Ivona Percec

Successful prosthetic breast reconstruction after radiation therapy.

Radiation has been considered a relative contraindication to prosthetic breast reconstruction. While this dogma has been challenged by recent reports, the data on radiation and immediate prosthetic reconstruction remain contradictory. We performed a controlled retrospective review of one surgeons 7-year experience with 21 irradiated patients who underwent tissue expander/implant breast reconstruction. When compared with nonirradiated patients, irradiated patients experienced a higher rate of seroma formation, infection, delayed healing, implant exposure, and systemic complications. The rate of capsular contracture, while significantly higher in the irradiated group, was comprised mostly of mild to moderate capsules. Hematoma formation, implant rupture, and operative revision rates were similar between the 2 groups and complication rates among irradiated patients remained overall low. This study supports prosthetic reconstruction as a reasonable option for many radiation patients. Although irradiated patients remain at higher risk for complications, overall complication rates are low and rates of successful reconstruction are high.

Fat Grafting’s Past, Present, and Future: Why Adipose Tissue Is Emerging as a Critical Link to the Advancement of Regenerative Medicine

Fat grafting is a common reconstructive and aesthetic procedure with extensive clinical applications. Recently, significant strides have been made in investigating the biology behind the success of this procedure. Surgeons and scientists alike have advanced this field by innovating fat graft harvesting and injection techniques, expanding the use of adipose tissue and its stem cell components, and broadening our understanding of the viability of fat grafting at the molecular and cellular levels. The objectives of this review are to (1) discuss the clinical applications of fat grafting, (2) describe the cellular biology of fat and the optimization of fat graft preparation, (3) illustrate the significance of adipose-derived stem cells and the potentiality of fat cells, (4) highlight the clinical uses of adipose-derived stem cells, and (5) explore the current and future frontiers of the study of fat grafting. Although collaborative knowledge has increased exponentially, many of the biological mechanisms behind fat grafting are still unknown. Plastic surgeons are in a unique position to pioneer both the scientific and clinical frontiers of fat grafting and to ultimately further this technology for the benefit of our patients.

Expression-based assay of an X-linked gene to examine effects of the X-controlling element (Xce) locus

