Paul N. Afrooz

Investigation of Antibody-Mediated Rejection in Composite Tissue Allotransplantation in a Rat Limb Transplant Model

BACKGROUND Despite the widely accepted implication of antidonor antibodies and complement in solid organ transplantation, their role in reconstructive allotransplantation is not clear. The aim of this study was to analyze the humoral immune response using a rat orthotopic limb transplantation model. METHODS We used the Brown Norway to Lewis rat orthotopic hind-limb transplant model: Group 1, isografts; group 2, allografts with daily continuous cyclosporine treatment to prevent acute rejection; and group 3, allografts undergoing multiple episodes of acute rejection. Samples were taken at 30, 60, and 90 days. Serum was analyzed by FACS for antidonor antibodies. Tissue deposition of antibodies and complement was investigated by immunofluorescence. RESULTS By day 90, animals in group 3 had undergone 19 (+/-3.2) acute rejection episodes. There was no difference in the occurrence of serum antidonor antibodies between the three groups at any time point. However, at 90 days, anti-third-party antibodies were significantly greater among group 3. There was no difference in antibody or complement deposition in muscles between the 3 groups. CONCLUSION Despite the increased antibody against a third party after multiple rejection episodes in this animal model, there was no clear evidence of an antibody-mediated alloresponse in limb transplantation.

Correction of Cocaine-Related Nasal Defects

Background: Cocaine abuse causes nasal defects ranging from minor septal perforation to loss of dorsal support, potentially leading to collapse of the entire nose. The authors review the defects caused by frequent insufflation of cocaine, outline representative internal and external nasal deformities, and detail the surgical methods available to correct these deformities. Methods: The patient must be cocaine-free for several years and committed to remaining free of cocaine use permanently. Next, a clear definition of the existing deformity and precise plan of surgical correction should be established. Surgical correction involves adequate dissection of the soft tissues and cephalic release and caudal advancement of the nasal lining, with a complete and waterproof separation of the nasal cavity from the external reconstructive site. Using costal cartilage, a tongue-and-groove technique is used to elongate the nasal frame. Kirschner wires may be used for costal cartilage graft fixation; avoiding penetration of the nasal cavity is critical. Maxillary defects are restored with cartilage and bone grafts. To address notching of the alae, V-to-Y caudal advancement flaps of the nasal lining and alar rim grafts are used. Tip projection and definition are restored with a columella strut with or without a tip graft. Results: The surgical outcome is gratifying and does not necessarily require external skin or nasal lining graft, or local or regional flaps. Reconstruction of massive septal perforation is unnecessary, as the nasal form can be restored without repair of this defect. The key to success is avoiding postoperative infection. Conclusion: Correction of cocaine-related internal and subsequent external nasal defects is extremely challenging and requires a clear understanding of the patients psychology and nasal abnormality.

Pediatric facial fractures: occurrence of concussion and relation to fracture patterns.

Background Children and adolescents with injuries resulting in facial fractures are a population that is potentially at risk for suffering concomitant concussion. Concussion results in a variety of physical symptoms and often affects cognition, emotion, and sleep. These effects can have a significant impact on academics and social functioning. Early recognition of concussion and active management have been shown to improve outcomes. The goal of this study was to describe the occurrence of concussion in patients sustaining facial fractures and to determine whether certain fracture types are associated with concussion. Methods We performed a retrospective review of patients aged 0 to 18 years who were evaluated in the emergency department of the Children’s Hospital of Pittsburgh from 2000 to 2005 with an International Classification of Diseases, Ninth Revision code indicative of facial fractures. Data included demographics, documentation of concussion, and facial fracture type. Patients with intracranial injury were excluded from the study. Univariate &khgr;2 analysis and logistic regression were performed to determine characteristics associated with concussion. Results Facial fracture was diagnosed in 782 patients. Ninety-one patients had an intracranial injury and were excluded, leaving 691 patients for evaluation. The mean age was 11.1 (SD, 4.6) years. Males made up 69.6% of patients, and 80.6% of patients were white. Concussion was diagnosed in 31.7% of patients. Age, sex, and race were not associated with concussion. Univariate analysis demonstrated that skull and orbital fractures were associated with higher rates of concussion, whereas maxillary fractures showed a trend toward higher rates of concussion, and nasal and mandible fractures showed a trend toward lower rates of concussion. Logistic regression analysis demonstrated the odds of having a concussion were higher in those with skull fractures (odds ratio, 2.3; confidence interval, 1.5–3.7). Conclusions Nearly one third of pediatric patients with facial fractures in this retrospective series were diagnosed with a concomitant concussion. Our data suggest that a higher index of suspicion for concussion should be maintained for patients with concomitant skull fractures and potentially orbital and maxillary fractures. Given the possibility of a worse outcome with delayed concussion diagnosis, patients with facial fractures may benefit from more active early concussion screening.

