Superiority of a Silk Surgical Site Wound Closure Device Over Synthetic Dressings.

BACKGROUND: Silk fibroin is an emerging biomaterial with enhanced properties of cellular regeneration, growth and proliferation. The use of a silk fibroin wound dressing has the potential to decrease the incidence of wound healing complications and to improve patient outcomes compared to synthetic dressing alternatives. METHODS: A prospective, randomized, single-blinded clinical trial was conducted on 50 patients who were dressed with a silk fibroin dressing on one side of their body and on the contralateral side with 3M Steri-Strips® after undergoing abdominoplasty, reduction mammaplasty, or brachioplasty procedures. Data was collected over 5 postoperative visits using photographs and an investigator administered questionnaire to monitor erythema, skin irritation, skin discomfort, the need for pharmaceutical intervention, wound dehiscence and mechanical skin injury. A comprehensive 75 patient statistical analysis was conducted combining the results with a previously published study comparing Dermabond® Prineo® to the silk dressing. RESULTS: 20.8% (10/48) of patients were assessed by surgeons as having skin erythema (7-10) on the Steri-Strip® control side and 0% (0/48) on the silk dressing side (p=0.002). The frequency of breast triple point separation in 43 cases was 30.2% (13/43) on the Steri-Strip® side and 9.3% (4/43) on the silk side (p=0.012). 75% (36/48) of patients had partial or total detachment of Steri-Strips® while 0% (0/48) had total detachment of the silk dressing and 18.8% (9/48) had partial detachment of the silk dressing within the first two weeks (p<0.001). CONCLUSION: A silk fibroin wound dressing significantly reduces the incidence of wound healing complications throughout the postoperative period.Clinical Relevance Statement: The adoption of a silk fibroin wound dressing into clinical practice has the potential to improve patient outcomes, decrease medical adhesive related skin injuries and reduce the rate of wound healing complications.

Report on Mortality from Gluteal Fat Grafting: Recommendations from the ASERF Task Force.

Background: Gluteal fat grafting is among the fastest growing aesthetic procedures in the United States and around the world. Given numerous anecdotal and published reports of fatal and nonfatal pulmonary fat embolism resulting from this procedure, the Aesthetic Surgery Education and Research Foundation (ASERF) formed a Task Force to study this complication. Objectives: To determine the incidence of fatal and nonfatal pulmonary fat embolism associated with gluteal fat grafting and provide recommendations to decrease the risks of the procedure. Methods: An anonymous web-based survey was sent to 4843 plastic surgeons worldwide. Additional data on morbidity and mortality was collected through confidential interviews with plastic surgeons and medical examiners, public records requests for autopsy reports in the United States, and through the American Association for the Accreditation of Ambulatory Surgical Facilities (AAAASF). Results: Six hundred and ninety-two (692) surgeons responding to the survey reported 198,857 cases of gluteal fat grafting. Over their careers, surgeons reported 32 fatalities from pulmonary fat emboli as well as 103 nonfatal pulmonary fat emboli. Three percent (3%) of respondents experienced a patient fatality and 7% of respondents reported at least one pulmonary fat embolism in a patient over their careers. Surgeons reporting the practice of injecting into the deep muscle experienced a significantly increased incidence rate of fatal and nonfatal pulmonary fat emboli. Twenty-five fatalities were confirmed in the United States over the last 5 years through of autopsy reports and interviews with surgeons and medical examiners. Four deaths were reported from 2014 to 2015 from pulmonary fat emboli in AAAASF facilities. Conclusions: Despite the growing popularity of gluteal fat grafting, significantly higher mortality rates appear to be associated with gluteal fat grafting than with any other aesthetic surgical procedure. Based on this survey, fat injections into the deep muscle, using cannulae smaller than 4 mm, and pointing the injection cannula downwards should be avoided. More research is necessary to increase the safety of this procedure.

Protective effects of boron and vitamin E on ethylene glycol-induced renal crystal calcium deposition in rat.

