Rebecca M. Garza

Studies in fat grafting: Part III. Fat grafting irradiated tissue--improved skin quality and decreased fat graft retention.

Background: Following radiation therapy, skin becomes fibrotic and can present a difficult problem for reconstructive surgeons. There is an increasing belief that fat grafting under irradiated skin can reverse the damage caused by radiation. The present study evaluated the effect of fat grafting on irradiated skin, along with fat graft quality and retention rates in irradiated tissue. Methods: Nine adult Crl:NU-Foxn1nu CD-1 mice underwent 30-Gy external beam irradiation of the scalp. Four weeks after irradiation, scalp skin from irradiated and nonirradiated mice was harvested and compared histologically for dermal thickness, collagen content, and vascular density. Human fat grafts were then injected in the subcutaneous plane of the scalp. Skin assessment was performed in the irradiated group at 2 and 8 weeks after grafting, and fat graft retention was measured at baseline and every 2 weeks up to 8 weeks after grafting using micro–computed tomography. Finally, fat graft samples were explanted at 8 weeks, and quality scoring was performed. Results: Fat grafting resulted in decreased dermal thickness, decreased collagen content, and increased vascular density in irradiated skin. Computed tomographic analysis revealed significantly decreased fat graft survival in the irradiated group compared with the nonirradiated group. Histologic scoring of explanted fat grafts demonstrated no difference in quality between the irradiated and nonirradiated groups. Conclusions: Fat grafting attenuates dermal collagen deposition and vessel depletion characteristic of radiation fibrosis. Although fat graft retention rates are significantly lower in irradiated than in nonirradiated tissue, the quality of retained fat between the groups is similar.

Studies in fat grafting: Part IV. Adipose-derived stromal cell gene expression in cell-assisted lipotransfer.

Background: Fat graft volume retention remains highly unpredictable, but addition of adipose-derived stromal cells to fat grafts has been shown to improve retention. The present study aimed to investigate the mechanisms involved in adipose-derived stromal cell enhancement of fat grafting. Methods: Adipose-derived stromal cells isolated from human lipoaspirate were labeled with green fluorescent protein and luciferase. Fat grafts enhanced with adipose-derived stromal cells were injected into the scalp and bioluminescent imaging was performed to follow retention of adipose-derived stromal cells within the fat graft. Fat grafts were also explanted at days 1, 5, and 10 after grafting for adipose-derived stromal cell extraction and single-cell gene analysis. Finally, CD31 immunohistochemical staining was performed on fat grafts enriched with adipose-derived stromal cells. Results: Bioluminescent imaging demonstrated significant reduction in luciferase-positive adipose-derived stromal cells within fat grafts at 5 days after grafting. A similar reduction in viable green fluorescent protein–positive adipose-derived stromal cells retrieved from explanted grafts was also noted. Single-cell analysis revealed expression of multiple genes/markers related to cell survival and angiogenesis, including BMPR2, CD90, CD105, FGF2, CD248, TGFß1, and VEGFA. Genes involved in adipogenesis were not expressed by adipose-derived stromal cells. Finally, CD31 staining revealed significantly higher vascular density in fat grafts explanted at day 10 after grafting. Conclusions: Although adipose-derived stromal cell survival in the hypoxic graft environment decreases significantly over time, these cells provide multiple angiogenic growth factors. Therefore, improved fat graft volume retention with adipose-derived stromal cell enrichment may be attributable to improved graft vascularization.

Nasal Bone Osteotomies with Nonpowered Tools

Controlling the shape of the nasal bones has long been a frustrating problem. Conventional osteotomies are associated with bleeding, loss of reduction, inability to achieve the desired alignment, improperly placed osteotomy sites, and spicule formation. A nonpowered osteotomy method empirically provided the safest and most controlled technique to achieve the desired anatomic result. The nasal bones should be thought of as 2 thin nasal plates that can be released from their medial and lateral attachments to become mobile units that can affect the dorsal width and bony base independently. There is a learning curve to osteotomies.

