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Lymphedema is extremity swelling caused by lymphatic dysfunction. The affected limb enlarges because of accumulation of fluid, adipose, and fibrosis. There is no cure for this disease. A mouse tail model that uses a focal full thickness skin excision near the base of the tail, resulting in tail swelling, has been used to study lymphedema. However, this model may result in vascular comprise and consequent tail necrosis and early tail swelling resolution, limiting its clinical translatability. The chronic murine tail lymphedema model induces sustained lymphedema over 15 weeks and a reliable perfusion to the tail. Enhancements of the traditional murine tail lymphedema model include 1) precise full thickness excision and lymphatic clipping using a surgical microscope, 2) confirmation of post-operative arterial and venous perfusion using high resolution laser speckle, and 3) functional assessment using indocyanine green near infrared laser lymphangiography. We also use tissue nanotransfection technology (TNT) for novel non-viral, transcutaneous, focal delivery of genetic cargo to the mouse tail vasculature.

Background: Patients with hormone receptor-positive breast tumors receive hormonal therapy with either selective estrogen receptor modulators (SERMs) (eg, tamoxifen) or aromatase inhibitors (AIs) (eg, anastrozole) for 5 to 10 years. Patients are using these therapies frequently during breast reconstruction. Literature investigating the effects of hormonal modulators on breast reconstruction outcomes demonstrates conflicting results. We sought to perform a systematic evaluation to assess the effects of hormonal therapy on breast reconstruction outcomes and to guide perioperative management of antiestrogen therapies., Methods: A MEDLINE, PubMed, and EBSCO Host search of articles regarding the effects of SERMs and AIs on breast reconstruction was performed. Outcomes evaluated included wound complications, total or partial flap loss, and thromboembolic events. Included studies were assigned Methodological Index for Nonrandomized Studies quality scores., Results: A total of 2581 flaps were analyzed for complete loss: patients taking SERMs at the time of reconstruction had higher rates of flap loss compared with patients not taking hormone modulators (P < 0.001). Flap loss was not affected by concurrent AI use (P = 0.11). Both SERMs and AIs had an increased risk of donor site complications (P = 0.0021 and P < 0.0001, respectively). Neither hormone modulator had an effect on flap wound complications or venous thromboembolic event rates., Conclusions: Evidence indicates patients using SERMs at the time of operation are at an increased risk of flap loss and those taking either SERMs or AIs have higher rates of donor site complications. These findings support holding these medications for 1 to 2 half lives (tamoxifen, 14-28 days; AIs, 2-4 days) preoperatively.

Supplemental Digital Content is available in the text., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background:  Anastomotic couplers expedite venous microvascular anastomoses and have been established as an equivalent alternative to hand-sewn anastomoses. However, complications unique to the coupler such as palpability and extrusion can occur. The purpose of this study was to perform a systematic review of the literature to assess complications distinct to the venous anastomotic coupler., Methods:  A Medline, PubMed, EBSCO host search of articles involving anastomotic venous couplers was performed. Studies involving arterial anastomotic couplers, end-to-side anastomoses, and reviews were excluded. Data points of interest were flap failure, venous thrombosis, hematoma, partial flap necrosis, infection, coupler extrusion, and coupler palpability., Results:  The search identified 165 articles; 41 of these met inclusion criteria. A total of 8,246 patients underwent 8,955 venous-coupled anastomoses. Combined reoperation rate was 3.3% and all-cause unsalvageable flap failure was 1.0%. Complications requiring reoperation included venous thrombosis (2.0%), hematoma (0.4%), partial flap necrosis (0.4%), and infection (0.3%). Eight patients had palpable couplers and 11 patients had extrusion of couplers (head/neck, hand, and feet) and required operative management., Conclusion:  Venous couplers remain an equivalent alternative to conventional hand-sewn anastomosis. However, venous coupler extrusion and palpability in the late postoperative period is a complication unique to anastomotic couplers, particularly in radiated head and neck, feet and hand free flaps. Removing extruded venous couplers is safe after tissue integration 3 weeks postoperatively. Coupler palpability and extrusion should be integrated into preoperative patient counseling and assessed in follow-up examinations., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background:  Sarcopenia is a condition characterized by the loss of skeletal muscle mass and strength. Recently, there has been a tremendous amount of research into the prognostic value of sarcopenia in surgical outcomes. The purpose of this study was to compare postoperative outcomes in free flap breast reconstruction in patients with and without sarcopenia., Methods:  One hundred three patients who underwent autologous breast reconstruction from 2013 to 2016 were studied. The cross-sectional area (CSA) of skeletal muscle was measured from preoperative computed tomography images at L3 using the National Institutes of Health ImageJ software. CSA was then normalized to patient stature by dividing CSA by height (cm 2 /m 2 ). A previously published skeletal muscle index cutoff of 38.5 cm 2 /m 2 was used to define sarcopenia. Intraoperative and postoperative surgical outcomes were recorded retrospectively. Outcomes were analyzed using multivariate, univariate, and regression statistics., Results:  Eight of the 103 (7.8%) patients were found to have sarcopenia. Sarcopenia was associated with a statistically significant increase in flap site delayed healing (37.5% vs. 20%, p  = 0.046), take back to the operating room (25% vs. 11.6%, p  = 0.05), intensive care unit length of stay (1.5 vs. 0.02 days, p  < 0.0005), and hospital length of stay (8.38 vs. 5.49 days, p  < 0.0005) when compared with patients without sarcopenia. There were no significant differences in flap loss, surgical site infection, hematoma, seroma, donor site delayed healing, intraoperative complications, and number of revision surgeries., Conclusion:  Sarcopenia is significantly associated with increased complications in patients undergoing free flap breast reconstruction. Further investigation into the biochemical and physiologic changes associated with sarcopenia is needed., Competing Interests: None declared., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Breast cancer-related lymphedema (BCRL) is a debilitating condition with morbidity, hindered quality of life, and increased health-related costs. Experimental studies support the use of musculocutaneous flaps for managing animal models with lymphedema. Although vascularized lymph node transfer (VLNT) and lymphovenous anastomosis are used to surgically treat patients with lymphedema, it is not known whether musculocutaneous or adipocutaneous flaps (eg, delayed autologous breast reconstruction) are effective for treating refractory upper extremity BCRL. We conducted a systematic review and pooled analysis to assess the impact of delayed breast reconstruction on developed BCRL., Methods: Following PRISMA guidelines, we systematically searched PubMed, Scopus, EMBASE, and Google Scholar databases for relevant studies published through November 11, 2016. We screened 934 unique articles. Of these, we conducted full-text and reference screening on 37 articles. We then performed a pooled and sensitivity analysis using random effects., Results: Eight studies met our inclusion criteria. One study was a case report; 7 studies were case series with sample sizes ranging from 3 to 38 patients. According to our pooled analysis 58% of patients reported improvement after breast reconstruction with or without VLNT. Sensitivity analysis revealed that 84% (95% confidence interval, 0.74-0.95) of patients who underwent breast reconstruction and VLNT reported improvement, whereas only 22% (95% confidence interval, 0.12-0.32) of those who had breast reconstruction alone reported improvement., Conclusions: Our review summarizes the current evidence regarding the effect of delayed breast reconstruction on established lymphedema. The VLNT component of the autologous breast reconstruction procedures may be the largest contributing factor leading to lymphedema improvement.

