Juliana E. Hansen

Identification of the familial cylindromatosis tumour-suppressor gene

Familial cylindromatosis is an autosomal dominant genetic predisposition to multiple tumours of the skin appendages. The susceptibility gene (CYLD) has previously been localized to chromosome 16q and has the genetic attributes of a tumour-suppressor gene (recessive oncogene). Here we have identified CYLD by detecting germline mutations in 21 cylindromatosis families and somatic mutations in 1 sporadic and 5 familial cylindromas. All mutations predict truncation or absence of the encoded protein. CYLD encodes three cytoskeletal-associated-protein–glycine-conserved (CAP–GLY) domains, which are found in proteins that coordinate the attachment of organelles to microtubules. CYLD also has sequence homology to the catalytic domain of ubiquitin carboxy-terminal hydrolases (UCH).

Analysis of complications from abdominoplasty: a review of 206 cases at a university hospital.

The number of abdominoplasties performed in the United States has been steadily increasing over the past decade. A large proportion of these patients are bariatric patients who remain obese despite prior weight-reduction surgery. This study was done to review the experience of patients undergoing abdominoplasty at a university hospital. A retrospective chart review of 206 consecutive patients was performed. The overall complication rate was 37.4%. Major complications [hematoma requiring surgical intervention, seroma requiring aspiration or surgical drainage, cellulitis or abscess requiring hospitalization and intravenous (IV) antibiotics, deep vein thrombosis (DVT), and pulmonary embolism (PE)] occurred in 16% of patients. The rate of minor complications (hematoma or seroma requiring no intervention, epidermolysis, small-wound dehiscence, neuropathic pain, and minor cellulitis) was 26.7%. Obese patients had a significantly increased risk of developing major complications as compared with nonobese patients (53.4% versus 28.8%, P = 0.001). An in-depth analysis of all complications and risk factors was done.

A Retrospective Analysis of Temporomandibular Joint Reconstruction With Free Fibula Microvascular Flap

Objectives The temporomandibular joint is occasionally encountered in extirpative surgery of the head and neck. It presents a difficult management issue. Little has been reported on functional outcomes after resection and reconstruction of the temporomandibular joint.

Integrated Plastic Surgery Residency Applicant Survey: Characteristics of Successful Applicants and Feedback about the Interview Process

Background: Integrated plastic surgery residency training is growing in popularity, bringing new challenges to program directors and applicants. The purpose of this study was to identify characteristics of successful applicants and to obtain feedback from applicants to improve the integrated plastic surgery residency training application and interview process. Methods: An anonymous survey assessing applicant academic qualifications, number of interviews offered and attended, and opinions about the application and interview process was distributed electronically to the 2006 integrated plastic surgery residency training applicant class. The number of interviews offered was used as an indicator of potential applicant success. Results: A 38 percent survey participation rate (139 of 367) was achieved. United States Medical Licensing Examination Step 1 score correlated with number of interview invitations (p ≤ 0.001). Successful Alpha Omega Alpha designation (p ≤ 0.001), high class rank (p = 0.034), presence of a plastic surgery residency program at the participant’s school (p = 0.026), and authorship of one or more publications (p ≤ 0.001) were associated with receiving greater number of interview invitations. Geographic location was an important consideration for applicants when applying to and ranking programs. Applicants desired interviews on weekdays and geographic coordination of interviews. Conclusions: Integrated plastic surgery residency training is highly competitive, with the number of interview invitations correlating with academic performance and, to a lesser extent, research. Applicant feedback from this survey can be used to improve the application and interview process.

Pursestring Closure of Radial Forearm Fasciocutaneous Donor Sites

Background The radial forearm fasciocutaneous free flap has become one of the most common methods of reconstructing defects after head and neck ablative surgery. The fasciocutaneous flap is an excellent replacement for the tissue that has been removed. Unfortunately, donor site morbidity remains a problem. Donor site morbidity is primarily related to poor skin graft take, cosmesis, and neural dysfunction. Decreasing the size of the donor site defect may allow for improved cosmesis with decreased morbidity.