Functional outcomes following multiple acute rejections in experimental vascularized composite allotransplantation

Background: Vascularized composite allotransplantation has become a clinical reality. Patients undergoing vascularized composite allotransplantation have modest functional return. Most patients have had multiple acute rejections. The effect of multiple acute rejections influencing functional outcomes is unknown. This study systematically analyzes the effects of multiple acute rejections on functional outcome. Methods: Rat functional orthotopic hind-limb transplants were performed from Brown-Norway to Lewis rats. Group 1 consisted of isografts. In group 2, daily cyclosporine was administered to prevent acute rejection. In group 3, recipients did not receive regular immunosuppression but received only pulsed cyclosporine and dexamethasone to rescue acute rejection. The study endpoint was 90 days. Muscle and sciatic nerve biopsy specimens were taken for histologic analyses. Hind-limb function was assessed using sciatic nerve axon density, nerve conduction velocity, and muscle force generated by the gastrocnemius muscle. Novel video kinematics was used to analyze gait. Results: By the endpoint, group 3 animals had 17 ± 5.1 acute rejections. Muscle biopsy showed significant atrophy and fibrosis in group 3 compared with groups 1 and 2. Withdrawal to pin prick was evident by days 31 ± 1.2, 30 ± 2.3, and 31 ± 3.7 in groups 1, 2, and 3, respectively. At the endpoint, there was no significant difference in the axon density or nerve conduction velocity among the three groups, but muscle force generated was significantly less in group 3. Gait was abnormal in group 3 animals compared with other groups. Conclusions: In this study, multiple acute rejections induced muscle atrophy and fibrosis and consequent decreased function. This emphasizes the importance of preventing acute rejection to achieve optimum function following vascularized composite allotransplantation.

Noninvasive and Minimally Invasive Techniques in Body Contouring

Major surgical body contouring procedures have several inherent drawbacks, including hospitalization, anesthetic use, pain, swelling, and prolonged recovery. It is for these reasons that body contouring through noninvasive and minimally invasive methods has become one of the most alluring areas in aesthetic surgery. Patient expectations and demands have driven the field toward safer, less-invasive procedures with less discomfort, fewer complications, and a shorter recovery. In this article, the current minimally invasive and noninvasive modalities for body contouring are reviewed.

Reply: Dynamics of Gluteal Cleft Morphology in Lower Body Lift: Predictors of Unfavorable Outcomes.

Background: The number of lower body lifts is increasing with the increase in post–bariatric surgery patients. An undesirable result of the lower body lift is elongation of the gluteal cleft. The authors assessed their patients for gluteal cleft elongation to determine predictors of this unfavorable result. Methods: Lower body lift excision patterns were classified based on their relationship to the gluteal cleft. Type I patterns were superior to the gluteal cleft; type II were central, partially incorporating the superior portion of the cleft; and type III were characterized by the cleft spanning the entire height of the pattern. Postoperative deformities were classified as cleft unchanged (grade 1), moderate cleft lengthening (grade 2), or severe cleft lengthening (grade 3). Gluteal autoaugmentation was also determined. Results: Eighty-six patients were included (average age, 46.4 ± 9.0 years). Thirty-two patients (37 percent) had type I excision patterns, 30 (35 percent) had type II, and 24 (28 percent) had type III. Seventeen (19.8 percent) had grade 1 clefts, 43 (50 percent) had grade 2 clefts, and 26 (29.9 percent) had grade 3 clefts. Age, sex, change in body mass index, and gluteal autoaugmentation were not significantly associated with postoperative cleft grade. Type I patterns were significantly less likely to cause postoperative cleft elongation (p = 0.001). Two patients (2.3 percent) desired correction achieved by excision and direct closure. Conclusions: Although lower body lift patterns may be based lower for better contour of the buttocks, there is an increased propensity for gluteal cleft elongation. This often occurs in patients with significant horizontal length discrepancy between the upper and lower incisions. Careful planning and markings can reduce the risk of this unfavorable result. Excision and direct closure provides a reliable solution. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A comparison of speech outcomes using radical intravelar veloplasty or furlow palatoplasty for the treatment of velopharyngeal insufficiency associated with occult submucous cleft palate.

