Use of an acellular regenerative tissue matrix over chronic wounds.

OBJECTIVES: Bioengineered skin grafts, including acellular dermal matrices, may be effective in treating lower extremity and trunk wounds that are not responsive to traditional wound management. Acellular dermal wound matrix is derived from human acellular dermal wound matrix (HADWM) tissue and provides a scaffold that supports cellular repopulation and revascularization. The major structural components of the dermis are retained during processing, and a single application has been shown to help achieve wound closure. METHODS: This patient case series examined the use of HADWM on lower extremity and trunk wounds in 11 patients (6 male and 5 female) with a mean age of 55 years (range: 31-83 years). Wounds were debrided 1 to 2 times, followed by placement of HADWM (range: 4-330 cm(2)) on wounds that varied from the dorsal surface of the foot, lower abdomen, and lower extremity to the Achilles flap. A nonadherent layer in conjunction with bacitracin was placed over HADWM. Negative pressure wound therapy (NPWT) was placed over the HADWM and initiated continuously at -125 mm Hg for 1 to 2 weeks. After the application of NPWT, HADWM was covered with various gauze dressings using mineral oil. RESULTS: All patients completed their treatment successfully, and follow-up ranged from 1 week to 6 months. One patient experienced an infection, which resulted in partial graft loss that required replacement with HADWM and NPWT. No additional complications occurred in the other patients. CONCLUSIONS: This patient case series demonstrated successful use of HADWM and NPWT, which further supports published studies documenting HADWM success in chronic wounds.

The National Practitioner Data Bank: issues in plastic surgery.

BACKGROUND: The purpose of this article is to increase awareness among plastic surgeons of the applications and implications of the National Practitioner Data Bank. METHODS: A literature review using PubMed and Google was conducted regarding the history, function, and outcomes of the National Practitioner Data Bank, a federally maintained database of malpractice payments and disciplinary actions involving licensed healthcare providers. Particular attention was paid to institutional reporting requirements, the process of querying the data bank, and controversies regarding the effectiveness of the data bank as they apply to physicians. RESULTS: Many physicians in practice and training remain unaware of the requirements of the data bank. Specifically, situations in which an institution must report to the National Practitioner Data Bank on a physician's behalf can be surprising, such as payment to a patient in settlement of written claim without the suggestion of malpractice, denial of additional credentialing, and suspension of privileges for greater than 30 days. Mandatory and voluntary querying of the National Practitioner Data Bank also varies among entities. A listing with the National Practitioner Data Bank can have consequences for licensure and credentialing throughout a physician's career, and reporting requirements begin as an intern. Lastly, it is not clear that the existence of the National Practitioner Data Bank has improved the quality of health care in the United States. CONCLUSION: Knowledge of the requirements and limitations of the National Practitioner Data Bank is useful for plastic surgeons because of the diverse implications of its contents for their current and future practices.

International interdisciplinary rhytidectomy survey.

Facial rhytidectomy is a complex and multi-faceted operation performed by different methodologies between practitioners. This study elucidates current international trends in facelift surgery, including patient selection, operative technique, and postoperative care. A 43-item questionnaire was sent electronically to 7247 members of the following societies: ASPS, ISAPS, CSPS, IFFPS, and the AAFPRS. The survey focused on 3 main areas: (a) background information, (b) intraoperative technique, and (c) postoperative care. The response rate was 11.4%. The majority of our population was from the United States (US) (73%). Most (85%) of the respondents have practices where over 50% of their procedures are considered aesthetic surgery. Statistical differences between the uses of minimally invasive adjuvant treatments (thread lifts, endotine mid-face devices, superficial and deep skin resurfacing procedures) were found between plastic surgeons (PS) and facial plastic surgeons (FPS), as well as between US, Canadian, and international surgeons. Suture imbrication (42%) was the most common way of handling the submuscular aponeurotic system. International surgeons were more likely (49.6% vs. 37.7%, P < 0.05) to use this technique than US or Canadian surgeons. Difference in handling patients who smoke and postoperative management differences were also found between the groups queried. No differences were found between FPS and PS in the handling of the submuscular aponeurotic system, treatment of platysmal bands, treatment of ptotic submandibular glands, or treatment of submental fat deposits (P > 0.05). Differences exist between FPS and PS, and between US, Canadian, and international surgeons with regard to facelift techniques and perioperative management. These differences need to be addressed in order to measure outcomes across specialties and between techniques. This data will additionally be helpful for less experienced and younger surgeons who wish to define best practice patterns.

The effect of electroacustimulation on postoperative nausea, vomiting, and pain in outpatient plastic surgery patients: a prospective, randomized, blinded, clinical trial.

