Louis P. Bucky

Incidence of sentinel node metastasis in patients with thin primary melanoma (≤1 mm) with vertical growth phase

Background: Patients with thin primary melanomas (#1 mm) generally have an excellent prognosis. However, the presence of a vertical growth phase (VGP) adversely impacts the survival rate. We report on the rate of occurrence of nodal metastasis in patients with thin primary melanomas with a VGP who are offered sentinel lymph node (SLN) biopsy.Methods: Among 235 patients with clinically localized cutaneous melanomas who underwent successful SLN biopsy, 71 had lesions 1 mm or smaller with a VGP. The SLN was localized by using blue dye and a radiotracer. If negative for tumor by using hematoxylin and eosin staining, the SLN was further examined by immunohistochemistry.Results: The rate of occurrence of SLN metastasis was 15.2% in patients with melanomas deeper than 1 mm and 5.6% in patients with thin melanomas. Three patients with thin melanomas and a positive SLN had low-risk lesions, based on a highly accurate six-variable multivariate logistic regression model for predicting 8-year survival in stage I/II melanomas. The fourth patient had a low- to intermediate-risk lesion based on this model. At the time of the lymphadenectomy, one patient had two additional nodes with metastasis.Conclusions: VGP in a melanoma 1 mm or smaller seems to be a risk factor for nodal metastasis. The risk of nodal disease may not be accurately predicted by the use of a multivariate logistic regression model that incorporates thickness, mitotic rate, regression, tumor-infiltrating lymphocytes, sex, and anatomical site. Patients with thin lesions having VGP should be evaluated for SLN biopsy and trials of adjuvant therapy when stage III disease is found.

Reliable soft tissue augmentation: a clinical comparison of injectable soft-tissue fillers for facial-volume augmentation.

While injectable fillers for facial-volume augmentation have been extensively marketed, there are few published reports comparing the clinical efficacy and cost-effectiveness of multiple injectable agents for soft-tissue augmentation in the face. We present our experience in 976 patients with the use of 4 common injectable agents: autologous fat, Hylaform, Restylane, and Radiesse. We analyzed the injection characteristics of each filler, including injection volume, complication rate, revision rate, and longevity, across 3 commonly treated anatomic regions: the nasolabial fold, glabella, and lips. We subsequently performed a detailed cost-effectiveness analysis of each filler in each anatomic region. Our results demonstrate that autologous fat transplantation is ideally suited for the treatment of the nasolabial fold and glabella, particularly in combination with other procedures. Fat grafting to the lips is limited to use as an adjunct to other facial surgery due to the prolonged recovery time required. We prefer Radiesse for the isolated treatment of the nasolabial folds and glabella. However, Radiesse is not recommended in the lips due to the increased incidence of complications. Last, the hyaluronic fillers Restylane and Hylaform have an excellent safety profile and are our first choice for isolated lip augmentation procedures.

The science of autologous fat grafting: views on current and future approaches to neoadipogenesis.

LEARNING OBJECTIVESnThe reader is presumed to have a broad understanding of plastic surgical procedures and concepts. After studying this article, the participant should be able to: 1. Describe the current clinical applications and limitations of autologous fat grafting. 2. Identify the important physiological steps and molecular pathways of neoadipogenesis. 3. Cite current in vitro and in vivo models for the analysis of fat grafting techniques. Physicians may earn 1 AMA PRA Category 1 credit by successfully completing the examination based on material covered in this article. The examination begins on page 322. ASAPS members can also complete this CME examination online by logging on to the ASAPS Members-Only website (http://www.surgery.org/members) and clicking on Clinical Education in the menu bar. Autologous fat transplantation has become a well established and frequently applied method of soft tissue augmentation for both cosmetic and reconstructive indications. There is no consensus, however, about the best fat grafting technique, nor is there reproducible data regarding its durability. The most significant drawback to autologous fat grafting remains its largely unpredictable rate of resorption. A thorough understanding of the developmental biology and molecular regulation of adipogenesis and adipocyte survival is critical to optimizing the fat grafting technique. Consequently, numerous in vitro and in vivo studies on fat graft viability have recently been undertaken. Here, we discuss the latest advances in the basic science of adipogenesis, adipocyte viability, and its clinical application to fat grafting, arguing that the data produced by in vitro and in vivo studies still fail to produce a clear picture of the required components for successful, consistent, and durable fat transplantation; however, it is undetermined if this lack of clarity may simply be a lack of systematic scientific data acquisition or if these findings truly reflect the biology of neoadipogenesis. As a first step in strengthening autologous fat grafting scientific data collection, we recommend that a collective, multidisciplinary, multicenter effort be undertaken to establish in vitro and in vivo models of neoadipogenesis that are clearly reproducible from one investigator to another. With the implementation of systematic scientific approaches to the study of neoadipogenesis, we anticipate the future of autologous fat transplantation for correction of soft tissue volume loss to be extremely promising.

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.

