Robotics in Implant-Based and Autologous Breast Reconstruction.

Autologous and implant-based breast reconstruction continues to evolve as new technology and mastectomy techniques become available. Robotic-assisted breast reconstruction represents a growing field within plastic surgery, with the potential to improve aesthetic and functional outcomes, as well as patient satisfaction. This article provides a review of indications, techniques, and outcome data supporting the use of robotic assistance in both implant-based and autologous breast reconstruction from surgeons around the world.

Histological Evaluation of the Skin After Fat Grafting: A Blinded, Randomized, Controlled Clinical Study.

BACKGROUND: Autologous fat graft is often employed to treat body contour defects. There is currently increased interest in the regenerative properties of fat grafting. OBJECTIVES: The authors evaluated the histological changes of fat grafting in a blinded randomized controlled trial of staged fat grafting-abdominoplasty. METHODS: Ten women between 24 and 55 years of age with a body mass index <30 kg/m2 and previous cesarean scar were submitted to fat grafting followed by staged abdominoplasty. The C-section scar served as a landmark for standardization of fat grafting site and control. One side of the abdomen was fat grafted and the other was left intact (control). At the time of abdominoplasty, 4 months later, a full-thickness skin sample from each hemi abdomen (fat-grafted area and control) was collected and sent to histological analysis. RESULTS: All of the fat-grafted samples showed extracellular lipids and signs of fat graft viability, whereas no such changes occurred in the control group. There were no statistically significant differences in fat-grafted vs control samples regarding skin inflammatory infiltrate (P = 0.582), dermis thickness (P = 0.973), vascular density (P = 0.326), and amount of elastic fibers (P = 1). CONCLUSIONS: The histological evaluation of women's abdominoplasty surgical site skin after 4 months of fat grafting showed signs of fat graft in 100% of the grafted sides but no change in skin inflammatory infiltrate, dermis thickness, vascularity density, or elastic fiber quantity.

Lateral thigh perforator flap for breast reconstruction: Computed tomographic angiography analysis and clinical series.

PURPOSE: Although abdominal-based flaps remain the first choice for autologous breast reconstruction, alternative donor sites are necessary when the abdomen is unavailable. Abdominal donor site suitability is determined, at times, according to deep inferior epigastric perforator (DIEP)-protocol computed tomographic angiography (CTA) results. CTA provides information about the pelvis/upper thigh that can be used to evaluate the suitability of other donor sites. This study aimed to examine the utility of DIEP-protocol CTA in the assessment of a lateral thigh perforator (LTP) flap. Furthermore, a small clinical LTP flap breast reconstruction series was presented. METHODS: The LTP flap anatomy was studied in 100 DIEP-protocol CT angiographies (200 thighs). Collected data included lateral circumflex femoral artery (LCFA) origin; number, type, and course of LTPs; pedicle characteristics; and reference point measurements. Relative relationships between reference point anatomy and perforator anatomy were analyzed. RESULTS: Perforators originated from the LCFA ascending branch (4.6 mm average diameter), averaging 2.6 perforators/thigh. The mean estimated pedicle length was 7.7 cm (±0.7 cm). Septocutaneous perforators were present in 97% (1.8 perforators/thigh). Musculocutaneous perforators were present in 64% (0.9 perforators/thigh). The mean distance between anterior superior iliac spine and perforator was 9.9 cm (±1.5 cm). Perforators were located 0.13 cm (±1.1 cm) below the pubic symphysis. Our LTP flap clinical series featured dissection in the supine position and primary donor site closure and highlighted the difficulty in flap design (six patients, nine LTP flaps). CONCLUSIONS: LTPs are consistent, reliably present, and radiographically appear to be suitable for microsurgical transfer. DIEP-protocol CTA is an acceptable method for imaging the pertinent LTP anatomy.

Is the SMAS Flap Facelift Safe? A Comparison of Complications Between the Sub-SMAS Approach Versus the Subcutaneous Approach With or Without SMAS Plication in Aesthetic Rhytidectomy at an Academic Institution.