A multicenter randomized controlled trial comparing absorbable barbed sutures versus conventional absorbable sutures for dermal closure in open surgical procedures.

BACKGROUND Barbed sutures were developed to reduce operative time and improve security of wound closure. OBJECTIVE The authors compare absorbable barbed sutures (V-Loc, Covidien, Mansfield, Massachusetts) with conventional (smooth) absorbable sutures for soft tissue approximation. METHOD A prospective multicenter randomized study comparing barbed sutures with smooth sutures was undertaken between August 13, 2009, and January 31, 2010, in 241 patients undergoing abdominoplasty, mastopexy, and reduction mammaplasty. Each patient received barbed sutures on 1 side of the body, with deep dermal sutures eliminated or reduced. Smooth sutures with deep dermal and subcuticular closure were used on the other side as a control. The primary endpoint was dermal closure time. Safety was assessed through adverse event reporting through a 12-week follow-up. RESULTS A total of 229 patients were ultimately treated (115 with slow-absorbing polymer and 114 with rapid-absorbing polymer). Mean dermal closure time was significantly quicker with the barbed suture compared with the smooth suture (12.0 vs 19.2 minutes; P<.001), primarily due to the need for fewer deep dermal sutures. The rapid-absorbing barbed suture showed a complication profile equivalent to the smooth suture, while the slow-absorbing barbed suture had a higher incidence of minor suture extrusion. CONCLUSIONS Barbed sutures enabled faster dermal closure quicker than smooth sutures, with a comparable complication profile. LEVEL OF EVIDENCE 1.

Professional burnout among US plastic surgeons: Results of a national survey

PurposeLittle is known about professional burnout among plastic surgeons. Our purpose is to describe its prevalence among a large national sample of plastic surgeons and identify contributing factors. MethodsA mailed, self-administered survey was sent to 708 plastic surgeons who were randomly sampled from the American Society of Plastic Surgeons national membership (71% response rate). The dependent variable was professional burnout, measured by 3 subscales from the validated Maslach Burnout Inventory-Human Services Survey. “High” scores in either the emotional exhaustion or depersonalization subscale categories predict professional burnout. The independent variables included surgeon sociodemographic and professional characteristics. &khgr;2 was used for the bivariate analyses. ResultsNearly one third (29%) of surgeons scored high in subscale categories predictive of professional burnout. Factors associated with high emotional exhaustion scores included surgeon age, 40–50 years (P = 0.03); fair/poor physician health (P < 0.01); ER call (P < 0.01); >60 work hours per week (P = 0.03); primarily reconstructive practice (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). Factors associated with high depersonalization scores included fair/poor physician health (P= 0.01); ER call (P < 0.01); private practice (P = 0.01); and group practice (P = 0.02). ConclusionsNearly one third of plastic surgeons have signs of professional burnout. Middle-aged surgeons and those in poor health are most at risk; along with those who have a reconstructive rather than cosmetic practice, long work hours, ER call responsibility, a nonacademic setting. and group as compared to solo practice. These data have important implications for future workforce shortages and health care quality.

Variance in the origin of the pectoralis major muscle: implications for implant-based breast reconstruction.

