I. Garrido

Human Solid Tumors Contain High Endothelial Venules: Association with T- and B-Lymphocyte Infiltration and Favorable Prognosis in Breast Cancer

The mechanisms governing infiltration of lymphocytes into tumors remain poorly characterized, in spite of the critical impact of these cells on patient prognosis and therapeutic responses. High endothelial venules (HEV) are blood vessels found in lymphoid tissues, specialized in lymphocyte recruitment, but their implications in human cancer are unknown. In this article, we report the presence of MECA 79(+) blood vessels displaying all the phenotypic characteristics of HEVs in most of the 319 human primary solid tumors, including melanomas, breast, ovarian, colon, and lung carcinomas, analyzed. Tumor HEVs were specifically located within lymphocyte-rich areas, and their density within the tumor stroma was a strong predictor of infiltration by CD3(+) and CD8(+) T cells as well as B cells. Large-scale flow cytometric and quantitative reverse transcriptase-PCR analyses in freshly operated breast tumors revealed that high densities of tumor HEVs correlated with increased naive, central memory and activated effector memory T-cell infiltration and upregulation of genes related to T-helper 1 adaptive immunity and T-cell cytotoxicity. Finally, in a retrospective cohort of 146 invasive breast cancer patients, we found that high densities of tumor HEVs independently conferred a lower risk of relapse and significantly correlated with longer metastasis-free, disease-free, and overall survival rates. Together, our findings suggest that tumor HEVs function as major gateways for lymphocyte infiltration into human tumors, and may represent attractive targets for cancer diagnosis and therapy.

Histological regression in primary melanoma: not a predictor of sentinel lymph node metastasis in a cohort of 397 patients

Background  Regression has been proposed as a potential marker of dissemination in thin melanomas. Previous studies have shown conflicting results.

A Systematic Review and Meta-Analysis of Double Venous Anastomosis in Free Flaps.

Background: Venous problems are the most frequent causes of flap failure and surgical revision in free flap surgery. Double venous anastomosis can be used to improve flap drainage, but this procedure has not been adopted universally and remains controversial. The authors evaluated the benefits of double venous anastomosis in terms of venous thrombosis rate, surgical revision of flaps, and flap failure rate. Methods: A systematic literature review was conducted searching the MEDLINE, PubMed Central, Cochrane, and Embase databases for articles published between 1996 and July of 2014. Data analysis consisted of evaluating the pooled relative risks of single and double venous anastomoses in fixed and random-effects models. Results: The final analysis included 27 articles involving 6842 flaps. The overall success rate was 97.48 percent. Single venous anastomosis was performed in 4591 flaps versus two anastomoses in 2251 flaps. The failure rate was 3.1 percent for single anastomosis versus 1.3 percent for double anastomosis (OR, 0.511; 95 percent CI, 0.349 to 0.747; p = 0.001). The respective thrombosis rates were 3.1 percent versus 2.3 percent (OR, 0.586; 95 percent CI, 0.390 to 0.880; p = 0.010). In addition, more single venous anastomoses were revised: 7.7 percent versus 6 percent (OR, 0.601; 95 percent CI, 0.469 to 0.770; p < 0.0001). Stratified analysis by flap type did not show any significant differences. Conclusions: Although the physiologic mechanisms remain poorly understood, the data strongly support double venous anastomosis, considering the reduction in flap failure, microsurgical venous thrombosis, and surgical revision. The authors recommend double anastomosis whenever it is feasible in free flap surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Smoking and plastic surgery, part I. Pathophysiological aspects: Update and proposed recommendations

OBJECTIVES Smoking patients undergoing a plastic surgery intervention are exposed to increased risk of perioperative and postoperative complications. It seemed useful to us to establish an update about the negative impact of smoking, especially on wound healing, and also about the indisputable benefits of quitting. We wish to propose a minimum time lapse of withdrawal in the preoperative and postoperative period in order to reduce the risks and maximize the results of the intervention. METHODS A literature review of documents from 1972 to 2014 was carried out by searching five different databases (Medline, PubMed Central, Cochrane library, Pascal and Web of Science). RESULTS Cigarette smoke has a diffuse and multifactorial impact in the body. Hypoxia, tissue ischemia and immune disorders induced by tobacco consumption cause alterations of the healing process. Some of these effects are reversible by quitting. Data from the literature recommend a preoperative smoking cessation period lasting between 3 and 8 weeks and up until 4 weeks postoperatively. Use of nicotine replacement therapies doubles the abstinence rate in the short term. When a patient is heavily dependent, the surgeon should be helped by a tobacco specialist. CONCLUSIONS Total smoking cessation of 4 weeks preoperatively and lasting until primary healing of the operative site (2 weeks) appears to optimize surgical conditions without heightening anesthetic risk. Tobacco withdrawal assistance, both human and drug-based, is highly recommended.

