Postoperative analgesia after microsurgical breast reconstruction using liposomal bupivacaine (Exparel).

Conventional opioid-based regimen for postoperative analgesia after autologous breast reconstruction can be associated with significant side effects. The purpose of this study was to assess the efficacy of an intraoperatively administered transversus abdominis plane (TAP) block with liposomal bupivacaine on postoperative narcotic use in patients undergoing microsurgical breast reconstruction with free abdominal flaps. Patients treated between December 2016 and June 2017 were included in the study. Parameters of interest were patient-reported pain score, total narcotic use (in oral morphine equivalent [OME]) during the hospitalization, length of stay (LOS), and the need for patient-controlled analgesia (PCA). Eighty-two free abdominal flaps were transferred in 46 patients with a mean age of 47.6 years and a mean body mass index (BMI) of 28.1 kg/m2 . The average LOS was 3.5 days (range, 3-5). Postoperatively, 42 patients (91.3%) did not require patient-controlled analgesia (PCA). The mean time to first narcotic use after arrival on the nursing unit was 6 hours (range, 0-19 hours). The mean total postoperative OME use was 123.2 mg (range, 0-285 mg). However, analysis of OME use excluding the four patients requiring PCA revealed a mean OME use of 90.3 mg (range, 0-167.5 mg). Liposomal bupivacaine provides for reliable, safe, and long-acting postoperative analgesia and contributes to a reduction in postoperative narcotic intake. The use of liposomal bupivacaine shows great promise in improving the standard of care in postoperative analgesia in microsurgical breast reconstruction.

Breast Reconstruction with Free Abdominal Flaps Is Associated with Persistent Lower Extremity Venous Stasis.

BACKGROUND: Previous work has demonstrated the occurrence of lower extremity venous stasis in the early postoperative period after breast reconstruction with free abdominal flaps. The authors investigated whether venous stasis persisted through the day of discharge, thus potentially exposing patients to an elevated risk of venous thromboembolism following discharge. METHODS: Patients who underwent breast reconstruction with free abdominal flaps were enrolled prospectively and underwent duplex ultrasound of the common femoral vein at the following time points: preoperatively, postoperative day 1, and day of discharge. Parameters of interest included common femoral vein diameter, area, and maximum flow velocity. RESULTS: Thirty patients with a mean age of 50.3 years (range, 29 to 70 years) underwent breast reconstruction with 52 free abdominal flaps. A significant increase in common femoral vein diameter (19.1 percent; p < 0.01) and area (46.8 percent; p < 0.01) correlated with a significant reduction in maximum flow velocity (-10.9 percent; p = 0.03) between baseline and postoperative day 1. These changes persisted through the day of discharge [common femoral vein diameter, 17.8 percent (p < 0.01); area, 46 percent (p < 0.01); and maximum flow velocity, -11.3 percent (p = 0.01)]. Venous parameters were not influenced by unilateral versus bilateral flap harvest (p = 0.48). CONCLUSIONS: Postoperative lower extremity venous stasis following autologous breast reconstruction with free abdominal flaps seems to persist through the day of discharge. This finding may explain why patients remain at risk for venous thromboembolism after discharge. Although the authors' findings are at odds with current venous thromboembolism prophylaxis recommendations, additional studies are indicated to examine whether these findings translate into venous thromboembolism events. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Social Media and the Plastic Surgery Patient.

BACKGROUND: Many plastic surgeons use social media as a marketing tool to attract and retain patients, but information about how patients use social media and their preferred types of plastic surgery posts have been lacking. METHODS: To investigate patients' preferred social media networks and the type of posts they wished to see, a cross-sectional study was conducted in a single aesthetic practice of two plastic surgeons by surveying 100 consecutive patients. RESULTS: The age of the patients averaged 44.4 years (range, 17 to 78 years). Facebook had the greatest patient use and engagement, with YouTube second in use, and Instagram second in number of engaged users. Over half used Pinterest, but with little daily engagement. Only one-fourth used Snapchat, but the percentage of users who were highly engaged was second only to Facebook. The least popular network was Twitter, with the fewest patient users and least engagement. Social media played a minor role compared with the practice's Web site in both influencing patients to choose the practice and providing information on the day of the appointment. Patients most wanted to see posts on a plastic surgeon's social media platform related to practice information, before-and-after photographs, and contests. Articles about plastic surgery held the least interest. Among five types of Web site content, patients expressed most interest in before-and-after photographs. CONCLUSIONS: This study is the first to articulate the plastic surgery patient perspective regarding social media. The findings aim to help plastic surgeons maximize their influence on their target audience.