BACKGROUND: For treating the aging face, a facelift is the surgical standard. A variety of techniques have been described. The purpose of the current study is to evaluate the safety of the sub-SMAS facelift compared to the subcutaneous facelift with or without SMAS plication. METHODS: A retrospective chart review was conducted on all patients who underwent facelift surgery between 2003 and 2011. Patients included in the study were seeking elective improvement of facial appearance. All charts were reviewed to identify the presence of hematoma, seroma, deep venous thrombosis, skin loss, unfavorable scar, wound infection, or motor and sensory deficit following the operation. The primary outcome was overall complication rate. RESULTS: A total of 229 facelifts were included; 143 patients underwent a subcutaneous facelift with or without SMAS plication and 86 underwent a sub-SMAS facelift. For the subcutaneous facelifts, 88% of the patients were female with a mean age of 62 years. For the sub-SMAS dissections, 88% of the patients were female with a mean age of 59 years. The overall complication rate was 29.4% (n = 42) for patients who underwent a subcutaneous facelift compared to 24.4% (n = 21) for patients with a sub-SMAS facelift (p = 0.4123). Analysis of each individual complication failed to yield any statistically significant difference between the two groups. CONCLUSIONS: In the present study, sub-SMAS facelift complication rates were not statistically different compared to those of subcutaneous facelift with or without SMAS plication. These data suggest that sub-SMAS dissection can be performed with similar safety compared to the traditional subcutaneous facelift, with the potential additional advantage of the SMAS flap elevation. LEVEL OF EVIDENCE IV: 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.

Facelift complications related to median and peak blood pressure evaluation.

BACKGROUND: Hematoma remains the most challenging complication of facelifting and has been associated with male sex, hypertension, aspirin use, smoking, and high body mass index. Patients who underwent a facelift were studied to determine rates of hematoma and other complications and to identify predictive and protective factors, including meticulous analysis of perioperative blood pressure. METHODS: Charts of patients who underwent a facelift from 2003 to 2011 at our institution were retrospectively reviewed. Demographic, clinical, and procedural data were collected. All postoperative complications were recorded. Data from continuous blood pressure monitoring in the operating and recovery rooms were obtained from a perioperative database and stratified by median and peak values. Logistic regression was used for data analysis. RESULTS: Of the 229 patients included, the majority were female (88.2 %), mean age at presentation was 62 years, and 35.8 % had hypertension. Postoperative complications occurred in 60 patients (26.2 %). The most common complication was unfavorable scar (7.4 %), followed by hematoma (6.5 %). Male sex (P = 0.02), history of hypertension (P = 0.04), preoperative systolic blood pressure (SBP) greater than 160 mmHg (P = 0.04), and operating room peak SBP greater than 165 mmHg (P = 0.04) were predictive factors for hematoma. Recovery room peak SBP greater than 150 mmHg (P = 0.09) was also associated with hematoma. On multivariate analysis, only male sex and preoperative SBP greater than 160 mmHg remained independent risk factors for hematoma. CONCLUSIONS: This study is unique in that it compares the rate of hematoma to continuous blood pressure data in the operating and recovery rooms stratified by median and peak values. Meticulous control of perioperative SBP is recommended for a safe facelift. History of hypertension, increased SBP at admission, and increased perioperative peak SBP are predictors for postoperative hematoma. LEVEL OF EVIDENCE IV: 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 .

Challenges in replantation of complex amputations.

Surgical ingenuity has resulted in continuing microsurgical innovation in replantation. In this article, the authors define complex amputations as those that stretch the boundaries or fall outside traditionally defined indications for replantation. They discuss management of difficult situations involving multiple digit amputations, multiple-level amputations, prolonged ischemia, and multiple trauma. The role of transpositional and ectopic replantation, as well as the requirement for secondary procedures in replantation is also discussed. Although technically challenging, microsurgical management of complex amputations ultimately results in far superior outcomes.

Development of a mouse model for sporadic and metastatic colon tumors and its use in assessing drug treatment.

