Mitchell A. Stotland

Patient-reported benefit and satisfaction with botulinum toxin type A treatment of moderate to severe glabellar rhytides: results from a prospective open-label study.

Background: Patient satisfaction is a key measure of success when using botulinum toxin type A to treat glabellar rhytides. However, lack of a standardized method of assessing satisfaction has limited its evaluation. Methods: In this open-label study, 58 women with moderate or severe glabellar rhytides at maximum frown were treated with 20 units of botulinum toxin type A (divided injections in corrugator and procerus muscles). Patients’ self-perceptions were assessed at baseline and the following were assessed at days 30 and 120: investigator- and patient-rated global assessment of change in glabellar line severity, patient self-perception of age, and patient satisfaction with the effects of treatment and the procedure itself (using the Facial Lines Treatment Satisfaction Questionnaire). Results: Overall, patients had a positive self-image at baseline. At day 30, the investigator reported that all patients had 50 percent or greater improvement in glabellar line severity. At days 30 and 120, 95 percent and 86 percent of patients, respectively, reported satisfaction with treatment overall and 82 percent or more reported satisfaction with various aspects of the effects of treatment (time to onset of action, improvement in facial lines and appearance, and appearing better and relaxed) and the procedure itself (absence of downtime and side effects). More than one-third of patients considered that they looked younger than they did before treatment (by a median of 5 years at both time points). Conclusions: Botulinum toxin type A treatment of glabellar rhytides resulted in high levels of patient satisfaction, and more than one-third of patients thought they appeared younger than they did before treatment.

E- and L-selectin adhesion molecules in musculocutaneous flap reperfusion injury

&NA; Definition of the elements governing leukocyte adhesion to the microvascular endothelium may lead to new forms of treatment for reperfusion injury. The objectives of this study, employing a porcine latissimus dorsi flap reperfusion model, were (1) to characterize the expression of E‐ and L‐selectin adhesion molecules and (2) to test for a possible benefit of E‐ and L‐selectin blockade in the preceding experimental setting. In experiment 1, full‐thickness biopsies were collected sequentially over an 8‐hour ischemia and subsequent 6‐hour reperfusion period. Immunocytochemistry was performed with monoclonal antibody EL‐246, an antibody that crossreacts with both E‐ and L‐selectin. In experiment 2, the binding of EL‐246 to L‐selectin on circulating porcine neutrophils was determined by flow cytometric analysis. In experiment 3, in situ hybridization was performed using complementary RNA probes for detection of endothelial E‐selectin mRNA. In experiment 4, bilateral flaps were elevated in six pigs and subjected to 8 hours of arterial ischemia followed by 20 hours of reperfusion. Flaps on each animal were randomly assigned to receive either treatment with a continuous local intraarterial infusion of EL‐246 (1 mg per flap) or solvent vehicle. Muscle and skin survivals were assessed by nitroblue tetrazolium and intravenous fluorescein staining techniques, respectively. Computer digitization permitted quantitation of relative tissue survival. In experiment 1, specific immunostaining of microvascular endothelium was achieved using EL‐246. Greaterintensity staining was detected in reperfusion than in baseline or ischemic sections. In experiment 2, flow cytometric analysis indicated specific recognition by EL‐246 of isolated peripheral porcine neutrophils (>45 percent staining) as compared with an isotype‐matched control antibody (<3 percent staining). In experiment 3, in situ hybridization studies demonstrated an early ischemic upregulation and later reperfusion downregulation of Eselectin mRNA during the reperfusion period. In experiment 4, administration of monoclonal antibody EL‐246 afforded a significant augmentation in mean percentage survival of muscle (37.6 versus 18.7 percent, p = 0.015) and skin (48.6 versus 29.3 percent, p = 0.046). In conclusion, it was determined that E‐selectin is expressed along the microvascular surface and is upregulated and subsequently downregulated during ischemiareperfusion conditions. The monoclonal antibody EL‐246 appears to recognize porcine L‐selectin as well as E‐selectin. Blockade of E/L‐selectin‐mediated leukocyte adhesion significantly reduces musculocutaneous flap reperfusion injury. (Plast. Reconstr. Surg. 99: 2010, 1997.)

