Richard J. Zienowicz

Implant-based breast reconstruction with allograft.

Background: Reconstructive breast surgeons often prefer autologous tissue for those patients who can tolerate it. However, reconstruction with implants is technically easier, quicker, less traumatic, and less costly. Nevertheless, inherent problems associated with implants present some limitations to their use in reconstruction. In this study, a multipurpose application of allogenic dermal grafts to solve the problems seen in immediate breast reconstruction with implants was examined. Methods: After skin-sparing mastectomy, a subpectoral pocket is created for the implant. After the origins of the pectoralis major muscle are released, AlloDerm is sewn to the lower pole of the released muscle. Grafts are tailored according to the dimensions of the defect. AlloDerm, an allogenic dermal graft, is fixed to the pectoralis major superiorly, to the chest wall inferiorly and inferomedially, and to the serratus anterior flap laterally. A postoperative adjustable implant is placed into the pocket that has bene created. Result: Allografts were used to reconstruct 30 breasts in 24 patients immediately after skin- or nipple-sparing mastectomy. There was no complication related to simultaneous allograft application. No rippling, symmastia, or bottoming-out deformity was seen. Conclusions: Breast reconstruction with implant and AlloDerm enables the surgeon to create a submuscular pocket large enough to place a fully inflated breast implant. Interposition of a lower-pole internal sling, to increase the capacity of the pectoralis major pocket while providing immediate ability to achieve full or subtotal prosthetic fill and optimal aesthetic breast contouring and to maintain thicker muscle coverage in the upper and medial pole areas and stronger lower pole support, would obviate many of the current disadvantages to implant reconstruction.

Chemical delay: an alternative to surgical delay experimental study.

The delay phenomenon has long been recognized as a powerful adjunct to flap surgery. Currently, delay procedures remain a reliable method of maximizing flap survival. Although delay yields successful results, the necessity of an additional surgical procedure is a persistent disadvantage from both clinical and economic perspectives. The authors’ purpose is to demonstrate the usefulness of a novel chemical delay technique that obviates the need for a surgical delay procedure. This technique contains an epinephrine-loaded microsphere delivery system. In this study, 30 rats were subdivided into three groups of 10 animals. In group I, transverse rectus abdominis musculocutaneous (TRAM) flaps were delayed surgically 1 week before formal elevation. Group II (sham chemical delay) animals were injected with saline-loaded microspheres into the entire undersurface of the proposed TRAM flaps, which were elevated 1 week later. In group III rats, epinephrine-loaded microspheres were injected into the undersurface of the TRAM flaps to initiate a chemical delay 1 week before surgical elevation. Groups were compared via TRAM flaps 1 week after elevation. There was a significant difference between groups I and III in favor of surface area viability and angiographic assessment (p < 0.05). Surgical delay has traditionally been accepted to be the most reliable method of enhancing flap viability. Statistically similar results were obtained by chemical delay initiated by epinephrine-loaded microspheres. Chemical delay is less invasive, less time-consuming, and far more cost-effective compared with its surgical alternative. The chemical delay model lends further support to the role of relative hypoxia as the primary promoter of the delay phenomenon.

Sympathetic maintained pain (causalgia) associated with a demonstrable peripheral-nerve lesion. Operative treatment.

Nine patients who had sympathetic maintained pain (causalgia) and a total of ten identifiable lesions involving peripheral nerves were managed with a continuous sympathetic block; repair, reconstruction, or lysis of the involved nerve, or a combination of these procedures; and rotation of a muscle flap over the nerve in an attempt to enhance the blood supply in the area and to reduce scarring in the region surrounding the nerve. The lesions were located in the median nerve at the wrist in five of the patients; in both the ulnar nerve at the elbow and the median nerve at the wrist in one; and in the ulnar nerve at the elbow, the radial digital nerve of the index finger, and the posterior tibial nerve near the ankle in one patient each. The average duration of symptoms before treatment was seventeen weeks. All nine patients had clinical findings that were considered diagnostic of sympathetic maintained pain or causalgia. Electrophysiological evidence of dysfunction of one peripheral nerve or more was found in the eight patients who had an electromyogram and a nerve-conduction study. In all nine patients, the causalgic pain diminished within the first seventy-two hours after the operation, and none of the patients had had any recurrence of symptoms at an average of forty-eight months. Although all of the patients had some residual limitation of function, all had improvement after this treatment, and the improvement was maintained.

