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Patient demand for nonsurgical and minimally invasive cosmetic treatments has increased in recent years, resulting in a growing market that is particularly vulnerable to specialty creep. Despite this growing demand, nonsurgical cosmetic training for plastic surgery residents is often inconsistent and challenging. To ensure the continued safe and effective delivery of nonsurgical cosmetic care by board-certified plastic surgeons, it is critical to implement standardized training models for plastic surgery residents. In this Special Topic article, the authors describe their experience with a resident-run clinic training model that incorporates graduated autonomy, volunteer patient recruitment, and grant-based industry support that has been successfully implemented at their institution for the past 6 years. The article provides a framework for a resident educational model and addresses common obstacles in resident cosmetic training. The authors also provide recommendations for patient recruitment, optimizing clinic workflow, and the management of patient complications.

Background Adult acquired buried penis syndrome may be associated with an inability to void, sexual dysfunction, and recurrent infection. Previously published classification systems rely on intraoperative findings, such as penile skin quality. Objectives The purpose of this study was to evaluate outcomes after adult acquired buried penis repair and to develop a classification system based on preoperative assessment. Methods The authors reviewed data from patients who underwent buried penis reconstruction at a single institution. Patient history and physical examination guided the development of a classification system for surgical planning. Results Of the 27 patients included, the mean age was 56 ± 15 years and mean body mass index was 49 ± 14 kg/m2. Patients were classified into 4 groups based on examination findings: (I) buried penis due to skin deficiency, iatrogenic scarring, and/or diseased penile skin (n = 3); (II) excess abdominal skin and fat (n = 6); (III) excess skin and fat with diseased penile skin (n = 16); and (IV) type III plus severe scrotal edema (n = 2). Surgical treatment (eg, excision and grafting, mons suspension, panniculectomy, translocation of testes, and/or scrotectomy) was tailored based on classification. Complications included wound breakdown (n = 3), cellulitis (n = 4), and hematoma (n = 1). Nearly all patients (96%) reported early satisfaction and improvement in their symptoms postoperatively. Conclusions Classifying patients with buried penis according to preoperative examination findings may guide surgical decision-making and preoperative counseling and allow for optimized aesthetics to enhance self-esteem and sexual well-being. Level of Evidence: 4

Parry Romberg disease (hemifacial atrophy) and linear scleroderma (coup de sabre) are progressive, usually unilateral facial atrophies of unknown cause. The gold standard treatment for these patients has been microsurgical reconstruction following the "burning out" of the facial atrophy and stable contour for 2 years.The authors report their experience treating patients with hemifacial atrophy and linear scleroderma with free tissue transfers between 1989 and 2016. A modified parascapular flap based on the circumflex scapular artery was most commonly used.A total of 177 patients were included. The most common complication was hematoma, occurring in 12 patients (7 percent). Follow-up ranged from 1 to 26 years. All patients subjectively experienced improved facial symmetry and aesthetics. No disease process has recurred to date, even in cases of severe, progressive disease.In the authors' experience, patients treated early in their disease course have immediate and sustained correction of their deformity, with slowing or in most cases cessation of the disease process following free tissue transfer. The authors now advocate for immediate reconstruction for active disease, especially in young children.Therapeutic, IV.

