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BackgroundAutologous fat grafting is commonly used for soft-tissue repair (approximately 90,000 cases per year in the United States), but outcomes are limited by volume loss (20% to 80%) over time. Human allograft adipose matrix (AAM) stimulates de novo adipogenesis in vivo, but retention requires optimization. The extracellular matrix derived from superficial fascia, interstitial within the adipose layer, is typically removed during AAM processing. Thus, fascia, which contains numerous important proteins, might cooperate with AAM to stimulate de novo adipogenesis, improving long-term retention compared to AAM alone.MethodsHuman AAM and fascia matrix proteins (back and upper leg regions) were identified by mass spectrometry and annotated by gene ontology. A three-dimensional in vitro angiogenesis assay was performed. Finally, AAM and/or fascia (1 mL) was implanted into 6- to 8-week-old male Fischer rats. After 8 weeks, the authors assessed graft retention by gas pycnometry and angiogenesis (CD31) and adipocyte counts (hematoxylin and eosin) histologically.ResultsGene ontology annotation revealed an angiogenic enrichment pattern unique to the fascia, including lactadherin, collagen alpha-3(V) chain, and tenascin-C. In vitro, AAM stimulated 1.0 ± 0.17 angiogenic sprouts per bead. The addition of fascia matrix increased sprouting by 88% (2.0 ± 0.12; P < 0.001). A similar angiogenic response (CD31) was observed in vivo. Graft retention volume was 25% (0.25 ± 0.13) for AAM, significantly increasing to 60% (0.60 ± 0.14) for AAM/fascia ( P < 0.05). De novo adipogenesis was 12% (12.4 ± 7.4) for AAM, significantly increasing to 51% (51.2 ± 8.0) for AAM/fascia ( P < 0.001) by means of adipocyte quantification.ConclusionsCombining fascia matrix with AAM improves angiogenesis and adipogenesis compared to AAM alone in rats. These preliminary in vitro and pilot animal studies should be further validated before definitive clinical adoption.Clinical relevance statementWhen producing an off-the-shelf adipose inducing product by adding a connective tissue fascial component (that is normally discarded) to the mix of adipose matrix, vasculogenesis is increased and, thus, adipogenesis and graft survival is improved. This is a significant advance in this line of product.

Background Human immunodeficiency virus (HIV)-associated lipodystrophy is a known consequence of long-term highly active antiretroviral therapy (HAART). However, a significant number of patients on HAART therapy were left with the stigmata of complications, including fat redistribution. Few studies have described the successful removal of focal areas of lipohypertrophy with successful outcomes. This manuscript reviews the outcomes of excisional lipectomy versus liposuction for HIV-associated cervicodorsal lipodystrophy. Methods We performed a 15-year retrospective review of HIV-positive patients with lipodystrophy. Patients were identified by query of secure operative logs. Data collected included demographics, medications, comorbidities, duration of HIV, surgical intervention type, pertinent laboratory values, and the amount of tissue removed. Results Nine male patients with HIV-associated lipodystrophy underwent a total of 17 procedures. Of the patients who underwent liposuction initially (n=5), 60% (n=3) experienced a recurrence. There were a total of three cases of primary liposuction followed by excisional lipectomy. One hundred percent of these cases were noted to have a recurrence postoperatively, and there was one case of seroma formation. Of the subjects who underwent excisional lipectomy (n=4), there were no documented recurrences; however, one patient’s postoperative course was complicated by seroma formation. Conclusions HIV-associated lipodystrophy is a disfiguring complication of HAART therapy with significant morbidity. Given the limitations of liposuction alone as the primary intervention, excisional lipectomy is recommended as the primary treatment. Liposuction may be used for better contouring and for subsequent procedures. While there is a slightly higher risk for complications, adjunctive techniques such as quilting sutures and placement of drains may be used in conjunction with excisional lipectomy.