A multivariate approach to the treatment of peripheral nerve transection injury : the role of electromagnetic field therapy

A multivariate approach to the treatment of peripheral nerve transection injury has been used in a rat model. A pilot study (48 animals, 8 groups) examined variables associated with the method and timing of surgical repair, the arrest of wallerian degeneration, and the role of pulsing electromagnetic field therapy (PEMF) in functional recovery. A second phase (90 animals, 6 groups) then studied the timing and duration of pulsing electromagnetic field therapy as the only variable in larger groups of animals. The pilot study revealed that a vein-graft conduit did not improve functional recovery compared with standard epineurial repair. Additionally, delayed repair compared favorably with immediate repair. The use of chlorpromazine to inhibit the toxic effects of calcium influx appeared to enhance early functional recovery, and the combination of delayed nerve repair and pulsing electromagnetic field therapy seemed to consistently improve function. The second phase of the study has demonstrated (for the first time) statistical improvement in ambulation in animals treated with delayed surgical repair and prolonged pulsing electromagnetic field therapy. We postulate that future treatment of nerve transection injuries will involve a combined treatment regimen consisting of the immediate arrest of wallerian degeneration, delayed surgery, and pulsing electromagnetic field therapy.

Investigation of the growth and metastasis of malignant melanoma in a murine model: the role of supplemental vitamin A.

Vitamin A possesses both wound-healing and antitumor actions. Vitamin A–induced fibroplasia results in subsequent increased collagen production and deposition. This effect of vitamin A has been shown to result in the production of collagenous capsules around several murine breast and lung tumor systems. This tumor encapsulation process can potentially convert a systemic disease to a local one that can be easily treated by tumor excision. The goal of the present study was to determine whether supplemental vitamin A could promote the encapsulation of a murine melanoma. Sixty DBA/2J male mice were inoculated intracutaneously with 1 × 106 Cloudman S91 melanoma cells using a 30-gauge needle. The mice were divided into three groups: a control group, a pre-vitamin A group, and a post-vitamin A group. The control mice were fed a commercial chow containing 15,000 IU of vitamin A and 6.4 mg of beta-carotene per kilogram diet, considerably more than the National Research Council’s recommended daily allowance of vitamin A for normal mice. The control diet was, therefore, not vitamin A–deficient. The pre-vitamin A mice were fed the basal chow supplemented with 150,000 IU of vitamin A per kilogram diet for 10 days before inoculation and for the remainder of the study. The post-vitamin A mice were fed the vitamin A–supplemented diet beginning on the day of inoculation and continuing for the remainder of the study. Sixty days after inoculation, tumor growth was assessed and the five mice remaining in each group were euthanized. Ventral skin at the site of inoculation was harvested for histologic assessment of local tumor growth and invasiveness. The liver and lungs of each of these mice were also harvested for histologic assessment of tumor metastasis. Sixty days after tumor inoculation, a 60 percent survival rate was observed in the control group as opposed to the vitamin A–supplemented animals, which demonstrated a 100 percent survival rate in both groups (n = 5 in each group). Decreased mean tumor size and gross tumor in most vitamin A–supplemented animals were statistically significant when compared with the control animals. The control animals had a mean tumor size of 26.1 mm, whereas the post-vitamin A group had a mean tumor size of 5.7 mm. One hundred percent of the control group exhibited tumor; one animal had distant metastases. The pre-vitamin A group did not exhibit any tumor growth, and the post-vitamin A group exhibited tumor growth in 40 percent of animals. Neither vitamin A–supplemented group showed any evidence of distant metastases. The animals supplemented with vitamin A demonstrated decreased tumor growth and metastasis. This in vivo model may indicate a potential prophylactic and therapeutic role for supplemental vitamin A in the treatment of malignant melanoma.