Subungual melanoma : For a conservative approach on the thumb scale

Melanoma management requires consideration of both oncologic and reconstructive principles to optimize both the likelihood of cure and quality of life. The plastic surgeon is encountering melanoma management that requires not only oncologic but also reconstructive surgery while considering both esthetic and functional results. Management of acrolentiginous melanoma typically involves the partial amputation of the thumb or the toe, with removal of the distal phalanx and the adjacent interphalangeal joint. The simple partial amputation of the second phalanx, preserving the pulp and the interphalangeal function (joints and tendinous insertions), and a made-to-measure ungual transfer provide excellent functional and esthetic results while maintaining similar oncologic outcomes. This report attempts to clarify the management of melanoma of the thumb.

Smoking and plastic surgery, part II. Clinical implications: a systematic review with meta-analysis.

OBJECTIVES Tobacco addiction is a risk factor for complication in plastic surgery. The authors have assembled concrete arguments detailing the risks of perioperative and postoperative complication that are incurred by a patient with continued tobacco intoxication who wishes to undergo a surgical intervention. RESEARCH STRATEGY Through application of the PRISMA criteria, we have carried out a systematic review of the literature, in which we explored five databases while using predefined keywords. We selected randomized, controlled observational studies on the perioperative and postoperative complications related to tobacco use in actively smoking, abstinent and non-smoking patients. DATA COLLECTION AND ANALYSIS The levels of evidence for each article were evaluated. Risk of bias was assessed using the Newcastle-Ottawa Scale. Incidence parameters including the Odds Ratio and relative risk were calculated for each complication of which the number of occurrences had been indicated. Meta-analysis of the results was carried out. RESULTS We included 60 observational studies. In the cosmetic surgery group, we calculated a combined Odds Ratio of 2.3 [1.51-3.54] P<0.001 for surgical site infections and 2.5 [1.49-4.08] P<0.001 for delayed wound healing. In the bariatric surgery sequelae group, we found a combined Odds Ratio of 3.3 [1.90-5.64] P<0.001 with regard to delayed wound healing and 3.1 [1.39-7.13] P=0.006 for cutaneous necrosis. No proof was provided as to the possible influence of tobacco on the success rate of free flap microsurgery, but it is difficult to extrapolate results on the latter to digital reimplantation. CONCLUSIONS The review underlines the fact that patients with smoking habits run a significantly heightened risk of cutaneous necrosis, particularly in the event of major detachment (cervico-facial lift, skin-sparing mastectomy, abdominoplasty), of additionally delayed wound healing and of addition surgical site infections. Rigorous preoperative evaluation of smokers could help to diminish these risks.

Mechanically Isolated Stromal Vascular Fraction Provides a Valid and Useful Collagenase-Free Alternative Technique: A Comparative Study.

Background: The use of stromal vascular fraction and adipose-derived stromal cells in tissue regeneration is now being increasingly investigated, and studies have demonstrated that adipose-derived stromal cells present differentiation and immunomodulatory capacities. The development of a rapid, inexpensive, and enzyme-free technique to isolate adipose-derived stromal cell–enriched stromal vascular fraction is a major goal for stem cell therapy. Therefore, the authors compared innovative mechanical procedures to the gold standard technique, collagenase digestion. Methods: Stromal vascular fraction was prepared from 21 liposuctions using either enzymatic digestion or two different mechanical methods: high vortexing/centrifugation and dissociation by intersyringe processing. The effects of tissue processing on cell count, viability, proliferation, clonogenic enrichment, and the phenotypes of the different native cell were determined. Adipose-derived stromal cell phenotypes from the different protocols, and their differentiation and immunosuppressive potential, were compared. Results: Enzymatic digestion isolated more viable cells than dissociation by intersyringe processing and vortexing/centrifugation. The expansion rate and clonogenic enrichment were higher for stromal vascular fraction isolated with collagenase. The proportion of adipose-derived stromal cells was higher in stromal vascular fraction extracted with dissociation than with enzymatic digestion and vortexing/centrifugation (p < 0.01). Interestingly, all cultured adipose-derived stromal cells displayed similar differentiation and immunosuppressive capacities. Conclusions: Enzymatic digestion extracts more adipose-derived stromal cells, but intersyringe dissociation enables the rapid extraction of adipose-derived stromal cell–enriched stromal vascular fraction. Moreover, mechanical methods enable adipose-derived stromal cell isolation with stemness and immunosuppressive properties, similar to enzymatic digestion. Such mechanical procedures could allow easier and more rapid isolation of adipose-derived stromal cell–enriched stromal vascular fraction for practitioners. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Latissimus dorsi flap invasion by ductal breast carcinoma after lipofilling.

