Lloyd A. Hoffman

The use of fibrin sealant in the prevention of seromas.

&NA; Seroma formation is a difficult problem to treat and prevent. Its sequelae include wound infection, dehiscence, and skin‐flap necrosis. The purpose of this study was to determine the effects of fibrin sealant on seroma formation and wound healing. Seromas were created in a rat model by harvesting the latissimus dorsi muscle. In group I (n = 20), only the latissimus dorsi muscle was harvested. In group II (n = 20), the latissimus dorsi muscle was harvested and fibrin sealant applied. Seromas were routinely aspirated. In group III (n = 20), the latissimus dorsi muscle was harvested, and once a seroma was evident clinically, it was aspirated and injected with fibrin sealant. Fibrin sealant was created by combining virally deactivated fibrinogen and thrombin (American Red Cross, Rockville, Md.). In group I, 90 percent of the animals formed seromas compared with only 20 percent in group II. The average total fluid aspirated in group I was 21 cc versus 6 cc in group II. Sixty percent of the animals in group I and 5 percent in group II required serial drainage for chronic seromas. Skin‐flap necrosis occurred in 80 percent of the animals in group I, in 10 percent of group II, and in 40 percent of group III. Histologic evaluation confirmed that group II underwent better wound healing. At necropsy, group I animals with seromas had gross capsular formation; this was not readily apparent in the fibrin sealant groups. We conclude that (1) the harvesting of the rat latissimus dorsi muscle is a reliable model for creating seromas, (2) fibrin sealant effectively prevents seroma formation when applied intraoperatively, (3) wound healing in the seroma rat model is improved with intraoperative fibrin sealant application, (4) closed injection of fibrin sealant for existing seromas cannot be recommended at this time, (5) virally deactivated fibrin sealant retains its hemostatic and adhesive properties, and (6) current clinical trials of virally deactivated fibrin sealant may facilitate its use in the United States. (Plast. Reconstr. Surg. 99: 842, 1997.)

The role of the cranial base in facial growth : Experimental craniofacial synostosis in the rabbit

Craniofacial synostosis designates premature fusion in sutures of the cranial vault (calvarium). When craniofacial synostosis is associated with a syndrome (e.g., Apert, Crouzon), premature fusion of the cranial base has been postulated to occur as well. This study was designed to determine whether the primary growth disturbance in craniofacial synostosis is located at the cranial base (i.e., spheno-occipital synchondrosis) or the calvarial vault (i.e., coronal and sagittal sutures) or both. Sixty newborn New Zealand White rabbits were randomly assigned to six groups: (I) calvarial control, (II) cranial base control, (III) cranial base immobilization, (IV) coronal suture immobilization, (V) coronal and sagittal suture immobilization, and (VI) cranial base and coronal and sagittal suture immobilization. An anterior cervical microsurgical approach to the cranial base was used, while cranial vault sutures were exposed through a bicoronal scalp incision. All sutures were fused by periosteal abrasion and application of methyl cyanoacrylate. Cephalograms were taken at 30, 60, and 90 days postoperatively to assess craniofacial growth. Linear and angular measurements of facial, calvarial, and basicranial growth were subjected to multivariate analysis. Analysis indicated that (1) craniofacial length was shortened most significantly by cranial base fusion, (2) cranial base fusion and cranial vault fusion had an additive effect on craniofacial length restriction, (3) the anterior cranial base was significantly shortened by cranial base and cranial vault fusion (p < 0.05), (4) the posterior cranial base was shortened by cranial base fusion only (p < 0.05), and (5) cranial base fusion alone significantly flattened the cranial base angle (p < 0.05), whereas cranial vault fusion alone did not. These results suggest that cranial base fusion alone may account for many dysmorphic features seen in craniofacial synostosis. This model is consistent with the findings of other investigators and confirms both a primary directive and translational role of the cranial base in craniofacial growth.

Intestinal perforation after suction lipoplasty: a case report and review of the literature.