Osteochondral reconstruction of a non-weight-bearing joint using a high-density porous polyethylene implant.

Currently, there is no reliable reconstructive modality allowing anatomic resurfacing of traumatic digital osteochondral articular defects. The purpose of the present study is to demonstrate the utility of Medpor, a high-density porous polyethylene (HDPP) scaffold biomaterial that can (1) be readily contoured to fit any joint defect, (2) permit stable internal fixation, and (3) permit osteocyte and chondrocyte ingrowth and subsequent articular cartilage resurfacing necessary to restore joint congruity. HDPP has gained wide acceptance for use in craniofacial and skeletal reconstruction and augmentation. An avian non-weight-bearing joint model was designed to study the role of the HDPP implant in small joint reconstruction. An osteochondral defect was created with a 5-mm circular punch in the humeral articular surface of both glenohumeral joints of 32 adult White Leghorn chickens. In each animal, one defect was press-fitted with a correspondingly sized HDPP implant (HDPP implant group); the contralateral defect was filled with the original osteochondral plug (isograft group) or left unrepaired (control group). At 2 weeks, and 1, 3, and 6 months,joints from each group were harvested and evaluated. Over the 6-month study period, joints in the control group demonstrated healing with dense collagenous scar tissue leaving residual defects at the articular surfaces and significant degenerative disease of the glenohumeral joints radiographically. Joints in the isograft group demonstrated near-complete resorption with some preservation of the cartilaginous cap but overall depression of the articular surface and significant degenerative joint disease. Joints in the HDPP implant group demonstrated stable fixation by highly mineralized bony trabecular ingrowth, preservation of the articular contour of the humeral head, and no evidence of significant degenerative joint disease. These findings indicate a potential role for this high-density porous polyethylene implant in the reconstruction of small joint articular and osseous defects.

Does sustained epinephrine release trigger a hypoxia-neovascularization cascade?

Background: Recent data regarding the long-term local administration of epinephrine to soft tissues for the purpose of inducing prolonged vasoconstriction have yielded promising results. These studies postulated that long-term release of epinephrine by a microsphere/drug delivery system caused continuous vasoconstriction and subsequent vascular augmentation. The goal of this study was to test the hypothesis that epinephrine induces a hypoxia-neovascularization cascade and plays a primary role in vascular proliferation within soft tissues. Methods: Thirty male New Zealand White rabbits were randomly grouped as follows: group I, control (n = 10); group II, saline-loaded microsphere/drug delivery system injection (n = 10); and group III, epinephrine-loaded microsphere/drug delivery system injection (n = 10). A 2 × 1-cm rectangle was marked on the dorsal surface of the left ear of each rabbit. No solutions were injected in the control group, whereas 1 ml of saline-loaded and epinephrine-loaded microspheres was injected into groups II and III, respectively. A laser Doppler device was used to measure tissue blood volume and tissue blood flow. Results: Laser Doppler monitoring in tissue blood flow yielded a distinct difference between the epinephrine-loaded microsphere–injected group and the other two groups (p < 0.05). Conclusions: The ability of epinephrine-loaded microspheres to augment the vascular network in vivo is the result of sustained vasoconstriction with consequent tissue hypoxia and subsequent neovascularization. Data extracted from the present study, first, might be applied to improve hemostasis for operations typically plagued by serious intraoperative blood loss. Second, the ability to intentionally augment the vascularity of certain flaps before elevation should result in their increased survival. Radiation-injured tissues may also derive great benefit from this treatment.

Augmentation mammaplasty by reverse abdominoplasty (AMBRA).