Why Women Request Labiaplasty.

BACKGROUND: In recent years, labiaplasty has jumped in popularity, despite opposition to the procedure. In 2007, the American College of Obstetricians and Gynecologists declared the recommendation of cosmetic vaginal procedures to be "untenable," although in 2016 they allowed consideration of labiaplasty in adolescents if symptoms persist. The reasons for labiaplasty requests are not yet fully understood, and physician opposition limits patient access to surgical relief. METHODS: In this prospective study, 50 consecutive patients consulting about labiaplasty were given a questionnaire assessing 11 physical and appearance-related symptoms associated with elongated labia. RESULTS: The mean patient age was 33.5 years (range, 17 to 51 years). Fifty-eight percent of women had given birth, 52 percent noticed that their labia had become elongated as they got older, and 93 percent had bilateral elongation. When asked about physical symptoms, over half of patients experienced tugging during intercourse, found tight pants uncomfortable, experienced twisting of the labia, and noted labia visibility in yoga pants. Nearly half experienced pain during intercourse, and 40 percent said their labia could become exposed in bathing suits. Regarding appearance, almost all patients were self-conscious and over half felt less attractive to their partner, experienced restricted clothing choice, and noted a negative impact on self-esteem and intimacy. Nearly all patients experienced at least four symptoms. CONCLUSIONS: Most patients requesting labiaplasty experience both physical and appearance-related symptoms. Understanding this patient perspective is crucial in assessing surgical outcomes. Furthermore, the better all physicians understand labia symptomatology, the better supported patients will be in seeking surgical relief.

Optimizing functional upper extremity reconstruction-Simultaneous free anterolateral thigh flap and tendon transfers-A case report.

Composite upper extremity defects involving muscle-tendon units are amongst the most formidable reconstructive challenges and mandate functional restoration in addition to stable soft-tissue coverage. Here, the authors present a case of a composite defect involving the extensor muscle-tendon units of the forearm resulting from surgical resection of a recurrent Merkel cell cancer. Functional restoration was achieved via multiple tendon transfers followed by soft tissue coverage with a free anterolateral thigh (ALT) flap. No donor- or recipient-site complications were encountered and complete flap survival was noted. Following a 6-week period of immobilization, physical therapy and range of motion exercises were initiated. Excellent functional outcome and high patient satisfaction were noted at 8 weeks postoperatively. In summary, simultaneous tendon transfers and microsurgical tissue transfer may provide a potentially superior approach for upper extremity reconstruction in complex composite defects. © 2014 Wiley Periodicals, Inc. Microsurgery 37:71-74, 2017.

The Role of Stem Cell Therapeutics in Wound Healing: Current Understanding and Future Directions.

BACKGROUND: Chronic wounds present unique challenges for healthcare providers as they place patients at increased risk for various morbidities and mortality. Advances in wound care technology have expanded the treatment options available for wound management, but few products fully address the underlying core deficiencies responsible for the development of poorly healing wounds. In the future, addressing these derangements will undoubtedly play a key role in the treatment of these patients. Broad enthusiasm has surrounded the field of stem cell biology, which has shown great promise in repairing damaged tissues across numerous disease phenotypes. METHODS: In this review, we provide a comprehensive review of the literature and evaluate the present landscape of wound therapeutics while discussing the rationales and allure behind stem cell-based products. We further propose 2 challenges that remain as new stem cell-based therapies are being developed and as this technology moves toward clinical translation. RESULTS: Given the relatively young age of this newer technology in wound healing, numerous challenges continue to surround its effective use including identifying the ideal population of stem cells to use and determining the optimal cell delivery method. However, significant forward progress has been made, with several clinical trials beginning to demonstrate reliable clinical benefit. CONCLUSION: The upward trajectory of stem cell technologies provides an exciting opportunity to positively impact patient outcomes through the controlled application of regenerative cell-based therapy.

A novel oxysterol promotes bone regeneration in rabbit cranial bone defects.

