Michael L. Bentz

Mesenchymal Stem Cell Therapy for Nonhealing Cutaneous Wounds

Summary: Chronic wounds remain a major challenge in modern medicine and represent a significant burden, affecting not only physical and mental health, but also productivity, health care expenditure, and long-term morbidity. Even under optimal conditions, the healing process leads to fibrosis or scar. One promising solution, cell therapy, involves the transplantation of progenitor/stem cells to patients through local or systemic delivery, and offers a novel approach to many chronic diseases, including nonhealing wounds. Mesenchymal stem cells are multipotent, adult progenitor cells of great interest because of their unique immunologic properties and regenerative potential. A variety of preclinical and clinical studies have shown that mesenchymal stem cells may have a useful role in wound-healing and tissue-engineering strategies and both aesthetic and reconstructive surgery. Recent advances in stem cell immunobiology can offer insight into the multiple mechanisms through which mesenchymal stem cells could affect underlying pathophysiologic processes associated with nonhealing mesenchymal stem cells. Critical evaluation of the current literature is necessary for understanding how mesenchymal stem cells could potentially revolutionize our approach to skin and soft-tissue defects and designing clinical trials to address their role in wound repair and regeneration.

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.

Transition to surgical residency: a multi-institutional study of perceived intern preparedness and the effect of a formal residency preparatory course in the fourth year of medical school.

Purpose To evaluate interns’ perceived preparedness for defined surgical residency responsibilities and to determine whether fourth-year medical school (M4) preparatory courses (“bootcamps”) facilitate transition to internship. Method The authors conducted a multi-institutional, mixed-methods study (June 2009) evaluating interns from 11 U.S. and Canadian surgery residency programs. Interns completed structured surveys and answered open-ended reflective questions about their preparedness for their surgery internship. Analyses include t tests comparing ratings of interns who had and had not participated in formal internship preparation programs. The authors calculated Cohen d for effect size and used grounded theory to identify themes in the interns’ reflections. Results Of 221 eligible interns, 158 (71.5%) participated. Interns self-reported only moderate preparation for most defined care responsibilities in the medical knowledge and patient care domains but, overall, felt well prepared in the professionalism, interpersonal communication, practice-based learning, and systems-based practice domains. Interns who participated in M4 preparatory curricula had higher self-assessed ratings of surgical technical skills, professionalism, interpersonal communication skills, and overall preparation, at statistically significant levels (P < .05) with medium effect sizes. Themes identified in interns’ characterizations of their greatest internship challenges included anxiety or lack of preparation related to performance of technical skills or procedures, managing simultaneous demands, being first responders for critically ill patients, clinical management of predictable postoperative conditions, and difficult communications. Conclusions Entering surgical residency, interns report not feeling prepared to fulfill common clinical and professional responsibilities. As M4 curricula may enhance preparation, programs facilitating transition to residency should be developed and evaluated.

Glomus tumor of the index finger.

A 41-year-old female patient presented with localized worsening subungual pain of her right index finger. Subsequent diagnostic evaluation revealed the presence of a glomus tumor. A glomus tumor is a rare tumor with a predilection for the hand. Classic symptoms include pain, pain with pressure, and pain with cold temperature. We present a completely updated literature review that addresses the epidemiology, pathology, presentation, diagnostic evaluation, classification, histology, genetics, and treatment options for glomus tumors.

Initial Platelet Deposition at the Human Microvascular Anastomosis: Effect on Downstream Platelet Deposition to Intact and Injured Vessels

Initial platelet deposition (PD) in and around the region of a small-vessel anastomosis may set the stage for thrombosis and tissue loss. To study this problem, a human vessel model (human placental artery, HPA) has been designed to mimic the vascular injuries attendant on clinical microsurgery. To perform these studies, dissected lengths of human placental artery were treated to provide the following four types of injury: group I: control, dissected but otherwise uninjured (N = 5); group II: distal portion of vessel endothelium removed (N = 5); group III: central anastomosis, distal endothelium intact (N = 7); and group IV: central anastomosis, distal endothelium removed (N = 4). Vessels were perfused with 25 ml human whole blood for 17 ± 5 s at an average shear rate of 536 s−1. Vessels in groups I to IV were segmented at 2-cm intervals, and the number of 111In-labeled plateles was measured. Data from the following groups of exposure zones were pooled and analyzed: endothelium intact, endothelium absent, anastomosis present, postanastomosis with endothelium intact, and postanastomosis with endothelium absent. Significant numbers of platelets were found to attach to intact endothelium, indicating that ischemia and micro-surgical handling may augment platelet deposition to otherwise uninjured vessels. A similar degree of platelet deposition was measured after exposure of the subendothelium and perfusion, indicating that superficial subendothelial exposure in the absence of an additional prothrombotic stimulus may lead to no greater platelet deposition than occurs on slightly injured endothelium alone. Platelet deposition at anastomoses was strikingly elevated, although the anastomosis had no additive effect on platelet deposition to downstream endothelium. In contrast, an upstream anastomosis significantly augmented platelet deposition to exposed downstream subendothelium. (Plast. Reconstr. Surg. 90: 650, 1992.)

Local delivery of allogeneic bone marrow and adipose tissue-derived mesenchymal stromal cells for cutaneous wound healing in a porcine model.