Purpose We evaluate outcomes of our single center using vertical rectus abdominis myocutaneous (VRAM) flaps for reconstruction after abdominoperineal resection (APR). Our goal was to analyze factors that may affect perineal wound healing, a problematic complication with APR reconstructions due to location and high frequency of neoadjuvant chemoradiation. Methods This single-center, retrospective study analyzed all VRAM flap perineal reconstruction patients after APR defect over a 10-year period (from July 2008 to June 2018). Outcome measures focused on factors that may affect perineal wound healing complication rates: cancer stage (I/II vs III/IV), neoadjuvant chemoradiation, surgeon's years in practice ( 5 years), and pelvic closed suction drain use. Results Twenty-eight patients met inclusion criteria. The overall major perineal wound complication rate was 14.3% (4 patients). Lack of perioperative closed suction pelvic drain use was associated with a significantly higher rate of major perineal wound complications (28.6% vs 0% and p = 0.031). All four major wound complications occurred in patients who did not have a pelvic drain. The major perineal wound complication rate for patients who underwent neoadjuvant chemoradiation was 22% vs 0% with no neoadjuvant chemoradiation (p = 0.107). Conclusion While our cohort represents a relatively small single-center study, our 14.3% rate of major perineal wound complications is consistent with previous studies in the literature. Our findings show that perioperative pelvic closed suction drain use is associated with a lower rate of perineal wound complications. While neoadjuvant chemoradiation trended toward a higher incidence of perineal wound complications, it did not reach statistical significance.

Background Microtia is an inherited condition that results in varying degrees of external ear deformities; the most extreme form is anotia. Effective surgical reconstruction techniques have been developed. However, these usually require multistage procedures and have other inherent disadvantages. Tissue engineering technologies offer new approaches in the field of external ear reconstruction. In this setting, chondrocytes are cultured in the laboratory with the aim of creating bioengineered cartilage matrices. However, cartilage engineering has many challenges, including difficulty in culturing sufficient chondrocytes. To overcome these hurdles, the authors propose a novel model of cartilage engineering that involves co-culturing chondrocytes and adipose-derived stem cells on an allograft adipose-derived extracellular matrix scaffold. Methods Auricular chondrocytes from porcine ear were characterized. Adipose-derived stem cells were isolated and expanded from human lipoaspirate. Then, the auricular chondrocytes were cultured on the allograft adipose matrix either alone or with the adipose-derived stem cells at different ratios and examined histologically. Results Cartilage induction was most prominent when the cells were co-cultured on the allograft adipose matrix at a ratio of 1:9 (auricular chondrocyte-to-adipose-derived stem cell ratio). Furthermore, because of the xenogeneic nature of the experiment, the authors were able to determine that the adipose-derived stem cells contributed to chondrogenesis by means of a paracrine stimulation of the chondrocytes. Conclusions In this situation, adipose-derived stem cells provide sufficient support to induce the formation of cartilage when the number of auricular chondrocytes available is limited. This novel model of cartilage engineering provides a setting for using the patient's own chondrocytes and adipose tissue to create a customized ear framework that could be further used for surgical reconstruction.

Summary:. The techniques used to make preoperative markings before soft tissue reconstruction have remained relatively unchanged since the earliest years of plastic surgery. Using skin-marking pens, many surgeons continue to draw markings freehand as “best estimates” before their first incisions. Although efficient for the experienced surgeon, this strategy may prove challenging for residents and trainees striving to learn and maintain consistency while replicating the intricate geometries of flap markings. To address this need, Operating Room Stencil was developed as a novel tool for digitally planning flap markings that may then be projected onto contoured surfaces such as the human body. As a cost-free mobile application, Operating Room Stencil is widely accessible to the medical community and offers educational captions for a majority of the flaps featured in its database. Users can plot relaxed skin tension lines onto uploaded facial images, thus enabling surgeons to orient surgical markings in a way that optimizes scar formation and reduces wound contraction. Although originally intended to appeal to trainees as a reliable way to learn about flaps and practice their technique, Operating Room Stencil may prove useful even among more experienced surgeons striving to further perfect their visualization and execution of flap markings.

Debated topics and new and evolving techniques in breast surgery are discussed in this chapter. Antibiotics and the use of closed-suction drains vary among surgeons, but the existing evidence favours discontinuation of antibiotics within 24 hours in most cases, and the indications for drains are limited but include breast reconstruction with acellular dermal matrix (ADM). ADM is a biological tissue substitute with many applications in breast surgery. The product selected and surgical technique used are often case specific; cost and patient anatomy play major roles. Although not suitable for all patients, ADM is an asset to prosthetic breast reconstruction. In addition, ADM is useful in the correction of breast surgery complications, including malpositioning and capsular contracture. It may be combined with fat grafting to mask rippling. Fat grafting, or lipomodelling, is an evolving science with promising results. Technique is critical for good results, and is described in this chapter. Radiographic changes after fat grafting are usually discernible from suspicious lesions, and growing evidence supports the oncological safety of this procedure