The role of platelet-activating factor in musculocutaneous flap reperfusion injury.

&NA; Platelet‐activating factor is an extremely potent lipidinflammatory mediator implicated in the pathophysiologic mechanism of reperfusion injury in a variety of organs. The purpose of this study, employing a porcine latissimus dorsi flap model, was to (1) examine the expression of platelet‐activating factor and (2) evaluate the possible benefit and mechanism of action of platelet‐activating factor antagonism in musculocutaneous flap reperfusion injury. Experiment 1: In 6 pigs, bilateral flaps underwent 8 hours of arterial ischemia followed by 12 hours of reperfusion. Biopsies were collected sequentially and analyzed immunohistochemically for platelet‐activating factor expression. Different processing techniques, however, were unable to detect specific tissue expression of platelet‐activating factor. Experiment 2: In 11 pigs, bilateral flaps underwent 8 hours of arterial ischemia followed by 20 hours of reperfusion. A lipophilic plateletactivating factor receptor antagonist (L‐659,989) was administered as a single dose to treated flaps by a local intraarterial route prior to reperfusion. This treatment augmented the survival of both muscle (48.3 versus 19.7 percent) and skin (49.8 versus 42.0 percent) components of the flaps in a statistically significant fashion (p = 0.001). Experiment 3: In 3 pigs, a radiolabeled structural analogue of L‐659,989 (14C‐L‐680,573) was administered to flaps in a fashion similar to experiment 2. After 8 hours of ischemia, sequential full‐thickness flap biopsies were collected over the initial 6 hours of reperfusion. The radiolabeled platelet‐activating factor receptor antagonist was found to be highly concentrated within treated flaps, with gradual decay over the initial 6 hours of reperfusion. Experiment 4: Thirty minutes prior to completion of 8 hours of arterial ischemia, autologous neutrophils labeled with indium‐111 were reintroduced into the systemic circulation of 5 pigs. Prior to reperfusion, treated flaps received L‐659,989 as in experiment 2. Over the initial 4 hours of reperfusion, the flaps were imaged in situ by a gamma camera at 3‐minute intervals. The platelet‐activating factor receptor antagonist was found to significantly attenuate the accumulation of radioactivity within treated flaps. Conclusion: Platelet‐activating factor expression within musculocutaneous flaps subjected to ischemia and reperfusion was not directly demonstrated in this study. Still, we have shown that (1) the specific platelet‐activating factor receptor antagonist L‐659,989 is beneficial to the survival of both muscle and skin flap components, (2) a single, prereperfusion local dose of this lipophilic drug remains concentrated within the flap during the early inflammatory phase of reperfusion, and (3) during reperfusion, platelet‐activating factor antagonism is able to directly or indirectly diminish the accumulation of acute inflammatory cells in musculocutaneous flaps. (Plast. Reconstr. Surg. 99: 1989, 1997.)

Local anesthetics in liposuction: considerations for new practice advisory guidelines to improve patient safety.

Summary: The Practice Advisory on Liposuction published by the American Society of Plastic Surgeons provides a thorough review of anesthetic techniques and guidelines for surgeons who perform liposuction. However, there is evidence to support several changes to the anesthetic infiltrate guidelines that will improve patient safety. These proposed recommendations will have the most impact on patients undergoing office-based procedures, where dedicated anesthesia providers may not be present, but they should also guide practice in both ambulatory care centers and hospitals. The primary foci of the proposed changes include restrictions on bupivacaine use and creation of lidocaine concentration guidelines.

The use of mesh versus primary fascial closure of the abdominal donor site when using a transverse rectus abdominis myocutaneous flap for breast reconstruction: a cost-utility analysis.