Locally recurrent malignant melanoma characteristics and outcomes: a single-institution study.

Despite improvements in the identification and treatment of melanoma, local recurrence continues to challenge the success of current melanoma therapy. A retrospective analysis of 1,996 patients presenting from 1990 to 1997 at the Pigmented Lesion Group of the University of Pennsylvania was performed to assess clinical characteristics and outcomes of locally recurrent melanoma. The cases were analyzed by chart and pathological slide review. A control group was identified for statistical comparison. The incidence of locally recurrent melanoma during the study period was 2.2%. Lentigo maligna melanoma (LMM) accounted for 37% of the local recurrences. Increased tumor thickness and microsatellites were associated with “early” local recurrence and decreased survival from time of recurrence. Nineteen percent of the local recurrences occurred more than 5 years after the initial definitive treatment. The preponderance of locally recurrent LMM suggests the need for refinements in the techniques of margin identification and surgical excision of LMM. Tumors with increased thickness and microsatellites should receive particularly close attention. Lastly, with nearly 20% of the local recurrences occurring more than 5 years after the initial date of treatment, the authors suggest extending the follow-up time for all melanoma lesions beyond 5 years.

Ultraviolet-assisted punch biopsy mapping for lentigo maligna melanoma.

Lentigo maligna melanoma (LMM) accounts for a substantial incidence of all locally recurrent melanoma. In addition, the head and neck area accounts for 60% to 90% of all LMMs, which has important functional and cosmetic implications. The difficulty in the identification of the true borders of LMM may account for the high incidence of local recurrence. The purpose of this study was to evaluate the efficacy of ultraviolet-assisted punch biopsy mapping to identify clear margins using identified, 2-mm circumferentially arranged punch biopsies at the junction of the pigmented and nonpigmented borders. A retrospective chart review of 20 patients with biopsy-confirmed LMM of the head and neck was performed. Using ultraviolet identification, 2-mm circumferentially arranged biopsy specimens were obtained and sent for formal pathological review, including immunohistochemical staining. The average time for completion of pathological review was 5 to 7 days. If the punch biopsies were positive for lentigo maligna or LMM, punch biopsies were obtained more peripherally. Once clear, margins were obtained and definitive resection was performed. Twenty patients with biopsy-proved LMM were evaluated. Follow-up ranged from 6 months to 3 years (mean follow-up, 1 year). Fourteen patients were cleared after their first series of biopsies, 3 patients required a second series of biopsies, 2 patients required a third session, and 1 patient required a fourth biopsy session. To date, there has been no evidence of recurrence. No patients required reexcision for positive surgical margins. One complication has been local cellulitis of a punch biopsy site requiring a short course of antibiotics. Ultraviolet-assisted punch biopsy mapping of LMM is a safe, well-tolerated, and accurate technique for identifying the true histological margin of LMM. The procedure reduces the need for repeat surgical excisions to obtain clear margins and may decrease the risk for recurrence by mapping accurately the true histological margin.

Beyond fat grafting: what adipose tissue can teach us about the molecular mechanisms of human aging.

BackgroundThe concept of aging and the mechanisms responsible for soft tissue aging have become progressively more important as the world’s population ages and demands a higher quality of life. Although molecular mechanisms of aging have been evaluated in model organisms, specific genomic, genetic, and epigenetic modifications that can be translated to normal human tissue aging have yet to be identified. We propose that adipose tissue is an excellent model with which to investigate molecular aging pathways. The goal of this study is to demonstrate that primary human adipose tissue can serve as a model of human aging, and further, can be used to detect differences in genomic transcriptional profiling between cell types in adipose tissue as well as between youthful and older age groups. MethodsSubcutaneous adipose tissue was excised during cosmetic procedures from healthy patients. Adipocytes and stromal vascular fractions from the anterior abdomen were isolated from 3 young (26–39 years) and 3 old (52–64 years) patients and analyzed for genome-wide transcriptional differences between varying ages and cell types using the Affymetrix GeneChip Human Gene Chip 1.0ST. ResultsGenes specific to adipocytes were more highly expressed in adipocytes than in stromal vascular fractions, validating that adipose tissue should be examined in a cell-specific manner. An increase in overall gene expression was observed among patients in the older age group, consistent with senescence-related chromatin dysregulation. Principal components analysis revealed no clear delineation between age groups and a clear separation by cell type. Analysis of variance revealed cell type as the most significant variable in transcriptional differences, whereas age-related differences were a distant second. Gene Ontology categories of the most significantly modified genes included RNA splicing and mRNA metabolism, plasma membrane, and mitochondrial metabolism. ConclusionsPrimary adipose tissue is an effective model for the study of the molecular mechanisms of human aging. Our findings are consistent with the hypothesis that epigenetic modifications play a more important role than transcriptional modifications in early human adipose tissue aging. Our future studies will examine the contribution of specific epigenetic markers to human adipose tissue aging and promise to advance approaches in regenerative medicine, and the prevention and treatment of aging.