OBJECTIVES: Kidney stone disease is a common form of renal disease. Antioxidants, such as vitamin E (Vit E) and boron, are substances that reduce the damage caused by oxidation. METHODS: Adult male rats were divided into 5 groups (n=6). In group 1, rats received standard food and water for 28 days (control group); in group 2, standard rodent food and water with 0.75% ethylene glycol/d (dissolved in drinking water) (EG Group); in group 3, similar to group 2, with 3 mg of boron/d (dissolved in water) (EG+B Group); in group 4, similar to group 2, with 200 IU of vitamin E injected intraperitoneally on the first day and the 14th day, (EG+Vit E Group); in group 5, mix of groups 3 and 4, respectively (EG+B+Vit E Group). RESULTS: Kidney sections showed that crystals in the EG group increased significantly in comparison with the control group. Crystal calcium deposition score in groups of EG+B (160), EG+Vit E, and EG+B+Vit E showed a significant decrease compared to EG group. Measurement of the renal tubules area and renal tubular epithelial histological score showed the highest significant dilation in the EG group. Tubular dilation in the EG+B+Vit E group decreased compared to the EG+B and EG+Vit E groups. CONCLUSIONS: Efficient effect of boron and Vit E supplements, separately and in combination, has a complimentary effect in protection against the formation of kidney stones, probably by decreasing oxidative stress.

The efficacy of antioxidant therapy against oxidative stress and androgen rise in ethylene glycol induced nephrolithiasis in Wistar rats.

Administration of natural antioxidants has been used to protect against nephrolithiasis. Urolithiasis was induced by ethylene glycol (EG) in Wistar rats. For 4 weeks, group 1 (control) was fed with a standard commercial diet. Group 2 received the same diet with 0.75% of EG. Group 3 received EG plus the diet and water added with antioxidant nutrients and lime juice as the dietary source of citrate (EG + AX). Group 4 same as group 3 with no EG in water. For 8 weeks, group 5 was fed the standard diet with EG in water for the first 28 days, followed by no EG. Group 6 received the diet with EG for the first 28 days, followed by discontinuation of EG and addition of antioxidant nutrients. Group 7 were provided the diet with antioxidant nutrients for 8 weeks. Group 8 received the diet with antioxidant nutrients for 4 weeks, followed by antioxidant nutrients with EG for the next 4 weeks. Blood samples were collected and kidneys were removed. The size and the mean number of crystal deposits in EG-treated groups was significantly higher than the EG-treated groups, added with antioxidant nutrients and lime juice. After 4 weeks, the mean concentration of malondialdehyde in group 2 was higher than the group 3, and significantly lower in group 4; and in groups 7 after 8 weeks, as well. After 8 weeks, supplementation developed less mean number of deposits in group 6 as compared to group 5; and in group 8, the crystal deposits was substantially less than either group 2 or group 5 (EG-treated rats). Elevated concentration of androgens (as promoters of the formation of renal calculi) as a result of EG consumption decreased following antioxidant supplementations. Results showed a beneficial effect of antioxidant and provided superior renal protection on treating and preventing stone deposition in the rat kidney.

Recombinant production of mecasermin in E. coli expression system.

Human Insulin-like growth factor 1 (hIGF-1) consists of 70 amino acids in a single chain with three intermolecular disulfide bridges possessing valuable therapeutic effects. To date, numerous variants of specifically engineered hIGF-1 have been produced so as to improve hIGF-1 biological activity, stability and stronger binding to IGF-1 receptor. Mecasermin is one of the modified variants with one amino acid substitution near the N-terminal (T4I) approved for the treatment of growth failure diabetes, wound healing, amyotrophic lateral sclerosis and severe primary IGF-1 deficiency. No scientific report for recombinant production of mecasermin in Escherichia coli (E. coli) expression system has been sofar reported. In the present study, we therefore investigated the overexpression of mecasermin in two different E. coli strains in order to obtain higher yield of recombinant protein. To achieve this goal, mecasermin DNA encoding sequence was designed based on polypeptide sequence, optimized according to E. coli codon preference, and cloned in pET15b. Recombinant vector, pET15-mecasermin, transferred into two E. coli strains rigami B (DE3) and BL21 (DE3) and induced for expression in a small scale. Results revealed the E. coli Origami B (DE3) expression system was a preferable host for mecasermin production due to its high expression level being around twice as much as BL21 (DE3). Large scale mecasermin production was performed in batch culture and produced recombinant protein specifically confirmed by western blotting and mass spectroscopy. Since major part of recombinant mecasermin was expressed as inclusion body, isolation and refolding was accomplished through developed purification procedure, and finally recombinant protein was successfully purified by gel filtration chromatography.

The antimicrobial effects and metabolomic footprinting of carboxyl-capped bismuth nanoparticles against Helicobacter pylori.