Background: All terrain vehicle accidents are a common cause of trauma admission and often associated with extremity injuries. However specifics of injury patterns to the upper extremity has not previously been described. A multicenter, retrospective study was conducted to determine the frequency and distribution of upper extremity injuries sustained from ATV accidents., Methods: Medical records of all patients presenting to two trauma centers with ATV related upper extremity trauma from 2001 to 2013 were reviewed. Patient records and radiographic data were analyzed for detailed extremity injury data. The identified injuries were classified by: anatomic location (shoulder, arm, elbow, forearm, wrist, hand) and structures involved (fracture/dislocation, amputation, nerve, artery, soft tissue). In addition, patient demographic information, length of stay (LOS), airway status, intensive care unit (ICU) stay, Glasgow coma scale (GCS), use of safety equipment, and associated injuries RESULTS: Two hundred seventy-seven patients with upper extremity injuries secondary to ATV accidents presented from 2001 to 2013. The frequency and distribution of ATV related upper extremity injuries classified by anatomic location demonstrated 18% of injuries involving the shoulder, 20% arm, 16% elbow, 18% forearm, 40% wrist, and 24% hand, with 30% of patients having injuries that involved more than one anatomic location. Injuries classified by structure involved indicated 73% of injuries were fracture/dislocations, 4% nerve injury, 2% vascular injury, and 36% soft tissue injury., Conclusion: The most common upper extremity injuries experienced in ATV injuries were fractures/dislocations with one third of patients having injuries that involved more than one anatomical location. Less than half of the patients were documented as having worn safety equipment, illustrating a need for increased awareness and enacted of measures to improve safety and prevent accidents., (Copyright © 2018. Published by Elsevier Ltd.)

Lymphedema is the chronic enlargement of tissue due to inadequate lymphatic function. Diagnosis is made by history and physical examination and confirmed with lymphoscintigraphy. The purpose of this study was to assess the accuracy of lymphoscintigraphy for the diagnosis of lymphedema and to determine characteristics of patients with false-negative tests., Methods: Individuals referred to our lymphedema program with "lymphedema" between 2009 and 2016 were analyzed. Subjects were assessed by history, physical examination, and lymphoscintigraphy. Patient age at presentation, duration of lymphedema, location of disease, gender, previous infections, and lymphedema type were analyzed., Results: The study included 227 patients (454 limbs); lymphedema was diagnosed clinically in 169 subjects and confirmed by lymphoscintigraphy in 162 (117 primary, 45 secondary; 96% sensitivity). Fifty-eight patients were thought to have a condition other than lymphedema, and all had negative lymphoscintigrams (100% specificity). A subgroup analysis of the 7 individuals with lymphedema clinically, but normal lymphoscintigrams, showed that all had primary lymphedema; duration of disease and infection history were not different between true-positive and false-negative lymphoscintigram results ( P = 0.5). Two patients with a false-negative test underwent repeat lymphoscintigraphy, which then showed lymphatic dysfunction consistent with lymphedema., Conclusion: Lymphoscintigraphy is very sensitive and specific for lymphedema. All patients with false-negative studies had primary lymphedema. A patient with a high clinical suspicion of lymphedema and a normal lymphoscintigram should be treated conservatively for the disease and undergo repeat lymphoscintigraphy., Competing Interests: Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.