Mammalian skin impacts metabolic efficiency system-wide, controlling the rate of heat loss and consequent heat production. Here we compare the unique fat depots associated with mouse and human skin, to determine whether they have corresponding function and regulation. For human, we assay a skin-associated fat (SAF) body-wide depot to distinguish it from the subcutaneous fat pads characteristic of abdomen and upper limbs. We show that the thickness of SAF is not related to general adiposity; it is much thicker (1.6-fold) in women than men, and highly subject-specific. We used molecular and cellular assays of β-adrenergic induced lipolysis and found that dermal white adipose tissue (dWAT) in mice is resistant to lipolysis; in contrast, the body-wide human SAF depot becomes lipolytic, generating heat in response to β-adrenergic stimulation. In mice challenged to make more heat to maintain body temperature (either environmentally or genetically), there is a compensatory increase in thickness of dWAT: A corresponding β-adrenergic stimulation of human skin adipose (in vivo or in explant) depletes adipocyte lipid content. We summarize the regulation of skin-associated adipocytes by age, sex, and adiposity, for both species. We conclude that the body-wide dWAT depot of mice shows unique regulation that enables it to be deployed for heat preservation; combined with the actively lipolytic subcutaneous mammary fat pads they enable thermal defense. The adipose tissue that covers human subjects produces heat directly, providing an alternative to the brown adipose tissues.KEY POINTS SUMMARYSeveral distinct strategies produce and conserve heat to maintain body temperature of mammals, each associated with unique physiologies, with consequence for wellness and disease susceptibilityHighly regulated properties of skin offset the total requirement for heat productionWe hypothesize that the adipose component of skin is primarily responsible for modulating heat flux; here we evaluate the relative regulation of adipose depots in mouse and human, to test their recruitment to heat production and conservationWe found that insulating mouse dermal white adipose tissue accumulates in response to environmentally- and genetically-induced cool stress; this layer is one of two adipose depots closely apposed to mouse skin, where the subcutaneous mammary gland fat pads are actively recruited to heat productionIn contrast, the body-wide adipose depot associated with human skin produces heat directly, potentially creating an alternative to the centrally regulated brown adipose tissue

Background Few studies have examined the impact of abdominoplasty on chronic back pain. Objectives The aim of this study was to test our hypothesis that patients undergoing abdominoplasty with anterior abdominal wall plication will show significant improvements in back pain and physical function compared with those without plication. Methods We utilized Current Procedural Terminology (CPT) codes to identify patients who underwent abdominoplasty with the senior author over a 10-year period. The Oswestry Disability Index (ODI) and the RAND 36-Item Short-Form Health Survey (SF-36) were administered. All patients indicating preoperative back pain were reviewed. Results Of 338 patients, 143 surveys (42.3%) were returned; 51 patients (35.7%; n = 28 aesthetic, n = 23 massive weight loss) reported preoperative back pain on the ODI. Paired t tests compared overall and strata-specific changes in ODI and SF-36 pre- and postsurgery. Multivariable linear regression models were fitted to model relations between scores and plication, adjusting for presurgery scores and patient variables. There were significant improvements in overall patient cohort in ODI (–15.14), SF-36 physical function (19.92), and pain (17.42) (P Conclusions Abdominoplasty with and without anterior abdominal wall plication significantly improves ODI and SF-36 scores relating to physical function and pain, in both aesthetic and massive weight loss patients. Outcomes did not differ based on plication status. All patients with preoperative back pain showed improvement regardless of operation performed, suggesting that abdominoplasty with or without abdominal wall plication improves chronic back pain in this patient population. Level of Evidence: 4

Hemifacial atrophy (Parry-Romberg syndrome) is an enigmatic craniofacial disorder characterized by progressive facial atrophy. Early age at onset is associated with significant skeletal involvement and jaw abnormalities. Standard reconstructive dogma dictates that the disease should "burn out," with at least 2 years of no disease progression, before pursuing reconstructive intervention. The purpose of this article is to present the senior author's (J.W.S.) experience treating preadolescent children with free soft-tissue transfer for reconstruction of progressing hemifacial atrophy, and to review surgical techniques in this patient population.Pediatric free tissue transfer cases performed by the senior author were reviewed. Free tissue transfer using a circumflex scapular adipofasciocutaneous flap was performed to treat deformities arising from hemifacial atrophy.Thirty-six patients aged 3 to 6 years underwent free tissue transfer in the presence of progressing, active disease. Follow-up ranged from 7 months to 25 years. There were no cases of flap loss. In all patients, the disease process seemed to be altered, with no symptoms recurring to date.The authors believe that early microsurgical correction of hemifacial atrophy in children as young as 3 years is reliable and effective. The authors theorize that the interposition of vascularized, healthy tissue may alter or even halt the progression of disease, and may also prevent the skeletal hypoplasia classically seen in older patients. Further study incorporating autologous fat grafting as a control procedure may provide additional insight into this challenging disease process.Therapeutic, IV.