Summary Introduction Extracellular vesicles (EVs) are cell-secreted packages that deliver cargo to target cells to effect functional and phenotypic changes. They are secreted by many different cell types, including adipose-derived stem cells (ADSCs), which are a promising field of study in regenerative medicine. Our aim was to perform a systematic review of the literature to summarize the scientific work that has been conducted on ADSC EVs to date. Methods The Pubmed database was queried with keywords (and variations of) “adipose derived stem cell,” “stromal vascular fraction,” and “extracellular vesicles.” We excluded review papers, then manually screened articles based on title and abstract. Full-text articles were assessed for eligibility to include in final review. Results While an extensive body of research exists on EVs, a much smaller proportion of that is original research on ADSC EVs. Of 44 manuscripts that met our database search criteria, 21 articles were selected for our systematic review. Conclusion ADSC EVs were found to exert effects on angiogenesis, cell survival and apoptosis, inflammation, tissue regeneration, and reduction of disease pathology. Further studies examine characteristics of ADSC EVs. Future work should aim to further detail the safety profiles of ADSC EVs given their potential for cell-based therapies. The body of research studies characterizing ADSC EVs continues to expand, and much work remains to be done before human pilot studies can be considered. To our knowledge, we offer the first systematic review summarizing the research on ADSC EVs and their determined roles to date.

Background: Digit replantation affords the opportunity to restore hand function following amputation. To date, however, few studies have evaluated functional outcomes following replantation. Therefore, it was the objective of this study to perform a meta-analysis to better characterize the predictors of hand function. Methods: A literature search was performed using the PubMed database to identify studies that focused on digit amputation/replantation and functional outcomes. Studies were evaluated for patient- and injury-related factors and their respective effects on clinical outcomes of sensation, grip strength, and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. Statistical analysis was conducted across the pooled data set to identify significant trends. Results: Twenty-eight studies representing 618 replanted digits were included in this study. We found the average grip strength was 78.7% (relative to contralateral), the average 2-point discrimination (2PD) was 7.8 mm, and the average DASH score was 12.81. After conducting statistical analysis, we found patients with more proximal injuries had lower grip strength scores ( P < .05). We found 2PD scores were influenced by age, mechanism of injury, and amputation level ( P < .05). Finally, we found DASH scores after replantation were predicted by mechanism of injury and level of amputation ( P < .05). The following variables did not influence outcomes: gender, tobacco use, ischemia time, and digit number. Conclusions: Digit replant does not restore premorbid hand function but does result in adequate hand function. Expected functional outcomes following replant should be considered in the decision-making process. These data can help risk-stratify patients, guide postreplant expectations, and influence the decision for replantation.

Introduction Secondary procedures following digit and hand replants are often necessary to optimize functional outcomes. To date, the incidence and characteristics of secondary procedures have yet to be fully defined. Materials and Methods A literature search was performed using the NCBI (National Center for Biotechnology Information) database for studies evaluating secondary procedures following digit and hand replantation/revascularization. Studies were evaluated for frequency and type of secondary procedure following replantation. Descriptive statistical analysis was conducted across the pooled dataset. Results Nineteen studies representing 1,485 replants were included in our analysis. A total of 1,124 secondary procedures were performed on the 1,485 replants. Secondary procedures most commonly addressed tendons (27.1%), bone/joints (16.1%), soft tissue coverage (15.4%), nerve (5.4%), and scar contractures (4.5%). A total of 12.7% of replants resulted in re-amputation (16.7% of secondary procedures). The details of secondary procedures are further described in the article. Conclusion Secondary procedures are often necessary following hand and digit replants. Patients should be informed of the possible need for subsequent surgery, including delayed amputation, to improve hand function. These data improve our understanding of replant outcomes and can help patients better comprehend the decision to undergo replantation.

Defects involving the esophagus can pose a complex challenge to the reconstructive surgeon. Appropriate choice of recipient vessel lays the foundation for these operations. These cases often involve a “vessel-depleted” or “frozen” neck secondary to resection and treatment of malignancy, making knowledge of the various recipient vessel options vital. This chapter describes the recipient vessels available in esophagus reconstruction, and the pertinent anatomy, benefits, and downsides associated with each vessel option.

Vascular compromise and blindness are reported but rare complications of facial soft tissue filler injections. Stroke is an even rarer complication resulting from intraarterial injection of fillers. We present a case of a patient suffering all 3 complications following hyaluronic acid filler injection: forehead skin vascular compromise, unilateral blindness, and ipsilateral subclinical strokes. Were it not for a stroke workup protocol, the incidental strokes may have otherwise gone undetected, suggesting the incidence of stroke from intraarterial injection may be higher than reported. Further, we review the literature and recommendations for prevention and management of threatened tissue ischemia and vision loss from facial filler injection. Level of Evidence: 5

Soft tissue reconstruction of head and neck defects is a broad, challenging task. The key to a successful operation is choosing an appropriate reconstructive option based on the location, size, and characteristics of the defect. This chapter describes the main principles to consider when deciding on a primary reconstructive option for the defects created by oncologic resection. These principles include placing scars in relaxed skin tension line, minimizing donor defects, and reconstructing entire facial aesthetic subunits. This chapter also focuses on the reconstruction methods that maximize function and minimize aesthetic deformity.

