Afshin Mosahebi

Trends in tertiary breast reconstruction: Literature review and single centre experience

BACKGROUNDnAutologous flap reconstruction can improve aesthetic results after failed implant reconstruction and be considered following previous failed autologous flap reconstruction. This study presents a review of the indications, motivation and outcomes of tertiary breast reconstruction.nnnMETHODSnA comprehensive literature review was conducted using Pubmed, Embase, Web of Science and Google Scholar. Articles were identified using key search terms and through citations. A single centre, retrospective, review of all patients who underwent autologous flap reconstruction following previous breast reconstruction between 2004 and 2010. Details on patient demographics, surgical outcomes and patient satisfaction were collected.nnnRESULTSnOut of 580 autologous flap breast reconstructions, 31 patients had 36 tertiary breast reconstructions with an autologous free or pedicled flap. Indications for surgery included: capsule contracture with discomfort (nxa0=xa024), asymmetry (nxa0=xa08), extrusion of implant (nxa0=xa04), exposed implant (nxa0=xa01). and previous failed autologous flap reconstruction (nxa0=xa07). The mean age our cohort was 50.1 years, BMI of 26.1, 52.3% had radiotherapy (nxa0=xa019) and 51.6% had chemotherapy. We performed free DIEP(nxa0=xa022), LD with or without an implant (nxa0=xa011) and free TRAM flap (nxa0=xa03). 5 were bilateral procedures. Flap complications included total flap loss (nxa0=xa02), partial skin necrosis (nxa0=xa01) and fat necrosis (nxa0=xa01). Mean follow up time was 20 months. Overall satisfaction, excluding the two flap failures was good.nnnLITERATURE REVIEWnOnly small case series were published on tertiary breast reconstruction. More recent literature had larger patient samples. A total of 7 studies were identified, with a total of 532 flaps, following unsatisfactory or failed implant reconstruction. The Deep Inferior Epigastric Artery Perforator (DIEP) flap was the most favourable first choice for autologous tertiary reconstruction. Breast cancer was the commonest indication for primary surgery. Motivations for tertiary surgery included cosmesis (including asymmetry and shape), symptomatic capsule contracture and desire for a natural feel. A handful of studies explored the outcomes of autologous flaps following a previously failed flap.nnnCONCLUSIONnAutologous breast reconstruction for tertiary reconstruction can be performed successfully to improve cosmesis and physical discomfort following failed or unsatisfactory results from implant reconstruction or previous failed flap reconstruction. The goal is to excise scarred tissue, recreate the breast mound and the normal anatomical shape. It provides new skin and well vascularised tissue to facilitate healing, producing a more natural feel and aesthetic breast.

Determining the outcomes of post-mastectomy radiation therapy delivered to the definitive implant in patients undergoing one- and two-stage implant-based breast reconstruction: A systematic review and meta-analysis

BACKGROUNDnPost-mastectomy radiation therapy (PMRT) is known to increase the complication rate and implant loss in implant-based breast reconstruction. The purpose of this study was to systematically review the literature regarding the outcome of PMRT delivered to the permanent/definitive implant.nnnMETHODSnSystematic review and meta-analysis of studies involving immediate implant-based reconstruction and PMRT when delivered to the permanent implant.nnnRESULTSnSeven studies included 2921 patients (520 PMRT, 2401 control). PMRT was associated with significant increase in capsular contracture (7 studies, 2529 patients, 494 PMRT, 2035 control, OR 10.21, 95% CI 3.74 to 27.89, pxa0<xa00.00001). In addition, PMRT was associated with a significant increase in revisional surgery (7 studies, 2921 patients, 520 PMRT, 2401 control, OR 2.18, 95% CI 1.33 to 3.57, pxa0=xa00.002) and reconstructive failure (6 studies, 2814 patients, 496 PMRT, 2318 control, OR 2.52, 95% CI 1.48 to 4.29, p+0.0007). Moreover, it was associated with a significant reduction in patient satisfaction (4 studies, 468 patients, 138 PMRT, 294 control, OR 0.29, 95% CI 0.15 to 0.57, pxa0=xa00.0003) and cosmetic outcome (4 studies, 1317 patients, 238 PMRT, 1009 control, OR 28, 95% CI. 0.11 to 0.67, pxa0=xa00.005).nnnCONCLUSIONSnThis meta-analysis demonstrates that within the first 5 years, post implant-based reconstruction for those patients who receive PMRT, the rates of adverse events are increased, and there is a significant reduction in patient satisfaction and cosmetic outcome.

