Allen L. Van Beek

V-y Advancement Flap for Facial Defects

We have used 107 V-Y advancement flaps in 76 patients with only loss of one flap and loss of hair growth in a second. The versatility of this method of closure and its superior cosmetic result recommend it to the plastic surgeon who must close defects of the face.

Successful Treatment Protocol for Canine Fang Injuries

The most common bite injury in the United States is that of the dog and is associated with serious social and economic problems. Our series of 61 dog bite patients shows a majority of them to be in children and of the face and neck. Our treatment protocol centers on copious saline pressure irrigation, meticulous wound and wound edge debridement, repeated copious saline pressure irrigation, adequate antibiotic treatment, and close postoperative monitoring. Two hundred fifteen dog bite wounds in 61 patients were closed with this regimen with only a single wound infection. This is a wound infection rate of 0.47% and a patient infection rate of 1.6%.

Guidelines for pediatric perioperative care during short-term plastic reconstructive surgical projects in less developed nations.

Many physicians, nurses, and other health care providers are involved in short-term plastic/ reconstructive surgical care of children in the less developed world. They provide an enormously important service to children that otherwise might not receive surgical care. Care may involve a variety of procedures ranging from cleft lip repair to complex craniofacial reconstruction. Regardless of the type of care, the overriding goal should always be the safety of the child. Patient safety can be optimized by careful selection of patients, facilities, and procedures, by ensuring the availability of proper equipment and staffing, and by close coordination with host professionals and officials. As with care in the developed world, preparation and planning are crucial to the provision of high-quality care in the developing world. Volunteers in Plastic Surgery (VIPS) is a committee of the Plastic Surgery Education Foundation (PSEF), which is highly supportive of volunteer surgical programs in developing countries. The PSEF is a part of the American Society of Plastic Surgeons. In 2006, VIPS undertook a project to develop guidelines that would indicate what practices are consistent with quality and safety during short-term reconstructive plastic surgery endeavors in developing countries. That undertaking involved the input of numerous pediatric anesthesiologists and plastic reconstructive surgeons who have particular expertise in short-term surgical care in developing countries (including input from all the authors of this manuscript). The project therefore started as an initiative of VIPS, but soon involved members of the Society for Pediatric Anesthesia (SPA) and in particular the SPA Committee on International Education and Service. Once completed, those guidelines were circulated to many societies and organizations that conduct reconstructive plastic surgery in developing countries. Specifically, they were reviewed and endorsed by the boards of the American Society of Plastic Surgeons, the PSEF, the SPA, the American Cleft Palate-Craniofacial Association, the American Society of Maxillofacial Surgeons, European Society of Plastic, Reconstructive and Aesthetic Surgery, and the American Association for Hand Surgery. Interplast, Operation Smile International, and Smile Train have also endorsed the guidelines. Those guidelines are available in a document titled Guidelines for the Care of Children in the Less Developed World, which can be found at the VIPS web site. The guidelines below, although not specifically endorsed by the organizations listed above, started with that same document posted at the VIPS web site and therefore resembles it substantially. However, we have added clarifications, referencing, tabular presentation, and in a few cases new recommendations. This article is intended to assist in preparation and planning for, and evaluation of, short-term reconstructive plastic surgical projects. It provides a framework for the delivery of high-quality plastic surgical care in remote settings. That framework should help health care providers and program organizers from developed countries determine what manpower and equipment they want to use during these projects. Also, the same framework may help organizations located in less developed nations who would like to host a surgical mission and need to determine whether the surgical support offered to them will be of high quality. These guidelines were developed specifically with plastic surgical projects in mind, although many of these recommendations apply to other types of surgical projects conducted in remote locations, which hereafter are referred to as surgical missions. Below, we review important aspects of planning and performing surgical missions, including selection of the mission site and facility, and the appropriate selections of patients, procedures, professional staff, and equipment. It is important to recognize that facilities, equipment, and staffing appropriate for low-risk patients and uncomplicated procedures may not be adequate for higher-risk patients and more complex procedures. For example, a mission that involves caring for an infant (a high-risk patient) receiving a craniosynostosis repair (a complex procedure) necessitates a much greater level of professional expertise and facility than a mission that only entails care of healthy children receiving cleft lip repairs. Surgical mission leadership should ensure sufficient professional expertise, equipment, and facilities to manage the level of perioperative care that will be required. In the sections that follow, we have defined “high-risk patients” and “complex procedures,” because we believe these definitions are helpful for determining appropriate selection of patients, equipment, facilities, and health care personnel needed to provide quality perioperative care in this unusual setting. However, we recognize that our definitions are not all-inclusive or authoritative and that defining “high-risk” patients and “complex procedures” is not always as clear as in the example above. Authors’ affiliations are listed at the end of the article.

Nerve regeneration—Evidence for early sprout formation

Following microneurorrhaphy, sharply transected rat sciatic nerves were harvested 2, 5, 12, 16, 21, and 30 days after repair. Transverse sections of these specimens were made 3, 5, 7, 9 and 11 mm distal to the repair and examined with the scanning electron microscope. Myelinated sprouts were found 3 mm distal to the repair on the fifth day. Sprout migration occurred even though old myelin sheaths were present. Sprouts did not appear in old myelin sheath lumens. Many 5 U myelinated sprouts were found 11 mm distally 21 and 30 days after repair. This study demonstrates that nerve regeneration begins early, before degeneration is complete.

