONCLUSION: Percutaneous imaging-guided radiofrequency ablation shows promise in the treatment of solid renal malignancies.