Background  Although conservative management of lymphedema remains the first-line approach, surgery is effective in select patients. The purpose of this study was to review the literature and develop a treatment algorithm based on the highest quality lymphedema research. Methods  A systematic literature review was performed to examine the surgical treatments for lymphedema. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. Results  A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow-up was the most common cause of low scores. Thirty-nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI]: 86.2-107%) for liposuction, 33.1% (95% CI: 14.4-51.9%) for LVA, and 26.4% (95% CI: - 7.98 to 60.8%) for VLNT. Included excision articles did not report excess volume reduction. Conclusion  Although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high-quality studies. These studies were used to develop an evidence-based algorithm to guide clinical practice. Further studies with a particular focus on patient follow-up will improve the validity of lymphedema surgery research., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: Rhinophyma causes a nasal deformity and functional airway obstruction. Partial excision (eg, tangential) with secondary healing commonly removes hypertrophic soft tissues but does not improve nasal support. The subunit method for rhinophyma uses 6 nasal flaps to provide exposure for removal of rhinophymatous tissue and enhance structure. The purpose of this study was to evaluate outcomes of subunit method., Methods: Medical records of patients with rhinophyma treated with the subunit method between 2013 and 2016 were analyzed. The technique comprises degloving the distal half of the nose by elevating 6 subunit-based flaps; debulking phymatous tissues to perichondrium; enhancing nasal support with sutures/cartilage grafts; trimming excess skin; and redraping the soft tissues. Patient age, gender, need for cartilage grafts or skin grafts, revisions, and follow-up were assessed., Results: The study comprised 8 patients (6 male). Mean age was 63 years (range 34-72). All individuals had interdomal sutures for tip enhancement and 4 patients underwent cartilage grafts (alar batten) to correct external valve collapse. One patient had 2 subunits (alar) replaced with skin graft. Average follow-up was 1.6 years (range 0.2-3.7). Six patients underwent revisional procedures primarily to modify the scar between the dorsum and tip subunits., Conclusion: The subunit method addresses the 3 fundamental problems of the rhinophymatous nose: hypertrophic sebaceous tissues, excess skin, and destruction of support. Most patients may benefit from a minor revisional procedure to optimize the result. Individuals should be counseled that operation will likely require 2 stages.

Purpose: The treatment of venous malformations is difficult because these lesions frequently recur after resection or sclerotherapy. The purpose of this study was to determine whether recanalization of sclerosed venous lumens could be prevented with systemic angiogenic inhibition using bevacizumab or peginterferon alfa-2a., Methods: To establish an animal model of recanalization of sclerosed facial veins, 18 rabbits had ethanol sclerotherapy of 1 facial vein followed by venography after 4weeks (n=6), 12weeks (n=6), and 24weeks (n=6). Subsequently, 21 different leporids underwent sclerotherapy of both facial veins (n=42 veins) and were treated pharmacologically in three ways: (1) control (n=14); bevacizumab (n=14); or peginterferon alfa-2a (n=14). Animals received 2 systemic drug doses 1month prior to and during the procedure. Vessel patency was determined 24weeks later using venography., Results: Venous recanalization occurred in 33.3% of sclerosed facial veins after 4weeks and 50.0% after 12 and 24weeks. For animals treated with systemic medication, recanalization occurred less frequently when bevacizumab (14.3%, n=2/14) (P=0.04) or peginterferon alfa-2a (7.7%, n=1/14) (P=0.01) was administered compared to controls (57.1%, n=8/14)., Conclusions: Systemic treatment with bevacizumab or peginterferon alfa-2a reduces venous recanalization following sclerotherapy in an animal model. Further studies are indicated to determine whether anti-angiogenic pharmacotherapy can prevent recurrence of venous malformations in humans after sclerotherapy., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Inlay cranioplasty in children is challenging because autologous bone is limited. Cranial particulate bone graft effectively closes defects when placed over normal dura. The purpose of this study was to determine if particulate bone graft will ossify when used for secondary cranioplasty over scarred dura., Methods: A 17 × 17-mm critical-sized defect was made in the parietal bone of 16 rabbits. Four animals had no implant (group 1). Twelve animals had the defect remade 16 weeks postoperatively, which was managed in 2 ways: group 2 (no implant; n = 6) and group 4 (particulate bone graft; n = 6). Particulate graft was obtained using a brace and bit from the frontal bone. Computed tomography was used to determine the area of ossification and thickness of the healed graft. Eight animals previously managed with particulate bone graft over normal dura were used as an additional control (group 3)., Results: Critical-sized defects filled with particulate bone graft over scarred dura (group 4) exhibited superior healing of the area (83.8%; range, 73.0%-90.6%) compared to control defects over normal dura (group 1: 62.9%; range, 56.5%-73.4%) or scarred dura (group 2: 56.9%; range, 40.0%-68.3%) (P = 0.0004). Particulate bone on scarred dura exhibited less ossified area (P = 0.002), and thinner bone (0.95 mm, range, 0.71-1.32 mm) compared to defects in which graft was placed over normal dura (group 3: area, 99.2%; range, 96.8%-100%; thickness, 1.9 mm, range; 1.1-3.1 mm) (P = 0.04)., Conclusions: Particulate bone graft ossifies inlay cranial defects over scarred dura although inferior to placement over normal dura. Clinically, particulate bone graft may be used for secondary inlay cranioplasty.

We report a child with a congenital pigmented nevus of the nose involving the left ala, sidewall, soft triangle, and tip. Removal of the lesion was performed using dermabrasion, topical hydroquinone, and serial excision to optimize the aesthetic outcome. The patient was left with a linear scar and did not require reconstruction with a skin graft or flap.