Critical need for accurate and quantitative viability assays to optimize fat grafting protocols.

Outcomes following autologous fat grafting continue to be unpredictable. The lack of a standardized protocol for fat harvest, processing, and transplant produces variable graft retention rates. Plastic surgeons historically have relied on trial and error to modify their techniques.1 To optimize fat grafting protocols, systematic evaluation of each procedural step for its specific impact on adipose tissue (AT) viability is critically needed. Many assays have been developed to measure AT viability, but most measurements are neither accurate nor quantitative, are operator dependent, and have not helped correlate fat grafting protocols (or changes to protocols) with outcomes.1 AT viability has been estimated through visual assessment, membrane integrity staining, conventional histology, or special staining for apoptosis or mitochondrial function; all these techniques are largely semiquantitative, because the outcome still depends on the individual operators evaluation of results. The …

Are We Killing Our Fat Cells before Grafting Them

1 David A. Sieber, MD Allen L. Van Beek, MD Division of Plastic and Reconstructive Surgery University of Minnesota Minneapolis, Minn. Sir: S its inception by Neuber in 1893, there have been numerous modifications in fat grafting techniques, all attempting to maximize posttransplant adipocyte survival. Despite ongoing research, there remains wide variations in viability after autologous fat grafting, with reported loss ranging from 40% to 60%.1 Research studying various methods of harvesting, force and time of centrifugation, effects of local anesthetic, cannula size, hand versus machine aspiration, and location of donor sites are discussed.2,3 However, the question remains: why are so many adipocytes being resorbed after transfer? There is suggestion in the literature that high negative pressures may contribute to cellular rupture before injection.4 Our study was able to identify that high negative pressures are generated through hand aspiration with minimal amounts of distraction. The maximum negative pressure generated exceeds 600 mm Hg, which is likely enough negative pressure to cause cellular rupture and also creates excess pressure with distractions greater than 3 mL. To date, there has been a lack of convincing research to define a range of negative pressures that cause direct cellular rupture of living adipocytes. A single study suggests that cells begin to rupture at negative pressures over 20 mm Hg, but the scientific literature has never addressed this issue directly.4 Coleman5 recommends displacing the plunger by 1–2 mL in a 10-mL syringe. This distraction amount generates negative pressures in the range of 50–115 mm Hg (Fig. 1). The pressure at which cell rupture occurs has yet to be determined; however, some studies do suggest higher cell viability with low pressure harvesting of aggregates of cells. The current literature evaluates cells under negative 760mm Hg and negative 380mm Hg of pressure but is lacking in comparing high negative pressures of 760 mm Hg with low negative pressures of <150 mm Hg. Persistent issues in the literature are the lack of a standardized protocol for lipoaspiration and a need for a quantitative method of evaluating adipocyte viability. Without standard methods, available studies have multiple variables that potentially confound the data and provide conflicting results. This may be the reason that so many of the currently published studies have not been able to show significance between experimental and control groups. Many authors have attempted to determine cell viability by preserving cells in fixative. This merely suspends the cell in time, providing a snapshot of healthy cellular architecture, but it does not provide an accurate picture of eventual cell death due to programmed apoptosis or induced cell death. Newer assays measuring cytoplasmic enzymes such as 3-phosphate dehydrogenase do a better of job of determining viable cells from those that are programmed to die, but it still does not provide a quantitative evaluation of living cells ability to survive. Clinical fat grafting is an evolving process where the end result is variable, and the factors creating that variability have yet to be adequately studied. It seems likely that high negative pressure and other technical factors during aspiration and grafting contribute to premature cellular death. However, more stringent standardized protocols and quantitative measurements of cell viability need to be developed before that question can be answered.

Characterization of Adipose Tissue Product Quality Using Measurements of Oxygen Consumption Rate

Background: Fat grafting is a common procedure in plastic surgery but associated with unpredictable graft retention. Adipose tissue (AT) “product” quality is affected by the methods used for harvest, processing and transfer, which vary widely amongst surgeons. Currently, there is no method available to accurately assess the quality of AT. Objectives: In this study, we present a novel method for the assessment of AT product quality through direct measurements of oxygen consumption rate (OCR). OCR has exhibited potential in predicting outcomes following pancreatic islet transplant. Our study aim was to reapportion existing technology for its use with AT preparations and to confirm that these measurements are feasible. Methods: OCR was successfully measured for en bloc and postprocessed AT using a stirred microchamber system. OCR was then normalized to DNA content (OCR/DNA), which represents the AT product quality. Results: Mean (±SE) OCR/DNA values for fresh en bloc and post‐processed AT were 149.8 (± 9.1) and 61.1 (± 6.1) nmol/min/mg DNA, respectively. These preliminary data suggest that: (1) OCR and OCR/DNA measurements of AT harvested using conventional protocol are feasible; and (2) standard AT processing results in a decrease in overall AT product quality. Conclusions: OCR measurements of AT using existing technology can be done and enables accurate, real‐time, quantitative assessment of the quality of AT product prior to transfer. The availability and further validation of this type of assay could enable optimization of fat grafting protocol by providing a tool for the more detailed study of procedural variables that affect AT product quality.