Lester Silver

Locally Administered Vascular Endothelial Growth Factor cDNA Increases Survival of Ischemic Experimental Skin Flaps

&NA; Microvascular surgery has emerged as an attractive area for recent advances in the field of gene therapy. The present study investigated the survival of ischemic, experimental skin flaps after treatment with the gene encoding vascular endothelial growth factor (VEGF). In 30 Sprague‐Dawley rats, anterior abdominal skin flaps supplied by the epigastric artery and vein were created. Ten animals were treated with a mixture of liposomes and the cDNA encoding the 121‐amino acid isoform of VEGF. Another 10 animals were treated with control plasmid DNA and liposome transfection medium; a third group of 10 animals was given physiologic saline. Each solution was injected directly into the femoral artery distal to the origin of the epigastric pedicle supplying the flap. Four days after injection, the pedicle was ligated and blood flow in the flap was approximated using dye fluorescence. Seven days later, the amount of viable tissue within the flap was measured by planimetry. After the animals were killed, specimens from both the operated and nonoperated sides of the abdomen were harvested for immunohistologic evidence of VEGF protein expression. Average dye fluorescence indices of the three groups (VEGF cDNA, control plasmid, and saline) 2 hours after pedicle ligation were 35.9, 23.9, and 53.9 percent, respectively (p < 0.05). Compared with the two control groups, flaps receiving VEGF cDNA had significantly greater tissue viability at the end of 7 days: 93.9 versus 28.1 percent for the control plasmid DNA group and 31.9 percent for the saline group (p < 0.05). Immunohistochemical staining documented increased deposition of VEGF protein in flaps that were infused with the VEGF cDNA versus saline alone (p < 0.05). The results indicated that the survival of ischemic tissues can be enhanced by administration of a cDNA encoding VEGF, a protein known to be important in the process of angiogenesis and wound healing. (Plast. Reconstr. Surg. 102: 2033, 1998.)

Plastic surgical perspectives on vascular endothelial growth factor as gene therapy for angiogenesis.

The practice of plastic surgery has always remained at the frontier of medical science. Over the past few decades, this frontier has been marked by significant developments in the field of gene therapy. Gene therapy serves to replace, supplement, or manipulate a patients genetic makeup to restore function that has been lost or to correct function that is aberrant. Recent technology may allow surgeons to augment the processes of wound healing and angiogenesis by transfecting genes encoding desirable proteins, such as vascular endothelial factor (VEGF), into ischemic tissues. VEGF is a vital growth factor in the development of blood vessels. Although its mechanisms of action are numerous, its sole function seems to be the augmentation of angiogenesis. VEGF is active in growth and development, in wound healing, and in various pathologic conditions, such as psoriasis and rheumatoid arthritis. The role of VEGF in the field of plastic surgery is just beginning to be explored; it may someday prove to be very rewarding.

Measuring quality of life in cleft lip and palate patients: currently available patient-reported outcomes measures.

Background: Patient-reported outcomes in cleft lip and palate treatment are critical for patient care. Traditional surgical outcomes focused on objective measures, such as photographs, anatomic measurements, morbidity, and mortality. Although these remain important, they leave many questions unanswered. Surveys that include aesthetics, speech, functionality, self-image, and quality of life provide more thorough outcomes assessment. It is vital that reliable, valid, and comprehensive questionnaires are available to craniofacial surgeons. Methods: The authors performed a literature review to identify questionnaires validated in cleft lip and palate patients. Qualifying instruments were assessed for adherence to guidelines for development and validation by the scientific advisory committee and for content. Results: The authors identified 44 measures used in cleft lip and palate studies. After 15 ad hoc questionnaires, eight generic instruments, 11 psychiatric instruments, and one non-English language questionnaire were excluded, nine measures remained. Of these, four were never validated in the cleft population. Analysis revealed one craniofacial-specific measure (Youth Quality of Life–Facial Differences), two voice-related measures (Patient Voice–Related Quality of Life and Cleft Audit Protocol for Speech–Augmented), and two oral health–related measures (Child Oral Health Impact Profile and Child Oral Health Quality of Life). The Youth Quality of Life–Facial Differences, Child Oral Health Impact Profile, and Child Oral Health Quality of Life questionnaires were sufficiently validated. None was created specifically for clefts, resulting in content limitations. Conclusions: There is a lack of comprehensive, valid, and reliable questionnaires for cleft lip and palate surgery. For thorough assessment of satisfaction, further research to develop and validate cleft lip and palate surgery–specific instruments is needed.

Principles and practice of disaster relief: lessons from Haiti.