This case study examines a common agricultural cooperative structure in the United States, namely that of a business which both sells farm supplies to its members and also markets, to others, the agricultural products of its members. The case concerns whether the United Agricultural Cooperative should sell the cooperative’s agronomy supply division. This division sells fertilizer, chemicals and seed. It also provides related services. The cooperative has received an acquisition inquiry from rapidly expanding agricultural retailer, Pinnacle Agricultural Holdings, LLC. The case allows readers to examine both detailed financial information as well as the cooperative’s political environment. The case ends with readers being asked to recommend a decision; namely should the cooperative sell the agronomy division or should it be kept? Professors can read the authors’ teaching note to learn recommended classroom teaching strategies and also to learn the actual decision which was made by this cooperative.

In the public’s view, there is no procedure more synonymous with plastic surgery than the facelift. The ultimate goal of a facelift is to provide patients with a natural, unoperated appearance that results in a younger, refreshed version of himself or herself. While individuals vary in the onset and rate at which they age, there is a fundamental pattern and sequence to changes in facial appearance that occurs throughout the decades of life. The surgeon must appreciate the anatomic pathogenesis of facial aging in order to address the signs of aging in a natural way. Overall, the main principle of overriding importance in facelift is to restore harmony among the areas of the face with smooth transitions from the brow to the periorbital region to the midface to the jaw and to the neck. In consultation, it is important in the assessment to identify what areas need to be addressed and to understand the underlying pathogenesis that occurs with aging in order to restore this harmony.

BACKGROUND Parry-Romberg syndrome is an enigmatic craniofacial disorder characterized by progressive facial atrophy. The pathogenesis and molecular mechanisms governing Parry-Romberg syndrome have never before been described. The purpose of the current study was twofold: (1) to begin to elucidate the pathophysiology of this disease using next-generation RNA sequencing and (2) to evaluate the effect of surgical treatment on gene expression. METHODS Patients with Parry-Romberg syndrome underwent microvascular free tissue transfer to the face to address contour deformity in both active and burned out disease. Tissue samples were collected for analysis at the time of initial microvascular free tissue transfer, and 6 months later at a scheduled revision operation. Patients presenting for rhytidectomy had tissue samples taken as control tissue. Samples from patients with disease were compared to control samples. RESULTS Twenty-two subjects were evaluated (six control and 16 Parry-Romberg syndrome patients). All patients with Parry-Romberg syndrome underwent microvascular free tissue transfer to the face. Thirteen patients underwent scheduled 6-month revision surgery. Disease samples were distinct from healthy controls, and postoperative patient samples were more similar to healthy control samples. Parry-Romberg syndrome patients had a unique proinflammatory gene expression profile, including up-regulation of IL24, ADAMTS4, and GFCSF3. Postoperatively, more than 3400 genes were changed (p < 0.005), and of the 460 genes dysregulated in disease, 118 were changed in a corrective fashion by microvascular free tissue transfer. CONCLUSIONS The authors describe for the first time molecular signatures in Parry-Romberg syndrome. Molecular signatures in skin became more similar to those in healthy controls and were associated with clinical improvement after microvascular free tissue transfer in Parry-Romberg syndrome.

Free tissue transfer to improve bulk and contour in facial deformities has been proven useful, yet refinements that turn an acceptable result into an excellent result are essential to reconstruction. The authors reviewed their experience and described these refinements.The charts of 371 free tissue transfer cases (1989 to 2010) performed by the senior author (J.W.S.) were reviewed. Free tissue transfer of a circumflex scapular variant flap or superficial inferior epigastric was performed to treat deformities arising from hemifacial atrophy (n = 126), hemifacial microsomia (n = 89), radiation therapy (n = 40), bilateral malformations including lupus and polymyositis (n = 50), other congenital anomalies (n = 25), facial palsy (n = 17), and burns and trauma (n = 24).Revision surgery planning began at initial flap operation where the flap was stretched maximally and interdigitated with recipient tissue. More tissue was required in the malar region. Revision refinement was indicated in all cases (after 6 months). Flap revision involved liposuction, debulking, reelevation, and release of tethering, followed by tissue rearrangement by means of advancement, rotation, transposition, and/or turnover flaps of subcutaneous tissues from the previous free flap. The jawline frequently required more debulking. Periorbital reconstruction was combined with lower lid support with or without canthal repositioning. Conventional face-lift techniques with the flap as superficial musculoaponeurotic system augmented the result. Autologous fat injection to the alar rim, medial canthus, upper eyelid, and lip was a useful adjunct. Severe lip deficiencies were addressed with local flaps.The keys to improving results were continual critical reassessment, open-mindedness to new approaches, and maintaining high expectations.Therapeutic, V.