BackgroundThe pectoralis major muscle plays a crucial role in implant-based breast reconstruction. The goal of this study is to document variations of the origin of the pectoralis major muscle (PM). We hope to understand how many women have anatomy allowing for total submuscular coverage of an implant with the PM alone in immediate breast reconstruction. MethodsFifty patients undergoing mastectomy were recruited. Breast width and the costal origin of the natural inframammary fold (IMF) were measured preoperatively and intraoperatively. The PM width at its origin and the rib origin of the PM were measured intraoperatively. A ratio of the PM origin width to breast width was calculated. ResultsForty-four percent of breasts studied had the IMF at the level of the seventh rib, 53% at the sixth rib, and 3% at the fifth rib. Twenty percent of PM muscles originated from the seventh rib, 68% from the sixth rib, and 12% from the fifth rib. Thirty-six percent of chests showed a PM originating one rib level above the IMF, 61% at the same level, and 3% one level below the IMF. Seventy-seven percent of chests showed a PM origin width to breast width ratio of <0.8. ConclusionsOverall, 72% of chests had either a high origin of the PM, a narrow PM relative to the breast width, or both. This anatomy is suboptimal for implant coverage using the PM alone. Surgeons performing implant-based breast reconstruction should be prepared to utilize wide dissection, alternative muscle recruitment, or supplemental acellular dermal matrix.

Correlation of Breast Cancer Axillary Lymph Node Metastases With Stem Cell Mutations

IMPORTANCE Mutations in oncogenes AKT1, HRAS, and PIK3CA in breast cancers result in abnormal PI3K/Akt signaling and tumor proliferation. They occur in ductal carcinoma in situ, in breast cancers, and in breast cancer stem and progenitor cells (BCSCs). OBJECTIVES To determine if variability in clinical presentation at diagnosis correlates with PI3K/Akt mutations in BCSCs and provides an early prognostic indicator of increased progression and metastatic potential. DESIGN, SETTING, AND PARTICIPANTS Malignant (BCSCs) and benign stem cells were collected from fresh surgical specimens via cell sorting and tested for oncogene mutations in a university hospital surgical oncology research laboratory from 30 invasive ductal breast cancers (stages IA through IIIB). MAIN OUTCOMES AND MEASURES Presence of AKT1, HRAS, and PIK3CA mutations in BCSCs and their correlation with tumor mutations, pathologic tumor stage, tumor histologic grade, tumor hormone receptor status, lymph node metastases, and patient age and condition at the last follow-up contact. RESULTS Ten tumors had mutations in their BCSCs. In total, 9 tumors with BCSC mutations and 4 tumors with BCSCs without mutations had associated tumor present in the lymph nodes (P = .001). CONCLUSIONS AND RELEVANCE Tumors in which BCSCs have defects in PI3K/Akt signaling are significantly more likely to manifest nodal metastases. These oncogenic defects may be missed by gross molecular testing of the tumor and are markers of more aggressive breast cancer. Molecular profiling of BCSCs may identify patients who would likely benefit from PI3K/Akt inhibitors, which are being tested in clinical trials.

The Use of Microplates for Internal Fixation of Mandibular Fractures

BACKGROUND The use of microplates in mandible fractures is not widely accepted, although microplate systems are commonly used for treatment of maxillofacial fractures. This study evaluated the use of microplates for internal fixation of mandibular fractures with no comminution or bony defects. METHODS Thirty-five patients with mandibular fractures (26 double and nine single) were treated. Of the 61 fractures, 54 were stabilized using 0.55-mm-thick microplates and 1.2-mm monocortical microscrews. The fractures were exposed through either an intraoral or a percutaneous approach. In general, two-point fixation with two microplates or one microplate and wires was performed. Interdental wiring was added for symphyseal or body fractures to confer further stability onto the dental arch. No intermaxillary fixation was used. RESULTS During a follow-up period ranging from 3 to 29 months, all fractures showed complete bone healing. There were eight complications in seven patients with a double fracture, including mild malocclusion (n = 3), paresthesia (n = 3), asymptomatic delayed union (n = 1), and asymptomatic plate fracture (n = 1). No further orthodontic or surgical treatment was performed as a result of these complications. No other complications requiring further treatment occurred. There were three residual complications of mild malocclusion, paresthesia, and asymptomatic plate fracture at final follow-up. CONCLUSIONS These results indicate that two-point fixation with microplates is appropriate for the internal fixation of simple, isolated mandibular fractures. Its advantages include a high adaptability to the fracture site, occlusal self-adjustment, a minimal mass effect, and a relatively strong holding power of two-point fixation.