Background The role of surgical reconstruction following melanoma extirpation is well recognized. Although technical considerations depend on patient anatomy and surgeon preference, the optimal timing of reconstruction remains unclear. This study aims to evaluate clinical and oncologic outcomes in melanoma extirpation followed by immediate reconstruction. Methods We retrospectively identified patients who underwent immediate reconstruction following head and neck melanoma excision at our institution between January 2013 and December 2016. Demographic and clinical characteristics, operative variables, and outcome data were extracted. Results Overall, 197 patients (male 70.6%) underwent excision followed by immediate reconstruction. Of the 70 patients with a history of cutaneous malignancy, 46 (65.7%) had a prior melanoma and 26 (37.1%) had 2 or more types of skin cancers. Of the 202 lesions resected, 138 (68.3%) were invasive, whereas 64 (31.7%) were in situ. The most frequent anatomic location involved was the cheek (34.2%), followed by scalp (31.2%). Reconstruction technique varied, with 116 (57.4%) lesions repaired by adjacent tissue transfer, 24 (11.9%) by full-thickness skin graft, 23 (11.4%) by complex primary closure, 17 (8.4%) by split-thickness skin graft, and 22 (10.9%) by more than 1 technique. On postoperative pathologic assessment, 2 patients had positive margins and 5 experienced local recurrence (mean follow-up: 2.3 years). In an unadjusted bivariate analysis, history of melanoma (P = 0.015) was significantly associated with local recurrence. Conclusions Reconstruction at time of excision is an oncologically safe approach for the management of patients with malignant melanoma. A prior history of melanoma may be associated with local recurrence.

Background Time spent under the microscope is often a limiting factor as plastic surgery residents work toward proficiency in microsurgery. This study describes and assesses a novel application of a digital microscope compatible with smart devices which can consistently and reliably magnify microsurgical fields. Methods A digital microscope was used to display an “operating” field on a tablet device. Two junior plastic surgery residents participated in multiple training sessions. During each session, residents completed two sessions of a knot-tying task and a chicken vessel anastomosis task. The sessions were recorded on the tablet, photographed, and graded by an experienced microsurgeon utilizing three standardized microsurgery training scales (OWOMSA, OSATS, and Global scale) for evaluation. Between sessions, the residents received feedback from the experienced microsurgeon. Results Statistically significant improvements (p Conclusion Traditional operating microscopes present considerable barriers for effective microsurgical training. The digital microscope analyzed in the present study provides solutions to several of these barriers: it is economical, lightweight, portable, and can be set up by the trainee on any flat surface; photographing and recording capabilities via the connected tablet device make the digital microscope setup optimized for education. Our study demonstrates measurable improvements in trainee's skills with use of—as well as favorable trainee attitudes toward—the digital microscope, which could present a valuable addition to plastic surgery education.

Diabetes mellitus (DM) is a chronic disease that results in a variety of systemic complications. Recently, stem cell-based therapies have been proposed as potential modalities to manage DM related complications. Mesenchymal stem cell (MSC) based therapies are often considered as an ideal stem cell-based treatment for DM management due to their immunosuppressive characteristics, anti-inflammatory properties and differentiation potential. While MSCs show tremendous promise, the underlying functional deficits of MSCs in DM patients is not well understood. Using the MEDLINE database to define these functional deficits, our search yielded 1826 articles of which 33 met our inclusion criteria. This allowed us to review the topic and illuminate four major molecular categories by which MSCs are compromised in both Type 1 DM and Type II DM models which include: (1) changes in angiogenesis/vasculogenesis, (2) altered pro-inflammatory cytokine secretion, (3) increased oxidative stress markers and (4) impaired cellular differentiation and decreased proliferation. Knowledge of the deficits in MSC function will allow us to more clearly assess the efficacy of potential biologic therapies for reversing these dysfunctions when treating the complications of diabetic disease.

Level of Evidence: 4.