Bouma has recently been appointed to the National Milk Producers Federation's (NMPF) Board of Directors. "When my local cooperative appointed me to the NMPF board I was humbled. Now I have a lot of getting ready to do." Members of the NMPF board are also members of the Cooperatives Working Together (CWT) Committee. The committee is in charge of the CWT program, a major industry-funded effort to manage the U.S. milk supply by reducing herd numbers and subsidizing the export of dairy products. Courtney Phillips has just started her second summer internship at the Bouma Dairy Farm. She has been given the assignment of providing key information to help Mr. Bouma get ready for his role on the CWT Committee. "Courtney may like to work outside, but she is a 4.0 student in agribusiness. Through her research this summer, I can gain an understanding of both the background issues and the current operations of CWT. As a member of the board, Fd like to determine the effectiveness of CWT and also how it might be improved."

Extracellular functions of the endoplasmic reticulum chaperone protein calreticulin (CRT) are emerging. Here we show novel roles for exogenous CRT in both cutaneous wound healing and diverse processes associated with repair. Compared with platelet-derived growth factor-BB-treated controls, topical application of CRT to porcine excisional wounds enhanced the rate of wound re-epithelialization. In both normal and steroid-impaired pigs, CRT increased granulation tissue formation. Immunohistochemical analyses of the wounds 5 and 10 days after injury revealed marked up-regulation of transforming growth factor-beta3 (a key regulator of wound healing), a threefold increase in macrophage influx, and an increase in the cellular proliferation of basal keratinocytes of the new epidermis and of cells of the neodermis. In vitro studies confirmed that CRT induced a greater than twofold increase in the cellular proliferation of primary human keratinocytes, fibroblasts, and microvascular endothelial cells (with 100 pg/ml, 100 ng/ml, and 1.0 pg/ml, respectively). Moreover, using a scratch plate assay, CRT maximally induced the cellular migration of keratinocytes and fibroblasts (with 10 pg/ml and 1 ng/ml, respectively). In addition, CRT induced concentration-dependent migration of keratinocytes, fibroblasts macrophages, and monocytes in chamber assays. These in vitro bioactivities provide mechanistic support for the positive biological effects of CRT observed on both the epidermis and dermis of wounds in vivo, underscoring a significant role for CRT in the repair of cutaneous wounds.

Background: Free tissue transfer for adult mandibular reconstruction is a well-established technique; however, there are few reports of pediatric microvascular lower jaw reconstruction. Methods: This retrospective study was undertaken to review the range of indications, choices, safety, and efficacy of pediatric free tissue transfer to the lower jaw. All patients underwent a parascapular, scapular, or fibula free tissue transfer. Flap choice was based on preoperative clinical examination, radiographic findings, need for linear or multiplanar mandibular reconstruction, need for dental restoration, severity of soft-tissue deficit, and peroneal artery anatomy. Results: Over a 10-year period (1989 to 1999), we performed eightfree tissue transfers to reconstruct the mandibles of seven children, aged 6 to 17 years. Indications included radiation-induced hypoplasia (n = 1), postsurgical resection of fibrous dysplasia (n = 1), hemifacial microsomia (n = 3), Robin sequence with severe micrognathia (n = 1), and osteomyelitis (n = 1). The authors transferred four parascapular osseocutaneous, two scapular osseocutaneous, one fibular osseocutaneous, and one fibular osseous flap to reconstruct five ramus, four condyle, and two subtotal mandibular defects. All bony defects were successfully bridged and all osseous flaps successfully integrated. Postoperatively, mandibular symmetry and Angle class I occlusion were restored in all patients throughout the 10.5-year follow-up period (range, 9 to 14 years). Two patients received osseointegrated dental implants. Our only complication was the partial loss of a skin paddle. Conclusion: Microvascular reconstruction of the pediatric mandible, in selected patients, is a safe, reliable procedure that provides the bone stock and soft tissue necessary to restore normal maxillomandibular growth and dental rehabilitation.