BackgroundThe safety, efficacy, and direct comparison of various surgical treatments for velopharyngeal insufficiency (VPI) associated with occult submucous cleft palate (OSMCP) are poorly characterized. The aim of this study was to report and analyze the safety and efficacy of Furlow palatoplasty (FP) versus radical intravelar veloplasty (IVV) for treatment of VPI associated with OSMCP. MethodsA retrospective review of one institution’s experience treating VPI associated with OSMCP using IVV (group 1) or FP (group 2) during 24 months was performed. Statistical significance was determined by Wilcoxon matched-pair, Independent-Samples Mann-Whitney U, and analysis of variance (SPSS 20.0.0). ResultsIn group 1 (IVV), 18 patients were identified from August 2010 to 2011 (12 male and 6 female patients; average age, 5.39 years). Seven patients were syndromic and 11 were nonsyndromic. In group 2 (FP), 17 patients were identified from August 2009 to 2011 (8 male and 9 female patients; average age, 8.37 years). Three patients were syndromic and 14 patients were nonsyndromic. There was statistical significance between the average pretreatment Pittsburgh Weighted Speech Score (PWSS) of the 2 groups (group 1 and 2 averages 19.06 and 11.05, respectively, P = 0.002), but there was no statistical significance postoperatively (group 1 and 2 averages 4.50 and 4.69, respectively, P = 0.405). One patient from each group required secondary speech surgery. Average operative time was greater for FP (140 minutes; range, 93–177 minutes) compared to IVV (95 minutes; range, 58–135 minutes), P < 0.001. Average hospital stay was 3.9 days for IVV (range, 2–9 days) and 3.2 days for FP (range, 2–6 days), with no significant difference (P = 0.116). There were no postsurgical wound infections, oral-nasal fistulas, postoperative bleeding complications, or mortalities. ConclusionsNonsyndromic patients with hypernasal speech are treated effectively and safely with either IVV or FP. Intravelar veloplasty trended toward lower speech scores than FP (76% IVV, 58% FP PWSS absolute reduction). Syndromic patients with OSMCP may be more effectively treated with FP (72% IVV vs 79% FP PWSS absolute reduction). Intravelar veloplasty is associated with shorter operative times. Both techniques are associated with low morbidity, improved speech scores, and low reoperative rates.

Components of the Hanging Columella: Strategies for Refinement

The columella is a significant factor in the aesthetic balance of the nose and particularly the lower one-third of the nose. Its position is dependent upon the anatomic constituents of the columella, as well neighboring anatomic structures. Six components of the hanging columella have been identified: the caudal septum, medial crura, columellar skin, membranous septum, anterior nasal spine, and the depressor nasi septi muscle.Columellar refinement begins with a careful analysis and diagnosis of the contributing components, followed by surgical techniques to address these components individually. The cumulative effect of correction of individual components appropriately positions the columella and contributes significantly to the enhancement of nasal aesthetics.Refinement of the columella can be achieved through appropriate trimming of the caudal septum, repositioning and reshaping the medial crura, excising redundant columellar skin, membranous septum and nasal mucosa, appropriately contouring the anterior nasal spine, and dividing the depressor nasi septi.Summary: The columella is a significant factor in the aesthetic balance of the nose, particularly the lower one-third of the nose. Its position is dependent on the anatomical constituents of the columella, and neighboring anatomical structures. Six components of the hanging columella have been identified: the caudal septum, medial crura, columellar skin, membranous septum, anterior nasal spine, and depressor septi nasi muscle. Columellar refinement begins with a careful analysis and diagnosis of the contributing components, followed by surgical techniques to address these components individually. The cumulative effect of correction of individual components appropriately positions the columella and contributes significantly to the enhancement of nasal aesthetics. Refinement of the columella can be achieved through appropriately trimming the caudal septum; repositioning and reshaping the medial crura; excising redundant columellar skin, membranous septum, and nasal mucosa; appropriately contouring the anterior nasal spine; and dividing the depressor nasi septi nasi.

Reply: Dynamics of Gluteal Cleft Morphology in Lower Body Lift

1055e resuspension. Carloni et al. concur that this leads to the medial gathering of tissue and in increased propensity for gluteal cleft elongation. We reiterate the judicious medialization of this tissue, particularly if the gluteal cleft is involved in the excision pattern, as this tissue migrates into the cleft, thereby accentuating and lengthening it. Furthermore, the lateral shaping achieved with tissue medialization may not necessarily be desirable in male patients. We hope that the insightful comments and recommendations of Dr. Carloni et al. in conjunction with our recent article will provide some general principles and nuances to be espoused in avoiding undesirable alterations of the gluteal cleft in lower body lift. DOI: 10.1097/PRS.0000000000002201

Rhinoplasty Refinements: The Role of the Open Approach

Summary: The open rhinoplasty technique facilitates accurate visualization of deformities and aesthetic disharmonies in addition to visualization for precise correction. Through a series of videos, this case represents the evolution of the open rhinoplasty technique, demonstrating a wide range in complexity of maneuvers to achieve the desired correction in rhinoplasty. The video demonstrates reduction of the nasal dorsum by way of a component dorsal reduction, reconstitution of the cartilaginous midvault, and suture techniques for reshaping the nasal tip. Nasal tip deprojection and placement of alar contour grafts are also demonstrated in this case. The aim is to provide the rhinoplasty surgeon with examples of basic and sophisticated techniques and also to demonstrate the minutia and nuance of open rhinoplasty.