This article describes the formation of the International Confederation of Plastic Surgery Societies (ICOPLAST) as a novel, transparent, dynamic, and proactive confederation of national plastic surgery societies. ICOPLAST aspires to provide a voice for the entire international community of plastic surgeons. ICOPLAST has been designed to benefit the patient, plastic surgery as a profession, and each individual plastic surgeon. Its principal objective is to enhance international communication, education, and advocacy processes to ultimately improve patient outcomes for plastic surgery patients globally. The new ICOPLAST's focus is to add true value for patients. ICOPLAST's evolution, philosophy, governance, and bylaws are explained and all societies worldwide are encouraged and cordially invited to join. An open and warm invitation is provided. Additional information is found at www.ICOPLAST.org.

BACKGROUND Although recent estimates predict a large impending shortage of plastic surgeons, graduate medical education funding through the Centers for Medicare and Medicaid Services remains capped by the 1997 Balanced Budget Act. The authors' aim was to develop a plan to stimulate legislative action. METHODS The authors reviewed responses of the American Society of Plastic Surgeons, American College of Surgeons, and American Medical Association from January of 2015 to a House Energy & Commerce Committee request for input on graduate medical education funding. In addition, all program directors in plastic surgery were surveyed through the American Council of Academic Plastic Surgeons to determine their graduate medical education funding sources. RESULTS All three organizations agree that current graduate medical education funding is inadequate to meet workforce needs, and this has a significant impact on specialty selection and distribution for residency training. All agreed that funding should be tied to the resident rather than to the institution, but disagreed on whether funds should be divided between direct (allocated to residency training) and indirect (allocated to patient care) pools, as is currently practiced. Program directors' survey responses indicated that only 38 percent of graduate medical education funds comes from the Centers for Medicare and Medicaid Services. CONCLUSIONS Organized medicine is at risk of losing critically needed graduate medical education funding. Specific legislation to support additional graduate medical education positions and funding (House Resolutions 1180 and 4282) has been proposed but has not been universally endorsed, in part because of a lack of collaboration in organized medicine. Collaboration among major organizations can reinvigorate these measures and implement real change in funding.

Free tissue transfer is a common reconstructive surgical technique used to treat a wide variety of defects and injuries. Distant donor tissue, which can include bone, muscle, skin, and fascia, is recruited in order to restore both form and function. Inherent to these procedures are the challenges involved in revascularizing donor tissue as well as monitoring flap viability during the operative and postoperative period. This chapter details the process that microsurgeons go through as they assess patients and their need for free tissue transfer in addition to describing operative techniques and equipment used in microsurgery for both vessel anastomosis and free flap monitoring.

Latissimus dorsi muscle and myocutaneous flaps provide a versatile means of providing both implant-based and pure autologous breast reconstructions. The technique is well suited to lean patients and those with contraindications to the use of the lower abdomen as a donor site. The technique has been progressively refined over time to provide concealed scars and to reduce donor site morbidity. The use of endoscopic assistance, robotic flap harvest, muscle-sparing flap design, and perforator flaps based on the thoracodorsal vascular access (the thoracodorsal artery perforator flap or TAP-flap), continue to increase the utility of this donor site for breast reconstruction.

Preoperative evaluation and management of complex perineal wounds must account for any history of previous surgery, radiation, or trauma; the size and surface area following resection or debridement; and the loss of function or structural integrity. The gracilis muscle or myocutaneous flap is a local, well-vascularized option suitable for perineal soft tissue reconstruction, particularly for moderately sized defects of the groin. The use of functional gracilis muscle for anal sphincter reconstruction may also be considered for the treatment of fecal incontinence due to significant neurologic, traumatic, or iatrogenic injury, as well as for congenital abnormalities.

Reconstruction of the vagina is usually performed in patients undergoing abdominal-perineal resection or pelvic exenteration for carcinoma of the cervix, vagina, or rectum. Vaginal reconstruction is indicated for both psychological rehabilitation and perineal wound healing. Immediate reconstruction after partial or total vaginal resection facilitates primary healing of the perineal defect, decreases fluid loss from the pelvis, reduces infection rate, prevents herniation of abdominal contents into the perineum, and decreases nutritional demands. Additionally, flap closure provides neovascularization of the remaining pelvic tissue, which is particularly important in successful wound healing for patients who have either had radiation to the area or who are having postoperative radiation therapy. Moreover, even in the sexually inactive patient, this surgery provides patients with faster healing and overall enhanced self-esteem

The rectus abdominis flap is a versatile, workhorse flap. It is ideal for head and neck reconstruction requiring large, soft tissue bulk without bony reconstruction, particularly for defects of the tongue, orbits, maxilla, cheek, posterior mandible, and cranial base. Its ability to be folded upon itself and harvested with multiple skin paddles makes it versatile for complex three-dimensional and multilaminar defects. Its pedicle size and length and consistent vascular anatomy make the flap a reliable choice for head and neck reconstruction. Its indications in head and neck reconstruction and technique in harvest are elaborated in this chapter.