Disaster relief is an interdisciplinary field dealing with the organizational processes that help prepare for and carry out all emergency functions necessary to prevent, prepare for, respond to, and recover from emergencies and disasters caused by all hazards, whether natural, technological, or human-made. Although it is an important function of local and national governing in the developed countries, it is often wanting in resource-poor, developing countries where, increasingly, catastrophic disasters tend to occur and have the greatest adverse consequences. The devastating January 12, 2010, Haiti earthquake is a case study of the impact of an extreme cataclysm in one of the poorest and most unprepared settings imaginable. As such, it offers useful lessons that are applicable elsewhere in the developing world. Emergency preparedness includes 4 phases: mitigation or prevention, preparedness, response, and recovery. Periods of normalcy are the best times to develop disaster preparedness plans. In resource-poor countries, where dealing with the expenses of daily living is already a burden, such planning is often neglected; and, when disasters strike, it is often with great delay that the assistance from international community can be deployed. In this increasingly interconnected world, the Haiti earthquake and the important international response to it make a strong case for a more proactive intervention of the international community in all phases of emergency management in developing countries, including in mitigation and preparedness, and not just in response and recovery. Predisaster planning can maximize the results of the international assistance and decrease the human and material tolls of inevitable disasters. There should be a minimum standard of preparedness that every country has to maintain and the international assistance to achieve that. International academic medical centers interested in global health could strengthen their programs by prospectively including in them contingency planning for international relief operations. Healthcare professionals of these institutions who travel to disaster zones should rigorously prepare themselves and make provisions for collecting and reporting data, which will enrich the knowledge of this growing activity.

A survey of microvascular protocols for lower-extremity free tissue transfer I: perioperative anticoagulation.

Reconstruction of the lower extremity using free tissue transfer is performed throughout the country by numerous surgical teams. However, no established protocol exists for the use of anticoagulation in the perioperative period. The present study sought to analyze trends in current protocols regarding perioperative anticoagulation for lower-extremity free flap reconstruction. Members of the American Society of Plastic Surgeons were surveyed with regard to their preferences for perioperative anticoagulation in conjunction with lower-extremity free tissue transfer. The results demonstrated tremendous variability in both the agents used and therapeutic periods employed. They highlighted the absence of 1 or more common anticoagulation protocols and tried to establish common trends in the use of such agents.

A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care.

Due to the complex, and often tenuous nature of microsurgical tissue transfer, postoperative monitoring of free tissue flaps plays a vital role in the management of such patients. Some of the more challenging reconstructive problems occur in patients with lower extremity trauma, yet to date, no preferred protocol exists for the postoperative care of lower extremity free flaps. The present study sought to evaluate and assess current preferences in monitoring following lower extremity free tissue transfer. Members of the American Society of Plastic Surgeons (ASPS) were surveyed with regard to their choice for postoperative monitoring and return to dependent positioning (“dangling”). The results demonstrate that there is some agreement among surgeons regarding the optimal means for postoperative monitoring. Most rely on clinical observation in addition to conventional Doppler probe for an average of 4.8 days. Most surgeons follow their own flaps in addition to relying on the residents and nursing staff. The study also notes a wide variety in the times and frequencies at which dangling of the extremity was commenced. Most respondents initiate dangling within 2 weeks of surgery and begin with only 1 to 5 minutes per session.

Leadership trends in plastic surgery.

Background: The authors examined the recent trends in the composition, appointment, and turnover of chairpersons in academic plastic surgery. Methods: A survey regarding the characteristics of the current and former department chairpersons in plastic surgery was mailed to the 89 existing academic plastic surgery programs. The survey focused on the age, gender, subspecialty, interim tenure, and overall tenure of the two groups. Results: An initial response was received from 60 chairpersons. The majority of current chairpersons are male (81 of 89, 91 percent), which is slightly lower than the group of immediate past chairs, of whom 98 percent (87 of 89) were male. From the questionnaires, it was noted that for both the current and former groups of chairpersons, the 40- to 50-year age range was the most frequent age group at which an individual was appointed to that position. Approximately one-third (35.7 percent) of the current group consider themselves “general plastic surgeons.” This differs from their predecessors, of whom 56.0 percent reported the same designation. An increase in the promotion of existing faculty to chairpersons was also noted. As compared with 44.2 percent of the previous group, 69.5 percent of the current chairpersons were promoted from within the department. Conclusions: The population of academic chairpersons in plastic surgery is changing. Today, more chairpersons appear to be younger and specialty trained. Examining the history of academic leadership and identifying trends in any field of medicine can only help to better prepare the specialty for the future.

Congenital Midline Cervical Cleft

Congenital midline cervical cleft (CMCC) is a rare disorder of the ventral neck that is clinically evident at birth and must be differentiated from the more common thyroglossal duct cyst. The case of CMCC presented here was associated with chromosomes 13/14 de novo Robertsonian translocations as well as midline deformities including a sacral tuft and a minor tongue-tie. The case is presented as well as discussion of histopathology, embryology, and surgical treatment.

Cleft and Craniofacial Coding in ICD-10.

Objective With the gradual replacement of the ICD-9 coding system by the newer ICD-10 system, there is a need to critically evaluate how the system improves—or fails to improve—the coding of specific cleft and craniofacial anomalies. The following review examines the new system and the key components for practitioners who treat patients with such anomalies. Conclusions While seemingly beneficial in certain respects, the newer ICD-10 system remains far from ideal for cleft and craniofacial anomalies. With future iterations of the system, a more concerted effort to precisely code such anomalies is warranted, which will likely require input from key practitioners.

Hand abnormalities in the fetal hydantoin syndrome.

The fetal hydantoin syndrome exhibits a multisystem pattern of abnormalities including distal phalangeal hypoplasia, craniofacial malformations, mental retardation, and other defects occurring in some newborn infants exposed in utero to the hydantoin group of anticonvulsive drugs. Hand abnormalities serve as a warning signal of more severe associated anomalies.