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Background Anastomotic leakage remains a dreaded complication after colorectal surgery. Stem-cell-based therapies have been shown to increase angiogenesis and cell proliferation. Objective The purpose of this research was to investigate the use of adipose-derived stem cells on the healing of ischemic colonic anastomoses in a rat model. Design This is an animal research study using xenotransplantation. Settings Male Wistar rats (300-400 g, n = 48) were purchased from a licensed breeder. Patients Adipose stem cells were isolated from the subcutaneous fat of healthy human donors. Interventions The rats underwent laparotomy with creation of an ischemic colorectal anastomosis created by ligation of mesenteric vessels. The animals were divided into 3 groups: control group with an ischemic anastomosis, vehicle-only group in which the ischemic anastomosis was treated with an absorbable gelatin sponge, and a treatment group in which the ischemic anastomosis was treated with an absorbable gelatin sponge plus adipose stem cells. Animals were killed at postoperative days 3 and 7. Main outcome measures Anastomotic leakage was defined as the finding of feculent peritonitis or perianastomotic abscess on necropsy. Rat mRNA expression was measured using real-time polymerase chain reaction. Results Adipose-derived stem cells significantly decreased anastomotic leakage when compared with control at both postoperative days 3 (25.0% vs 87.5%; p = 0.02) and 7 (25.0% vs 87.5%; p = 0.02). The use of an absorbable gelatin sponge alone had no effect on anastomotic leakage when compared with control and postoperative days 3 or 7. We found that stem cell-treated animals had a 5.9-fold and 7.4-fold increase in the expression of vascular endothelial growth factor when compared with control at 3 and 7 days; however, this difference was not statistically significant when compared with the absorbable gelatin sponge group. Limitations This is a preclinical animal research study using xenotransplantation of cultured stem cells. Conclusions Locally transplanted adipose stem cells enhance the healing of ischemic colorectal anastomoses and may be a novel strategy for reducing the risk of anastomotic leakage in colorectal surgery. See Video Abstract at http://links.lww.com/DCR/B203. EL TRANSPLANTE LOCAL DE CELULAS MADRE ADIPOSAS REDUCE LA FUGA ANASTOMOTICA EN LAS SUTURAS COLORRECTALES ISQUEMICAS: MODELO EN RATAS: Las fugas anastomoticas son una complicacion pusilanime despues de toda cirugia colorrectal. Se ha demostrado que el tratamiento con celulas madre aumenta la angiogenesis y la proliferacion celular.Investigar el uso de celulas madre derivadas de tejido adiposo en la cicatrizacion de una anastomosis colonica isquemica basada en ratas como modelo.Estudio de investigacion en animales utilizando xenotrasplantes.Adquisicion de tipicas ratas de laboratorio raza Wistar, todas machos (300-400 g, n = 48) de un criadero autorizado.Aislamiento de celulas madre de tipo adiposo del tejido celular subcutaneo en donantes humanos sanos.Las ratas se sometieron a laparotomia con la creacion de una anastomosis colorrectal isquemica obtenida mediante ligadura controlada de los vasos mesentericos correspondientes. Los animales se dividieron en tres grupos: grupo de control con anastomosis isquemica, grupo de vehiculo unico en el que la anastomosis isquemica se trato con una esponja de gelatina absorbible, y un grupo de tratamiento en el que la anastomosis isquemica se trato con una esponja de gelatina absorbible asociada a un vastago adiposo de celulas madre. Los animales fueron sacrificados el POD3 y el POD7.La fuga anastomotica fue definida como el hallazgo de peritonitis fecaloidea o absceso perianastomotico a la necropsia. La expresion de RNAm de las ratas se midio usando PCR en tiempo real.Las celulas madre derivadas de tejido adiposo disminuyeron significativamente la fuga anastomotica en comparacion con el grupo control tanto en el POD3 (25% frente a 87.5%, p = 0.02) como en el POD7 (25% frente a 87.5%, p = 0.02). El uso de una esponja de gelatina absorbible sola, no tuvo efecto sobre la fuga anastomotica en comparacion con los controles el POD3 o el POD7. Descubrimos que los animales tratados con celulas madre adiposas tenian un aumento de 5,9 y 7,4 veces en la expresion de VEGF en comparacion con el control a los 3 y 7 dias, respectivamente; sin embargo, esta diferencia no fue estadisticamente significativa en comparacion con el grupo de esponja de gelatina absorbible.Este es un estudio preclinico de investigacion en animales que utiliza xenotrasplantes de celulas madre adiposas cultivadas.Las celulas madre de tipo adiposo trasplantadas localmente mejoran la cicatrisacion en casos de anastomosis colorrectales isquemicas, y podrian convertirse en una nueva estrategia para reducir el riesgo de fugas anastomoticas en casos de cirugia colorrectal. Consulte Video Resumen en http://links.lww.com/DCR/B203. (Traduccion-Dr Xavier Delgadillo).

Introduction: Abdominal aortic aneurysms (AAA) are responsible for over 150,000 deaths worldwide annually. Attempts at producing a reliable large-animal model of AAA have proven challenging. We sought to create a reproducible swine model of AAA using enzymatic degradation of the aortic wall. Methods: A total of 9 male Yorkshire swine received periadventitial injections of type 1 collagenase (23.5 mg) and porcine pancreatic elastase (500 mg) into a 4 cm segment of infrarenal aorta. Aortic diameter growth was monitored at POD 7 and 14 using ultrasound. The animals were euthanized on POD 21, and the suprarenal (control) and infrarenal (treated) aorta was harvested for analysis, after gross measurement of aortic diameter under physiologic blood pressure. Sections of control and treated aorta were used to obtain tensile strength using a tensiometer. Additional segments of the aorta were collected for histopathological analysis (H&E, elastin, alpha smooth muscle actin). PCR of matrix metalloproteinases (MMP9) was conducted. Groups were compared with paired t-tests, or ANOVA for repeated measures, where appropriate. Results: Average percent growth of aortic diameter at POD 21 for treated segments was 27% +/- 16.5% versus 4.5% +/- 4% for control tissue. The average difference in aortic growth by subject, was 26.7% [14.6%-38.8%]; (p Conclusion: A reproducible, large-animal model of AAA, with anatomical, histopathological, and biomechanical properties that are clinically translatable, can be achieved with extraluminal enzymatic degradation.