Organic salts of bismuth are currently used as antimicrobial agents against Helicobacter pylori. This study evaluated the antibacterial effect of elemental bismuth nanoparticles (Bi NPs) using a serial agar dilution method for the first time against different clinical isolates and a standard strain of H. pylori. The Bi NPs were biologically prepared and purified by a recently described method and subjected to further characterization by infrared spectroscopy and anti-H. pylori evaluation. Infrared spectroscopy results showed the presence of carboxyl functional groups on the surface of biogenic Bi NPs. These biogenic nanoparticles showed good antibacterial activity against all tested H. pylori strains. The resulting MICs varied between 60 and 100 µg/ml for clinical isolates of H. pylori and H. pylori (ATCC 26695). The antibacterial effect of bismuth ions was also tested against all test strains. The antimicrobial effect of Bi ions was lower than antimicrobial effect of bismuth in the form of elemental NPs. The effect of Bi NPs on metabolomic footprinting of H. pylori was further evaluated by (1)H NMR spectroscopy. Exposure of H. pylori to an inhibitory concentration of Bi NPs (100 µg/ml) led to release of some metabolites such as acetate, formic acid, glutamate, valine, glycine, and uracil from bacteria into their supernatant. These findings confirm that these nanoparticles interfere with Krebs cycle, nucleotide, and amino acid metabolism and shows anti-H. pylori activity.

The effect of supplementation of calcium, vitamin D, boron, and increased fluoride intake on bone mechanical properties and metabolic hormones in rat.

Evidence indicates that optimal nutrition plays a role in bone formation and maintenance. Besides major components of mineralization such as calcium, phosphorus, and vitamin D, other nutrients like boron and fluoride have beneficial role, too. In this study, 34 male Wistar rats were divided into five groups: control diet, fluoride, fluoride + boron, fluoride + calcium + vitamin D, and fluoride + boron + calcium + vitamin D. Boron equal to 1.23 mg, calcium and vitamin D equal to 210 mg + 55 IU and fluoride equal to 0.7 mg/rat/day was added to their drinking water for 8 weeks. Plasma blood samples and bones were collected. Findings are evidence that fluoride + boron intake revealed significant positive effects on bone mechanical properties and bone metabolic hormones. These findings suggest that combined intake of these two elements has beneficial effects on bone stiffness and breaking strength comparing to even calcium + vitamin D supplementation. This evidence dealing with health problems related to bone and skeletal system in humans should justify further investigation of the role of boron and fluoride with other elements in relation to bone.

Buttock augmentation with silicone implants: a multicenter survey review of 2226 patients.

BACKGROUND: Enhancement of buttock volume with gluteal silicone implants has been performed by surgeons for over 30 years, but no studies have examined complication rates or outcomes of more than single-surgeon experiences. Numerous technical differences in how gluteal augmentation surgery with implants is performed also exist, and to date, surgeon preferences for implant plane, incisional access, implant type, and drain use have not been quantified. METHODS: A 10-question survey was sent to 83 targeted members of the American Society of Plastic Surgeons requesting information about number of cases performed, duration of surgeon experience, implant placement plane and incisional access, implant type, length of typical surgery, use of drains and antibiotic irrigation solution, surgeon satisfaction and surgeon assessment of patient satisfaction, and number of complications experienced. RESULTS: Nineteen respondents (25 percent response rate) provided data on 2226 patients. Thirteen respondents (68.4 percent) favored the intramuscular plane of dissection over the subfascial plane. Preference for incisional access was nearly equally divided between a single incision in the gluteal cleft (10 respondents) and two incisions separated within the cleft (nine respondents). The total number of complications reported was 848 (38.1 percent). CONCLUSIONS: Gluteal augmentation with silicone implants has gained popularity in the last decade. Despite this, no previous studies have examined multisurgeon experiences with this procedure to determine complication rates or surgeon technical preferences. The authors present data from a survey sent to experienced gluteal augmentation surgeons. Advances in technique and implant options are needed to improve complication rates experienced with this procedure.

Abdominoplasty revision using tissue expansion.