A study of undergraduates at Texas A&M University, Purdue University, and the University of Florida reveals that students viewing grades as a contributor to career success tend to be more academically motivated. Several measures of academic motivation are examined by means of general linear and also nonlinear models. Electronic entertainment, socializing, and time spent working are all negatively associated with academic motivation. Greater academic motivation exists among females. To the extent that additional work is needed for the support of increased tuition costs, students have the potential to be less academically motivated. Copyright 2006, Oxford University Press.

The objectives of this case study are to describe the strategic positioning of the Johnny Carino's1 concept and to enable students to financially evaluate the purchase of a single-site franchise unit. Accordingly, this case begins with the formation of the Johnny Carino's parent company, Fired Up, Inc. Next the parent company's strategy and operations are examined. Finally, the student is guided in an analysis of individual restaurant financial performance.(A teaching note for this case is available from the author upon request).

Background: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. Methods: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. Results: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). Conclusions: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

This study is designed to assist small meat processors seeking to expand their sales volume. The analysis pertains to a procurement survey of 191 restaurants. Fifty-one different variables are analyzed by means of cross-tabulations among different restaurant groups. For example, three restaurant annual sales groupings (under $500,000, $500,000 to $2,000,000, and over $2,000,000) are used to examine which of these fifty-one restaurant variables significantly differ by group. Other cross-tabulations are also presented regarding dinner ticket price levels, management structure, and chain affiliation, respectively. Many significant differences are found to exist in terms of food quality, delivery methods, product types, and more. Small meat processors will be able to develop more effective sales growth strategies through gaining an understanding of such differences. This study should be of value to small food manufacturers interested in direct marketing to restaurants. For example, based on the gener...

A survey of agribusiness firms identifies characteristics associated with above average starting salary offers in the allied fields of agribusiness, agricultural economics, business, and economics. A complementary survey is made of students at Texas A&M University and University of Georgia. Results show that firms value work experience and leadership experience more than students do, whereas students value raising grade point average and interview preparation more than do firms. Students seeking a firm's maximum starting salary offer will need to enhance academic performance with substantial work experience and leadership experience. Copyright 2002, Oxford University Press.

Reconstruction of challenging surgical problems has undergone a dramatic evolution over the past quarter of a century. Microsurgical correction of facial contour deformities is a prime example of how far microsurgical reconstruction has evolved. This article discusses the current surgical techniques.

Suiza Foods has rapidly grown to become the largest company in the U.S. fluid milk industry. This teaching case is designed to familiarize students with the challenges which confront Suiza in its quest for further growth and, in turn, high profitability. Interviews with top executives describe the history of Suiza as well as the rationale behind Suiza’s strategies. Information is presented on both economic and financial trends so as to allow the student to assess Suiza’s past, present and future performance.

Aggregate consumption of most dairy products in the U.S. has remained relatively constant. To examine factors affecting consumption, a two-step estimation procedure is used to obtain parameter estimates of a censored multipleequation quadratic expenditure model for dairy products. Several sociodemographic and economic factors were found to affect weekly household expenditures on fresh whole milk, other fresh milk, butter, cheese, ice cream and yogurt, and Other dairy products.