Retrohepatic inferior vena cava (RIVC) injuries are often lethal due to challenges in obtaining hemorrhage control. We hypothesized that packing with a new kaolin-based hemostatic dressing (Control+; Z-Medica, Wallingford, CT) would improve hemorrhage control from a penetrating RIVC injury compared with packing with standard laparotomy sponges alone.Twelve male Yorkshire pigs received a 25% exchange transfusion of blood for refrigerated normal saline to induce a hypothermic coagulopathy. A laparotomy was performed and a standardized 1.5 cm injury to the RIVC was created which was followed by temporary abdominal closure and a period of uncontrolled hemorrhage. When the mean arterial pressure reached 70% of baseline, demonstrating hemorrhagic shock, the abdomen was re-entered, and the injury was treated with perihepatic packing using standard laparotomy sponges (L; n = 6) or a new kaolin-based hemostatic dressing (K; n = 6). Animals were then resuscitated for 6 hours with crystalloid solution. The two groups were compared using the Wilcoxon rank sum test and Fisher exact test. A p value of 0.05 or less was considered statistically significant.There was no difference in the animal's temperature, heart rate, mean arterial pressure, cardiac output, and blood loss at baseline or before packing was performed (all p0.05). In the laparotomy sponge group, five of six pigs survived the entire study period, whereas all six pigs treated with kaolin-based D2 hemostatic dressings survived. Importantly, there was significantly less blood loss after packing with the new hemostatic kaolin-based dressing compared with packing with laparotomy sponge (651 ± 180 mL vs. 1073 ± 342 mL; p ≤ 0.05).These results demonstrate that the use of this new hemostatic kaolin-based dressing improved hemorrhage control and significantly decreased blood loss in this penetrating RIVC model.This is basic science research based on a large animal model, level V.

Paclitaxel improves the oncologic response of breast cancer resections; however, it may negatively affect the wound-healing potential of human adipose-derived stem cells (hASCs) for fat grafting and reconstructive surgery. Histone deacetylase inhibitors (HDACis) modify the epigenetic regulation of gene expression and stabilize microtubules similarly to paclitaxel, thus, creating a synergistic mechanism of cell cycle arrest. We aim to combine these drugs to enhance cytotoxicity towards breast cancer cells, while preserving the wound-healing function of hASCs for downstream reconstructive applications.Triple negative breast cancer cells (MBA-MB-231) and hASCs (institutional review board-approved clinical isolates) were treated with a standard therapeutic dose of paclitaxel (1.0 μM) or with low-dose paclitaxel (0.1 μM) combined with the HDACi suberoylanilide hydroxamic acid or trichostatin A. Cell viability, gene expression, apoptosis, and wound-healing/migration were measured via methylthiazol tetrazolium assay, quantitative real-time polymerase chain reaction, annexin V assay, and fibroblast scratch assay, respectively.Combined HDACi and low-dose paclitaxel therapy maintained cytotoxicity towards breast cancer cells and preserved adipose-derived stem cell viability. Histone deacetylase inhibitor demonstrated selective anti-inflammatory effects on adipose-derived stem cell gene expression and decreased expression of the proapoptotic gene FAS. Furthermore, HDACi therapy did not increase relative apoptosis within hASCs. A scratch assay demonstrated enhanced wound healing among injured fibroblasts indirectly co-cultured with HDACi-treated hASCs.Combining HDACi with low-dose paclitaxel improved cytotoxicity towards breast cancer cells and preserved hASC viability. Furthermore, enhanced wound healing was observed by improved migration in a fibroblast scratch assay. These results suggest that the addition of HDACi to taxane chemotherapy regimens may improve oncologic results and wound-healing outcomes after reconstructive surgery.

Objectives: The goal of our study is to investigate the effect of adipose derived stem cells (ASCs), endothelial differentiated (ED) ASCs, and various conditioned medium (CM) on wound healing in a diabetic swine model. Methods: Diabetes was induced in 4 male Yorkshire pigs via intravenous injection of 150 mg/kg Streptozotocin. Pig ASCs were harvested and cultured in either M199 or EGM-2 medium with 30 mm glucose. Fourteen circular dorsal wounds (5 cm diameter; 5 mm depth) were created. Duplicate wounds were treated with one of 4 cell-based therapies by injection of 5 million (M) ASCs, 10M ASCs, 5M ED ASCs, or 10M ED ASCs on day 0 and half the initial dose on day 15. Wounds assigned to the topical CM therapy were covered with 2 cc of either serum free M199 primed by ASCs or Human Umbilical Vein Endothelial Cells every 3 days. One set of wound was designated as control. Wounds were assessed at day 0, 10, 15, 20 and 28. Animals were sacrificed on day 28. Image J software was used to evaluate percent wound healing. Results: On day 10, 15, 20 and 28 there was a significant increase in percent wound closure rates in both cell-based treatments when compared to control (pFigure 1 ). All treatments displayed significant increase in wound closure rates on day 28 when compared to control. Histology revealed a decrease in dermal inflammatory cells and improved restoration of normal skin architecture in therapeutic treatment groups when compared to untreated controls. Conclusions: Cellular therapy with ASCs, ED ASCs and topical CM accelerate diabetic wound healing in the swine model. Cellular therapy may provide the greatest benefit, as cells may continuously supply growth factors and adapt to the evolving microcellular environment as the wound progresses through the various phases of healing

Background: Diabetes type 1 and 2 cause hyperglycemia and result in endothelial dysfunction with endothelial vessel and poor wound healing. Adipose-derived stem cells (ASCs), progenitor cells in wound healing, show decreased function under hyperglycemic conditions in vitro and in vivo . We hypothesized that exposing ASCs in the presence of high glucose with the human umbilical vein endothelial cell (HUVEC) secretome will reverse the deleterious effects of glucose on ASCs and subsequently enhance angiogenesis and wound healing. Methods: Human umbilical vein endothelial cells (HUVEC) were treated with glucose (30mM) and the conditioned media (CM) were collected every 3 days. ASCs were then co-cultured with EC/CM for 2 weeks. To produce thermal denaturation of protein, EC/CM was heated at 95 0 C for 30 mins. Cell activity, proliferation, and endothelial-like properties of ASCs were determined by MTT assays, growth curves, and real-time RT-PCR, respectively. EC/CM treated ASC were injected into a normal or diabetic murine left thigh muscle at three different points with hindlimb ischemia. After 4 weeks injection, animals were sacrificed. H & E and double immunostaining for CD31 and anti-human nuclei were used to determine if the ASCs primed with EC/CM underwent neovascularization. Results: In fact, ASCs increased in proliferation when co-cultured with HUVEC/CM (1.4 fold) when compared with controls. This promoting effect was lost in heated HUVEC/CM, indicating that the active molecules are of protein origin. After 10 days stimulated with EC/CM an increase in mRNA expression levels of EC markers were also observed in high glucose (30mM) EC/CM environment including CD31 (2-fold), vWF (1.1-fold), and eNOS (3.2-fold) when compared to ASCs cultured in M199. H & E and immunohistochemical staining results showed elevated vessel density and CD31 + cell levels in HUVEC-primed ASC injection sites of diabetic mice when compared with the control animals. Conclusions: HUVEC secrete protein factors that increase proliferation and endothelial differentiation of ASCs under diabetic conditions. Injection of ischemic hindlimbs in diabetic mice with HUVEC-primed ASCs leads to improved angiogenesis.