Background: During breast reconstruction using the transverse rectus abdominis myocutaneous (TRAM) flap, the use of mesh for abdominal donor-site closure provides for a technology that potentially offers clinical benefit yet incurs an added cost. The authors’ goal was to determine whether it is cost effective to use mesh during abdominal donor-site closure when performing a TRAM flap for breast reconstruction. Methods: A literature review was conducted to identify and collect published hernia and bulge rates at abdominal TRAM flap donor sites closed either primarily or with mesh. A decision tree analysis was performed. Outcome probabilities, costs of complications, and expert utility estimates were populated into the decision tree model to evaluate the cost-utility of using mesh in TRAM abdominal donor-site closure. One-way sensitivity analyses were performed to verify the robustness of the results. Results: The authors’ literature review resulted in 10 articles describing 1195 patients who had TRAM abdominal donor-site closure primarily and 696 patients who had donor-site closure performed with mesh. Pooled hernia/bulge complication rates for these two groups were 7.87 percent and 4.45 percent, respectively. The use of mesh was more clinically effective based on total quality-adjusted life-years gained of 30.53 compared with 30.41 when performing primary fascial closure alone. The incremental additional cost incurred by the mesh arm when running the decision tree model was

Kinetics of E-selectin expression in surgical flaps.

693.14. This difference in cost, divided by the difference in clinical efficacy (0.12), results in an incremental cost-utility ratio value of

Abstract 28: effect of glabellar paralysis by botulinum toxin on ability to communicate emotion.

5776.17 per quality-adjusted life-year gained when using mesh, making it cost effective (when using a willingness-to-pay threshold of

Chapter 105 – Principles of Skin Flap Surgery

50,000). One-way sensitivity analysis revealed the following: (1) using mesh was a cost effective option, provided that the price of mesh was less than or equal to

A better template for microtia reconstruction: the waterproof, mirror-image digital photograph of the contralateral ear.

5970; (2) mesh was cost effective when its use led to a hernia/bulge rate less than or equal to 7.25 percent; and (3) primary facial closure was cost effective when its use led to a hernia/bulge rate less than or equal to 4.75 percent. Conclusion: The use of mesh when repairing the abdominal donor site during a pedicled or free TRAM flap breast reconstruction is cost effective compared with primary fascial closure alone.

Intravenous Extravasation: A Comprehensive Management Algorithm

&NA; During the ischemia/reperfusion phenomenon, adhesion molecules seem to play a critical role in the recruitment of neutrophils to sites of eventual tissue injury. Eselectin is an endothelium‐derived molecule that mediates adhesion of neutrophils to activated endothelial cells. In vitro expression of E‐selectin, after exposure to stimuli such as endotoxin, interleukin 1, or tumor necrosis factor &agr; is maximal at 4 to 6 h, followed by a decline toward basal levels at 24 to 48 h. Characterizing the temporal expression of E‐selectin in an in vivo model of skin flap ischemiareperfusion would help to determine the optimal approach to eventual pharmacologic blockade. This intervention may prove therapeutically beneficial in attenuating flap injury. This study, using the standard porcine buttock skin flap model, was designed to evaluate immunohistochemically the expression of E‐selectin in flaps subjected to (1) arterial ischemia (8 h)‐reperfusion (18 h), (2) venous ischemia (8 h)‐reperfusion (18 h), and (3) distal ischemia (26 h). Four flaps were examined per group, with 8 biopsies being collected sequentially over the 26‐h study period from each flap. Blinded, semi‐quantitative histologic scoring revealed the following results: (1) E‐selectin is absent in normal porcine skin; (2) with arterial ischemia/reperfusion, E‐selectin expression in flaps was maximal at 1 h of reperfusion, declining thereafter; (3) with venous ischemia/reperfusion, E‐selectin expression peaked during the first hour of ischemia, with subsequent decline; and (4) within a flap designed to sustain distal ischemia, E‐selectin expression is relatively more intense in regions of the flap distant from the vascular pedicle, and maximal at 6 h after flap elevation. Our conclusion, therefore, is that the kinetics of E‐selectin expression within the tissues of porcine skin flaps differs depending on the type of ischemic insult sustained. Interpretation of these findings, correlating possible pathophysiologic differences in the different models of ischemia, is offered. (Plast. Reconstr. Surg. 100: 1482, 1997.)