Standard resection of pediatric facial skin lesions consists of lenticular excision and linear closure. This one-stage procedure for circular lesions results in a linear scar 3 times longer than the diameter of the removed specimen. Circular excision and purse-string closure has been described for infantile hemangiomas to reduce the length of scar. The purpose of this study was to analyze the application of this technique for any type of circular facial skin lesion in the pediatric population. Records of consecutive pediatric patients with facial skin lesions treated with circular excision and purse-string closure from 2007-2014 were reviewed. Patient age, sex, type of lesion, location, and size were recorded. Number of stages necessary to remove the area and complications were analyzed. Seventy-seven children (74% female) underwent circular excision and purse-string closure for an infantile hemangioma (46%), pigmented nevus (27%), Spitz nevus (7%), pilomatrixoma (5%), pyogenic granuloma (5%), vascular malformation (4%), or another type of skin lesion (6%). Age at the time of resection was 6.0 years (range 4 months-17 years) and mean lesion area was 3.9  cm (range 0.2-19.6); 30% of patients underwent a second procedure and no infection or wound dehiscence occurred. Circular excision and purse-string closure is an effective technique to manage any type of circular skin lesion in the pediatric population. It is particularly useful for lesions on the face because it limits the length of a scar. A subset of patients may benefit from second procedure to convert the circular scar from a circle into a line.

Autologous ear construction for microtia creates an auricle using a costal cartilage framework. To separate the construct from the mastoid, a skin graft is required to form a retroauricular sulcus. Skin graft donor sites that have been described include the inguinal area (split or full-thickness) or scalp (split-thickness). The purpose of this study is to report a novel skin graft donor site for ear construction. We harvest a full-thickness graft from the subcostal area based on the previous scar from the cartilage harvest. Unlike the inguinal donor site, this method does not place an additional scar on the child. In contrast to the scalp donor site, the technique is simpler and a full-thickness graft minimizes contraction of the retroauricular sulcus.

Background: A multicenter, retrospective study was conducted to determine the frequency and distribution of craniofacial fractures sustained from all terrain vehicle (ATV) accidents., Methods: Medical records of all patients presenting to 2 trauma centers with ATV-related craniofacial trauma from 2001 to 2013 were reviewed. Patient notes and radiographic images were analyzed for detailed craniofacial injury data. The identified fractures were classified as: frontal/skullbase, naso-orbital, maxilla/zygoma, and mandible. In addition, patient demographic information, length of stay, airway status, intensive care unit stay, Glasgow coma scale, use of safety equipment, associated traumatic brain injury, and surgical intervention were compiled., Results: One hundred fifty-six patients with craniofacial fractures secondary to ATV accidents presented from 2001 to 2013. The incidence of craniofacial fractures found in patients with ATV injuries was 12.2%. Sixty-one patients (39.1%) suffered frontal/skullbase fractures, 98 (62.8%) naso-orbital fractures, 62 (39.7%) maxillary/zygoma fractures, and 35 (22.4%) mandibular fractures. Forty-one patients (26.3%) required surgical intervention to correct their craniofacial injuries., Conclusions: The most common craniofacial fractures experienced in ATV injuries are naso-orbital fractures. The correlation of nonuse of safety equipment and associated traumatic brain injuries displays the importance of using helmets when operating ATVs. Future studies can be conducted examining ATV-related upper extremity injuries, among others.

Background: Large congenital melanocytic nevi (CMN) cause significant deformity and are at risk for malignant degeneration. Techniques used to remove difficult CMN include serial excision, skin grafting, or tissue expansion. Some authors prefer skin grafting or tissue expansion if several stages would be required to serially resect the CMN. The purpose of this study was to determine the efficacy of serial excision for CMN requiring ≥3 procedures., Methods: Medical records and clinical images of patients with CMN treated between 2007 and 2013 were reviewed. Inclusion criteria were: (1) lesions that required ≥3 serial excisions to remove and (2) CMN that could have been treated reasonably with skin grafting or tissue expansion. Patient age, gender, location of the lesion, size of the CMN, number of serial excisions, and complications were recorded., Results: The study included 21 patients. Lesions were located on the lower extremity (38.1%), head/neck (33.3%), upper extremity (14.3%), or trunk (14.3%). Nevus size was 2.2%±1.2% total body surface area. The age during the first operation was 4.3 years (range 3 months to 15 years). The number of excisions was 3.5±0.7, spaced 8.2±4.3 months apart. Partial suture line dehiscence occurred after 2/72 operations and seroma resulted after 1/72 operations; there were no infections., Conclusion: Challenging CMN amenable to serial excision can be removed effectively and safely using this technique. Children are left with a favorable linear scar, do not have donor or recipient site morbidity from skin grafting, and are not subjected to potential tissue expander complications and injections required for expansion., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The authors share their experience with the issuance of iPads to all residents, faculty, and physician extenders in their plastic surgical division. They found that these devices (1) optimized compliance with the Health Insurance Portability and Accountability Act by eliminating the use of paper service lists; (2) improved clinical efficiency; and (3) promoted resident education. They believe the use of these devices in residency is cost-effective when considering mitigating patient privacy risk and enriching educational value.

Infantile hemangioma is the most common tumor of infancy, affecting approximately 5.0% of Caucasians. We present the unlikely occurrence of four siblings with infantile hemangiomas; there was no family history of the tumor. One child was low birth weight, there was one set of twins, and three infants had multiple lesions. The estimated probability of four consecutive children having this phenotypic expression of infantile hemangioma is 1/4,232,804., (© 2012 Wiley Periodicals, Inc.)