This pilot study examined the efficacy of 5-bromo-2-deoxyuridine-labeled autologous adipose-derived stem cells seeded onto collagen scaffolds to augment and/or regenerate the fat-enriched hypodermal tissue in an acute porcine wound model.Porcine autologous adipose-derived stem cells were isolated and cultured. At passage 2, the cells were labeled with 5-bromo-2-deoxyuridine, seeded onto a three-dimensional collagen scaffold, and cultured for 10 days. Scaffolds were implanted subcutaneously in adult pigs with two adipose-derived stem cell scaffolds and two control scaffolds. Animals were euthanized at 2, 4, 8, and 12 weeks; all scaffold conditions were explanted for histology and immunohistochemistry analyses.For all time points, adipose-derived stem cell scaffolds had increased connective tissue matrix within the subcutaneous tissue compared with scaffold alone and untreated porcine skin (p0.01). The neosynthesized connective tissue was vascularized and composed of small cells within an abundant extracellular matrix organized in layers. 5-Bromo-2-deoxyuridine cells were detectable only up to 4 weeks and mature adipocytes were absent. Levels of collagen types I, III, and VI differed among the experimental groups, with increased extracellular matrix associated with the presence of adipose-derived stem cells.The authors' data clearly show the efficacy of adipose-derived stem cells for soft-tissue repair and skin aging because it induces a significant increase of the dermis thickness. Moreover, the authors' results demonstrate the interest of their acute wound model and allowed them to show the skin thickness variation over time of the experiment, which is one of the challenges with which clinicians struggle in fat grafting.

The use of knotless barbed sutures has shortened operation times for wound closure. In experimental models, their use in tendon surgery is still under investigation. This study looks at the use of barbed sutures in a porcine model for fascial repair when compared with traditional absorbable suture to further extend their clinical use.Six animals were included in this study. Each had two paramedian incisions, down to the fascia at the junction between the lateral edge of the rectus abdominis muscle and the transverse abdominis/oblique muscles of the abdominal wall. One fascial incision was closed with 2-0 Quill polydioxanone barbed suture and the other was closed with the control suture 1-0 PDS II (polydioxanone). The overlying skin was closed with Quill polydioxanone barbed suture for both incisions. At 6 weeks, the fascia was excised and the suture lines were tested for tensile strength.There were no wound infections and no incisional hernias. The Quill polydioxanone barbed suture had a mean tissue tensile strength of 265.59 N (range, 206.86 to 306.38 N) and the control suture (polydioxanone) had a mean tissue tensile strength of 227.28 N (range, 132.79 to 290.35 N). The difference was not statistically significant (p = 0.341).This study demonstrated that barbed sutures for fascial repair have equivalent tensile strength when compared with traditional nonbarbed sutures, with no adverse events such as wound dehiscence or incisional hernia. This preclinical study lends support to the practice of using barbed sutures for indications such as rectus sheath plication.

Adipose-derived stem cells are multipotent cells that can easily be extracted from adipose tissue, are capable of expansion in vitro, and have the capacity to differentiate into multiple cell lineages, which have the potential for use in regenerative medicine. However, several issues need to be studied to determine safe human use. For example, there are questions related to isolation and purification of adipose-derived stem cells, their effect on tumor growth, and the enforcement of U.S. Food and Drug Administration regulations. Numerous studies have been published, with the interest in the potential for regenerative medicine continually growing. Several clinical trials using human adipose stem cell therapy are currently being performed around the world, and there has been a rapid evolution and expansion of their number. The purpose of this article was to review the current published basic science evidence and ongoing clinical trials involving the use of adipose-derived stem cells in plastic surgery and in regenerative medicine in general. The results of the studies and clinical trials using adipose-derived stem cells reported in this review seem to be promising not only in plastic surgery but also in a wide variety of other specialties. Nevertheless, those reported showed disparity in the way adipose-derived stem cells were used. Further basic science experimental studies with standardized protocols and larger randomized trials need to be performed to ensure safety and efficacy of adipose-derived stem cells use in accordance with U.S. Food and Drug Administration guidelines.

The sartorius muscle is a superficial thigh muscle with specific anatomical characteristics in terms of shape and vascular supply. Few studies have assessed the vascular supply of the muscle and overlying skin paddle and its potential in reconstructive surgery. The study used three-dimensional, four-dimensional imaging to analyze the segmental vascularity of the muscle, as well as the overlying skin paddle, to define arcs of rotation based on its major pedicles.Thirty sartorius muscles and the circumferential skin of the thigh were harvested from adult cadavers. Anatomic considerations, such as pedicle number, location, diameter, and length, were recorded. Three-dimensional and four-dimensional computed tomography angiography was used to measure the length of muscle perfused by a single pedicle defined as a major pedicle. Lastly, the area of cutaneous territory supplied by each major pedicle was calculated.The sartorius muscle is supplied by six to eight vascular pedicles. Two clusters of major pedicles (diameter greater than 1.8 mm) were described (proximal and distal), which are located 18 to 25 cm and 35 to 44 cm from the anterior superior iliac spine, respectively. The proximal major pedicle perfuses almost 80 percent of the muscle, and the distal major pedicle perfuses almost 90 percent. The average area of skin perfused was 330 cm.This study suggests greater anatomical assurance of the potential use of the sartorius muscle and its overlying skin as a local transposition and free flap. The vascular supply of the muscle and skin by two major pedicles allows two pivot points for muscular or musculocutaneous flaps. The various applications for reconstructive surgery based on these arcs of rotation are discussed.