BACKGROUND: Current rates of postoperative nausea and vomiting experienced by outpatient surgery patients are as high as 20 to 30 percent. Electroacustimulation therapy has been demonstrated to be effective in controlling these symptoms, but trials identifying its efficacy in the outpatient surgery population are lacking. METHODS: One hundred twenty-two patients undergoing surgical procedures at an outpatient surgery center were randomized to two treatment arms. The first arm received the standardized pharmacologic postoperative nausea and vomiting prevention typical for patients undergoing outpatient surgery, whereas in the second arm, the ReliefBand and pharmacologic measures were used. The ReliefBand is a U.S. Food and Drug Administration-approved electroacustimulation device. Electroacustimulation is a derivative of acupuncture therapy that uses a small electrical current to stimulate acupuncture points on the human body and is thought to relieve nausea, vomiting, and pain. Outcomes measured were pain and nausea symptoms, emetic events, the need for rescue medications, and the time to discharge. RESULTS: The electroacustimulation arm reported statistically significant lower nausea scores at 30 minutes and 120 minutes postoperatively (p < 0.05). In addition, subgroup analysis demonstrated significant findings in favor of the experimental group, with anatomical subsets of surgical patients requiring less pain medication and shorter times from surgery to discharge when compared with the standard treatment. However, electroacustimulation did not have a significant effect on the amount of pain experienced by patients in any group. CONCLUSION: The authors' study demonstrates that electroacustimulation offers added protection against symptoms of postoperative nausea and vomiting in an outpatient cosmetic surgery population, representing a safe and cost-effective addition to current pharmacologic preventive measures.

National bariatric surgery and massive weight loss body contouring survey.

BACKGROUND: As bariatric surgery has become more popular, plastic surgeons have seen increases in post-bariatric surgery body contouring procedures. The aim of the authors' survey was to better understand perspectives of bariatric surgeons toward body contouring procedures and referral patterns to plastic surgeons. METHODS: A questionnaire was sent to 500 surgeon members of the American Society for Metabolic and Bariatric Surgery. Questions focused on bariatric surgery practices, perspectives toward massive weight loss body contouring, and referral patterns. One hundred eighty-eight surveys were analyzed. RESULTS: Sixty-four percent of surgeons surveyed reported that patients ask about body contouring procedures before bariatric procedures. Only 54 percent reported routine counseling on the potential functional and aesthetic consequences of bariatric surgery. Ninety-six percent of bariatric surgeons have access to plastic surgeons, but only 7 percent of bariatric surgeons always refer their patients to a plastic surgeon and 33 percent rarely refer to a plastic surgeon. Fifty-one percent of surgeons report that patients who have undergone body contouring procedures are overall more satisfied with their decision to undergo bariatric surgery versus bariatric patients who have not had body contouring. Seventy-five percent of surgeons reported that patients rarely express any concern regarding their decision to undergo plastic surgery. CONCLUSIONS: Bariatric surgery requires multispecialty care from bariatric and plastic surgeons. Results and outcomes can be improved with body contouring procedures, especially with regard to better self-image, self-confidence, and satisfaction. However, there are deficiencies in pre-bariatric surgery counseling regarding outcomes and discussions of body contouring procedures. Therefore, better methods of referrals to plastic surgeons need to be identified.

Correction of internal nasal valve stenosis: a single surgeon comparison of butterfly versus traditional spreader grafts.

Nasal obstruction due to internal nasal valve (INV) collapse is relatively common. This article evaluates 2 different methods repairing the INV.Our subject population is a single-surgeon group of 82 patients who underwent a septorhinoplasty for nasal airway obstruction. Patients received either a spreader graft or butterfly graft. There are 30 patients who received spreader grafts and 52 patients who received a butterfly graft. All patients had a minimum of 3 months follow-up. All patients were evaluated with standardized questionnaire. Participants were asked to evaluate improvement in their nasal airway on an analog scale of 1 to 5. Participants were also asked to comment on changes in pre and postoperative snoring and sleep habits. Lastly, participants were queried regarding the ear cartilage harvest and if this bothered them.Patients undergoing both procedures demonstrated an overall improvement in their nasal breathing. Significant differences in improvement were observed for patients in the categories of postoperative snoring, sleep, and continuous positive airway pressure use. Patients were not bothered by the ear cartilage harvest.In select patients, the butterfly graft is a useful solution for INV collapse correction.

In vitro adipogenic differentiation of preadipocytes varies with differentiation stimulus, culture dimensionality, and scaffold composition.

Despite the rapidly growing body of work on stem cell-based adipose tissue engineering, there remains much to be learned about the role of the scaffold and culture environments in directing the adipogenic differentiation of cells. The present study examined how various culture environments and differentiation stimuli (traditional differentiation medium [DM] and coculture with mature adipocytes) impacted the adipogenic differentiation of human preadipocytes, with studies progressing from two-dimensions (2D) to three-dimensions (3D) in vitro. Assays for adipogenic markers (leptin, adiponectin, and glycerol) and Oil Red O staining were used to assess differentiation. After 16 days of 2D culture, adipogenesis was substantially greater when preadipocytes were cocultured with adipocytes rather than treated with DM. In a 3D in vitro environment, the production of adipogenic markers was significantly elevated relative to 2D conditions, and the coculture condition continued to stimulate greater adipogenesis. Alterations in 3D scaffold physical properties had only a minimal effect on the function of mature adipocytes, but significantly impacted the ability of preadipocytes to undergo adipogenic differentiation in vitro. These alterations in scaffold environment and in medium conditions, particularly the application of adipocyte/preadipocyte coculture methods in lieu of traditional DM, may provide further means for optimizing adipogenic outcomes in vitro and in vivo.