Through an incompletely understood process, one of the two X chromosomes (Chrs) in mammalian XX female cells is inactivated, thereby achieving dosage equivalence with XY males (Lyon 1961). Studies of X;autosome translocations and of chromosomally abnormal embryos suggest that trans-acting autosomal factors interact with cis-acting X-linked elements to “choose” one X to remain active; all additional X Chrs subsequently undergo X inactivation (Russell 1963; Lyon 1971; Rastan 1983). Despite the expected complexity of these events, thus far only two genetic loci, the X-controlling element (Xce) locus (Cattanach and Isaacson 1967) and the Xist gene (Brockdorff et al. 1991; Brown et al. 1991), are known to influence this process (reviewed in Brockdorff and Duthie 1998; Carrel and Willard 1998; Goto and Monk 1998; Panning and Jaenisch 1998). The Xce locus influences the choice process such that there is an equal probability that either parental X Chr will be inactivated in Xce homozygotes, whereas one parental X is preferentially inactivated in Xce heterozygotes (Cattanach and Isaacson 1967). The relative strengths of the known Xce alleles are Xce < Xce < Xce, with an X carrying the stronger allele demonstrating an increased probability of being the active X (Cattanach et al. 1969; Cattanach and Williams 1972; Johnston and Cattanach 1981). Xce allele strength was originally defined and has primarily been assayed by counting vibrissae in mice heterozygous for an X-linked mutation, Tabby, which affects vibrissae number (Cattanach et al. 1969). Alternative assays have examined protein polymorphisms (West and Chapman 1978), chromosomal markers (Nesbitt and Gartler 1970; Kanda 1973), gene expression (Singer-Sam et al. 1992; Buzin et al. 1994; Avner et al. 1998), or DNA methylation patterns (Courtier et al. 1995; Avner et al. 1998) as a measure or correlate of Xce allele strength. Using these assays, the Xce alleles of several inbred strains have been reported as Xce (CBA/H, C3H/HeH, and BALB/cH), Xce (C57BL/6H and DBA/2H), and Xce-like (CAST/Ei) (Cattanach et al. 1969; West and Chapman 1978; Johnston and Cattanach 1981; Cattanach and Rasberry 1991, 1994). The AKR/H Xce allele has been reported to be intermediate between Xce and Xce (Fowlis et al. 1991), although rigorous Xce typing has not been performed in this strain. Xist is a key gene in the X inactivation pathway. Both knockout and transgenic studies have shown that Xist expression, in the correct developmental context, is both necessary and sufficient for X inactivation (Lee et al. 1996; Penny et al. 1996; Herzing et al. 1997; Marahrens et al. 1997; Clerc and Avner 1998). While Xist itself may be the inactivation signal, additional developmentally regulated factors appear to be required for X inactivation (Panning et al. 1997; Sheardown et al. 1997; Clemson et al. 1998; Hansen et al. 1998; Tinker and Brown 1998). Mutations in or including the Xist gene cause preferential inactivation of one parental X Chr in both the mouse (Clerc and Avner 1998; Marahrens et al. 1998) and human (Plenge et al. 1997), implying that it is involved in the choice process (Carrel and Willard 1998). Xce appears to map close to, but downstream of, the Xist gene itself (Simmler et al. 1993). It is unclear how (or whether) the two loci interact to control the choice process, although recent work has focused on a series of differentially methylated repeated sequences downstream of the Xist gene as a possible candidate for Xce (Courtier et al. 1995; Avner et al. 1998). Further, an antisense transcript, termed Tsix, which initiates in this region and continues through the Xist locus on the opposite strand, has been proposed to be an antisense regulator of Xist (Lee and Lu 1999). Targeted deletions downstream of Xist suggest that this region is also involved in the choice process (Clerc and Avner 1998; Lee and Lu 1999). As a necessary prelude to attempts to define further the role of these loci and to search for additional factors in the X inactivation pathway, a robust assay is needed to measure and quantify X inactivation patterns early in embryogenesis. One useful approach is to measure the proportion of cells expressing alleles from one or the other X Chr (i.e., the X Chr inactivation pattern) in adult somatic cells. Current assays, however, are limited by their inability to detect subtle differences in X inactivation patterns or by insufficient throughput necessary for large-scale screens (Cattanach and Isaacson 1967; Cattanach et al. 1969; Nesbitt and Gartler 1970; Cattanach and Williams 1972; Kanda 1973; West and Chapman 1978; Singer-Sam et al. 1992). Although several expression-based assays have been developed (e.g., Singer-Sam et al. 1992; Buzin et al. 1994; Avner et al. 1998), limited characterization of relative Xce allele strength has been performed at the level of transcription or RNA abundance. To overcome these limitations and to further characterize the Xce locus, we have developed a quantitative assay that measures allele-specific RNA levels of a ubiquitously expressed gene subject to X Chr inactivation, Pctk (Carrel et al. 1996). Our data establish the Pctk X inactivation assay as a quantitative expression-based assay to measure X inactivation patterns in the mouse and provide the foundation for future experiments to search for additional X inactivation genes.

Influence of Surgical and Minimally Invasive Facial Cosmetic Procedures on Psychosocial Outcomes A Systematic Review

IMPORTANCE Millions of surgical and minimally invasive cosmetic procedures of the face are performed each year, but objective clinical measures that evaluate surgical procedures, such as complication rates, have limited utility when applied to cosmetic procedures. While there may be subjective improvements in appearance, it is important to determine if these interventions have an impact on patients in other realms such as psychosocial functioning. This is particularly important in light of the Patient Protection and Affordable Care Act and its emphasis on patient-centered outcomes and effectiveness. OBJECTIVES To review the literature investigating the impact of facial cosmetic surgery and minimally invasive procedures on relevant psychological variables to guide clinical practice and set norms for clinical performance. EVIDENCE REVIEW English-language randomized clinical trials and prospective cohort studies that preoperatively and postoperatively assessed psychological variables in at least 10 patients seeking surgical or minimally invasive cosmetic procedures of the face. FINDINGS Only 1 study investigating minimally invasive procedures was identified. Most studies reported modest improvement in psychosocial functioning, which included quality of life, self-esteem, and body image. Unfortunately, the overall quality of evidence is limited owing to an absence of control groups, short follow-up periods, or loss to follow-up. CONCLUSIONS AND RELEVANCE The current literature suggests that a number of psychosocial domains may improve following facial cosmetic surgery, although the quality of this evidence is limited (grade of recommendation 2A). Despite the dramatic rise in nonsurgical cosmetic procedures, there is a paucity of information regarding the impact of chemodenervation and soft-tissue augmentation on psychosocial functioning.