This is a report of the secondary endpoints, Subject Global Evaluation (overall improvement) and Subject Satisfaction scores, from a study designed to examine the efficacy of injectable poly-L-lactic acid for the correction of nasolabial fold wrinkles over 25 months.A randomized, subject-blinded, parallel-group, multicenter clinical study was conducted to compare the effects of injectable poly-L-lactic acid with those of human collagen for the treatment of nasolabial fold wrinkles at 13 months following the last treatment. Injectable poly-L-lactic acid-treated subjects were followed for 25 months.From month 3 through month 13 following the last treatment, injectable poly-L-lactic acid-treated subjects (n = 116) reported significantly higher Subject Global Evaluation scores compared with human collagen-treated subjects (n = 117; p0.001). Overall Subject Global Evaluation scores for injectable poly-L-lactic acid-treated subjects were 99 percent at week 3, 91 percent at month 13, and 81 percent at month 25 (all times following the last treatment). In contrast, for human collagen-treated subjects, overall Subject Global Evaluation scores declined by 84 percent, from 96 percent at week 3 to 15 percent at month 13. Subject Satisfaction scores were significantly different (p0.01) between treatment groups beginning week 3 and continuing through month 13. Overall Subject Satisfaction scores were maintained for over 80 percent of injectable poly-l-lactic acid-treated subjects (n = 106) at month 25 after the last treatment.Treatment of nasolabial fold wrinkles with injectable poly-l-lactic acid resulted in statistically significantly higher Subject Global Evaluation and Subject Satisfaction scores compared with human collagen at 13 months. Injectable poly-l-lactic acid-treated subjects maintained improvements for up to 25 months after treatment.

Periorbital rejuvenation has increasingly relied on augmentation with fillers. Numerous techniques have been described, including augmentation of the sub-orbicularis oculi fat. Cadaver studies initiated 2 years ago yielded presumptive evidence that sub-orbicularis oculi fat consists of two distinct regions. Knowledge of this anatomy is important for precision in facial rejuvenation.A pilot study was performed with radiopaque dye injection into the sub-orbicularis oculi fat and computed tomographic evaluation with three-dimensional reconstruction. Eight hemifacial fresh cadaver dissections were then performed with a modified dye injection technique to isolate regions of sub-orbicularis oculi fat and periorbital fat. The relationship of suborbicularis fat to deep cheek fat was observed.This study confirms the presence of two distinct regions of sub-orbicularis oculi fat. A medial component extends along the orbital rim from the medial limbus to the lateral canthus. A lateral component extends from the lateral canthus to the temporal fat pad. The lateral component terminated superiorly at the lateral orbital thickening. Deep cheek fat abutted the medial sub-orbicularis oculi fat, thus creating a deep fat system in continuity across the face of the maxilla and along the orbital rim.This anatomy helps to define midface adipose tissue as a system of superficial and deep fat, of which medial and lateral sub-orbicularis oculi fat are a part. A working hypothesis of facial aging continues with the concept that loss and/or ptosis of deep fat compartments leads to changes in shape and contour. Folds, in contrast, occur at transition points between thick and thinner superficial fat compartments. These anatomical observations further the goal of site-specific augmentation and facial rejuvenation.

Reports suggest that the anterolateral thigh flap can be reliably extended to include adjacent vascular territories. The vascular basis of this phenomenon is poorly understood. This study examines the three- and four-dimensional arterial and venous anatomy of the extended anterolateral thigh flap and reports the results of a clinical series of extended anterolateral thigh flaps.Fifteen anterior hemithigh specimens harvested from fresh cadavers from the Western population were studied. Four-dimensional computed tomographic angiography was used to investigate the arterial and venous anatomy and pattern of perfusion. Injection of perforators within the lateral femoral circumflex femoral vascular territory, and those of the common femoral and superficial femoral arteries, was performed to investigate the vascular connections within the extended anterolateral thigh flap. Static three-dimensional imaging and latex dissections were also performed to confirm the results. A clinical series of 12 consecutive patients is also reported in which extended anterolateral thigh flaps were used for posttrauma or postoncologic reconstruction.Large-diameter linking vessels at the suprafascial level enabled perfusion of the adjacent common femoral and superficial femoral artery vascular territories. In the clinical series, the flap cutaneous territory ranged from 250 to 630 cm (mean, 365 cm), with all flaps except one perfused by a single perforator. No partial or complete flap losses occurred.This study reports the vascular basis and clinical safety of the extended anterolateral thigh flap, which can be harvested if the linking vessels between adjacent vascular territories in the anterior thigh are preserved. The extended flap is reliably perfused by a single dominant perforator.

Background: Accurate preoperative planning combined with facial fat compartment augmentation can improve precision and balance in facial rejuvenation techniques. Understanding the concept of "facial shaping" with respect to symmetry and soft-tissue (fat) distribution preoperatively is critical to optimizing aesthetic outcomes in various face lift techniques. Methods: A review of 822 consecutive face lifts performed from January of 1994 to June of 2007 by a single surgeon (R.J.R.) was conducted. From this database, randomly selected cohorts of 50 preoperative and postoperative photographs were critically analyzed by three plastic surgeons exclusive of the senior surgeon (RJ.R.). Three facial parameters were compared on each facial side: facial height, degree of malar deflation, and orbit size. Long-term improvement was evaluated to delineate factors contributing to success in creating an aesthetically balanced facial shape. Results: Asymmetry between the two facial sides was noted in every patient preoperatively with respect to the three study parameters and was improved postoperatively. There was no statistically significant interobserver bias in the evaluations (p < 0.005). Facial asymmetry dictated differential treatment of the superficial musculoaponeurotic system (SMAS) tissue between facial sides to achieve the desired youthful facial shape. The angle (vector) and extent of SMAS-stacking varied depending on the preoperative analysis. Similarly, the selection of SMAS-ectomy versus SMAS-stacking depended on the degree of malar deflation and resultant cheek fullness. Conclusions: Proper preoperative analysis for evaluating facial shape should address (1) facial height, (2) facial width, and (3) overall distribution/location of facial fullness. This method of evaluating facial shape and symmetry is simple and reproducible, and can aid in formulating a comprehensive treatment plan.

Fractional photothermolysis is extremely popular in skin rejuvenation and remodeling procedures. However, the extent of thermal cellular injury beyond the borders of the coagulated microcolumns produced with fractional phototherapy is undefined.Six abdominoplasty patients were pretreated with the Lux1540 Fractional Erbium device (Palomar, Inc., Burlington, Mass.) at various clinical laser settings. After tissue excision, the panni were immediately biopsied. Biopsy specimens were fixed in formalin, embedded in paraffin, sectioned, and evaluated with the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick end labeling (TUNEL) procedure for cellular necrosis/apoptosis. Tissue was sectioned horizontally and longitudinally to help define the depth and distribution of the microcolumns of injury in a three-dimensional plane.The extent of cellular necrosis/apoptosis at variable depths within the epidermis and dermis was demonstrated successfully with the TUNEL technique. After the Lux1540 treatment, TUNEL-positive nuclei were identified in a vertically oriented fashion that extended from the epidermis into the papillary and reticular dermis, highlighting the areas of injury. The TUNEL-positive nuclei defined lesions that were approximately 175 to 225 microm in diameter and penetrated to variable depths (200 to 900 microm), depending on the fluence used for treatment (18 to 100 mJ).TUNEL immunofluorescent labeling provided an accurate assessment of cellular damage within and surrounding the microthermal zones of coagulated collagen with respect to column depth and width. Because of its specificity, the TUNEL assay can be a useful adjunct to other histologic stains used to characterize cellular damage and matrix denaturation in skin treated with any fractional ablative or nonablative laser device.