Exploring the effect of the referring general surgeon's attitudes on breast reconstruction utilization.

BACKGROUND: Breast reconstruction rates remain low, at 5%-15% of mastectomy patients, despite the safety and high patient satisfaction of these procedures. Reasons for this are multifactorial, including the attitudes and biases of the referring breast surgeon, as well as patient factors. The purpose of this study was to explore attitudes of general surgeons towards breast reconstruction. METHODS: We surveyed 369 general surgeons in Wisconsin with questions about breast surgery. Responses from 135 (36%) surgeons were analyzed. RESULTS: Seventy-three percent of the respondents performed at least some breast surgery and were eligible for the study. For a little over 50% of the general surgeons surveyed, breast surgery made up less than 10% of their practice. Fifty-one percent never performed a skin-sparing mastectomy. A large number of breast surgeons (40%) did not refer all mastectomy patients for reconstruction. Reasons cited for not referring patients included the concerns over cancer recurrence and advanced patient age. Reasons for patients not undergoing reconstruction included patient's refusal, need for radiation therapy, delaying adjuvant oncologic treatment, patient factors, and having no plastic surgeon available locally. CONCLUSIONS: The decision by a patient to undergo breast reconstruction involves many complex factors. As a specialty, we should focus on improving the availability of breast reconstructive surgeons and educating referring surgeons and patients about reconstructive indications and options in order to positively affect the utilization of breast reconstruction.

Community-acquired methicillin-resistant staphylococcus aureus: diagnosis and treatment update for plastic surgeons.

LEARNING OBJECTIVES: : After studying this article, the participant should be able to: 1. Identify risk factors associated with community-acquired methicillin-resistant Staphylococcus aureus. 2. Recognize the clinical presentation of patients with community-acquired methicillin-resistant S. aureus. 3. Understand the treatment and indications for decolonization of patients who have community-acquired methicillin-resistant S. aureus infections. SUMMARY: : Community-acquired methicillin-resistant Staphylococcus aureus has evolved over the past 10 years as a new health threat seen by plastic surgeons and is an increasing cause of soft-tissue infections. This pathogen has several distinct virulence factors and unique antimicrobial susceptibilities that distinguish methicillin-resistant S. aureus from traditional hospital-acquired methicillin-resistant S. aureus. This article reviews the epidemiology, risk factors, clinical presentation, and treatment of community-acquired methicillin-resistant S. aureus.

Safety device use affects the incidence patterns of facial trauma in motor vehicle collisions: an analysis of the National Trauma Database from 2000 to 2004.

BACKGROUND: Airbags and seat belts are designed to decrease injuries sustained in motor vehicle collisions. The authors hypothesize that the use of these devices has an effect on the patterns of facial fractures and facial lacerations. METHODS: The records of 15,293 facial fracture patients and 114,623 facial laceration patients from motor vehicle collisions were analyzed from the National Trauma Database. Five hundred sixty-five patients were identified as having panfacial fractures. Fisher's exact test and chi-square analysis were used to study associations between safety devices and facial trauma. RESULTS: Panfacial fractures occurred in 3.7 percent of all patients sustaining facial fractures. In motor vehicle collisions resulting in facial fractures, 31.2 percent of patients had a seat belt, 5.6 percent had a seat belt and an airbag, 3.9 percent had an airbag only, and 59.3 percent had no safety device. The lack of a safety device in motor vehicle collisions increased the incidence of facial fractures (odds ratio, 2.26), panfacial fractures (odds ratio, 2.98), and facial lacerations (odds ratio, 1.95). Passengers with facial fractures were more likely to have not used a safety device (odds ratio, 1.69). CONCLUSIONS: Based on the largest reported series on motor vehicle collision-associated facial fractures in the United States, the use of airbags and seat belts is associated with a significantly decreased incidence of facial fractures and lacerations. Given that fewer than half of these patients used a safety device and the high morbidity and costs associated with these injuries, plastic surgeons should advocate for the increased use of these safety devices.

Management of mandible fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Review the incidence and etiology of mandible fractures. 2. Discuss indications and techniques for closed and open treatment of mandible fractures. 3. Review complications of mandible fractures. BACKGROUND: Mandible fractures are among the most common types of facial fractures treated by plastic surgeons. They must be managed carefully to maintain the function of the mandible, reestablish proper occlusion, and minimize secondary complications. METHODS: Current methods of management include combinations of soft diet, intermaxillary fixation, open reduction with plate fixation, and, rarely, external fixation. RESULTS: Decision-making depends on the age of the patient, type of fracture identified, and concomitant medical conditions or injuries. CONCLUSION: The authors review the diagnosis and current trends in management of mandible fractures.