Successful Isolation of Viable Adipose-Derived Stem Cells from Human Adipose Tissue Subject to Long-Term Cryopreservation: Positive Implications for Adult Stem Cell-Based Therapeutics in Patients of Advanced Age

We examined cell isolation, viability, and growth in adipose-derived stem cells harvested from whole adipose tissue subject to different cryopreservation lengths (2–1159 days) from patients of varying ages (26–62 years). Subcutaneous abdominal adipose tissue was excised during abdominoplasties and was cryopreserved. The viability and number of adipose-derived stem cells isolated were measured after initial isolation and after 9, 18, and 28 days of growth. Data were analyzed with respect to cryopreservation duration and patient age. Significantly more viable cells were initially isolated from tissue cryopreserved <1 year than from tissue cryopreserved >2 years, irrespective of patient age. However, this difference did not persist with continued growth and there were no significant differences in cell viability or growth at subsequent time points with respect to cryopreservation duration or patient age. Mesenchymal stem cell markers were maintained in all cohorts tested throughout the duration of the study. Consequently, longer cryopreservation negatively impacts initial live adipose-derived stem cell isolation; however, this effect is neutralized with continued cell growth. Patient age does not significantly impact stem cell isolation, viability, or growth. Cryopreservation of adipose tissue is an effective long-term banking method for isolation of adipose-derived stem cells in patients of varying ages.

The Fountain of Stem Cell-Based Youth? Online Portrayals of Anti-Aging Stem Cell Technologies

BACKGROUND The hype surrounding stem cell science has created a market opportunity for the cosmetic industry. Cosmetic and anti-aging products and treatments that make claims regarding stem cell technology are increasingly popular, despite a lack of evidence for safety and efficacy of such products. OBJECTIVES This study explores how stem cell-based products and services are portrayed to the public through online sources, in order to gain insight into the key messages available to consumers. METHODS A content analysis of 100 web pages was conducted to examine the portrayals of stem cell-based cosmetic and anti-aging products and treatments. A qualitative discourse analysis of one web page further examined how language contributes to the portrayals of these products and treatments to public audiences. RESULTS The majority of web pages portrayed stem cell-based products as ready for public use. Very few web pages substantiated claims with scientific evidence, and even fewer mentioned any risks or limitations associated with stem cell science. The discourse analysis revealed that the framing and use of metaphor obscures the certainty of the efficacy of and length of time for stem cell-based anti-aging technology to be publicly available. CONCLUSIONS This study highlights the need to educate patients and the public on the current limits of stem cell applications in this context. In addition, generating scientific evidence for stem cell-based anti-aging and aesthetic applications is needed for optimizing benefits and minimizing adverse effects for the public. Having more evidence on efficacy and risks will help to protect patients who are eagerly seeking out these treatments.

Digital image correlation: a novel dynamic three-dimensional imaging technique for precise quantification of the dynamic rhytid and botulinum toxin type a efficacy.

Background: Quantification of facial dynamic motion is paramount for improving cosmetic and reconstructive surgical outcomes. The authors introduce digital image correlation using speckle tracking photogrammetry and Aramis software (GOM mbH, Braunschweig, Germany) to study facial dynamics and demonstrate its application in quantifying botulinum toxin efficacy. Methods: Fourteen subjects were evaluated using a dual camera system and three-dimensional optical analysis. Using Aramis software, the anatomic regions of the glabella, forehead, and total face were identified and highlighted. Tissue strain, defined as either compression or stretch, was measured within these regions over 36 frames during brow furrowing. Each patient was measured before and 2 weeks after injection of 20 units of onabotulinumtoxinA in the glabella. Average stretch and compression in treated areas were analyzed across all available frames. Results were compared using a Wilcoxon signed rank test. Results: After neurotoxin injection, average vertical stretch of the glabella during brow furrowing decreased from 2.51 percent to 1.15 percent (p < 0.05), and average vertical stretch in the forehead decreased from 6.73 percent to 1.67 percent (p < 0.05). Horizontal compression in the glabella decreased from 9.11 percent to 2.60 percent (p < 0.05) and from 4.83 percent to 0.83 percent (p < 0.05) in the forehead. Total facial major strain decreased from 4.41 percent to 3.05 percent (p < 0.05), and total facial minor strain decreased from 5.01 percent to 3.51 percent (p < 0.05). Conclusions: The authors introduce digital image correlation as a novel technology for measuring dynamic rhytid and neurotoxin efficacy. This technique allows for advancements in the study of dynamic aging and neuromuscular disorders. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, II.