UNLABELLED: Postoperative revision after abdominoplasty may be necessary at times to improve contour, remove asymmetries, revise the umbilicus, or improve the scar. This report describes the case of an abdominoplasty performed outside the United States that resulted in an inappropriately high and unattractive scar with an elevated pubic hairline. The patient presented to our clinic 2 years after her initial surgery, and a scar-lowering procedure was performed with the assistance of tissue expansion. The reconstructive effort was staged over a period of 4 months, with an initial procedure to repair several hernias, bury the umbilicus, and place a tissue expander. Over several months, 3.5 L of expansion was performed. During a subsequent surgery, the tissue expander was removed, and the scar was successfully lowered and improved. The healing was uneventful, and the patient was satisfied with the outcome. The final result is exhibited in 1-month follow-up photographs. 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 .

Biosynthesis of bismuth nanoparticles using Serratia marcescens isolated from the Caspian Sea and their characterisation.

Today, synthesis of nanoparticles (NPs) using micro-organisms has been receiving increasing attention. In this investigation, a bismuth-reducing bacterium was isolated from the Caspian Sea in Northern Iran and was used for intracellular biosynthesis of elemental bismuth NPs. This isolate was identified as non-pigmented Serratia marcescens using conventional identification assays and the 16s rDNA fragment amplification method and used to prepare bismuth NPs. The biogenic bismuth NPs were released by liquid nitrogen and highly purified using an n-octanol water two-phase extraction system. Different characterisations of the purified NPs such as particle shapes, size and purity were carried out with different instruments. The energy-dispersive X-ray and X-ray diffraction (XRD) patterns demonstrated that the purified NPs consisted of only bismuth and are amorphous. In addition, the transmission electron micrograph showed that the small NPs formed larger aggregated NPs around <150 nm. Although the chemical syntheses of elemental bismuth NPs have been reported in the literature, the biological synthesis of elemental bismuth NPs has not been published yet. This is the first report to demonstrate a biological method for synthesising bismuth NPs and their purification with a simple solvent partitioning method.

Effect of consumption of fatty acids, calcium, vitamin D and boron with regular physical activity on bone mechanical properties and corresponding metabolic hormones in rats.

The consumption of fatty acids, nutrients, and regular physical activity, individually influence bone mechanical properties in rats. To investigate their effects in combination, male rats were divided into the seven groups: G1: regular food and drinking water; G2: same as Gr.1 + physical activity (Whole body vibration; WBV); G3: same as Gr.2 + Calcium, Vit. D, Boron; G4: same as Gr.3 + canola oil; G5: same as Gr.3 + sunflower oil; G6: same as Gr.3 + mix of sunflower oil and canola oil; and G7: same as Gr.3 + coconut oil; and treated for 8 weeks. Analysis between the control with the groups 2 and 3 revealed that vibration in the G2 increased the body weight (P = 0.04), with no other major difference in plasma and bone indices. Comparison between the control with the G4-G7 (the oil groups) revealed that the rats in the G5 had a lower body weight (15 % less) and a significant increase in plasma levels of Estradiol in the G7 was noted. In addition, levels of Testosterone in the G4 and G7, and Free Testosterone in the G7 had a remarkable increase. Similar trend was observed for plasma levels of Vit. D in the G4 and G5. The stiffness and the breaking strength of the femur in the G7, and the breaking strength of the lumbar in the G7 compared to the control and the G4 and G5 was significantly higher and tended to increase in comparison to the G6. Better and stronger measurements observed for coconut oil is warranted to further study its effect on biomechanical properties of bones.

Effect of combination therapy of fatty acids, calcium, vitamin D and boron with regular physical activity on cardiovascular risk factors in rat.

The effect of consumption of fatty acids and selected nutrients, along with regular physical activity, on cardiovascular risk factors in rats was investigated.Male rats were divided into the seven groups: Group 1: regular food and drinking water, Group 2: same as Group. 1 + physical activity (whole body vibration; WBV), Group 3: same as Group. 2 + calcium, vitamin D, boron, Group 4: same as Group. 3 + canola oil, Group 5: same as Group. 3 + sunflower oil, Group 6: same as Group. 3 + mix of sunflower oil and canola oil, Group 7: same as Group. 3 + coconut oil. Rats were treated for 8 weeks, and analysis of the frozen plasmas was performed. A- Analysis between the treatment groups and control revealed that vibration training in Group 2 increased body weight (P = 0.04), plasma creatin kinase (CK), (P = 0.02), and estradiol (E2), (P = 0.03). Rats in Group 5 consumed less food and plasma levels of cholesterol and LDL-cholesterol (LDL-C) increased significantly (P = 0.02) in Group 6 and in Group 7 (p<0.05). B- Analysis of data among Group 4 - 7 (the oil consuming groups) and Group 3 revealed significant differences in cholesterol (Chol), LDL-C, HDL-cholesterol (HDL-C), triglycerides (TG), C- reactive protein (hs-CRP), estradiol (E2), atherogenic index (AI), and risk factor (RF), (p<0.05). In addition, plasma levels of testosterone (T) and free testosterone (FT) in Group 7 had a remarkable but non-significant increase. As a result of vibration training, a similar trend was observed for vitamin D in Group 2-7. The findings show that WBV is effective in improving health status by influencing cardiovascular disease (CVD) risk factors. Moreover, canola oil and sunflower oil, separately, showed beneficial impacts on CVD risk factors; whereas their combination had negative impacts on lipid profile. Coconut oil revealed to be efficient to provide health benefits in terms of CVD treatments.

