Shane D. Morrison

Isolation of Human Adipose-Derived Stromal Cells Using Laser-Assisted Liposuction and Their Therapeutic Potential in Regenerative Medicine

Harvesting adipose‐derived stromal cells (ASCs) for tissue engineering is frequently done through liposuction. However, several different techniques exist. Although third‐generation ultrasound‐assisted liposuction has been shown to not have a negative effect on ASCs, the impact of laser‐assisted liposuction on the quality and differentiation potential of ASCs has not been studied. Therefore, ASCs were harvested from laser‐assisted lipoaspirate and suction‐assisted lipoaspirate. Next, in vitro parameters of cell yield, cell viability and proliferation, surface marker phenotype, osteogenic differentiation, and adipogenic differentiation were performed. Finally, in vivo bone formation was assessed using a critical‐sized cranial defect in athymic nude mice. Although ASCs isolated from suction‐assisted lipoaspirate and laser‐assisted lipoaspirate both successfully underwent osteogenic and adipogenic differentiation, the cell yield, viability, proliferation, and frequency of ASCs (CD34+CD31−CD45−) in the stromal vascular fraction were all significantly less with laser‐assisted liposuction in vitro (p < .05). In vivo, quantification of osseous healing by micro‐computed tomography revealed significantly more healing with ASCs isolated from suction‐assisted lipoaspirate relative to laser‐assisted lipoaspirate at the 4‐, 6‐, and 8‐week time points (p < .05). Therefore, as laser‐assisted liposuction appears to negatively impact the biology of ASCs, cell harvest using suction‐assisted liposuction is preferable for tissue‐engineering purposes.

Phalloplasty: A Review of Techniques and Outcomes.

Background: Acquired or congenital absence of the penis can lead to severe physical limitations and psychological outcomes. Phallic reconstruction can restore various functional aspects of the penis and reduce psychosocial sequelae. Moreover, some female-to-male transsexuals desire creation of a phallus as part of their gender transition. Because of the complexity of phalloplasty, there is not an ideal technique for every patient. This review sets out to identify and critically appraise the current literature on phalloplasty techniques and outcomes. Methods: A comprehensive literature search of the MEDLINE, PubMed, and Google Scholar databases was conducted for studies published through July of 2015 with multiple search terms related to phalloplasty. Data on techniques, outcomes, complications, and patient satisfaction were collected. Results: A total of 248 articles were selected and reviewed from the 790 identified. Articles covered a variety of techniques on phalloplasty. Three thousand two hundred thirty-eight patients underwent phalloplasty, with a total of 1753 complications reported, although many articles did not explicitly comment on complications. One hundred four patients underwent penile replantation and two underwent penile transplantation. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. Conclusions: Phalloplasty techniques are evolving to include a number of different flaps, and most techniques have high reported satisfaction rates. Penile replantation and transplantation are also options for amputation or loss of phallus. Further studies are required to better compare different techniques to more robustly establish best practices. However, based on these studies, it appears that phalloplasty is highly efficacious and beneficial to patients.

Enhancing In Vivo Survival of Adipose-Derived Stromal Cells Through Bcl-2 Overexpression Using a Minicircle Vector

Tissue regeneration using progenitor cell‐based therapy has the potential to aid in the healing of a diverse range of pathologies, ranging from short‐gut syndrome to spinal cord lesions. However, there are numerous hurdles to be overcome prior to the widespread application of these cells in the clinical setting. One of the primary barriers to effective stem cell therapy is the hostile environment that progenitor cells encounter in the clinical injury wound setting. In order to promote cellular survival, stem cell differentiation, and participation in tissue regeneration, relevant cells and delivery scaffolds must be paired with strategies to prevent cell death to ensure that these cells can survive to form de novo tissue. The Bcl‐2 protein is a prosurvival member of a family of proteins that regulate the mitochondrial pathway of apoptosis. Using several strategies to overexpress the Bcl‐2 protein, we demonstrated a decrease in the mediators of apoptosis in vitro and in vivo. This was shown through the use of two different clinical tissue repair models. Cells overexpressing Bcl‐2 not only survived within the wound environment at a statistically significantly higher rate than control cells, but also increased tissue regeneration. Finally, we used a nonintegrating minicircle technology to achieve this in a potentially clinically applicable strategy for stem cell therapy.

Modification of the tube-in-tube pedicled anterolateral thigh flap for total phalloplasty: the mushroom flap.