Pregnancy and the Plastic Surgery Resident

Background: Combining pregnancy with plastic surgery residency has historically been difficult. Two decades ago, 36 percent of plastic surgery program directors surveyed actively discouraged pregnancy among residents, and 33 percent of women plastic surgeons suffered from infertility.1 Most alarmingly, 26 percent of plastic surgery trainees had had an elective abortion during residency. With increasing numbers of women training in plastic surgery, this historical lack of support for pregnancy deserves further attention. Methods: To explore the current accommodations made for the pregnant plastic surgery resident, an electronic survey was sent to 88 plastic surgery program directors in the United States. Results: Fifty-four responded, for a response rate of 61.36 percent. On average, a director trained a total of 7.91 women among 17.28 residents trained over 8.19 years. Of the women residents, 1.43 were pregnant during a director’s tenure, with 1.35 of those residents taking maternity leave. An average 1.75 male residents took paternity leave. Approximately one-third of programs had a formal maternity/paternity leave policy (36.54 percent) which, in most cases, was limited to defining allowed weeks of leave, time required to fulfill program requirements, and remuneration during leave. Conclusions: This survey of plastic surgery directors is a first step in defining the challenges training programs face in supporting the pregnant resident. Directors provided comments describing their challenges accommodating an absent resident in a small program and complying with the American Board of Plastic Surgery’s required weeks of training per year. A discussion of these challenges is followed by suggested solutions.

Management of frontal sinus fractures: treatment modality changes at a level I trauma center.

Abstract The optimal management of frontal sinus fractures remains controversial, and previously accepted indications for surgical intervention are being challenged. The goals of this study were to determine how frontal sinus fracture management has changed at a single institution across multiple disciplines and to evaluate the long-term outcomes of operative and nonoperative treatment modalities. Patients treated for a frontal sinus fracture at Stanford Hospital and Clinics between June 1998 and June 2009 were included in the study. Inpatient records, clinic notes, operative reports, and radiographic studies were reviewed. The patients were invited for a follow-up clinic visit, physical examination, and focused sinus computed tomography. For a period of 11 years, 124 patients were treated for a frontal sinus fracture by physicians from 3 surgical subspecialties: otolaryngology, plastic surgery, and neurosurgery. A low short-term complication rate was observed (5.6%), and there was a trend toward nonsurgical management within the study population. Ten patients returned for a long-term follow-up. Of these, the 2 patients who underwent cranialization experienced as many or more long-term complications compared with the patients treated by other modalities. These complications included abnormal frontal bone contour with bony discontinuity and altered sensation in the distribution of the trigeminal nerve. The demonstrated trend toward nonsurgical management of frontal sinus fractures seems to be safe. In the limited group of patients who returned for follow-up, more long-term complications were observed in the patients who underwent cranialization. However, a larger long-term follow-up cohort will be necessary to elucidate the relationship between treatment modality and long-term outcomes and complications.

Parental leave policies in graduate medical education: A systematic review

BACKGROUND A thorough understanding of attitudes toward and program policies for parenthood in graduate medical education (GME) is essential for establishing fair and achievable parental leave policies and fostering a culture of support for trainees during GME. METHODS A systematic review of the literature was completed. Non-cohort studies, studies completed or published outside of the United States, and studies not published in English were excluded. Studies that addressed the existence of parental leave policies in GME were identified and were the focus of this study. RESULTS Twenty-eight studies addressed the topic of the existence of formal parental leave policies in GME, which was found to vary across time and ranged between 22 and 90%. Support for such policies persisted across time. CONCLUSIONS Attention to formal leave policies in GME has traditionally been lacking, but may be increasing. Negative attitudes towards parenthood in GME persist. Active awareness of the challenges faced by parent-trainees combined with formal parental leave policy implementation is important in supporting parenthood in GME.