Whole body vibration is a safe exercise training method and induces no impaired alterations on rat plasma parameters.

UNLABELLED: Whole body vibration (WBV) has been regarded as an exercise training method and as a non-pharmacological supportive treatment option appearing to be efficient for chronic disease conditions, such as bone disorders and cardio-respiratory fitness. Since, data on the safety and efficacy of vibration on plasma parameters are lacking, therefore, it was decided to assess the effects of WBV on the plasma parameters in adult male Wistar rat model. METHODS: Male Wistar rats, weighing 140­180 g, were divided into control and the vibration group. Vibration training consisted of vertical sinusoidal whole body vibration for 8 weeks, followed by blood collection. RESULTS: The vibrated rats weighed more than the control group (approximately 14% more). Plasma CK, E2 and IL-6 levels were significantly higher in the vibration group compared with the controls. The mean of Vit. D level was 15% higher; hsCRP level was 11% lower and IL-6 level was 32% higher in the vibration group. No difference was observed for other selected plasma parameters. DISCUSSION: The potential effects of physiological responses of WBV on several physiological systems are without deteriorations in plasma parameters.

Molecular cloning of gluconobacter oxydans DSM 2003 xylitol dehydrogenase gene.

Due to the widespread applications of xylitol dehydrogenase, an enzyme used for the production of xylitol, the present study was designed for the cloning of xylitol dehydrogenase gene from Glcunobacter oxydans DSM 2003. After extraction of genomic DNA from this bacterium, xylitol dehydrogenase gene was replicated using polymerase chain reaction (PCR). The amplified product was entered into pTZ57R cloning vector by T/A cloning method and transformation was performed by heat shocking of the E. coli XL1-blue competent cells. Following plasmid preparation, the cloned gene was digested out and ligated into the expression vector pET-22b(+). Electrophoresis of PCR product showed a 789 bp band. Recombinant plasmid (rpTZ57R) was then constructed. This plasmid was double digested with XhoI and EcoRI resulting in 800 bp and 2900 bp bands. The obtained insert was ligated into pET-22b(+) vector and its orientation was confirmed with XhoI and BamHI restriction enzymes. In conclusion, in the present study the recombinant expression vector containing xylitol dehydrogenase gene has been constructed and can be used for the production of this enzyme in high quantities.

Acellular dermal matrix in cosmetic breast procedures and capsular contracture.

Prevention and treatment of capsular contracture after breast augmentation is a controversial and oftentimes vexing problem. While there are traditional methods of addressing this condition, acellular dermal matrix materials offer a new and promising modality that is gaining momentum in the field of plastic surgery. In this article, the author examines the etiology and pathophysiology of capsular contracture and review the existing literature on acellular dermal matrix in breast surgery related to capsular contracture.

A novel technique for repositioning lower eyelid fat via the transoral approach in association with midface lift.