Intrabdominal penetration with intestinal perforation is a relatively uncommon complication after liposuction. Seven cases have been reported in the literature, with a mortality rate >50%. Here we present a case of a perforated viscus after suction lipoplasty of the abdomen using the tumescent technique. Multiple small-bowel enterotomies were made with the suction cannula. It is our hope that a heightened awareness of this potentially life-threatening complication will promote early and aggressive diagnosis and treatment of liposuction patients who present with gastrointestinal complaints in the early postoperative period.

Facial atrophy in HIV-related fat redistribution syndrome: anatomic evaluation and surgical reconstruction.

The use of highly active antiretroviral therapy (HAART) with protease inhibitors can result in a syndrome of peripheral wasting, facial fat atrophy, and central adiposity in as many as 64% of patients infected with human immunodeficiency virus (HIV) who are treated with this regimen for 1 year. In this study the authors evaluated 9 consecutive patients who presented with this disease to define further its anatomic features and to explore techniques for surgical correction. Three of these patients presented with severe facial atrophy, and underwent surgical exploration and reconstruction with submalar silicone implants. Two patients required additional soft-tissue augmentation with synthetic fillers and/or autologous fat. Outcomes were determined through clinical impressions of the patient and surgeons, and comparison of pre- and postoperative photographs. No extrusion or infection was encountered, although 1 patient required repositioning on one side. Both surgeons and patients were satisfied with the results at the long-term follow-up. Detailed anatomic evaluation revealed the presence of a fat pad of Bichat in all patients. Facial atrophy in HIV-related fat redistribution syndrome (HARS) is secondary to atrophy of the subcutaneous fat, but not of the deeper fat pads, as has been described. Durable surgical reconstruction is achieved with a combination of submalar silicone implantation and augmentation of the nasolabial fold. HARS causes noticeable disfigurement that stigmatizes the HIV-infected patient. Given the overall benefit of decreased morbidity and prolonged survival associated with HAART therapy, it is beneficial to attempt surgical correction of these debilitating sequelae before discontinuation of these drugs.

Squamous cell carcinoma of the breast after augmentation with liquid silicone injection.

Squamous cell carcinoma of the breast is an extremely rare neoplasm. Approximately 50 cases have been reported in the English literature since 1917. The pathogenesis of squamous cell carcinoma of the breast is puzzling because epithelial elements are not normally identified in breast tissue. It has been suggested that epithelial cells are derived from epidermoid cysts deposited during early embryological development, from metaplastic transformation of ductal cells, or after trauma or surgical manipulation. Although no evidence has been published to support a causal relationship between liquid silicone-induced mastopathy and breast carcinoma, squamous cell cancers are known to arise in the setting of prolonged inflammation often seen after liquid silicone injection. This case of primary squamous cell carcinoma of the breast, arising 25 years after augmentation with liquid silicone injections, occurred in a 70-year-old patient with silicone-induced mastopathy.

Ultraviolet excitation fluorescence spectroscopy : a noninvasive method for the measurement of redox changes in ischemic myocutaneous flaps

In this report, we discuss application of the noninvasive technology of ultraviolet fluorescence spectroscopy to the metabolic analysis of normal and compromised myocutaneous flaps. Acute changes in tissue redox states during ischemia and reperfusion were determined analysis of changes in the fluorescence spectrum of reduced nicotinomide adenine dinucleotide (NADH). Analysis of the system for NADH fluorescence showed good correlation between excitation spectra recorded at 450 nm from pure beta-NADH and those recorded from porcine rectus abdominis myocutaneous flaps. Sequential measurements of surface fluorescence were obtained from six flaps subjected to 6 hours of warm arterial ischemia and 4 hours of reperfusion. Results were compared with spectra obtained from six contralateral nonischemic control flaps. A significant mean increase in NADH fluorescence (49 percent; p < 0.05) was demonstrated within 30 minutes of vascular occlusion. Fluorescence intensity continued to increase throughout the ischemic period, reaching 320.5 percent of baseline values at 6 hours. Reperfusion resulted in the prompt return of fluorescence intensity to baseline levels. These results show that fluorescence spectroscopy of endogenous NADH is a sensitive and reliable indicator of vascular occlusion in experimental myocutaneous flaps.