Plastic surgery techniques, developed over the preceding 5,000 years, outline the chapters in the second edition of this original book, along with patient considerations. Chapters address the assessment of the defect, the preoperative factors in addressing the problem at hand, the influence of medical or adjuvant therapy, the pathology of the defect, the role of trauma in operative repair, and the correct marriage of donor to recipient tissue. Contributors also address operative indications, operative room setup, and postoperative care and details of pertinent dressings. Plastic surgery has evolved from the transfer of local, pedicle, and free flaps to the understanding of the requirements for angiogenesis and the physiology of tissue molding. Future discoveries will open new avenues for treatment and care.

Skin aging is a multivariate phenomenon that is influenced by an interdependent and patient-specific footprint of biologic and chronologic aging processes. The most common patterns of aging include degenerative changes to the skin, muscle, muscle fascia, and adipocyte. The interplay of these four variables is a fundamental focus of a modern plastic surgery practice. Plastic surgeons must be proficient in skin aging pathophysiology and the mechanisms to optimize skin with topical dermatologic monotherapy alone, or as a prelude to surgery or laser. The focus of this chapter is to highlight the importance of skin aging in the global assessment of the cosmetic patient and to elucidate the role of skin optimization in the management of the patient requesting rejuvenative cosmetic surgery.

Reconstruction of the vagina is performed for patients undergoing abdominoperineal resection, pelvic exenteration for cancer involving the cervix, vagina, or rectum, and other causes of acquired pelvic defects. Immediate reconstruction after partial or total vaginal resection facilitates primary healing of the perineal defect, decreases fluid loss from the pelvis, reduces infection rate, and decreases nutritional demands. The gracilis flap is one of the most commonly used flaps for reconstruction of these challenging pelvic defects because it is versatile, has minimal donor side morbidity, and often lies outside the field of radiation. This chapter provides a detailed account of patient assessment and operative techniques.

Resection of the perineal area is challenging. Not only is there a component of loss of skin and muscle, but one must also consider reconstruction in an immediate or delayed fashion; whether a vaginal resection will result in partial or a total defect; and, if partial, whether the vaginal loss will be on the anterior, posterior, or distal vaginal wall. The pudendal flap may not be the best option for some of these defects. Loss of the vaginal introitus as well as part of the vault requires careful planning to provide a flap design with adequate length and width to prevent stenosis. Fraught with bacterial contamination, limitation of tissue advancement, and often tissues subjected to previous adjuvant therapy, perineal reconstruction is frequently accompanied by complications. Knowledge of the appropriate anatomy reduces morbidity. This chapter will focus on the pudendal (Singapore) artery flap for reconstruction. At the end of the chapter, readers should be able to understand the anatomy, design of the flap, and management of potential complications

Radial forearm free-flaps (RFFF) offer great utility in the reconstruction of intraoral soft tissue defects. The use of a free tissue transfer with the radial forearm flap can obviate poor wound healing and replace previously irradiated tissue with well-perfused normal fascia and skin. Considerable care must be taken by the surgeon to preserve adequate function of speech and swallow, as well as to obtain good cosmesis. Knowledge of proper anatomical orientation and preoperative marking provide keys to a successful flap dissection and intraoral reconstruction. After reading this chapter, the reader should have an understanding of the assessment of intraoral defects, indications for RFFF, intraoperative techniques, and marking, as well as postoperative patient management.

Management of pressure ulcers requires a multifaceted approach for both prevention and treatment. The posterior thigh flap is one option for definitive surgical management. Treatment is initiated optimizing factors for wound healing and minimizing risk factors for recurrence. Obtaining adequate pressure offloading, moisture control, decreased wound contamination, and correction of any malnutrition should be addressed before considering surgery. The arc of rotation allows for potential closure of defects of the upper gluteal region, lower sacrum, greater trochanter, pubis, or perineum. Ischial ulcers treated with the posterior thigh flap can have a high rate of wound healing complications, but total flap loss and other serious complications are relatively rare. Partial loss or recurrence can often be treated with flap readvancement. Patient selection and preparation are keys to success.