BACKGROUND: Orbital fat repositioning in association with subperiosteal midface elevation has been variably described via both the transconjunctival and skin muscle flap approaches. Poor visualization, middle and posterior lamellar cicatricial fibrosis, technical difficulty, and incomplete release are disadvantages commonly ascribed to the transconjunctival approach. Lower eyelid malposition and retraction also are commonly seen in association with skin muscle flap approaches. A simple technique using the intraoral approach to release the orbital septum and postseptal fat is described in this report. This procedure avoids complications associated with the violation of key lower eyelid anatomic structures and markedly improves visualization through an incision allowing a much larger access. METHODS: A retrospective review of six patients who underwent endoscopically assisted midface elevation in combination with lower eyelid fat repositioning via a transoral approach since 2009 and were followed up for at least 1 year is presented. A pre- and postoperative assessment of tear trough depth, lower eyelid fat herniation, and midface descent is made. Four of the six patients presented also underwent concurrent additional facial rejuvenation procedures including endoscopically assisted brow-lift, genioplasty, structural fat grafting to the nasolabial folds, and lower eyelid "pinch" blepharoplasty. Standard upper buccal sulcus access incisions were used for subperiosteal midface elevation and exposure of the lower orbital septum. Fat redraped over the orbital rim was not secured with fixation sutures as is commonly performed using lower eyelid approaches. Human cadaveric dissection with endoscopic visualization also was performed to demonstrate the reported technique. RESULTS: During this study, one complication developed for a single patient who experienced a temporary dense right zygomatic and frontal branch nerve palsy lasting 8 weeks. No evidence of lower eyelid malposition, ectropion, entropion, incomplete release, or asymmetry was otherwise encountered. Improvement in tear trough appearance, lower eyelid herniation, and midface descent was noted in all six patients. CONCLUSION: A novel approach for lower eyelid fat transposition in combination with midface lift using the intraoral approach is presented. Excellent visualization, decreased operative times, technical ease, and improved outcomes all are potential advantages of this technique over standard approaches in which access to lower eyelid fat is achieved through the conjunctiva or a skin muscle flap.

Quantification of ergovaline using HPLC and mass spectrometry in Iranian Neotyphodium infected tall fescue.

Ergovaline, the main ergopeptine alkaloid produced in tall fescue (Fescue arundinacea Schreb.) infected with endophyte (Neotyphodium coenophialum Morgan- Jones & Gams), is known to cause tall fescue toxicosis. This study was conducted to examine the presence of fungal endophytes in five populations of tall fescue collected from various regions of Iran. The existence of Neotyphodium mycelia in the tissues of the samples was confirmed by microscopic examination, and the isolation was performed from leaf tissues of the hosts on potato dextrose agar. All isolates were confirmed as the Neotyphodium species by PCR, using specific primers. Mass detection and determination of ergovaline were performed by HPLC at three plant growth stages. Ergovaline was detected in all isolates, with the mean concentrations of 0.24 to 3.48 µg/g dry matter of different populations for the whole three plant growth stages. The differences in ergovaline content between plant populations and sampling time were statistically significant. This is the first report of ergovaline content in endophyte infected Fescue arundinacea from natural grasslands in Iran.

Pocket conversion made easy: a simple technique using alloderm to convert subglandular breast implants to the dual-plane position.

BACKGROUND: The advantages of dual-plane, partially submuscular breast implants are well documented. Standard conversion techniques to dual-plane positioning use marionette sutures and internal capsulorrhaphy sutures from the lower edge of the pectoralis major muscle to the anterior capsule or breast fascia within the subglandular plane. These techniques are limited by high rates of postoperative implant malposition and technical limitations that make combined mastopexy procedures difficult to perform. OBJECTIVE: We describe a simple technique familiar to most plastic surgeons accustomed to placing tissue expanders for use in breast reconstruction using Alloderm (LifeCell Corp., Branchburg, NJ) as a sling beneath the pectoralis major muscle to the chest wall. METHODS: We studied 25 women who underwent breast augmentation revision from the subglandular to the dual-plane position by performing a 9-year retrospective review from 1999 to 2007 of 2 surgeons' experience. We identified 10 women for whom Alloderm, sutured from the lower edge of the pectoralis major muscle to the chest wall, was used to create a composite pectoralis-Alloderm pocket for partial submuscular transfer of implants and 15 case controls who underwent pocket conversion using standard capsulorrhaphy and marionette suture techniques. RESULTS: The principal outcome variable of at least 1 complication was 73.3% without Alloderm, resulting in a 40% need for revision surgery, versus 0% with Alloderm (Fisher exact test; P < .05). CONCLUSIONS: The standard techniques available for conversion of subglandular breast implants to the dual-plane position using capsulorrhaphy and marionette sutures are limited by a high complication rate for the reliable positioning into a stable dual-plane pocket during implant exchange. A commonly used technique in reconstructive breast surgery using Alloderm is shown to reliably convert subglandular implants to the dual-plane position.