Tarsal ectropion repair and lower blepharoplasty: A case report and review of literature

Ectropion is frequently encountered in plastic surgery. A variety of etiologies exist, but tarsal ectropion, defined as complete eversion of the tarsal plate and its overlying conjunctiva, is rarely considered. First described in 1960 by Fox, this variant was initially attributed to pre-septal orbicularis oculi spasm or tarsoligamentous relaxation. However, subsequent investigators determined that the true etiology involved lower lid retractor disinsertion on the tarsal plate. We present a case of chronic right lower lid ectropion in a 66-year-old male. Through understanding of eyelid anatomy, especially that of the lower eyelid retractors, tarsal ectropion was correctly identified in our patient preoperatively. A repair including correction of retractor disinsertion on the tarsus was planned, and given our patients degree of lower lid delamination and mobilization, we also proceeded with bilateral lower lid blepharoplasty with canthal and lower lid soft tissue support. Ultimately, we were able to achieve an improved aesthetic appearance for our patient, along with resolution of his symptoms.

Abdominal flap for closing the donor site after groin lymph node transfer

Free vascularized lymph node transfer (VLNT) is one of the most recent developments in the treatment of lymphedema. The groin donor site is commonlyusedand includesnodes suppliedby thesuperficial circumflex iliac artery and vein. For patients with upper extremity lymphedema, groin VLNT is combined with a deep inferior epigastric perforator (DIEP) or transverse rectus abdominis myocutaneous (TRAM) flap for simultaneous breast reconstruction and treatment of lymphedema. During dissection, groin lymph nodes are harvested with surrounding adipose tissue, and the donor site traditionally is closed over suction drainage. Donor site complications including iatrogenic lymphedema, lymphocele, and persistent pain have previously been reported. But the most common donor site complication following inguinal node harvest is chronic seroma, as removal of nodes leaves a dead space in the groin. One effort to eliminate dead space at the lymph node donor site has included placement of quilting sutures. However, this technique further exacerbates the discrepancy in thickness between the upper abdominal flap and the suprapubic/groin tissue at the time of abdominal closure and leaves the patient with inguinal contour deformity. Therefore, to eliminate dead space at the groin donor site to prevent fluid collection, while also restoring the natural contour of the inguinal region, we advocate closure of the VLNT donor site utilizing a local abdominal flap. The flap is designed to contain subcutaneous abdominal fat and de-epithelialized skin located immediately cranial to the breast flap donor site (Fig. 1). When making the upper abdominal flap incision at

Immunological Effect of Skin Allograft in Burn Treatment: Impact on Future Vascularized Composite Allotransplantation.

Skin allografts are the gold standard in temporary burn wound coverage, but allografts are hypothesized to place a high antigenic load on recipients. This project aims to determine the degree of human leukocyte antigen sensitization in burn patients treated with allografts. Serum was obtained from nine adult, nontransfused, and nontransplanted burn patients treated with allografts. Group 1 included patients tested in the acute burn period, while group 2 included different patients tested months to years after injury. A calculated panel reactive antibody (cPRA) percent was assessed for each patient, and data for a control group of 92 adult nontransplanted males were used for comparison. Each patient received allografts from an average 3.55 ± 1.24 different donors. cPRA in group 1 was lower than in group 2 (6 ± 12% vs 42 ± 33%, P = .08). cPRA in the study group was significantly higher than in the control group (26 ± 31% vs 8 ± 17%, P = .0075). Burn patients who receive skin allograft demonstrate increased immunological sensitization compared with unsensitized controls. Detection of human leukocyte antigen antibody is lower in the acute burn period than months to years after injury. Increased sensitization may ultimately limit burn patients’ candidacy for vascularized composite allotransplantation or decrease success of these procedures.

Lymphovenous bypass for the treatment of lymphedema: GARZA and CHANG

Lymphovenous bypass (LVB) is a form of physiological lymphedema surgery, which was described decades ago, but recently it is gaining popularity with improved microsurgical technology available. Benefits of the procedure are its effectiveness in treating early stage lymphedema of either the upper or lower extremity and having low complication profile. In the following article, the history of the procedure, mechanism, and details of various LVB techniques, and outcomes will be discussed.