High reoperation rates continue to agonize the field of breast augmentation surgery. Patient dissatisfaction is a contributing factor for reoperations. This is often attributable to patients' desire to be larger after the augmentation. Polyethylene glycol (PEG) is a potential alternative breast implant filler under investigation. It has been shown to swell secondary to osmotic expansion when it is placed in vivo. We hypothesize that there is a finite expansion in this process. An experimental study was designed utilizing an in vitro model to quantify the rate and volume of the osmotic expansion of PEG-filled implants. Seventeen silicone elastomer shells were filled with various percent concentration and molecular weight PEG/saline solutions. These implants were kept in saline baths at varying temperatures to assess the effect of temperature on osmotic expansion. Daily weights were recorded to quantify the expansion and determine if a plateau was reached. Implant expansion was observed to plateau in all groups tested. Implants filled with 85% concentration PEG solutions demonstrated a uniform expansion at a rate of 0.032 to 0.037 g/d. Implants filled with 85% concentration PEG stored at human core temperature (37 degrees C) gained on average 6.2% to 7.6% of their original weight. Implants stored at 4 degrees C expanded to a higher volume than implants stored at 37 degrees C (P < 0.01). Implants filled with 50% concentration PEG solution gained only 2.7% of their original weight (P < 0.01). PEG-filled implants undergo controlled osmotic expansion to a final predictable weight in vitro. Higher concentration PEG induces greater volume expansion. A colder environment also induces greater volume expansion. PEG is biologically inert and may be an alternative filler for breast implants. The predictable expansion process may be beneficial in breast augmentation that may alleviate patient dissatisfaction about breast size once postoperative edema resolves.

There is a paucity of evidence within the plastic surgery literature concerning risk stratification and management of patients with respect to thromboembolic disease. A retrospective chart review was conducted to examine whether the Davison-Caprini risk-assessment model could stratify patients undergoing excisional body contouring surgery, allowing prophylaxis to be managed in an evidence-based manner.Three hundred sixty excisional body contouring patients at the University of Texas Southwestern Medical Center in Dallas, Texas, under the senior authors' (J.M.K. and R.J.R.) care were reviewed. Patients were stratified into groups according to the risk-assessment model and into groups based on procedure. Patient characteristics were investigated for their effects on thromboembolic risk. Complications of enoxaparin administration were analyzed. The data were analyzed using appropriate statistical procedures.The highest risk patients had a significantly increased rate of venous thromboembolism when compared with lower risk patients. Body mass index greater than 30 and hormone therapy use were associated with a significantly increased venous thromboembolism rate. Enoxaparin administration was associated with a statistically significant decrease in deep venous thrombosis in circumferential abdominoplasty patients. Enoxaparin administration was associated with higher bleeding rates.Low-molecular-weight heparin may affect the incidence of postoperative thrombotic complications in some surgical populations. In this study, patients who scored greater than four risk factors were at significant risk for venous thromboembolism. Enoxaparin significantly decreased deep venous thrombosis risk in patients undergoing circumferential abdominoplasty. This demonstrates the need for a multicenter, prospective, randomized study to examine various thromboembolic therapies and associated possible complications in these patients.

The vascular anatomy of the thoracodorsal artery perforator flap, which has not previously been elucidated, was examined using three- and four-dimensional computed tomographic angiography and venography.Twenty-five thoracodorsal artery perforator flaps were harvested from fresh cadavers from the Western population. Dynamic static computed tomographic angiography using iodinated contrast media was performed following cannulation of the largest perforator from the descending branch of the thoracodorsal artery and its vena comitans in 10 flaps. Imaging was repeated subsequent to flap thinning between the deep and superficial adipose layers. Colored latex injections and flap dissections were performed in a further 15 flaps to establish the location, caliber, and intramuscular length of the thoracodorsal artery perforators.Two distinct perforator complex types were described. Flap thinning can be safely performed between the deep and superficial adipose layers without significantly affecting flap vascularity, provided that a safety zone about the perforator is respected. The superficial venous system consisted of large veins arranged in a polygonal pattern situated at the subdermal level and was connected to the deep system by the venae comitantes of the thoracodorsal artery perforators. Perforators from the descending branch of the thoracodorsal artery were found in reliable locations.Using a novel dynamic three-dimensional imaging technique, perfusion of the arterial and venous system of the thoracodorsal artery perforator flap was elucidated. Although the flap is inherently thin, it can be safely thinned between the superficial and deep adipose layers. This study identified important advantages of the thoracodorsal artery perforator flap for use in reconstruction.

The removal of unwanted body fat using a noninvasive technique is desirable to patients and physicians. The authors describe a controlled, multicenter, clinical trial assessing the safety and efficacy of a focused therapeutic ultrasound device for noninvasive body contouring.Eligible healthy adult subjects were enrolled to the experimental group or the control group at five sites. The experimental group received one treatment with the Contour I device (UltraShape Ltd., Tel Aviv, Israel) in the abdomen, thighs, or flanks and were evaluated over a 12-week period. Efficacy outcomes were reduction of circumference and fat thickness. Circumference reduction was compared with the untreated group and with an untreated area (thigh) within the treated group. Safety monitoring included laboratory testing (including serum lipids), pulse oximetry, and liver ultrasound.One hundred sixty-four subjects participated in the study (137 subjects in the experimental group and 27 in the control, untreated group). A single Contour I treatment was safe and well tolerated and produced a mean reduction of approximately 2 cm in treatment area circumference and approximately 2.9 mm in skin fat thickness. The majority of the effect was achieved within 2 weeks and was sustained at 12 weeks. No clinically significant changes in the measured safety parameters were recorded. Seven adverse events were reported, all of which were anticipated, mild, and resolved within the study period.The Contour I device provides a safe and effective noninvasive technology for body contouring.