Female Genital Mutilation Reconstruction: A Preliminary Report

Background Female genital mutilation (FGM) is internationally recognized as a violation of human rights. Though rarely discussed, FGM is prevalent, affecting hundreds of millions of females worldwide. Objectives We believe that is important for plastic surgeons to be informed and prepared to address the surgical and emotional needs of these women. We present our experience on treatment of women subjected to FGM. Methods Three consecutive patients were treated by our clitoral restoration procedure. The procedure involves conscious sedation and involves wide release of scar tissue around the labia majora and clitoris. Labial flaps are elevated and secured down to the periosteum and the clitoris is allowed to remucosalize. Results Three females with grade II mutilation were treated. The average age was 32.3-years-old and the average follow up was 305 days. All patients self-reported improved sexual function and decreased embarrassment with their partners. And all recommended the treatment to other women subjected to FGM. Conclusions FGM is a violation of the basic rights of women and children. Plastic surgeons can help these women restore their physical and psychological sense of well-being by providing effective reconstructive options. Our goal is to raise awareness of this problem and describe a simple yet effective treatment for women that have been subject to FGM. Level of Evidence 5.

Current Applications of Facial Volumization with Fillers.

Learning Objectives: After reading this article and watching the accompanying videos, the participant should be able to: 1. Assess patients seeking facial volumization and correlate volume deficiencies anatomically. 2. Identify appropriate fillers based on rheologic properties and anatomical needs. 3. Recognize poor candidates for facial volumization. 4. Recognize and treat filler-related side effects and complications. Summary: Facial volumization is widely applied for minimally invasive facial rejuvenation both as a solitary means and in conjunction with surgical correction. Appropriate facial volumization is dependent on patient characteristics, consistent longitudinal anatomical changes, and qualities of fillers available. In this article, anatomical changes seen with aging are illustrated, appropriate techniques for facial volumization are described in the setting of correct filler selection, and potential complications are addressed.

Quantified Facial Soft-tissue Strain in Animation Measured by Real-time Dynamic 3-Dimensional Imaging.

Background: The aim of this study is to evaluate and quantify dynamic soft-tissue strain in the human face using real-time 3-dimensional imaging technology. Methods: Thirteen subjects (8 women, 5 men) between the ages of 18 and 70 were imaged using a dual-camera system and 3-dimensional optical analysis (ARAMIS, Trilion Quality Systems, Pa.). Each subject was imaged at rest and with the following facial expressions: (1) smile, (2) laughter, (3) surprise, (4) anger, (5) grimace, and (6) pursed lips. The facial strains defining stretch and compression were computed for each subject and compared. Results: The areas of greatest strain were localized to the midface and lower face for all expressions. Subjects over the age of 40 had a statistically significant increase in stretch in the perioral region while lip pursing compared with subjects under the age of 40 (58.4% vs 33.8%, P = 0.015). When specific components of lip pursing were analyzed, there was a significantly greater degree of stretch in the nasolabial fold region in subjects over 40 compared with those under 40 (61.6% vs 32.9%, P = 0.007). Furthermore, we observed a greater degree of asymmetry of strain in the nasolabial fold region in the older age group (18.4% vs 5.4%, P = 0.03). Conclusions: This pilot study illustrates that the face can be objectively and quantitatively evaluated using dynamic major strain analysis. The technology of 3-dimensional optical imaging can be used to advance our understanding of facial soft-tissue dynamics and the effects of animation on facial strain over time.