Background: The purpose of this article is to describe a novel technique of providing autologous tissues for breast augmentation and simultaneously rejuvenating the abdomen. Methods: Thirty-seven patients underwent augmentation mammaplasty by reverse abdominoplasty (AMBRA) between 1997 and 2006. The upper abdominal pannus present in women whose lower abdomen was typically less aesthetically compromised was harvested as deepithelialized adipofascial flaps, maintaining their connection to and thus blood supply from the attached breast parenchyma. These flaps are transposed subglandularly, creating autologous tissue breast implants, and reverse abdominoplasty accomplishes donor-site closure and aesthetic improvement. If previous surgery or inadequate inframammary fold tissue thickness renders the superior circulation unfavorable, the upper abdominal tissues can be used as advancement flaps vascularly supplied by their attachment to the abdominal skin apron. Results: Twenty-three patients (62 percent) had simultaneous mastopexy and 16 (43 percent) had simultaneous panniculectomy. Complications in the superior pedicle group were minimal. In the inferior pedicle group, complications were more extensive because of the premorbidity of this group of patients and the limitations of this technique, where the resuspension of the abdominal wall apron is less facile and generally weaker than closure with superiorly based flaps. Conclusions: Augmentation mammaplasty by reverse abdominoplasty is a versatile procedure that in the carefully selected patient can successfully address two aesthetic concerns simultaneously, providing durable autologous tissue that can obviate or enhance the outcome provided by prosthetic implants and rejuvenating the abdomen. It also shows promise as a significant adjunct to the techniques available to the breast reconstructive surgeon.

Calf contouring with endoscopic fascial release, calf implant, and structural fat grafting.

Background: Curved lower legs cause psychological stress for women. In evaluating the shape, if thickness is the main contributing factor of leg aesthetic, then lipoplasty or calf reducing procedures will be the option. If the legs are slender and have no muscle hypertrophy but still have some indentation or bulges on both sides and lack an aesthetic shape what will be the options? The answer to the question is discussed in detail in this article. Methods: Twenty-two patients, operated over a period of 5 years from 2007 to 2012, were included in the study. A novel technique has been introduced. This method requires release of fascia covering muscles of the inner leg bulge via endoscopic approach and simultaneous calf augmentation with calf implant, liposuction, and structural fat grafting to optimize the results. Results: Patients were followed on a regular basis with a mean follow-up of 31 months. The procedure was well tolerated with minimal discomfort during the postoperative period. Increase in diameter of proximal and distal lower legs was measured at least 6 months after surgery. Mean diameter change of proximal lower legs was 2.16 cm and 1.77 cm in distal lower legs. Conclusions: A novel endoscopic approach for lower leg contouring is discussed. Endoscopic fasciotomy technique with calf implant and structural fat grafting for improved lower leg aesthetics is a simple, effective, reliable, and predictable technique for calf contouring.

Improving Pressure Ulcer Reconstruction: Our Protocol and the COP (Cone of Pressure) Flap

Background: Surgical treatment of pressure ulcers is challenging for high recurrence rates. Deepithelialized flaps have been used previously with the aim to eliminate shearing forces and the cone of pressure (COP) effect. The goal of this study is to adopt a standardized protocol and evaluate if 2 different flap techniques affect outcomes. Methods: The novel COP flap is illustrated. Twenty patients were prospectively treated with flap coverage over a 36-month period. According to the flap type, patients were assigned to 2 groups: group 1 with 11 patients treated with the COP flap and group 2 with 9 patients treated with conventional flap without anchoring technique. We adopted a standardized protocol of debridement, tissue cultures, and negative-pressure wound therapy. Rotation fasciocutaneous flaps were used for both groups and mean follow-up was 19 months. The COP flap is a large deepithelialized rotation flap inset with transcutaneous nonabsorbable bolster sutures. The 2 groups were comparable for demographics and ulcer location and size (P < 0.05). Five patients showed positive cultures and were treated with antibiotics and negative-pressure therapy before surgery. Results: Recurrence rates were 12% in the COP flap group and 60% in the conventional flap coverage group (P < 0.001). Results were compared at 16-month follow-up. Conclusions: The COP flap significantly reduces recurrences and eliminates shearing forces, suture ripping, and tension on superficial soft-tissue layers. The technique can be applied to both ischial and sacral pressure sores. The flap provides padding over bony prominence without jeopardizing flap vascularity.