Bone morphogenetic proteins (BMPs) have played a central role in the development of regenerative therapies for bone reconstruction. However, the high cost and side-effect profile of BMPs limits their broad application. Oxysterols, naturally occurring products of cholesterol oxidation, are promising osteogenic agents alternative to BMPs. The osteogenic capacity of these non-toxic and relatively inexpensive molecules has been documented in rodent models. We studied the impact of Oxy49, a novel oxysterol analogue, on the osteogenic differentiation of rabbit bone marrow stromal cells (BMSCs). Moreover, we evaluated the capacity for in vivo bone regeneration with Oxy49 in rabbit cranial bone defects. We found that rabbit BMSCs treated with Oxy49 demonstrated differentiation along osteogenic pathways, and that complete bone regeneration occurred when cranial defects were treated with Oxy49. Collectively, these results demonstrate that Oxy49 has the ability to induce osteogenic differentiation in rabbit BMSCs with an efficacy comparable to that of BMP-2 and to promote significant bone regeneration in cranial defects. Oxysterols may be a viable novel agent in bone tissue engineering. Copyright © 2016 John Wiley & Sons, Ltd.

Surgical treatment of systemic sclerosis--is it justified to offer peripheral sympathectomy earlier in the disease process?

PURPOSE: Systemic sclerosis (SSc) is a rare connective tissue disease associated with significant digital vasculopathy. Peripheral sympathectomy is frequently offered late in the disease process after severe digital ischemia has already occurred with patients being symptomatic for numerous years. The purpose of the present study was to analyze the results of peripheral sympathectomy in patients with a confirmed diagnosis of SSc. PATIENTS AND METHODS: A retrospective analysis of 17 patients (26 hands) who underwent peripheral sympathectomy between January 2003 and September 2013 was performed. Data regarding patient demographics, clinical features, and postoperative outcomes were retrieved. Of note, preoperative pain was present in all patients with a mean duration of 9.6 years prior to peripheral sympathectomy. RESULTS: Pain improvement/resolution was seen in 24 hands (92.3%). Digital ulcers healed in all patients with only two patients (two hands; 7.7%) requiring surgical intervention for ulcer recurrence 6 months and 4.5 years later. Minor complications were seen in seven hands (26.9%); including infection, wound opening, and stitch abscess, but none required surgical intervention. Seven of eight patients queried would have preferred surgical treatment at an earlier point in the disease process. CONCLUSION: Peripheral sympathectomy is a well-tolerated procedure in patients with SSc and is associated with predictable pain relief and ulcer healing in the majority of patients. In light of these findings it seems prudent to offer surgical treatment not as a last resort but rather earlier in the disease process to decrease the duration that patients suffer pain.

In vitro osteoinductive effects of hydroxycholesterol on human adipose-derived stem cells are mediated through the hedgehog signaling pathway.

BACKGROUND: Human adipose-derived stem cells have been identified as a potential source of cells for use in bone tissue engineering because of their ready availability, ease of harvest, and susceptibility to osteogenic induction. The authors have previously demonstrated the ability of an osteogenic molecule called hydroxycholesterol, an oxidative derivative of cholesterol, to induce osteogenic differentiation in pluripotent murine and rabbit bone marrow stromal cells. In this study, the authors examine the ability of hydroxycholesterol to induce osteogenesis in human adipose-derived stem cells. METHODS: Human adipose-derived stem cells were isolated from raw human lipoaspirates through standard isolation and expansion of the stromal vascular fraction. Cells were plated onto tissue culture plates in control medium and harvested between passages 2 and 3, incubated with conventional osteogenic media, and treated with various concentrations (1, 5, and 10 µM) of the 20(S) analogue of hydroxycholesterol. Evaluation of cellular osteogenic activity was performed. The role of the hedgehog signaling pathway in hydroxycholesterol-mediated osteogenesis was evaluated by hedgehog inhibition assays. RESULTS: Alkaline phosphatase activity, bone-related gene expression, and mineralization were all significantly increased in cultures of human adipose-derived stem cells treated with 5 µM of 20(S)-hydroxycholesterol relative to controls. In addition, induction of hydroxycholesterol-mediated osteogenesis was mitigated by the addition of the hedgehog pathway inhibitor to cell cultures, implicating the hedgehog signaling pathway in the osteogenic mechanism on human adipose-derived stem cells by hydroxycholesterol. CONCLUSION: These in vitro studies demonstrate that hydroxycholesterol exerts an osteoinductive influence on human adipose-derived stem cells and that these effects are mediated at least in part through the hedgehog signaling pathway.