Various authors have advocated the use of enhanced communication between cattle producers and their customers, be they first handlers, processors, retailers, or the final consumer, to help address microbial food-safety concerns (see, e.g., Buchanan, Acuff, and Halbrook). Further, as producers adopt riskmanagement strategies for veterinary drug residues and microbial pathogen contents in and on animals presented for slaughter, it is essential that these farm-level food-safety gains not be eroded downstream. The greater initial control of microbial contamination preslaughter fits neatly into the recent stageand sector-specific HACCP-based (Hazard Analysis and Critical Control Point) regulatory regimes (e.g., USDA). Indeed, without evidence of such practices, producers risk the rejection of whole lots or herds upon delivery, due to food-safety concerns arising from processor's HACCP-based systems. Combined, these elements demonstrate the importance of a close dialogue between slaughter-processing plants and their customers and suppliers on all issues that can impact food safety. Key factors at the slaughter-processing stage(s) include: comingling of animals prior to slaughter, lot size and identification on the slaughter floor, animal-to-carcass and carcass-to-cut traceability, as well as general plant hygiene, sanitation, and foodsafety activities. This article assesses the economic implications of changes in these stages, suggesting potential hurdles to the development of farm-to-table food-safety systems. Demand for Traceback

Complex soft-tissue reconstruction after facial trauma presents a difficult challenge. Microvascular free-tissue transfer with customized circumflex scapular fasciocutaneous flaps offers a reliable and stable long-term correction of facial contour asymmetry attributable to facial trauma. Principles of skeletal reconstruction preceding soft-tissue surgery should be adhered to. By using the approach outlined in this article, soft-tissue camouflage can maximize the aesthetic outocme of reconstruction with microsurgical free-tissue transfer.

This teaching case enables students to examine basic forces transforming the structure of the dairy industry. A New Mexico family farm faces challenges associated with its large milk production volume. In an environment of rapid but uncertain change, questions regarding future management structure and investment priorities must be answered. The dairy examined is considered representative of the modern dairies of Netherlands lineage operating throughout the southwestern United States. This case does not represent an actual farm, but is a composite of realistic design.

An analysis is provided of the general value added challenge faced by farmers, cooperatives, economic development boards, and others. The VEST model is developed by which publicly traded equities (stocks) can be used directly by farmers as an alternative to traditional value added investment strategies. Numeric VEST Coefficients are developed to serve as investment guidelines for farmers seeking the benefits of value added in the grains, red meat, and poultry sectors. © 1997 John Wiley & Sons, Inc.

The correction of facial asymmetry in complex craniofacial deformities presents a challenging problem to reconstructive surgeons. Deficiencies of both the facial skeleton and the overlying soft tissue must be addressed to achieve the optimum reconstructive result. Soft tissue contour problems due to any cause can be corrected with microsurgical techniques. The transfer of customized free flaps based on the circumflex scapular vascular pedicle, consisting of dorsal thoracic fascia with variable contributions of overlying fat, can restore facial harmony. Both facial and donor site aesthetics are optimized.

Food-away-from-home (FAFH) accounts for an increasingly large component of consumers' food expenditures. The concept of examining both food and non-food suppliers to the FAFH market is introduced as a vehicle to expand student awareness and career choice. Pizza is examined as an industry case study for this agribusiness teaching purpose. © 1997 John Wiley & Sons, Inc.

To properly evaluate the potential benefits of in utero repair for cleft lip and palate, an animal model of cleft lip and palate formation is needed that simulates human cleft morphology. We have developed a fetal lamb model in which incisional or excisional unilateral cleft lips were created early in gestation and later repaired. Through a maternal celiotomy and hysterotomy, six excisional and six incisional clefts were created in early first trimester fetal lambs. Clefts were created by a novel space helmet technique and made completely through the lip and the alveolus. Two weeks later, the wound edges were freshened and repaired in all but one lamb in each group. In the early third trimester, the fetuses were harvested and studied. We found that the incisional clefts healed spontaneously with replacement of the native reticular collagen pattern and with regeneration of the skin appendages. However, the excisional clefts did not autorepair and, when repaired surgically, healed without a collagen scar but showed no regeneration of the skin appendages. This preliminary study is the first successful large animal model where cleft lips and palates were created, allowed to develop with the cleft, and later repaired in utero. Prior to repair, the edges of the excisional clefts epithelialize. When repaired early in the third trimester, excisional clefts heal without a dermal scar but exhibit incomplete regeneration of the skin appendages.