In 1998, the senior author presented the intraoperative fluid ratio, defined as the volume of super-wet solution and intraoperative intravenous fluid divided by the aspiration volume, to guide resuscitation fluid volumes in super-wet liposuction. The senior author demonstrated that intraoperative fluid ratios of 2.1 for small-volume and 1.4 for large-volume liposuction were safe and did not cause volume overload sequelae. A high urine output was common and reflected a mild overresuscitation, which could have adverse consequences in patients with undiagnosed cardiopulmonary disease. The purpose of this study was to compare overresuscitation sequelae in a cohort of consecutive super-wet liposuction patients using a new fluid management formula in which replacement fluid was given after 5000 cc of lipoaspirate instead of 4000 cc, as initially described.The charts of 89 consecutive patients undergoing super-wet liposuction were retrospectively reviewed.The intraoperative fluid ratio was 1.8 for the small-volume reductions (5000 cc, n = 68) and 1.2 (5001 cc, n = 21) for the large-volume reductions. There were no episodes of pulmonary edema, congestive heart failure exacerbation, or other major complications. The average urine output in the operating room, the recovery room, and while on the floor was 1.5, 1.6, and 2.9 cc/kg/hour for the small-volume group and 1.7, 1.8, and 2.5 cc/kg/hour for the large-volume group.The super-wet subcutaneous infiltration liposuction technique for both small- and large-volume reductions is safe and can be performed without adverse cardiopulmonary sequelae. Given the high urine outputs, the intraoperative fluid ratio can be further improved by possibly eliminating the replacement fluid altogether.

The determination of human skin thickness has been achieved through various methods, both in vivo and in vitro. Ultrasound and histometric analyses have been the most commonly used. However, absolute values of epidermal and dermal thicknesses have demonstrated variability among the different modalities, leaving questions regarding the ability to standardize or compare results of different studies.A cadaver study was designed to examine skin thicknesses in multiple anatomical sites from the same subject. Using three fresh adult cadavers, skin biopsy specimens were obtained at 15 facial sites that were identified as clinically relevant locations: upper lip vermilion, lower lip vermilion, philtral column, chin, upper eyelid, lower eyelid, brow/forehead, submental crease, right cheek, left cheek, right neck, left neck, malar eminence, nasal dorsum, and nasal tip. Histometric measurements were obtained at each location.In all subjects, the upper eyelid had the thinnest skin and was used as the denominator to calculate relative ratios of skin thicknesses with respect to other sites of the face. Using the upper eyelid average skin thickness, the nasal tip skin thickness was 3.30 times thicker and the brow/forehead was 2.8 times thicker.The authors propose a standardized and clinically useful method of skin thickness analysis by defining the relative thickness index. By examining relative values of skin thickness, using each subject as his or her own control, the authors demonstrated consistent ratios of dermal and epidermal thickness from one facial site to another.

Patients need to have realistic expectations for a long-term successful body contour result. There are four key elements for long-term successful improvement in body contour, and the patient is responsible for the first three: exercise, a proper diet, and other positive lifestyle changes; and successful body contouring. An extensive survey requesting information about the procedures, areas of liposuction, lifestyle habits, and satisfaction was mailed to 600 patients who had liposuction surgery performed between 1999 and 2003. One hundred and eight surveys were undeliverable and 209 completed surveys were returned (34.8 percent of 600 mailed surveys and 42.5 percent of 492 delivered surveys). Data were analyzed by a binary logistic regression with backward elimination. Weight gain (versus no weight gain) was used as the dependent variable. The results showed that regardless of whether the patient did or did not gain weight, both groups reported being very satisfied (30 percent and 48 percent, respectively) or satisfied (43 percent and 34 percent, respectively) with their procedure. Among the weight gain patients, 72 percent would still have the procedure again, compared with 82 percent of responders who did not gain weight. When asked if they would recommend the procedure to family or friends, 90 percent of responders who did not gain weight would recommend the procedure whereas only 74 percent of responders who did gain weight would recommend the procedure (p < 0.001). Among those patients who gained weight, only 29 percent thought their appearance was excellent or good (compared with 79 percent of those who did not gain weight). Among the 57 percent of patients who did not gain weight, 35 percent report exercising more postoperatively (compared with only 10 percent in the weight gain group, p = 0.002) and 50 percent report eating a healthier diet (22 percent in the weight gain group report eating a healthier diet, p = 0.002). In the weight gain group, 67 percent report no change in their diet regimen and only 17 percent thought their productivity increased (compared with 25 percent among the no weight gain group, p = 0.002). Successful body contouring surgery requires a patient to embrace positive lifestyle habits. The results of this survey have been used to create a quantitative decision-making framework or a "road map" for patients and plastic surgeons to use for navigating toward successful long-term results.

Patients are routinely exposed to high-dose epinephrine infiltration during large-volume liposuction. Because of the serious cardiovascular side-effect profile of catecholamine overdose, the authors examined the safety of larger-volume liposuction by assessing epinephrine pharmacokinetics. Five female volunteers with American Society of Anesthesiologists physical status of I or II, aged 29 to 40 years and weighing 75.9 to 95 kg, underwent liposuction. The wetting solution contained 7.3 mg (SEM, 0.7 mg) of epinephrine, corresponding to 0.09 mg/kg (0.04 mg/kg). Total plasma epinephrine and norepinephrine concentrations were assessed by high-performance liquid chromatography. Approximate exogenous epinephrine absorption was calculated after correction for estimated endogenous epinephrine production. Pharmacokinetic assessments were performed using standard equations. The total plasma epinephrine peak occurred at the final intraoperative reading (5 hours after induction) and was 323 pg/ml (24.8 pg/ml), three to four times maximum baseline resting levels. The norepinephrine level was slightly elevated throughout the study period, with a reversal of the normal epinephrine/norepinephrine ratio (0.5:1) demonstrated intraoperatively (5:1). Estimated time to peak exogenous epinephrine level ranged from 1 to 4 hours from the start of infiltration. Area under the plasma concentration versus time curve was approximately 2089 to 2610 pg x hour/ml. Peak exogenous epinephrine concentration was estimated to be 286 to 335 pg/ml. Clearance was 764,508 ml/hour and volume of distribution was 0.4 liter/kg (0.006 liter/kg). Total absorbed epinephrine was estimated, 1.8 mg to 2.2 mg, equivalent to 25 to 32 percent of the infiltrated dose. The reversal of the normal epinephrine/norepinephrine ratio and the fact that norepinephrine levels were within normal range implied that the majority of plasma epinephrine measured was exogenously infiltrated and not endogenously synthesized. On the basis of these observations, pharmacokinetic analyses were performed. Although unequivocal toxic epinephrine levels were not demonstrated, epinephrine peaks were three to four times the maximum observed in normal resting patients. Peak levels were comparable to those observed during major physiologic stresses, such as exercising to exhaustion, open abdominal surgery, or cross-clamping the aorta during surgical repair. Furthermore, epinephrine has been associated with myocardial infarction, arrhythmias, and fatal asystole in susceptible patients at these levels. Patients should be carefully screened for clinical evidence of hemodynamic and cardiac pathology before larger-volume liposuction is undertaken, as it may result in unnecessary high risk for patients who have preexisting cardiovascular disorders. Healthy American Society of Anesthesiologists physical status I or II patients should have sufficient cardiac reserve to tolerate these catecholamine levels.