Background :  Particulate bone graft and recombinant human bone morphogenetic protein-2 (rhBMP-2) are options for inlay cranioplasty in children who have not developed a diploic space. The purpose of this study was to determine whether particulate bone graft or rhBMP-2 has superior efficacy for inlay cranioplasty and to compare these substances to split cranial bone. Methods :  A 17 mm × 17 mm critical-sized defect was made in the parietal bones of 22 rabbits and managed in four ways: Group I (no implant; n=5), Group II (particulate bone graft; n=5), Group III (rhBMP-2; n=7), and Group IV (split cranial bone graft; n=5). Animals underwent microcomputed tomography and histologic analysis 16 weeks after cranioplasty. Results :  Defects without an implant (Group I) demonstrated inferior ossification (41.4%; interquartile range [IQR], 28.9% to 42.5%) compared to those treated with particulate bone graft (Group II: 99.5%; IQR, 97.8% to 100%), rhBMP-2 (Group III: 99.6%; IQR, 99.5% to 100%), or split cranial bone (Group IV: 100%) (P < .0001). There was no difference between Groups II, III, and IV (P = .1). Defects treated with rhBMP-2 exhibited thinner bone (0.90 mm; IQR, 0.64 to 0.98) than particulate bone graft (1.95 mm; IQR, 1.09 to 2.83) or split cranial bone (1.72 mm; IQR, 1.54 to 1.88) (P = .006); particulate and split cranial bone grafted defects had a similar thicknesses (P = .6). Conclusions :  Particulate bone graft, rhBMP-2, and split cranial bone close inlay calvarial defect areas equally, although the thickness of bone healed with rhBMP-2 is inferior. Clinically, particulate bone graft or split cranial bone graft may be superior to rhBMP-2 for inlay cranioplasty.

Robot assisted surgery is a technology that is being used frequently among multiple surgical specialties; robot assisted microsurgery (RAMS) and transoral robotic surgery (TORS) are applications relevant to plastic surgery that are being studied and clinically utilized. Advantages of RAMS include elimination of tremor and the ability to provide enhanced exposure. TORS facilitates oropharyngeal tumor excision and reconstruction without mandibular splitting. This article investigates current and potential uses of the surgical robot in plastic surgery as well as obstacles to its application., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Particulate bone graft (PBG) heals calvarial critical-size defects and is procured from the cranium with a hand-driven bit and brace. The donor sites ossify, and thus PBG potentially could be reharvested from the original areas. The purpose of this study was to determine if PBG obtained from a healed donor site is effective for inlay cranioplasty. A 17 × 17-mm critical-size defect was created in the parietal bones of 8 rabbits and treated with either no implant (group 1) or PBG harvested from the frontal bone (group 2). In 4 animals (group 3), a parietal defect was not created initially; PBG was harvested from the frontal bone and then discarded. Sixteen weeks later after the PBG donor sites had healed, a 17 × 17-mm parietal defect was made and filled with PBG reharvested from the previous donor area. Animals underwent micro-computed tomography 16 weeks after inlay cranioplasty. Critical-size defects in controls (group 1) exhibited partial ossification (35.1% ± 10.5%) compared with those treated with PBG (group 2) (99.1% ± 1.5%) or reharvested PBG (group 3) (99.3% ± 1.5%) (P = 0.02). No difference was found between groups 2 and 3 (P = 0.69). Bony thickness was similar in defects implanted with PBG (1.8 mm ± 1.1 mm) or reharvested PBG (2.1 mm ± 0.5 mm) (P = 0.68). Particulate bone graft reharvested from healed donor sites ossifies inlay cranial defects. Because the donor area for PBG is of partial thickness and less than critical size, reparative osteogenesis theoretically allows an unlimited supply of autologous bone for inlay cranioplasty using PBG.

Variable resorption occurs whenever calvarial bone graft is used for onlay cranioplasty. The recipient ectocortex may be burred to expose vessels and osteocytes to maximize healing. The purpose of this study was to determine whether abrading the recipient site improves the volume of onlay graft. The parietal bones of 17 rabbits were sectioned into split-thickness and full-thickness grafts. The right frontal cortex was abraded with a bur to punctate bleeding. Pairs of split-thickness (n = 48) or full-thickness (n = 20) grafts were onlayed to the burred right frontal bone and to the nonburred left frontal bone. Micro-computed tomography was used to determine graft volume immediately postoperatively and 16 weeks later. Histology, including tartrate-resistant acid phosphatase staining, was performed to quantify vascular channels and osteoclasts per high-power field 10 days postoperatively. Split-thickness graft volume decreased 58.0% when placed on the burred calvarial site, compared with grafts on the nonburred cortex (28.4%) (P = 0.01). Full-thickness grafts showed a similar trend: greater resorption (39.1%) when onlayed onto abraded calvaria compared with nonburred ectocortex (26.0%) (P = 0.11). Split-thickness graft orientation (cortical vs cancellous side in contact with the recipient site) did not affect resorption (P = 0.67). Onlay grafts placed on the burred recipient site had more vascular channels (11.8) and osteoclasts (5.7), compared with grafts over nonabraded cortex (3.4 and 4.2, respectively) (P < 0.05). Burring the recipient site cortex before onlay cranial bone grafting promotes resorption, possibly by increasing vascularization and osteoclastic activity. This technique cannot be recommended.