Summary: Autologous fat grafting is commonly performed in reconstructive breast surgery but also increasingly in breast augmentation surgery. On the international level, we are witnessing an important increased confidence for this procedure. Nevertheless, it continues to raise questions on the risks of cancer. A 66-year-old patient benefited from a lipofilling to improve a latissimus dorsi flap breast reconstruction, 7 years after initial cancer management. Two years later, constant pain in the flap leads to reoperation. The flap showed a major retraction with histologically massive infiltration of the muscle by an undifferentiated carcinoma of breast origin. The tumor cells were displayed directly in contact with lipofilling inside the muscle. Without establishing any causal link between these 2 events, this case raises the question once more of the risks of breast cancer and encourages us to continue being careful.

Correction of Pectus Excavatum by Custom-Made Silicone Implants: Contribution of Computer-Aided Design Reconstruction. A 20-Year Experience and 401 Cases.

Background: In the absence of demonstrable functional impairment, pectus excavatum is merely a congenital deformity, albeit with a marked psychological impact. Many patients do not wish to undergo thoracic remodeling operations, which are invasive and do not clearly result in respiratory or cardiac improvement. Methods: From 1993 to 2015, the authors designed 401 custom-made silicone implants to treat funnel chests. Before 2007, implants were made from plaster chest molds. Beginning in 2007, three-dimensional reconstructions were made from computed tomographic scans by computer-aided design. The authors prospectively recorded all assessments and follow-up data since 1993. Preoperative and postoperative photographs of two random groups of 50 patients were analyzed, in a blinded manner, by two surgeons independently. Intraoperative and postoperative complications, clinical outcomes, patient satisfaction, and quality of life were evaluated. Results: One infection and three hematomas were recorded. Periprosthetic seroma was evident in all cases. Patients rated the cosmetic outcomes of computer-aided design implants significantly higher than those of the earlier implants made using plaster molds (p = 0.030). Malformations were better corrected in the computer-aided design group (86 percent) than in the plaster group (72 percent) (p = 0.038). Patient satisfaction was higher in the former group (p = 0.011). Medical Outcomes Study 36-Item Short-Form Health Survey scores revealed significant improvements, both socially and emotionally. Conclusions: Correction of pectus excavatum using a computer-aided design silicone implant fulfils aesthetic and psychological demands. The technique is simple and reliable and yields high-quality results. In the medium term, the approach may render invasive techniques obsolete. These operations remain risky and of doubtful functional utility. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Professional Burnout Among Plastic Surgery Residents: Can it be Prevented? Outcomes of a National Survey.

BackgroundPlastic surgery residencies require significant investments of time and psychological resources. We herein determine the prevalence of burnout syndrome among plastic surgery residents and identify potentially protective factors. MethodsA national cross-sectional study was conducted among French plastic surgery residents in March 2013. We distributed a validated measure of burnout (Maslach Burnout Inventory) in addition to a general questionnaire collecting sociodemographic and professional information. ResultsFifty-two residents (61%) responded; their mean age was 29 years. A total of 25% and 13.5% of residents scored highly on the depersonalization and high-level emotional exhaustion burnout subscales, respectively, and 48.1% indicated perceived low-level personal accomplishment. The occurrence of a weekly ward round by a senior surgeon (reported by 67.3% of respondents) appears to protect against burnout (P = 0.007); regular staff meetings in the unit (75% of respondents) were also protective because they limited depersonalization (P = 0.048) and promoted personal accomplishment (P = 0.031). The number of hours worked/week was not significantly associated with burnout. Despite these data, 69.2% reported satisfaction with their careers. ConclusionsAlmost one third of plastic surgery residents exhibited a high degree of burnout; the risks were increased by being in the early years of training, feeling dissatisfied with career plans, and working in units in which senior surgeons did not make weekly ward rounds and in which regular staff meetings, which offer the opportunity to discuss cases or problems with other professionals, were not scheduled. Burnout increases the risk of medical errors and suicide among residents. Therefore, we suggest that screening for burnout is essential.