Migraine: A look down the nose

BACKGROUNDnStudies have suggested that contact between opposing mucosal surfaces in the nasal wall and cavity can be a target of the surgical treatment of migraines. Unfortunately, not enough is known about the role of nasal pathology in the pathogenesis of this condition. The co-existence of further rhinological disorders can be an impediment to defining the cause and effect of anatomical variants. The authors compared the MRI scans of migraine- and non-migraine patients (MPs and NMPs, respectively) to determine the prevalence of such mucosal contact points in order to extrapolate whether there is a significant association with migraines.nnnMETHODSnCoronal and axial MRI brain scans of 522 patients (412 migraineurs and 110 non-migraineurs) were analysed for the prevalence of anatomical variations of the nasal cavity, e.g. concha bullosa, septal deviations, mucosal swelling and contact points.nnnRESULTSnThe results showed no significant difference between MPs and NMPs patients for any of the parameters examined. Moreover, 87% MPs and 79% NMPs had at least one contact point. The most frequent contact point was between the middle turbinate and the septum, observed in 54% of MPs and 45% of NMPs.nnnCONCLUSIONSnContact points with the nasal mucosa are highly prevalent in both MPs and NMPs. Although a contact point does not cause a migraine in the absence of the disease, the concomitant presence of migraine and contact points can trigger an attack, and therefore, it is necessary to differentiate or exclude a rhinological disorder in these patients.

Applications of Smartphone thermal camera imaging system in monitoring of the deep inferior epigastric perforator flap for breast reconstruction

The rise in Smartphone availability has brought about the development of multiple mobile applications and devices utilized in the clinical setting. Hardwicke et al. have described the use of the FLIR ONE miniature thermal imaging camera (FLIR Systems, Wilsonville, Ore) in the evaluation of patients undergoing free tissue transfer. Thermal imaging captures the infrared radiation (IR) emitted from the skin surface and has been extensively used in plastic surgery as a means of determining burn depth, detecting post-operative infection, and postoperative free flap monitoring. The smartphone-friendly product enables clinicians to utilize this technology at a fraction of the price of standard thermographic cameras. The device clips into the mobile phone charging port and requires the installation of the FLIR ONE mobile application to operate. It possesses both a thermal and digital camera that takes photographs simultaneously. The images are then merged by the software allowing for the addition of greater physical detail an otherwise raw thermal reading. Hardwicke et al. argue that despite low image resolution and propensity for background thermal interference, it serves as an effective and inexpensive method of locating perforating vessels and evaluating overall tissue perfusion. We have used this in the peri-operative assessment of patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstructions. The device is portable and its software is similar to that of traditional Smartphone cameras which makes it easy to use and requires no additional training, however, factors such as vasoconstriction, warming blankets, or low ambient temperature significantly impact on accuracy. The heat signal identified by the camera strongly correlates with the position of the perforators as demonstrated by pre-operative radiological investigations and Doppler findings, even in the face of abundant overlying soft tissue (Fig. 1A). We propose that the perforators are best visualized following a 3–4 minute period of cooling of the skin as this will result in the faster warming of tissues immediately adjacent to the vessels allowing for more accurate localization (Fig. 1B). We are currently investigating additional uses of this device including monitoring of digital replantation and pre-operative assessment of hand trauma patients. Our positive experience with the camera is in keeping with that described by Hardwicke et al. and there is currently a need for larger comparative studies in order to better evaluate the clinical applicability of the FLIR ONE thermal imaging system.

Protocol for a systematic review of autologous fat grafting for wound healing

BackgroundAutologous fat grafting is an emerging therapeutic option for cutaneous wounds. The regenerative potential of autologous fat relates to the presence of adipose-derived stem cells (ADSCs) within the stromal vascular fraction (SVF). ADSCs are capable of differentiating into fibroblasts and keratinocytes, as well as secreting soluble mediators with angiogenic and anti-inflammatory properties. However, to date, there has been no comprehensive assessment of the wound healing literature in humans. This systematic review aims to critically evaluate the efficacy and safety of autologous fat grafting in acute and chronic cutaneous wounds with an appraisal of the quality of evidence available.MethodsFollowing PRISMA guidelines, MEDLINE, Embase and Cochrane Library databases will be searched from inception to December 2017. All primary clinical studies in which wounds are treated with lipotransfer, cell-assisted lipotransfer (CAL), SVF products or isolated ADSCs will be eligible for inclusion. Study screening and data extraction will be conducted by two authors in duplicate. Our primary outcome measure will be the proportion of completely healed wounds at 12xa0weeks. Secondary outcome measures will include the proportion of partially healed wounds at 12xa0weeks; the mean wound surface area reduction at 12xa0weeks; the mean time to wound healing; and adverse event rates. The quality of evidence for each summary outcome measure will be assessed using the GRADE approach.DiscussionIn light of the growing popularity of autologous fat grafting for wound healing, a systematic appraisal of the available evidence is timely. If autologous fat grafting is associated with a positive treatment effect, we will compare these outcomes to those achieved using alternative wound management strategies. This review also aims to determine if one or more autologous fat grafting techniques are superior and whether this varies according to patient- and wound-specific factors. We anticipate that these results will guide future research and inform clinical practice.Systematic review registrationPROSPERO CRD42017081499

Body Contouring Surgery and the Maintenance of Weight-Loss Following Roux-En-Y Gastric Bypass: A Retrospective Study