The use of Mitek anchors to secure mesh in abdominal wall reconstruction

Abdominal wall complications of TRAM flap breast reconstruction are well described. Synthetic mesh abdominal reinforcement is believed to decrease the incidence of these complications. An innovative technique with commonly available suture anchors has been used in a case of recurrent abdominal laxity after a TRAM flap. Osseous fixation of synthetic mesh with the Mitek GII suture anchor will undoubtedly be used more widely in abdominal wall reconstruction.

Silicone migration to the pleural space associated with silicone-gel augmentation mammaplasty.

We present a case report of silicone particles found in the pleural fluid of a patient 20 years after bilateral augmentation mammaplasty with silicone-gel implants. The patients history is notable for bilateral replacements of implants and multiple closed capsulotomies several years subsequent to the original augmentation procedure. A ruptured left implant was found in 1991 when she first experienced pain in the upper back. A left pleural effusion developed subsequently. Analysis of the pleural effusion fluid by scanning electron microscopy suggested the presence of silicone. All laboratory results were normal, and the effusion did not recur after thoracentesis. The patient has been under close follow-up, and further pulmonary complications or other symptoms have not developed. This case report demonstrates the potential for silicone migration to the pleura and the possibility of subsequent pulmonary complications, such as pleural effusion.

Ischemia-Reperfusion Injury in Myocutaneous Flaps: Role of Leukocytes and Leukotrienes

&NA; Leukotriene B4 is a potent inflammatory mediator that is derived from the 5‐lipoxygenase pathway of arachidonic acid metabolism and that has been implicated in the pathophysiology of polymorphonuclear leukocyte‐dependent reperfusion injury in a variety of organ systems. The objectives of these investigations were to determine whether inhibition of leukotriene B4 attenuates postischemic polymorphonuclear leukocyte infiltration and subsequent injury in myocutaneous flaps. Anesthetized female Yorkshire pigs were randomized to receive normal saline (n = 8), the 5‐lipoxygenase inhibitor diethylcarbamazine (n = 7), or the leukotriene B4 receptor antagonist SC‐41930 (n = 7). All animals underwent 6 hours of rectus abdominis myocutaneous flap ischemia followed by 4 hours of reperfusion. In saline‐treated controls, flap ischemia was associated with massive polymorphonuclear leukocyte infiltration at 1 and 4 hours of reperfusion (252 ± 70 and 619 ± 137 polymorphonuclear leukocytes per 25 high‐power fields, respectively). Skeletal muscle neutrophil content was significantly attenuated by pretreatment with diethylcarbamazine (72 ± 29 and 229 ± 63 polymorphonuclear leukocytes per 25 high‐power fields; p < 0.05) or SC‐41930 (25 ± 3 and 193 ± 25 polymorphonuclear leukocytes per 25 high‐power fields; p < 0.05). Wet‐to‐dry weight ratios of full‐thickness flap biopsies were lower in the diethylcarbamazine and SC‐41930 groups (2.98 ± 0.15 and 2.90 ± 0.26, respectively) than in the control group (4.13 ± 0.23; p < 0.01), and mean muscle infarct size, as determined by nitroblue tetrazolium staining, diminished from 47.6 ± 11.3 percent in controls to 25.1 ± 6.5 percent in diethylcarbamazine‐treated animals and 7.3 ± 4.8 percent in SC41930‐treated animals (p < 0.05). These data indicate that leukotriene B4 plays a critical role in mediating neutrophil‐dependent injury in postischemic skeletal muscle flaps.

Dendritic Cell-T Cell Conjugates that Migrate from Normal Human Skin are an Explosive Site of Infection for HIV-1

Distinctive features of dendritic cells include their potent antigen presenting capabilities and their migratory properties. Stimulation of the skin using contact sensitzing agents1,2, or following transplantation3, “activates” dendritic cells to migrate into the afferent lymphatics and on to the draining lymph node. Movement of dendritic cells via the lymph1,4–6 to the lymph node provides an explanation for the dependence on intact, cutaneous afferent lymphatics for effective primary immune responses to contact allergens7 and transplants8 in situ. Furthermore, injection of ex vivo antigen-pulsed dendritic cells back into mice results in migration of the dendritic cells to the draining lymphoid tissue9, where CD4+ T cells are primed10–12.