Background: Vascular malformations frequently enlarge during adolescence, suggesting that hormones may be involved. The purpose of this study was to determine whether pubertal hormone receptors are present in vascular malformations and whether they differ from normal tissue., Methods: Tissue specimens (arteriovenous malformation, lymphatic malformation, and venous malformation) were prospectively collected from patients undergoing resection. Immunohistochemistry was used to determine the presence of androgen, estrogen, progesterone, and growth hormone receptors. The effects of age, sex, location, and malformation type on receptor expression were analyzed. Age-, sex-, and location-matched normal tissues served as controls., Results: Forty-five vascular malformation specimens were collected: arteriovenous malformation (n = 11), lymphatic malformation (n = 20), and venous malformation (n = 14). Growth hormone receptor expression was increased in arteriovenous malformation (72.7 percent), lymphatic malformation (65.0 percent), and venous malformation (57.1 percent) tissues compared with controls (25.8 percent) (p < 0.05). Growth hormone receptor was present primarily in the endothelium/perivasculature of malformations (93.1 percent), whereas in normal tissue growth hormone receptor was located only in the stroma (p < 0.0001). Neither age, nor sex, nor location influenced receptor expression (p = 0.9). No differences in androgen receptor, estrogen receptor, and progesterone receptor staining were found between malformations and control samples (p = 0.7)., Conclusions: Growth hormone receptor is overexpressed and principally located in the vessels of vascular malformations. Growth hormone might contribute to the expansion of vascular malformations.

Background: Cranial particulate bone graft heals inlay calvarial defects and can be harvested as early as infancy. The purpose of this study was to test the hypothesis that particulate bone promotes ossification primarily by osteogenesis., Methods: Freshly harvested particulate bone, devitalized particulate bone, and high-speed drilled bone dust from rabbit calvaria were assayed for metabolic activity (resazurin) and viable osteoblasts (alkaline phosphatase). A rabbit cranial defect model was used to test the effect of devitalizing particulate bone on in vivo ossification. A parietal critical-size defect was created and managed in three ways: (1) no implant (n = 6); (2) particulate bone implant (n = 6); and (3) devitalized particulate bone implant (n = 6). Micro-computed tomographic scanning was used to measure ossification 16 weeks later; histology also was studied., Results: Particulate bone contained more viable cells (0.94 percent transmittance per milligram) compared with devitalized particulate bone (0.007 percent) or bone dust (0.21 percent) (p = 0.01). Particulate bone had greater alkaline phosphatase activity (0.13 μU/μg) than devitalized particulate bone (0.000) or bone dust (0.06) (p = 0.01). Critical-size defects treated with particulate bone had more ossification (99.7 percent) compared with devitalized particulate bone implants (42.2 percent) (p = 0.01); no difference was found between devitalized particulate bone and the control (40.8 percent) (p = 0.9)., Conclusions: Particulate bone graft contains living cells, including osteoblasts, that are required to heal critical-size cranial defects. These data support the hypothesis that particulate bone promotes ossification primarily by osteogenesis.

Aims: Right ventricular (RV) dysfunction is a frequent consequence of pulmonary embolism (PE) and a marker of increased risk. However, current qualitative methods assessing RV function are imprecise. We sought to determine whether RV strain analysis would have clinical utility in patients with PE compared with normal controls., Methods and Results: We compared 75 acute PE subjects (mean age 54 ± 16) with 30 normal controls (mean age 50 ± 15). Regional RV longitudinal strain was assessed using offline speckle tracking software to obtain strain and strain rate data from the basal, mid, and apical free wall and septum. Global RV free wall and septal strain was significantly reduced in PE subjects (-14.17 (±5.96) vs -24.92 (±4.16), P < 0.0001; -14.99 (±5.55) vs -18.54 (±7.34), P = 0.0082). Regional RV strain was markedly reduced in PE subjects in all regions of the free wall and in the mid and basal septum (P < 0.05). Strain rates of PE subjects were significantly reduced in all segments of the RV free wall (P < 0.05). In 36 PE subjects with regional RV dysfunction ("McConnell sign"), strain in the apical free wall was significantly reduced in comparison to those without (-10.08 vs -13.51; P = 0.0420), in parallel with higher RV:LV ratios (1.30, ±1.01 vs 0.78, ±0.16; P = 0.0035) and lower RV fractional area change (32.06, ±14.42 vs 42.52, ±11.61; P = 0.0021)., Conclusions: Regional RV longitudinal strain is altered in the free wall and mid and basal septum in subjects with acute PE. Strain rates are only reduced in the RV free wall., (© 2012, Wiley Periodicals, Inc.)

Venous malformations (VMs) can cause significant morbidity, particularly because they enlarge over time and become symptomatic. The purpose of this study was to determine the natural progression of VMs to facilitate patient counseling, gain insight into pathophysiology, and guide therapy. Our Vascular Anomalies Center database was reviewed for patients with cutaneous and soft-tissue VMs. Predictive variables were age, gender, location, pregnancy, and size. The outcome variable was natural progression of the malformation defined by expansion of the lesion or the onset/worsening of symptoms. The study included 614 patients. Children had a 26.1% risk of progression prior to adolescence, 74.9% before adulthood, and 93.2% over their lifetime. Progression was more likely in adolescence (60.9%) than in childhood (22.5%); the relative risk was 2.6 (95% confidence interval, 2.1-3.2) (P = 0.0001). Diffuse VMs progressed more often than localized lesions (P = 0.002); extremity and trunk VMs worsened more frequently than head/neck lesions (P = 0.03). VMs have a higher risk of progression in adolescents than in children; pubertal hormones may contribute to expansion. Because of their high rate of progression, early treatment of asymptomatic VMs should be considered.