BackgroundMalformation or absence of the penis can lead to physical and psychological problems for male patients. Reconstruction of the phallus should optimally be completed in a single procedure, be aesthetically pleasing, retain erogenous and tactile sensation, enable micturition in the standing position, and allow for penetrative sexual intercourse. The tube-in-tube flap was described nearly 30 years ago and forms both a urethra and an outer penile shaft with a single flap. Here we present our modification of the original tube-in-tube design with the pedicled anterolateral thigh (ALT) flap and an extension for the neoglans, which we have termed the “mushroom flap” because of its shape and design. MethodsThe flap is based on the ALT flap; however, the area that will become the neoglans is shaped with a semicircular extension, resembling the head of a mushroom. When the flap is tubularized, the neoglans has the proper anatomic landmarks such as the corona and more closely approximates a circumcised penis. When used in conjunction with the tube-in-tube design, the neophallus, neoglans, and neourethra can all be constructed in a single stage with a single flap. ResultsWe have performed total phalloplasties in three patients using the pedicled ALT flap, and the mushroom flap design evolved as we sought to improve the aesthetics of the neoglans. In comparing the aesthetic results among our patients as well as those published in the literature, the mushroom flap design seems to provide the most natural and aesthetically pleasing appearance. ConclusionsThe pedicled ALT flap can be used to reconstruct an entire penis, as well as a urethra, without the need for microsurgery. By modifying the original tube-in-tube design to include a semicircular extension (a.k.a. the “mushroom flap”), we feel that we have been able to achieve a more natural-appearing neoglans.

Antimycotic Ciclopirox Olamine in the Diabetic Environment Promotes Angiogenesis and Enhances Wound Healing

Diabetic wounds remain a major medical challenge with often disappointing outcomes despite the best available care. An impaired response to tissue hypoxia and insufficient angiogenesis are major factors responsible for poor healing in diabetic wounds. Here we show that the antimycotic drug ciclopirox olamine (CPX) can induce therapeutic angiogenesis in diabetic wounds. Treatment with CPX in vitro led to upregulation of multiple angiogenic genes and increased availability of HIF-1α. Using an excisional wound splinting model in diabetic mice, we showed that serial topical treatment with CPX enhanced wound healing compared to vehicle control treatment, with significantly accelerated wound closure, increased angiogenesis, and increased dermal cellularity. These findings offer a promising new topical pharmacologic therapy for the treatment of diabetic wounds.

Facial Feminization: Systematic Review of the Literature

Background: Facial feminization surgery encompasses a broad range of craniomaxillofacial surgical procedures designed to change masculine facial features into feminine features. The surgical principles of facial feminization surgery can be applied to male-to-female transsexuals and anyone desiring feminization of the face. Although the prevalence of these procedures is difficult to quantify, because of the rising prevalence of transgenderism (approximately one in 14,000 men) along with improved insurance coverage for gender-confirming surgery, surgeons versed in techniques, outcomes, and challenges of facial feminization surgery are needed. This review is designed to critically appraise the current facial feminization surgery literature. Methods: A comprehensive literature search of the Medline, PubMed, and EMBASE databases was conducted for studies published through October of 2014 with multiple search terms related to facial feminization. Data on techniques, outcomes, complications, and patient satisfaction were collected. Results: Fifteen articles were selected and reviewed from the 24 identified, all of which were either retrospective or case series/reports. Articles covered a variety of facial feminization procedures. A total of 1121 patients underwent facial feminization surgery, with seven complications reported, although many articles did not explicitly comment on complications. Satisfaction was high, although most studies did not use validated or quantified approaches to address satisfaction. Conclusions: Facial feminization surgery appears to be safe and satisfactory for patients. Further studies are required to better compare different techniques to more robustly establish best practices. Prospective studies and patient-reported outcomes are needed to establish quality-of-life outcomes for patients. However, based on these studies, it appears that facial feminization surgery is highly efficacious and beneficial to patients.

Long-Term Outcomes of Rectosigmoid Neocolporrhaphy in Male-to-Female Gender Reassignment Surgery.

Background: Favorable outcomes of rectosigmoid neocolporrhaphy have previously been reported. Unfortunately, rectosigmoid transfers are still perceived negatively, usually relegated to secondary vaginoplasties. This study aims to provide an objective investigation into the safety and efficacy of rectosigmoid neocolporrhaphy for vaginoplasty in male-to-female transsexual patients. Methods: A retrospective review was performed on male-to-female patients who had undergone rectosigmoid neocolporrhaphy performed by the senior author. Patient data including demographics, medical history, complications, and the need for revision surgery were obtained. Direct inquires were conducted to determine patients’ level of satisfaction with appearance, sexual function, and ease of postoperative recovery. Results: Eighty-three patients were included over the course of 22 years, with an average clinical follow-up of 2.2 years (83 patients) and phone interview follow-up of 23 years (21 patients). Overall, the patients were healthy, with minimal comorbidities. Forty-eight patients (58 percent) had complications, but the majority (83.3 percent) were minor and consisted mainly of introital stricture or excessive protrusion of the corpus spongiosum. Smoking was associated with higher complication rates (p = 0.05), especially stricture formation. Excessive mucorrhea occurred in 28.6 percent but resolved after the first year. Overall patient satisfaction with appearance and sexual function was high. Conclusions: This study is one of the largest and longest reported series of rectosigmoid transfers for vaginoplasty in transsexual patients. Rectosigmoid neocolporrhaphies have many times been recommended for secondary or revision surgery when other techniques, such as penile inversion, have failed. However, the authors believe the rectosigmoid transfer is safe and efficacious, and it should be offered to male-to-female patients for primary vaginoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Epidermal or dermal specific knockout of PHD-2 enhances wound healing and minimizes ischemic injury