Little is known about the physiology of large-volume liposuction. Patients are exposed to prolonged procedures, general anesthesia, fluid shifts, and infusion of high doses of epinephrine and lidocaine. Consequently, the authors examined the thermoregulatory and cardiovascular responses to liposucti

Nutritional therapy is critical for wound healing in people with severe malnutrition or specific metabolic deficiencies. Medical claims from manufacturers of many oral supplements are marketed to surgical patients for decreasing edema, bruising, and discomfort. The effect of supplementing nutrients on soft-tissue wound healing in otherwise normal, healthy adults is an area of clinical importance, but little information is available. Proteolytic enzymes have been reported to moderate the inflammatory cycle and may up-regulate the healing process. The goal of this study was to perform a clinical trial in normal, healthy adults that examined the effects of an oral nutritional supplement (InflammEnz, Enzymes, Inc., Parkville, Mo.) on soft-tissue healing times. Twenty-six normal, healthy volunteers were recruited into a randomized, crossover, placebo-controlled, clinical trial consisting of two phases, each lasting 21 days. In phase I, subjects were subjected to a 3-mm forearm skin biopsy and randomly received a placebo or oral supplement (four capsules per day for 7 days). After a 2-week washout period, a second biopsy was performed to start phase II, with each subject receiving the respective placebo or supplement capsules. Digital photographs were taken during wound healing in both phases and analyzed for wound areas (in square millimeters) and perimeters (in millimeters). Twenty-two subjects completed the clinical trial. On the basis of wound surface areas, 17 subjects had improved wound healing and five subjects did not respond or responded only slightly to the supplement treatment. The mean +/- SD healing time of the subjects responding to supplement-treated wounds was 15 +/- 2.2 days, compared with 18 +/- 2.5 days for the placebo group. The 17 percent acceleration of wound-healing time was significant (p < 0.005). In subjects responding to oral supplements, less redness in the wounds was observed that may have been associated with less inflammation. The authors' results demonstrate that InflammEnz oral supplementation accelerated soft-tissue wound healing in 77 percent of normal, healthy subjects studied. The authors' study validates observations made that this supplement modulates the wound-healing process and suggests that many patients with minor soft-tissue wounds may benefit from treatment.

Liposuction is a procedure that allows the surgical removal of excess adipose tissue in healthy individuals. Lipoplasty is commonly performed with few clinical side effects. However, with increased lipoaspirate volumes, complications have been reported. In addition, the abnormal appearance of fat cells in other tissues subsequent to lipoplasty has been reported in a small number of cases. The authors examined whether larger-volume lipoplasty, in the porcine model, resulted in disturbances in cardiac or pulmonary output levels, electrolytes, and liver chemistry analyses or alterations in organ histology. Nine adult porcine specimens were subjected to either lipoplasty (n = 6) with the superwet technique or no lipoplasty (n = 3). Using a Swan-Ganz catheter, cardiac output and pulmonary artery pressure measurements were obtained from initial placement before lipoplasty until 48 hours postoperatively. Blood analyte measurements were obtained. Upon euthanization, liver, kidney, and lung specimens were collected and tissue sections were prepared. No significant differences or trends were observed in cardiac parameters or blood analytes between control and experimental groups. Significant elevations in serum aspartate aminotransferase and alanine aminotransferase enzyme levels (p < 0.03) were observed in animals postoperatively (10 to 48 hours) subjected to lipoplasty compared with controls. Upon gross examination, the lung tissues of animals subjected to lipoplasty unexpectedly demonstrated patchy petechial hemorrhages on the pleural surface. Tissue sections revealed marked hemorrhagic congestion and evidence of pulmonary edema. Fat emboli were also identified within the pulmonary and renal systems.

Purpose: Shock wave lithotripsy is believed to cause renal damage directly through cellular injury from high energy shock waves and indirectly through vascular injury and resultant ischemia, which gives rise to oxygen free radical compounds. The transient and volatile nature of free radicals and derived products makes their detection difficult. Moreover, certain medications may provide a protective effect against shock wave lithotripsy induced renal parenchymal injury. We introduced an innovative microdialysis system for in vivo sampling of interstitial fluids that can be analyzed for free radical mediated lipid peroxidation products after shock wave lithotripsy treatment in the swine model. In addition, this system was used to test the antioxidant or renoprotective action of allopurinol.Materials and Methods: Ten juvenile swine were assigned to a nonmedicated control group that underwent shock wave lithotripsy or to a group that was premedicated with allopurinol before shock wave lithotripsy. Each group ...

Patient smoking status affects many aspects of plastic surgery, including patient selection, counseling, management, and outcomes. No specific recommendations for performing elective procedures on patients who smoke are available. The goal of this study was to determine the current practice standards and attitudes toward this often controversial topic. In September of 2000, 1600 members of the American Society for Aesthetic Plastic Surgery were sent questionnaires, 955 of which were returned. Questions elicited categorical answers, either dichotomous or multiple choice. Data were evaluated using logistic regression and the chi-square and binomial tests. Our results show that 60 percent (p < 0.01) of plastic surgeons routinely perform a less than optimal procedure on their patients who smoke. The survey measured willingness to perform various operative procedures on patients who smoke and types of smoking cessation aids offered. Of those physicians who require patients to quit smoking before surgery, only 16.7 percent (p < 0.01) would perform a nicotine test if they suspected noncompliance. Interestingly, 28.6 percent (p < 0.01) of the physicians responding admit to a smoking history, whereas only 1.5 percent (p < 0.01) continue to smoke, compared with the national smoking rate of almost 25 percent. Physicians who are previous smokers are less likely to offer smoking cessation aids than those who have never smoked, and the proportion not offering aids increases as the amount of previous smoking increases (p = 0.02). This study shows that a wide range of opinions exists on which elective surgical procedures should be performed on patients who smoke. Furthermore, the physician's prior smoking history influences this decision. No clear consensus exists on how best to treat patients who smoke who request elective surgeries. Although surgeons would prefer to operate on nonsmokers, they are faced with a significant population of patients who use tobacco. No clear consensus exists on how best to treat these individuals. Advancements in wound healing research and smoking cessation aids will provide more insight into this treatment dilemma.