BackgroundnBariatric surgery leads to significant weight loss with reduced morbidity and mortality. However, excess skin as a consequence of weight loss represents a major problem, impacting upon patients functionality with potential negative effects on weight loss.nnnObjectivesnWe evaluated the effect of body-contouring surgery on weight-loss maintenance following bariatric surgery.nnnMethodsnWe undertook a retrospective analysis of patients undergoing Roux-en-Y gastric bypass (RYGB) +/- body-contouring surgery (BC). The control group (n = 61) received RYGB, the test group (n = 30) received RYGB+BC 12 to 18 months after bariatric surgery. Each RYGB+BC patient was matched to two control patients for age, sex, glycaemic status, and weight on day of surgery. Per cent weight loss (%WL) was calculated at 3, 6, 12, 24, 36, 48, and 60 months post-RYGB for both groups.nnnResultsnThe %WL was similar at 3, 6, and 12 months post-RYGB. At 24 months, %WL was 35.6% in the RYGB+BC group and 30.0% in the RYGB group (P < 0.05). At 36 months, the RYGB+BC group maintained their weight loss (%WL 33.0%), in contrast, the RYGB gained weight (%WL = 27.3%, P < 0.05). This trend continued (RYGB+BC vs RYGB) at 48 months (%WL 30.8% vs 27.0%) and at 60 months (%WL 32.2% vs 22.7%, P < 0.05).nnnConclusionsnOur results suggest patients who undergo body contouring after bariatric surgery are able to lose significantly more weight and maintain weight loss at five years of follow up compared to those undergoing bariatric surgery alone.

Commentary on: Adipose-Derived Stem Cells in Aesthetic Surgery: A Mixed Methods Evaluation of the Current Clinical Trial, Intellectual Property, and Regulatory Landscape

Adipose-derived stem cells (ADSC) continue to incite controversy in the medical profession, are highly sought after by the public, incite excitement in commercial companies, and are seen as a lucrative income generator in clinics. This interesting analysis of ADSC registered trials as well as registered intellectual properties further illustrates these points.1 The article confirms the paucity of good quality trials, despite 1250 registered ones, almost none seem to plan long-term follow up of the effect. Additionally, there is no agreed standard methodology of assessment of the quality of the ADSC. This is in spite of the large number of patents put in for separation and concentration technologies, as well as innovative applications. The explanation of regulatory landscape is very enlightening, illustrating the great deal of variability in different continents. In some cases, vagueness and lack of clarity in regulation has enabled potential unscrupulous misinterpretations and misuses false promotion of services. An exemplar regulation is in Japan, where there is a specific section for regenerative medicine. This not only helps to promote innovation and genuine effect and uses, but also reduces the back-street rogue clinics and should be a lesson to regulatory bodies in the United States and European Union. This unique article gives ASJ readers a comprehensive overview of global landscape in ADSC field, trials, and regulation. Disclosures

Historical Overview of Stem Cell Biology and Fat Grafting

The last two decades have seen significant advances within the field of adipose stromal cell transfers, with novel clinical applications being published every few months. This article gives a brief historical overview of the development of stem cell biology and fat grafting.

Response to “In Defense of the International Collaboration of Breast Registry Activities (ICOBRA)”

The authors have provided in their response1 to our editorial2 a comprehensive history of the development of ICOBRA and how it evolved using what is regarded as “ best practice ” (rather than evidence-based best practice) from the experience of a number of countries and organizations. It has drawn from the analogies with the orthopedic experience, as have we in our article. It is apparent that much heartfelt endeavor has gone into the development of a hopefully successful international collaboration.nnIn their response, the authors seem to regard our article as a personal attack on their laudable efforts to create an internationally functional breast implant registry, rather than attempt to engage in the debate. Lack of a university appointment or elected position in a National professional body does not, as far as we are aware, exclude us from proffering an opinion for peer review, nor make it any less valid than theirs.nnAs they point out, as yet no data has been published concerning a “ successful pilot across seven centres, ” and therefore the basis on which they assert that the decisions made by ICOBRA are “ proven to be an optimal data profile ” is nothing more than supposition at present.nnSimilarly, PROMS, by which the registry may function, have yet to be defined, tested, published, and agreed upon. We believe that this alone justifies the title of our article, and that it is premature to institute a clinical quality registry (CQR) without either of …

Commentary on: The Fountain of Stem Cell-Based Youth? Online Portrayals of Anti-Aging Stem Cell Technologies.

The phrase “stem cell therapy” is flaunted liberally, and yet there is disconnect between what is offered, reality, the publics expectation, and proven, validated medical knowledge. In fact, some have used it to refer to cells from the stem of a plant!1 However, there is no doubt that stem cells do have many potential therapeutic uses as yet unexplored and will certainly be relevant in aesthetic medicine and the aesthetic-related industry moving forward.nnAlthough the attitude of plastic surgeon towards stem cell therapy has been looked at,2 this timely article from Rachul et al3 addresses the hype …