Introduction Hypoxia-inducible factor (HIF)-1α, part of the heterodimeric transcription factor that mediates the cellular response to hypoxia, is critical for the expression of multiple angiogenic growth factors, cell motility, and the recruitment of endothelial progenitor cells. Inhibition of the oxygen-dependent negative regulator of HIF-1α, prolyl hydroxylase domain-2 (PHD-2), leads to increased HIF-1α and mimics various cellular and physiological responses to hypoxia. The roles of PHD-2 in the epidermis and dermis have not been clearly defined in wound healing. Methods Epidermal and dermal specific PHD-2 knockout (KO) mice were developed in a C57BL/6J (wild type) background by crossing homozygous floxed PHD-2 mice with heterozygous K14-Cre mice and heterozygous Col1A2-Cre-ER mice to get homozygous floxed PHD-2/heterozygous K14-Cre and homozygous floxed PHD-2/heterozygous floxed Col1A2-Cre-ER mice, respectively. Ten to twelve-week-old PHD-2 KO and wild type (WT) mice were subjected to wounding and ischemic pedicle flap model. The amount of healing was grossly quantified with ImageJ software. Western blot and qRT-PCR was run on protein and RNA from primary cells cultured in vitro. Results qRT-PCR demonstrated a significant decrease of PHD-2 in keratinocytes and fibroblasts derived from tissue specific KO mice relative to control mice (*p<0.05). Western blot analysis showed a significant increase in HIF-1α and VEGF protein levels in PHD-2 KO mice relative to control mice (*p<0.05). PHD-2 KO mice showed significantly accelerated wound closure relative to WT (*p<0.05). When ischemia was analyzed at day nine post-surgery in a flap model, the PHD-2 tissue specific knockout mice showed significantly more viable flaps than WT (*p<0.05). Conclusions PHD-2 plays a significant role in the rates of wound healing and response to ischemic insult in mice. Further exploration shows PHD-2 KO increases cellular levels of HIF-1α and this increase leads to the transcription of downstream angiogenic factors such as VEGF.

Educational Exposure to Transgender Patient Care in Plastic Surgery Training.

Background: Gender dysphoria is estimated to occur in up to 0.9 percent of the U.S. population. With increasing awareness and decreasing stigma surrounding transgender issues, it is predicted that more patients will begin to seek medical and surgical transition. This study aims to determine the current state of transgender-related education in U.S. plastic surgery residency programs and to evaluate trainee perceptions regarding the importance of such training. Methods: Plastic surgery trainees from a representative sample of 21 U.S. training programs were asked to complete a cross-sectional eight-question survey between November of 2015 and January of 2016. Respondents were queried regarding demographics, transgender curricular exposure (didactic versus clinical), and perceived importance of training opportunities in transgender patient care. Results: A total of 322 residents or fellows responded to the survey (80 percent response rate) from four U.S. Census regions. Sixty-four percent of respondents had education on or direct exposure to transgender patient care during residency. Among those with experiences in gender-confirming surgery, more than half were exposed to chest and genital surgery. Overall, the majority of respondents believed that training in gender-confirming surgery is important, and 72 percent endorsed the necessity for gender-confirming surgery fellowship training opportunities. Conclusions: A significant number of plastic surgery trainees are exposed to transgender patient care, although exposure type is variable. The majority of trainees endorsed the importance of residency and fellowship training in gender-confirming surgery. To better serve the transgender population, formal fellowship training in gender-confirming surgery should be offered.

Current State of Female-to-Male Gender Confirming Surgery

Current advances in female-to-male gender confirming surgery allow for facial masculinization, chest masculinization, gynecologic removal of female sex organs, and genital reconstruction. With the breadth of approaches to each of these surgeries, it is important for providers as well as patients to be informed of the available options. In this review, the current state of female-to-male surgical approaches is discussed for the gender dysphoric patient who has typically initiated medical transition.