Kenneth L. Fan

Fat Grafting Versus Adipose-Derived Stem Cell Therapy: Distinguishing Indications, Techniques, and Outcomes

With adipose-derived stem cells (ASCs) at the forefront of research and potential clinical applications, it is important that clinicians be able to distinguish them from the fat grafting currently used clinically and to understand how the two approaches relate to one another. At times, there has been confusion in clinically considering the two therapies to be the same. This report is aimed at distinguishing clearly between fat grafting and ASC therapy with regard to the indications, harvesting, processing, application techniques, outcomes, and complications. Findings have shown that autologous fat transfer, a widely used procedure for soft tissue augmentation, is beneficial for reconstructive and cosmetic procedures used to treat patients with volume loss due to disease, trauma, congenital defects, or the natural process of aging. On the other hand, ASCs have been identified as an ideal source of cells for regenerative medicine, with the potential to serve as soft tissue therapy for irradiated, scarred, or chronic wounds. Recent advances in tissue engineering suggest that the supplementation of fat grafts with ASCs isolated in the stromal vascular fraction may increase the longevity and quality of the fat graft. Research suggests that ASC supplementation may be a great clinical tool in the future, but more data should be acquired before clinical applications.

Materials Used for Reconstruction After Orbital Floor Fracture

AbstractAdvances in biotechnology continue to introduce new materials for reconstruction of orbital floor fractures. Which material is best fit for orbital floor reconstruction has been a controversial topic. Individual surgeon preferences have been supported by inconsistent inconclusive data. The purpose of this study was to assess and analyze published evidence supporting various materials used for orbital floor reconstruction and to develop a decision-making algorithm for clinical application. A systematic literature review was performed from which 48 studies were selected after primary and secondary screening based on set inclusion and exclusion criteria. This cumulatively included 3475 separate orbital floor reconstructions. Results revealed risk and benefit profiles for all materials. Autologous calvarial bone grafts, porous polyethylene, and polydioxanone (PDS) were most widely used for orbital floor reconstruction. Increased infection rates were reported with polyglactin 910/PDS composites and silastic rubber. Ocular motility was reduced most with lyophilized dura and PDS. Preoperative and postoperative rates for diplopia and enophthalmos varied among the materials. In conclusion, our results revealed continued inadequate evidence to exclusively support the use of any one biomaterial/implant for orbital floor reconstruction. Results have served to create a decision-making algorithm for clinical application. Our authors propose certain parameters for future studies seeking to demonstrate a comparison between 2 or more materials for orbital floor reconstruction.

State of the art in topical wound-healing products

Summary: Chronic wounds represent a significant medical burden. Such wounds fail to normally progress through the stages of healing, often complicated by a proinflammatory milieu caused by increased proteinases, hypoxia, and bacterial burden. As a result, several modalities, such as dressings, antimicrobials, growth factors, and human skin substitutes, have been devised in an attempt to correct the chronic wound environment. This review addresses these modalities with a focus on evidence and randomized controlled trials.

Incidence of concomitant airway anomalies when using the university of California, Los Angeles, protocol for neonatal mandibular distraction.

Background: In newborns with micrognathia and severe upper airway obstruction, understanding potential airway lesions is important for determining appropriate treatment: observation, mandibular distraction, or tracheostomy. When concomitant airway anomalies are present, mandibular distraction is often unsuccessful at alleviating causes of obstruction, mandating the need for tracheostomy. The first part of this study evaluates 10-year results using the University of California, Los Angeles, algorithm for surgical candidacy to identify patients who will benefit from neonatal mandibular distraction. The second part describes the concomitant airway abnormalities found at the time of diagnostic laryngoscopy/bronchoscopy and how these anomalies affect neonatal distraction candidacy of these patients. Methods: Newborns admitted to the neonatal intensive care unit with micrognathia and upper airway obstruction (n = 133) were subjected to a decision tree model protocol formulated by a multidisciplinary team at the University of California, Los Angeles, to decide on appropriate treatment. Concomitant airway abnormalities were recorded and outcomes were documented for the first 5 years of life. Results: Fifty-five percent of patients underwent internal mandibular distraction with 97 percent success. Home observation with a nasopharyngeal tube was chosen in 11 percent of patients, and 34 percent had tracheostomies. On endoscopic examination, 51.7 percent of the nondistracted patients had concomitant airway anomalies: laryngomalacia (53.3 percent), tracheal web (20.0 percent), vocal cord paralysis (13.3 percent), epiglottal collapse (6.7 percent), and infraglottal narrowing (6.7 percent). Conclusions: For the management of neonatal upper airway obstruction with micrognathia, a decision tree algorithm is useful to determine candidates for mandibular distraction. Diagnostic laryngoscopy/bronchoscopy is an important component of this algorithm because a multitude of airway anomalies may be present. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Autologous Fat Transplantation in the Craniofacial Patient: The UCLA Experience