Lymphatic malformations (LMs) in soft tissues tend to enlarge over time, causing distortion, obstruction, and functional problems. The purpose of this study was to determine the natural progression of LMs to facilitate patient counseling, gain insight into pathophysiology, and guide therapy. Our Vascular Anomalies Center database was reviewed for patients with cutaneous and soft tissue LMs; combined or visceral lesions were excluded. Predictive variables were age, channel type (macrocystic, microcystic, combined), sex, lesion size (localized, diffuse), and location (head/neck, extremities, trunk). The outcome variable was natural progression of the malformation defined by expansion or the onset/worsening of signs and symptoms. The study included 441 patients: 234 females (53.1%) and 207 males (46.9%). Lymphatic malformations were located in the head/neck (61.2%), extremities (17.5%), trunk (16.1%), or multiple sites (5.2%). Children had a 42.2% risk of progression before adolescence, 84.7% before adulthood, and 95.3% during their lifetime. Progression was more likely in adolescence (63.8%) than in childhood (40.8%); the odds ratio was 2.6 (P=0.003). Diffuse LMs worsened more often than localized lesions (P=0.001), whereas channel type (P=0.63), sex (P=0.42), and location (P=0.28) did not influence progression.Lymphatic malformations have a greater risk of progression in adolescence than in childhood; pubertal hormones may contribute to expansion. Because of this high rate of progression, early treatment of asymptomatic LMs should be considered.

The ability of the human cranium to ossify full-thickness defects depends on the size of the area and the age of the patient. An adult leporid cranioplasty model is commonly used to study inlay cranioplasty materials; the influence of age on ossification is unknown in this model. The purpose of this study was to determine the effect of age on healing of a rabbit critical-size defect. Nineteen rabbits were divided into 4 groups: group 1 (n = 5) aged 4 months, group 2 (n = 4) aged 8 months, group 3 (n = 5) aged 12 months, and group 4 (n = 5) aged 16 months. A 17 × 17-mm defect was created in the parietal bones with preservation of the underlying dura. Animals underwent micro-computed tomography 4 months postoperatively to determine ossification of the defect. Group 1 defects healed by 28.5% (SD, 12.5%), group 2 defects ossified by 37.2% (SD, 5.7%), group 3 defects closed by 28.2% (SD, 11.9%), and group 4 defects healed by 39.4% (SD, 11.0%). No difference in ossification was found between groups (P = 0.31).Leporids as young as 4 months do not close a 17 × 17-mm defect; ossification is similar to animals as old as 16 months. Rabbits 4 months or older are suitable for a calvarial critical-size defect model.

Facial infiltrating lipomatosis causes diffuse overgrowth of subcutaneous fat, muscle, and bone. Because adipose tissue mass is angiogenesis dependent, the purpose of this study was to determine whether neovascularization is upregulated in this disease.Infiltrating lipomatosis tissue was collected prospectively from the preauricular cheek of 5 patients; neovascularization was compared to normal postauricular adipose. Specimens were analyzed using immunofluorescence for CD31 (microvascular density), α-smooth muscle actin (pericyte marker), CD31/Ki67 (proliferating endothelial cells), and CD34/CD133 (endothelial progenitor cells). Quantitative reverse transcription-polymerase chain reaction was used to determine messenger RNA expression of progenitor cells (CD133) and factors that recruit them: vascular endothelial growth factor (VEGF-A), hypoxia-inducible factor 1α, matrix metalloproteinase 9 (MMP-9), and stromal cell-derived factor 1α. Angiopoietin 1 and 2, MMP-2, VEGF receptors, and neuropilin receptors were quantified using quantitative reverse transcription polymerase chain reaction. There was no difference in microvascular density, pericytic density, or endothelial proliferation between infiltrating lipomatosis and normal adipose tissue (P = 0.2). Expressions of VEGF-A, hypoxia-inducible factor 1α, stromal cell-derived factor 1α, angiopoietin 1 and 2, MMP-2 and -9, VEGF receptors 1 and 2, neuropilin receptors 1 and 2, and CD133 messenger RNA were not elevated compared to control fat (P = 0.1). Endothelial progenitor cells were not present in specimens of infiltrating lipomatosis. Infiltrating lipomatosis does not exhibit elevated angiogenic or vasculogenic factors compared to normal fat; the vasculature is stable. Neovascularization does not seem to play a role in the pathogenesis of this condition.

Randomized controlled trials are the gold standard of evidence-based medicine. In the field of plastic surgery, designing these studies is much more challenging than in pharmaceutical medicine. Randomized trials in plastic surgery encompass several road blocks including problems shared with other surgical trials: equipoise, high cost, placebo issues and learning curves following the establishment of a novel approach. In addition, plastic surgery has more subjective outcomes, thus making study design even more difficult in assessing the end result.

We present a 5-year-old girl with Down syndrome and a 2.5-cm agminated atypical Spitz tumor of the nose. Although atypical Spitz tumor has uncertain malignant potential, trisomy 21 is protective against melanoma. This is the first description of an atypical Spitz tumor in a patient with Down syndrome and the largest nasal lesion reported., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Many lesions can masquerade as infantile hemangioma, the most common tumor of infancy. We describe an infant with pilomatrixoma mimicking hemangioma. The patient presented at 8 months of age with an 1.2-cm, red, asymptomatic lesion of the right ear. The mass was noted at 4 months of age and subsequently enlarged. Ultrasonography demonstrated hypervascularity "consistent with infantile hemangioma," and the infant was observed. At 12 months of age, the lesion continued to expand and became ulcerated; it was excised, and histopathology showed pilomatrixoma. Diagnostic confusion was caused by atypical features of this pilomatrixoma that overlapped with infantile hemangioma: onset in infancy, ulceration, red color, and fast flow on imaging. Deviation from the predictable clinical features of an infantile hemangioma should prompt consideration for other types of pediatric lesions, including pilomatrixoma.