Purpose The preservation of transplantable tissue is directly tied to and limited by the ischemia time. Micro/nanobubbles (MNBs) are miniature gaseous voids that allow for the oxygenation of tissue given their high oxygen-carrying capacity. One of the current limitations of islet cell transplantation for type 1 diabetes is poor islet survival, caused by hypoxia, after harvesting the cells from pancreata. As such, the purpose of this study was to elucidate whether MNBs, when added to standard culture medium, improve islet cell survival postharvest. Materials and methods Islet cells were harvested from Sprague-Dawley rat pancreas tissue via a standard collagenase digestion and gradient purification. To create the MNB solution, a shear-based generation system was used to produce both air- and oxygen-filled MNBs in standard Connaught Medical Research Laboratories (CMRL) medium. Four groups, consisting of 500 islet equivalents, were cultured with either the standard CMRL medium, macrobubble-CMRL, MNB (air)-CMRL, or MNB (O2)-CMRL, and they were incubated at 37°C. Each treatment solution was replenished 24 hours postincubation, and after 48 hours of culture, dithizone staining was used to determine the islet cell counts, and the viability was assessed using Calcein AM/propidium iodide staining. Results Islet cells that were preserved in macrobubble-CMRL, MNB (air)-CMRL, and MNB (O2)-CMRL conditions showed an increased survival compared with those cultured with standard CMRL. The islet cells cultured in the MNB (air)-CMRL condition demonstrated the greatest cell survival compared with all other groups, including the pure oxygen-carrying MNBs. None of the MNB treatments significantly altered the viability of the islet cells compared to the control condition. Conclusions The addition of MNBs to culture medium offers an innovative approach for the oxygenation of transplantable tissue, such as islet cells. This study demonstrated that MNBs filled with air provided the most optimal addition to the islet cell culture medium for improving islet cell survival amongst the treatment groups we tested. Given these findings, we hypothesize that MNBs may also improve the oxygenation and survival of a variety of other tissues, including fat grafts from lipoaspirate, chronic wounds, and solid organs.

Background Ever since the classification of Dupuytren disease into the proliferative, involutional, and residual stages, extensive research has been performed to uncover the molecular underpinnings of the disease and develop better treatment modalities for patients. The aim of this article is to systematically review the basic science literature pertaining to Dupuytren disease and suggest a new approach to treatment. Methods Following Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review was conducted using the MEDLINE database to identify basic science literature on Dupuytren pathophysiology falling under 1 or more of the following categories: (1) Molecular alterations, (2) Structural alterations, and (3) Genetic predisposition. Results A total of 177 articles were reviewed of which 77 studies met inclusion criteria. Articles were categorized into respective sections outlined in the study methods. Conclusion The pathophysiological changes involved in Dupuytren's disease can be divided into a number of molecular and structural alterations with genetic predisposition playing a contributory role. Understanding these changes can allow for the development of biologics which may disrupt and halt the disease process.

Introduction Patient satisfaction is an important clinical marker for hand/upper extremity patients. Few studies have investigated the predictors of patient satisfaction in the clinic setting. Our objective was to analyze patient satisfaction surveys to explore factors that influence patient satisfaction. Materials and Methods We conducted a retrospective analysis assessing patient satisfaction in the hand/upper extremity clinics at our university medical center between 2012 and 2018. Patient satisfaction was assessed via Press Ganey Hospital Consumer Assessment of Healthcare Providers and Systems surveys. Patient demographics, satisfaction scores, and clinic experience questionnaire responses were evaluated. Statistical analysis was conducted to identify significant trends. Results Between 2012 and 2018, 102 surveys were completed. Scores ranged from 5 to 10 with an average provider rating of 9.56. We found six factors significantly influenced patient satisfaction: adequate time was spent with the provider, provider showed respect, patient was seen by provider within 15 minutes of appointment time, provider listened sufficiently, patient received understandable medical instructions, and understandable medical explanations (p < 0.05). Conclusion Achieving patient satisfaction is an important clinical marker in hand/upper extremity clinics. Patient satisfaction has defined predictors wherein various clinical factors can influence patient satisfaction and willingness to refer their provider to other patients.

There are two accepted theories that describe the pathophysiology of fat grafting results. The first is that once grafted, there is at least partial survival of the adipocytes to achieve a lipofilling effect. The second theory is that the grafted adipocytes undergo necrosis, and it is the remaining stromal components and stem cells that recruit host tissue to fill the void through adipogenesis, neovascularization, and fibrosis. The authors discuss decellularization of adipose tissue, characterization of decellularized human adipose tissue extracellular matrix (hDAM), emerging trends in basic science and translational applications, hDAM supplementation, decellularization, hDAM 3d architecture, and clinical implications. hDAM has the potential to promote the attachment and proliferation of progenitor cells. Creating the optimal microenvironment for tissue regeneration may prove to be tissue specific, and recent research on hDAM manipulation and supplementation with synthetic scaffolds is paving the way for novel therapies in the field of regenerative medicine.