Abstract Patients with congenital craniofacial malformations present with complex challenges for reconstruction. Successful management requires individualized treatment often involving rebuilding the facial skeleton de novo, as well as correcting the overlying soft-tissue deficiencies in the final stages. At the University of California, Los Angeles (UCLA) Craniofacial Clinic, serial autologous fat transplantation performed during staged reconstruction is the preferred method. A total of 27 patients with a diagnosis of either craniofacial microsomia/Goldenhar (CM) (n = 19) or Treacher Collins syndrome (TC) (n = 8) were treated at the UCLA Craniofacial Clinic by autologous fat transfer between July 1999 and February 2009. Two-dimensional analysis was conducted on standardized preoperative and postoperative photographs to determine facial symmetry for every patient. Results was grouped based on pathology and analyzed by comparing adipocyte donor site (abdomen vs other). The mean ages at the time of first fat transfer were 17 years for the CM group and 15 years for the TC group. The average numbers of fat transfers per patient were 2.05 (CM) and 2.12 (TC). A mean of 3.74 procedures other than fat grafting was performed in each CM patient, whereas 4.38 other procedures were performed in each TC patient. In CM patients, less than 10.5 months between procedures resulted in improved symmetry. There was an average 6.63% improvement in facial symmetry in the CM group, and a 7.67% improvement in the TC group. Based on the UCLA experience, the durability of facial asymmetry and contour correction with fat transplantation is attainable in the craniofacial patient but may also require concomitant skeletal correction in the most severe cases.

Cochlear implantation in common forms of genetic deafness.

Genetic factors are among the main etiologies of severe to profound hearing loss and may play an important role in cochlear implantation (CI) outcomes. While genes for common forms of deafness have been cloned, efforts to correlate the functional outcome of CIs with a genetic form of deafness carried by the patient have been largely anecdotal to date. It has been suggested that the differences in auditory performance may be explained by differences in the number of surviving spiral ganglion cells, etiology of hearing loss, and other factors. Knowledge of the specific loci and mutations involved in patients who receive cochlear implants may elucidate other factors related to CI performance. In this review article, current knowledge of cochlear implants for hereditary hearing loss will be discussed with an emphasis on relevant clinical genotype-phenotype correlations.

Evaluation of plastic surgery training programs: integrated/combined versus independent.

Background: The authors aimed to differentiate between combined/integrated and independent (traditional) methods of plastic surgery training with regard to quality of trainees, caliber of graduates, and practice or career outcomes once graduated. Methods: To compare combined/integrated with independent residency program training, the authors conducted a Web-based survey of the American Society of Plastic Surgeons members looking at their experience and practice outcomes (n = 1056) and interviews of plastic surgery faculty looking at the quality of trainees (n = 72). The member survey evaluated background information, research credentials, pathway satisfaction, postgraduation activities, current practice, and academic affiliation. Faculty teacher interviews focused on knowledge base, diagnostic and treatment judgment, technical abilities, research capabilities, and prediction of future career success. Results: The member survey showed no difference (p > 0.05) between combined/integrated and independent trainees in practice type (cosmetic/reconstructive), practice volume, or academic achievements. Combined/integrated trained surgeons are three times more likely to recommend their training pathway and two times more likely to enter fellowship after residency. Alpha Omega Alpha Honor Medical Society membership correlated with a greater likelihood of having an academic practice at 5 and 10 years or more and higher professorship titles. Faculty evaluations showed that combined/integrated residents were superior in knowledge (49 percent versus 32 percent) but that independent residents were superior in technical ability (51 percent versus 20 percent) and research (57 percent versus 19 percent). Most faculty were unable to choose a pathway producing superior residents. Conclusions: Regarding future practice outcomes, there was not a superior training pathway. Regarding quality of trainees, there were differences in faculty evaluations, but there was no consensus on a better pathway.