Background: A binary classification of vascular anomalies was approved 14 years ago by the International Society for the Study of Vascular Anomalies. The purpose of this study was to determine whether the International Society for the Study of Vascular Anomalies system is being used to categorize anomalies, and whether incorrect nomenclature affects patient care., Methods: The PubMed database was searched for English language publications with the term "hemangioma" in the title/abstract during 2009. Outcome variables were (1) whether accepted nomenclature was used to describe the vascular anomaly and (2) whether or not patients received incorrect treatment. Predictive variables for terminological accuracy were patient age, location of the anomaly, and the primary author's medical specialty., Results: "Hemangioma" was used incorrectly in 71.3 percent (228 of 320) of publications. Patients whose lesions were mislabeled were more likely to receive improper treatment (20.6 percent) compared with subjects whose lesions were designated using International Society for the Study of Vascular Anomalies terminology (0.0 percent) (p = 0.001). The patients were younger in articles that properly identified hemangioma (4.1 months) compared with articles that used hemangioma to describe another anomaly (36.1 years) (p < 0.0001). Publications focused on integument/soft-tissue lesions were more accurate (57.4 percent) than those in other anatomical areas (86.3 percent) (p < 0.0001). The erroneous use of hemangioma was independent of the authors' discipline: pediatrics (60.0 percent), internal medicine (61.4 percent), surgery (68.9 percent), and obstetrics/gynecology (70.0 percent) (p = 0.68)., Conclusions: Hemangioma continues to be commonly misused to describe any type of vascular anomaly, and terminological imprecision is prevalent among both medical and surgical fields. Inaccurate designation of the vascular anomaly is associated with an increased risk of erroneous management.

Objectives: We sought to investigate the clinical prognostic value of longitudinal and circumferential strain (S) and strain rate (SR) in patients after high-risk myocardial infarction (MI)., Background: Left ventricular (LV) contractile performance after MI is an important predictor of long-term outcome. Tissue deformation imaging might more closely reflect myocardial contractility than traditional measures of systolic functions., Methods: The VALIANT (Valsartan in Acute Myocardial Infarction Trial) Echo study enrolled 603 patients with LV dysfunction, heart failure, or both 5 days after MI. We measured global peak longitudinal S and systolic SR (SRs) from apical 4- and 2-chamber views and global circumferential S and SRs from parasternal short-axis view with speckle tracking software (Velocity Vector Imaging, Siemens, Inc., Mountain View, California). We related global S and SRs to LV remodeling at 20-month follow-up and to clinical outcomes., Results: Both longitudinal (mean: -5.1 ± 1.6 100/ms) and circumferential SRs (mean: -8.0 ± 2.8 100/ms) were predictive of death or hospital stay for heart failure (hazard ratio: 2.4, 95% confidence interval [CI]: 2.0 to 3.1, p < 0.001; hazard ratio: 1.3, 95% CI: 1.2 to 1.4, p < 0.001, respectively) after adjustment for clinical covariates by Cox proportional hazards, and longitudinal SRs further improved in predicting 18-month survivor on a model based on clinical and standard echocardiographic measures (increase in area under the receiver-operator characteristic curve: 0.13, p = 0.009). With multivariable logistic regression, circumferential SRs, but not longitudinal SRs, was strongly predictive of remodeling (odds ratio: 1.3, 95% CI: 1.1 to 1.4, p < 0.001)., Conclusions: Both longitudinal and circumferential SRs were independent predictors of outcomes after MI, whereas only circumferential SRs was predictive of remodeling, suggesting that preserved circumferential function might serve to restrain ventricular enlargement after MI., (Copyright © 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

We present a patient with a history of infiltrating lobular breast carcinoma that metastasized to both the biliary and urinary tract after a ten year disease-free period following mastectomy and chemoradiotherapy. The patient presented with acute cholecystitis; imaging and histopathology revealed infiltrating lobular carcinoma of the gallbladder and urinary bladder. This report emphasizes the importance of long-term follow up in patients with a history of breast cancer and maintaining a high degree of suspicion for diagnosis of metastatic disease.

Many lesions can masquerade as deep infantile hemangioma, the most common tumor of infancy. We describe an infant with infantile hemangioma and concomitant metastatic subcutaneous neuroblastoma mimicking deep hemangioma. The patient presented at 8 months of age with 3 superficial infantile hemangiomas as well as 3 subcutaneous masses. History, physical examination, and ultrasonography of the deep lesions were consistent with subcutaneous hemangioma. New masses appeared at 10 months of age that prompted biopsy; histopathology demonstrated metastatic neuroblastoma. Deviation from the predictable clinical features of a deep infantile hemangioma should prompt consideration for other causes of a subcutaneous mass in infancy, including metastatic neuroblastoma., (Copyright © 2010 Elsevier Inc. All rights reserved.)

High-voltage electrical burns are rare but cause devastating injuries, resulting in potential limb loss and major morbidity and mortality. These injuries are more insidious than flame burns in that the extent of the injury is not obvious at first glance. Damage to underlying muscle, nerve, and vessels may occur, resulting in limb-threatening ischemia and delayed hemorrhage. The management of such injuries remains controversial and can be challenging for the vascular and reconstructive surgeon. We present a case of high-voltage electrical injury to bilateral upper extremities resulting in limb-threatening ischemia, review the literature on the management of such injuries, and propose an algorithm to guide the management of these devastating injuries., (Copyright 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc. All rights reserved.)