BackgroundTamoxifen is an important adjunct therapy in breast cancer treatment; however, it has been implicated in increasing microvascular flap complications. Current recommendations on stopping tamoxifen are conflicting and do not address tamoxifen therapy that is continued perioperatively. The pu

Current embodiments of negative pressure wound therapy (NPWT) create a hermetically sealed chamber at the surface of the body using polyurethane foam connected to a vacuum pump, which is then covered by a flexible adhesive drape. Commercially available NPWT systems routinely use flexible polyethylene films that have a sticky side, coated with the same acrylate adhesives used in other medical devices such as ECG leads and grounding pads. Severe reactions to the acrylate adhesives in these other devices, although uncommon, have been reported. We describe the case of a 63-year-old woman with an intractable leg ulcer resulting from external-beam radiotherapy (XRT). Treatment with a standard commercial NPWT system induced severe inflammation of the skin in direct contact with drape adhesive. We successfully administered prolonged, outpatient NPWT to the patient using an alternative method (first described by Bagautdinov in 1986), using plain polyethylene film and petrolatum. The necessary hermetic seal is achieved by smearing the skin with petrolatum before applying the polyethylene film and activating the vacuum pump. The Bagautdinov method is a practical solution to the problem of adapting NPWT to patients with contact sensitivity or skin tears related to the adhesive compounds in the flexible drapes. Its use of a circumferential elastic wrap to maintain constant pressure on the seal probably limits the Bagautdinov technique to the extremities.

Scarring following burn injury and its accompanying aesthetic and functional sequelae still pose major challenges. Hypertrophic scarring (HTS) can greatly impact patients' quality of life related to appearance, pain, pruritus and even loss of function of the injured body region. The identification of molecular events occurring in the evolution of the burn scar has increased our knowledge; however, this information has not yet translated into effective treatment modalities. Although many of the pathophysiologic pathways that bring about exaggerated scarring have been identified, certain nuances in burn scar formation are starting to be recognized. These include the effects of neurogenic inflammation, mechanotransduction, and the unique interactions of burn wound fluid with fat tissue in the deeper dermal layers, all of which may influence scarring outcome. Tension on the healing scar, pruritus, and pain all induce signaling pathways that ultimately result in increased collagen formation and myofibroblast phenotypic changes. Exposure of the fat domes in the deep dermis is associated with increased HTS, possibly on the basis of altered interaction of adipose-derived stem cells and the deep burn exudate. These pathophysiologic patterns related to stem cell-cytokine interactions, mechanotransduction, and neurogenic inflammation can provide new avenues of exploration for possible therapeutic interventions.

Adipose tissue is a rich source of cells with emerging promise for tissue engineering and regenerative medicine. The stromal vascular fraction (SVF), in particular, is an eclectic composite of cells with progenitor activity that includes preadipocytes, mesenchymal stem cells, pericytes, endothelial cells, and macrophages. SVF has enormous potential for therapeutic application and is being investigated for multiple clinical indications including lipotransfer, diabetes-related complications, nerve regeneration, burn wounds and numerous others. In Part 2 of our review, we explore the basic science behind the regenerative success of the SVF and discuss significant mechanisms that are at play. The existing literature suggests that angiogenesis, immunomodulation, differentiation, and extracellular matrix secretion are the main avenues through which regeneration and healing is achieved by the stromal vascular fraction.

Stromal Vascular Fraction (SVF) is a heterogeneous collection of cells contained within adipose tissue that is traditionally isolated using enzymes such as collagenase. With the removal of adipose cells, connective tissue and blood from lipoaspirate, comes the SVF, a mix including mesenchymal stem cells, endothelial precursor cells, T regulatory cells, macrophages, smooth muscle cells, pericytes and preadipocytes. In part 1 of our 2-part series, we review the literature with regards to the intensifying interest that has shifted toward this mixture of cells, particularly due to its component synergy and translational potential. Trials assessing the regenerative potential of cultured Adipose Derived Stem Cells (ADSCs) and SVF demonstrate that SVF is comparably effective in treating conditions ranging from radiation injuries, burn wounds and diabetes, amongst others. Aside from their use in chronic conditions, SVF enrichment of fat grafts has proven a major advance in maintaining fat graft volume and viability. Many SVF studies are currently in preclinical phases or are moving to human trials. Overall, regenerative cell therapy based on SVF is at an early investigative stage but its potential for clinical application is enormous.

Stem cells and tissue engineering have made great strides in plastic surgery. This review of the literature evaluates some current background information and recent advances in our laboratory to bring these areas more into the clinical setting.