The Inverted-V Chevron Umbilicoplasty for Breast Reconstruction and Abdominoplasty

The umbilicoplasty is a key component of abdominoplasty and closure of autologous abdominal wall donor sites in breast reconstruction (TRAM/DIEP). The aesthetically-pleasing umbilicus tends to be small and vertically-oriented in nature, with superior hooding and shadow, inferior retraction and slope, and positioning at the topmost level of the iliac crest. In this Featured Operative Technique, the authors describe their technique for performing an inverted-V chevron umbilicoplasty, which is their method of choice for restoring the umbilicus to an aesthetic and youthful appearance with minimal scarring.

Microvascular autologous breast reconstruction in the context of radiation therapy: comparing two reconstructive algorithms.

Background: When postmastectomy radiation therapy is anticipated, delaying autologous reconstruction prevents radiation delivery issues and radiation-induced contour irregularities. Delayed-immediate autologous breast reconstruction may allow for maintenance of the breast skin envelope as compared with delayed reconstruction with the temporary insertion of a tissue expander. The authors compared perioperative complications and revision surgery rates of comparative cohorts to determine which method is preferable. Methods: Delayed-immediate reconstruction was defined as placement of a temporary tissue expander in the first stage at the time of mastectomy before flap reconstruction, which occurred following postmastectomy radiation therapy. Delayed reconstruction was categorized as mastectomy with primary closure in the first stage followed by flap reconstruction. Results: One hundred fifty-two patients and 192 breasts met the study criteria for this retrospective review (delayed reconstruction, 118 breasts; delayed-immediate autologous breast reconstruction, 74 breasts). Patient age and body mass index were similar between groups (p > 0.05). Perioperative first-stage complication rates were 8.5 percent in the delayed group and 10.8 percent in the delayed-immediate cohort (p = 0.81). Total flap loss (2.5 versus 4.1 percent; p = 0.68) and arterial (1.7 versus 1.4 percent; p = 0.82) and venous (4.3 versus 5.4 percent; p = 0.73) anastomotic revision rates were similar between the cohorts, respectively. Reoperative surgery occurred in 11.9 percent versus 9.6 percent in the delayed and delayed-immediate cohorts, respectively (p = 0.69). Conclusions: In comparing two treatment algorithms, flap-related complication rates are comparable. First-stage surgery results in a slightly increased complication rate in the delayed-immediate cohort. Improved overall results with delayed-immediate reconstruction are implied, given significantly decreased rates of revision surgery following flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Optimizing the timing and technique of Treacher Collins orbital malar reconstruction.

AbstractThe optimal timing and treatment of Treacher Collins syndrome with regard to zygomatico-orbital osseous reconstruction has not been fully established. Osseous reconstruction performed at an early age may result in bone graft resorption; however, delays in surgical improvement may result in adverse psychosocial effects on the patient. To study the optimal age for reconstruction clinically, we examined 3 age groups based on timing of malar and eyelid reconstruction using a three-dimensional computed tomographic scan and three-dimensional photometric volume assessment. In addition, we collected outcome assessments from parents/patients using satisfaction surveys. Of 73 patients with Treacher Collins at the University of California Los Angeles Craniofacial Clinic, 45 had malar reconstruction, complete records, and were available for study. The patients were separated into 3 groups: (1) very young = 0 to 5 years, (2) mid-childhood = 6 to 12 years, and (3) adolescent/adult 13 years and older. As hypothesized, the 0 to 5 age group experienced the greatest percentage of complete bony resorption (77%) compared with the 6 to 12 age group (only 4%) and the 13 and older age group (0%). Interestingly, the 0 to 5 age group experienced the highest parent/patient satisfaction, possibly owing to better psychosocial experience. When dealing with treatment plans for patients with Treacher Collins, patients, parents, and physicians must balance the benefits of early surgical intervention, such as improved psychologic well-being, with the disadvantages of having to undergo a greater number of procedures, such as fat grafting after malar bone graft resorption.