In vitro study of a novel oxysterol for osteogenic differentiation on rabbit bone marrow stromal cells.

BACKGROUND: Bone morphogenetic proteins (BMPs) are powerful osteoinductive growth factors but are associated with exorbitant costs and undesirable side effects. Oxysterols are biocompatible cholesterol oxidation products with osteoinductive properties that may represent an alternative to BMP. In this study, the authors examine the osteogenic potential and mechanisms of actions of oxysterol 49, a novel oxysterol analogue, in primary rabbit bone marrow stromal cells. METHODS: Bone marrow stromal cells were isolated from the iliac crests of New Zealand White rabbits and then treated with various concentrations of oxysterol 49 or BMP-2, either alone or in combination. Alkaline phosphatase activity and expression of osteocalcin and osteopontin were evaluated. The effect of treatment of cells with cyclopamine, a known hedgehog signaling pathway inhibitor, was also assessed. RESULTS: Alkaline phosphatase activity was increased in cells treated with 1 µM oxysterol 49 relative to cells treated with BMP-2. Expression of osteocalcin and osteopontin in cells treated with oxysterol 49 and BMP-2 was equivalent. Alkaline phosphatase activity was decreased with the addition of cyclopamine. Combined treatment with oxysterol 49 and BMP-2 resulted in additive increases in alkaline phosphatase activity and osteocalcin and osteopontin expression. CONCLUSIONS: Oxysterol 49 has osteoinductive properties that are similar to those of BMP-2 in rabbit bone marrow stromal cells. The mechanism of this activity is at least in part related to the hedgehog signaling pathway. The two growth factors demonstrate additive effects when used in combination. Further study is required to examine the potential role of oxysterol 49 as a complement or alternative to BMP-2 in bone tissue engineering.

Evaluation of plastic surgery training programs: integrated/combined versus independent.

BACKGROUND: The authors aimed to differentiate between combined/integrated and independent (traditional) methods of plastic surgery training with regard to quality of trainees, caliber of graduates, and practice or career outcomes once graduated. METHODS: To compare combined/integrated with independent residency program training, the authors conducted a Web-based survey of the American Society of Plastic Surgeons members looking at their experience and practice outcomes (n = 1056) and interviews of plastic surgery faculty looking at the quality of trainees (n = 72). The member survey evaluated background information, research credentials, pathway satisfaction, postgraduation activities, current practice, and academic affiliation. Faculty teacher interviews focused on knowledge base, diagnostic and treatment judgment, technical abilities, research capabilities, and prediction of future career success. RESULTS: The member survey showed no difference (p > 0.05) between combined/integrated and independent trainees in practice type (cosmetic/reconstructive), practice volume, or academic achievements. Combined/integrated trained surgeons are three times more likely to recommend their training pathway and two times more likely to enter fellowship after residency. Alpha Omega Alpha Honor Medical Society membership correlated with a greater likelihood of having an academic practice at 5 and 10 years or more and higher professorship titles. Faculty evaluations showed that combined/integrated residents were superior in knowledge (49 percent versus 32 percent) but that independent residents were superior in technical ability (51 percent versus 20 percent) and research (57 percent versus 19 percent). Most faculty were unable to choose a pathway producing superior residents. CONCLUSIONS: Regarding future practice outcomes, there was not a superior training pathway. Regarding quality of trainees, there were differences in faculty evaluations, but there was no consensus on a better pathway.

Use of virtual 3-dimensional surgery in post-traumatic craniomaxillofacial reconstruction.

Traumatic craniofacial injuries often present as difficult reconstructive challenges for maxillofacial surgeons. Reconstruction is often complicated by significant soft tissue loss, comminuted bony fragments, a tenuous blood supply, and wound contamination. For panfacial injuries, restoration of normal facial width, facial height, and sagittal projection may be difficult to achieve. Marked swelling may limit the surgeons' ability to palpate and recognize subtle bony defects and malunion. Furthermore, a true 3-dimensional assessment of bony alignment may not be possible with traditional surgical exposures to the craniofacial skeleton. This article builds on previous work that introduced the use of 3-dimensionally guided surgery for microvascular free-flap reconstruction of the craniofacial skeleton. Use of this technology improves the planning, timing, and overall precision of microvascular reconstructive surgery. Based on this experience, a similar approach to reconstructing patients with significant craniofacial trauma has been adopted.