Most genetically engineered mouse (GEM) models for colon cancer are based on tissuewide or germline gene modification, resulting in tumors predominantly of the small intestine. Several of these models involve modification of the adenomatous polyposis coli (Apc) gene and are excellent models for familial cancer predisposition syndromes. We have developed a stochastic somatic mutation model for sporadic colon cancer that presents with isolated primary tumors in the distal colon and recapitulates the entire adenoma-carcinoma-metastasis axis seen in human colon cancer. Using this model, we have analyzed tumors that are either solely mutant in the Apc gene or in combination with another colon cancer-associated mutant gene, the Kras G12D allele. Because of the restricted location in the distal colon, the natural history of the tumors can be analyzed by serial colonoscopy. As the mammalian target of rapamycin (mTOR) pathway is a critical component of the complex signaling network in colon cancer, we used this model to assess the efficacy of mTOR blockade through rapamycin treatment of mice with established tumors. After treatment, Apc mutant tumors were more than 80% smaller than control tumors. However, tumors that possessed both Apc and Kras mutations did not respond to rapamycin treatment. These studies suggest that mTOR inhibitors should be further explored as potential colorectal cancer therapies in patients whose tumors do not have activating mutations in KRAS.

Quantitative endovascular fluorescence-based molecular imaging through blood of arterial wall inflammation.

PURPOSE: To evaluate an author-developed normalization algorithm for quantitative imaging of optical molecular probes through blood and to assess, in the rat aorta after focal aortic injury, the feasibility of measuring protease activity by using this method. MATERIALS AND METHODS: This study was performed according to a protocol approved by the institutional animal care committee. A Monte Carlo simulation was used to determine the pair of near-infrared (NIR) dyes that was best suited for the normalization algorithm. The authors tested the correction method in vitro and in vivo by injecting free dye mixtures intramurally in the aortas of four rats. The potential clinical utility was then evaluated by applying the method to the endovascular measurement of protease activity in a rat model of focal aortic injury. RESULTS: When the Monte Carlo simulation was used in the normalization algorithm, it was predicted that the intensities of signals from two NIR dyes would vary +/-3% across 1 mm of blood compared with the intensity of the raw fluorochrome signal, which would vary +/-60%. This result was validated in vitro. Endovascular imaging of free dye collections revealed that clinically relevant, uncontrollable differences in the amount of blood intervening between the imaging catheter and the dye collection precipitated dramatic variations in raw NIR fluorescence. However, use of the correction method resolved these variations such that the measured signal intensity correlated well with the different dye concentrations in the different animals. Moreover, endovascular imaging of the focal aortic injury model enabled successful measurement of enzyme activity in the walls of the rat aortas. CONCLUSION: The authors implemented a correction method for quantitative real-time endovascular imaging of fluorescence that enables one to resolve the attenuating effects of blood on NIR signal.

Intraductal papillary mucinous neoplasm of the biliary tract: a real disease?

BACKGROUND: Despite increasing numbers of reports, biliary tract intraductal papillary mucinous neoplasm (BT-IPMN) is not yet recognized as a unique neoplasm. The aim of the present study was to define the presence of BT-IPMN in a large series of resected biliary neoplasms. METHODS: From May 1994 to December 2006, BT-IPMN cases were identified by reviewing pathology specimens of all resected cholangiocarcinomas and other biliary neoplasms when cystic, papillary or mucinous features were cited in pathology reports. RESULTS: BT-IPMN was identified in 23 out of 253 (9%) specimens using the strict histopathological criteria of IPMN. The most common presenting symptom was abdominal discomfort which was present in 15 patients (65%). Only one of the original operative pathology reports used the term IPMN; 16 (70%) used the terms cystic, mucinous and/or papillary. BT-IPMN was isolated to non-hilar extra-hepatic ducts in 12 (52%), intra-hepatic ducts in 6 (26%) and hilar extra-hepatic ducts in 5 patients (22%). Carcinoma was found in association with BT-IPMN in 19 patients (83%); 5-year survival was 38% after resection. CONCLUSION: BT-IPMN occurs throughout the intra- and extra-hepatic biliary system and can be identified readily as a unique neoplasm. Broader acceptance of BT-IPMN as a unique neoplasm may lead to a better understanding of the pathogenesis of biliary malignancies.