The trauma and sepsis that follow open fractures and wounds may lead to the production of various cytokines. Understanding wound healing requires a direct knowledge of the specific cytokines and the respective wound fluid levels that are present at the wound site. An animal model was designed that mimics the open fracture and the clinical repair of the human, high-energy open fracture. Canine right tibiae were fractured with a penetrating, captive-bolt device, then repaired in a standard clinical fashion using an interlocking intramedullary nail. Before primary wound closure, microdialysis probes were placed at the fracture site and in a muscle located at a contralateral site. Canines received one of the following experimental protocols: (1) tibial fracture (n = 5); (2) tibial fracture plus Staphylococcus aureus inoculation at the fracture site (n = 5); and (3) tibial fracture, S. aureus inoculation, and a rotational gastrocnemius muscle flap (n = 5). Microdialysis fluid samples were collected intermittently for 7 days. Tumor necrosis factor alpha (TNFalpha) levels at the fracture site were significantly elevated 3 to 34-fold (p

Individuals with elevated levels of plasma cholesterol and triglyceride may be at higher risk for coronary artery disease than those with isolated elevations of either cholesterol or triglyceride. Sequence variation in the A-I/C-III/A-IV gene cluster has been implicated in the etiology of some disorders associated with premature atherosclerosis and/or hypertriglyceridemias with or without elevations of cholesterol. This led to the hypothesis that allelic variation at this gene locus alters plasma lipid transport and affects susceptibility for atherosclerosis. The study population, from the Atherosclerosis Risk in Communities (ARIC) Study, consisted of 50 normolipidemic individuals, 48 subjects with elevated plasma cholesterol, 47 subjects with elevated plasma triglyceride, and 123 subjects with both elevated plasma cholesterol and triglyceride who were used to evaluate associations between an Xmn I polymorphic site 2.5 kilobase pairs (kbp) upstream of the structural gene for apolipoprotein (apo) A-I, intimal-medial thickening of the extracranial carotid arteries, and several plasma lipid factors. The relative allele frequencies of the 8.3-kbp allele and the 6.6-kbp allele were .86 and .14, respectively, in the entire study population and did not differ among the lipid phenotypes. In the group with elevated plasma cholesterol and triglyceride, subjects possessing the 6.6-kbp allele exhibited a greater carotid artery intimal-medial thickness (P = .034) and higher plasma levels of apoA-I, high-density lipoprotein (HDL) cholesterol, and HDL3 cholesterol (P < .02) than subjects homozygous for the 8.3-kbp allele. In contrast, subjects with the 6.6-kbp allele displayed lower mean ratios of apolipoproteins C-II to C-III, C-II to A-IV and E to A-IV in plasma (P < .05) and a lower mean ratio of apolipoprotein C-II to C-III in the triglyceride-rich lipoproteins (P = .026). Sequence variation in or near the genes encoding apolipoproteins A-I, C-III, and A-IV may therefore identify a group of hypercholesterolemic-hypertriglyceridemic persons who are at higher risk for atherosclerosis than others with the same lipoprotein phenotype.

Plasma levels of lipoprotein[a] (Lp[a]) are associated with increased risk of coronary artery disease and show an inverse correlation with apolipoprotein[a] (apo[a]) molecular weight. We determined Lp[a] levels and apo[a] phenotypes in 171 cases with preclinical extracranial carotid atherosclerosis as ascertained by B-mode ultrasound and in 274 control subjects free of carotid atherosclerosis. Lp[a] protein levels measured by enzyme-linked immunosorbent assay ranged from 4 to 361 micrograms/mL in cases and from 2 to 392 micrograms/mL in controls, but median levels of Lp[a] were higher in cases than in controls (51 micrograms/mL versus 33 micrograms/mL, P < .003). In both groups, all 11 apo[a] polymorphs that are resolved by the procedure used were present, resulting in 43 and 39 different apo[a] phenotypes in cases and controls, respectively. An inverse relation between apo[a] polymorph size and Lp[a] level was observed in both cases (r = -0.49, P < .001) and controls (r = -0.34, P < .001). Apo[a] phenotype distributions were similar in cases and controls. However, in 17 phenotypes with three or more subjects per group, the difference of mean Lp[a] concentrations between cases and controls was 32 +/- 36 micrograms/mL (mean +/- SD). Thus, the higher Lp[a] levels in cases were not associated with a greater prevalence of small apo[a] polymorphs. Stepwise logistic regression analyses of known risk factors for coronary heart disease showed that plasma Lp[a] concentration was an independent predictor of case-control status, while Lp[a] phenotype was not, irrespective of the presence or absence of Lp[a] concentration in the model.(ABSTRACT TRUNCATED AT 250 WORDS)

The distributions of plasma lipids, lipoproteins, and apoproteins of 14,524 female and male black and white participants 45 to 64 years old in the Atherosclerosis Risk in Communities (ARIC) Study are presented. All specimens were analyzed at a central laboratory. Mean total cholesterol levels increased with increasing age across all ages from 204 to 229 mg/dL (12%) in women and from 208 to 213 mg/dL (2%) in men. Triglyceride levels increased with age in women, remained stable in men, and were higher in whites than blacks. High-density lipoprotein (HDL) cholesterol levels were higher in black and white women (range, 57 to 59 mg/dL) compared with black men (49 to 52 mg/dL) or white men (42 to 43 mg/dL). Cholesterol associated with HDL was distributed in a relatively constant proportion between HDL3 (70% to 76%) and HDL2 (24% to 30%) for all race/sex groups. Low-density lipoprotein (LDL) cholesterol levels increased with age in black (14.7%) and white (17.1%) women and in black (4.4%) and white (3.7%) men; more than 50% of all participants had LDL cholesterol levels > 130 mg/dL. Apoprotein A-I and B levels followed the same trends as HDL cholesterol and LDL cholesterol levels, respectively. Lipoprotein(a) [Lp(a)] levels were twice as high in blacks as in whites, and women's Lp(a) levels were higher than men's Lp(a) levels for each race. Menopause was associated with elevated total cholesterol, LDL cholesterol, apoprotein B, and Lp(a) levels, and hormone replacement medication use in postmenopausal subjects was associated with higher HDL cholesterol, triglyceride, and apoprotein A-I levels and lower LDL cholesterol, apoprotein B, and Lp(a) levels.