Wound healing remains a major challenge in modern medicine. Bone marrow‐ (BM) and adipose tissue‐ (AT) derived mesenchymal stromal/stem cells (MSCs) are of great interest for tissue reconstruction due to their unique immunological properties and regenerative potential. The purpose of this study was to characterize BM and AT‐MSCs and evaluate their effect when administered in a porcine wound model. MSCs were derived from male Göttingen Minipigs and characterized according to established criteria. Allogeneic BM‐ or AT‐MSCs were administered intradermally (1 x 106 cells) into partial‐thickness wounds created on female animals, and covered with Vaseline® gauze or fibrin in a randomized pattern. Animals were euthanized at 7, 10, 14 and 21 days. Tissues were analyzed visually for healing and by microscopic examination for epidermal development and remodelling. Polymerase chain reaction (PCR) was used to detect the presence of male DNA in the specimens. All wounds were healed by 14 days. MSC‐injected wounds were associated with improved appearance and faster re‐epithelialization compared to saline controls. Evaluation of rete ridge depth and architecture showed that MSC treatment promoted a faster rate of epidermal maturation. Male DNA was detected in all samples at days 7 and 10, suggesting the presence of MSCs. We showed the safety, feasibility and potential efficacy of local injection of allogeneic BM‐ and AT‐MSCs for treatment of wounds in a preclinical model. Our data in this large animal model support the potential use of BM‐ and AT‐MSC for treatment of cutaneous wounds through modulation of healing and epithelialization. Copyright

Nasal gliomas: identification and differentiation from hemangiomas.

SUMMARY Nasal gliomas are rare congenital midline tumors composed of heterotopic neuroglial tissue. The differential diagnosis of a nasal glioma includes neurogenic tumors, ectodermal tumors, mesodermal tumors, and teratomas. Initial evaluation of a nasal glioma should include skull radiographs and either a CT or MRI scan to rule out intracranial extension. CT or MRI scans can be used, but MRI scans are preferable due to their superior soft tissue enhancement. There have been several cases reported in which nasal gliomas were misdiagnosed as capillary hemangiomas. In cases in which clinical uncertainty exists, ultrasound and Doppler flow studies can be performed to noninvasively differentiate nasal gliomas from capillary hemangiomas. Ultrasound is useful for determining if the mass is cystic or solid. Doppler flow studies of nasal gliomas reveal a characteristic low arterial flow velocity during the end-diastolic phase. Microscopic and immunohistologic studies provide definitive confirmation of a nasal glioma. Once the diagnosis of a nasal glioma is established, early surgical resection is advocated to prevent local recurrence, nasal deformity, and secondary visual involvement.

Reconstruction of pediatric foot and ankle trauma.

Although reconstruction of complex distal lower extremity trauma has been studied extensively, the subject has rarely been evaluated in the pediatric population. The authors review their experience with 18 patients ranging from 2 to 18 years of age, who were admitted to the trauma service of the Childrens Hospital of the University of Pittsburgh between 1991 and 1999 and required plastic surgery evaluation for the management of foot and ankle injuries. The mechanism of injury included motor vehicle accidents (6), lawnmower injuries (6), gunshot wounds (2), crush injuries (2), burns (1), and complex soft tissue injuries (1). The average hospitalization was 14.3 days, and, on average, 3.1 surgical procedures were required per patient. Most of the cohort required microvascular free tissue transfer (11). One patient was managed conservatively, whereas the remainder underwent surgical reconstruction by primary wound closure (1), skin graft (2), or local flap (3). No patient has required treatment of growth disturbance or late functional problems, and the entire population was ambulatory by their 3-month postoperative evaluation. Despite the severity of these injuries, with reliance on microvascular free tissue transfer, an acceptable outcome can be achieved with preservation of the ability to ambulate.

Subtotal maxillectomy for melanotic neuroectodermal tumor of infancy

Melanotic neuroectodermal tumor of infancy is a rare pigmented neoplasm occurring in infants before 1 year of age. It is a rapidly growing tumor that most frequently affects the craniofacial skeleton. Although melanotic neuroectodermal tumor of infancy is benign in the vast majority of cases, inadequate excision, occasional multicentricity, and a small malignant potential result in a fairly high recurrence rate. On the basis of data obtained from the literature and our clinical experience, we advocate an aggressive surgical approach consisting of complete surgical excision when vital structures are not involved. Histopathologic confirmation of complete excision is mandatory to minimize the risk of recurrence and provide the patient with curative treatment and minimal morbidity.

Academic plastic surgery: faculty recruitment and retention.

Background: A critical element of a thriving academic plastic surgery program is the quality of faculty. A decline in recruitment and retention of faculty has been attributed to the many challenges of academic medicine. Given the substantial resources required to develop faculty, academic plastic surgery has a vested interest in improving the process of faculty recruitment and retention. Methods: The American Council of Academic Plastic Surgeons Issues Committee and the American Society of Plastic Surgeons/Plastic Surgery Foundation Academic Affairs Council surveyed the 83 existing programs in academic plastic surgery in February of 2012. The survey addressed the faculty-related issues in academic plastic surgery programs over the past decade. Recruitment and retention strategies were evaluated. This study was designed to elucidate trends, and define best strategies, on a national level. Results: Academic plastic surgery programs have added substantially more full-time faculty over the past decade. Recruitment efforts are multifaceted and can include guaranteed salary support, moving expenses, nurse practitioner/physician’s assistant hires, protected time for research, seed funds to start research programs, and more. Retention efforts can include increased compensation, designation of a leadership appointment, protected academic time, and call dilution. Conclusions: Significant change and growth of academic plastic surgery has occurred in the past decade. Effective faculty recruitment and retention are critical to a successful academic center. Funding sources in addition to physician professional fees (institutional program support, grants, contracts, endowment, and so on) are crucial to sustain the academic missions.