Hypertrophic scarring is characterized by disordered collagen fibrils. In order to determine whether this is, in part, a result of changes in the population of proteoglycans that are thought to be involved in regulation of collagen fibril formation, we have compared PGs from post-burn normal and hypertrophic scar tissue, as well as from human dermis and epidermis. Efforts to separate the two major iduronic acid-containing proteoglycans, decorin [PG(IdoA)-II] and biglycan [PG(IdoA)-I], for quantitation were not successful. The different N-terminal sequences of these two iduronic acid-containing proteoglycans PG(IdoA-I and -II were utilized to estimate the relative amounts in the above PG(IdoA) preparations. Normal scar, dermis and epidermis were all found to contain primarily decorin with low (< 10%) levels of biglycan relative to decorin. In contrast, iduronic acid-containing proteoglycans from hypertrophic scar were found to be approximately 30% biglycan [PG(IdoA)-I]. This may be a proximal cause of altered collagen fibrils, or may result in alterations in the sequestration of growth factors, which then results in changes in collagen that effect the appearance of the scar. 1966 Elsevier Science Ltd.

Restoring soft-tissue contour in patients with facial asymmetry is a difficult problem for plastic surgeons. We report our experience with 57 consecutive patients who underwent 60 microvascular free flaps for the correction of facial asymmetry between July of 1989 and June of 1994. Etiologies of facial asymmetry included hemifacial microsomia, hemifacial atrophy, postradiation sequelae, burns and trauma, and selected congenital anomalies. Thirty-eight patients were reconstructed with a customized parascapular flap incorporating extensions of dorsal thoracic fascia. Other donor sites utilized were as follows: six superficial inferior epigastric flaps, three myocutaneous flaps, seven muscle flaps, and six fasciocutaneous flaps with bone. To correct facial asymmetry, the recipient site was dissected through a limited preauricular incision whenever feasible, and the superficial temporal artery and vein were used as recipient vessels. A monitoring skin paddle was rarely used. There were no flap losses in this series. Six patients experienced a postoperative hematoma, three of which were drained at the bedside. Limited skin slough occurred in three patients. No donor-site complications other than hypertrophic scarring were encountered. Flap revisions were performed in 22 of the 57 patients to maximize aesthetic results. Based on our experience, we feel that the operative approach presented here allows excellent and stable correction of facial asymmetry due to a variety of etiologies. Furthermore, this technique is applicable to other congenital craniofacial deformities such as Treacher-Collins syndrome and orbital-facial clefts.

Microvascular techniques are important in making routine anastomoses quicker and difficult anastomoses easier. The authors have developed three types of sleeve anastomoses for different size vessels: a three-stitch sleeve anastomosis, four-stitch sleeve anastomosis, and sidecut sleeve anastomosis. Arteriography, in vivo observation, pulsed ultrasound Doppler hemodynamic study, histology, and ultrastructural examination with scanning electron microscopy at 2 to 90 days demonstrated that all three groups of sleeve anastomoses do not stenose, do not show hemodynamically significant vasospasm, and are not complicated by aneurysm formation by 90 days. The hemodynamics were comparable to control sutured anastomoses at 2 to 4 hr postoperatively. The sleeve anastomoses left no suture material within the vessel lumen. Reendothelialization was comparable with controls at 14 days, and the long-term patency rates were similar (p > 0.05). The operative times for all three types of sleeve anastomoses were significantly shorter than sutured control anastomoses (p < 0.001). Although limited by available vessel length and diameter, the sleeve anastomosis is a useful technique for the microsurgeon.

To elucidate the role for transforming growth factor-beta isoforms (beta(1), -beta(2), and -beta(3)) in wound repair, we used isoform-specific antibodies to detect the spatial and temporal expression of the latent and mature/active transforming growth factor-beta isoforms by immunohistochemical localization through 21 days after excisional and incisional wounding of ovine skin. Although incisional and excisional wounds showed similar patterns of transforming growth factor-beta immunoreactivity, we found a differential temporal and spatial expression of the latent and mature transforming growth factor-beta isoforms throughout wound repair. Specifically, 1 day after wounding, there was a marked increase in transforming growth factor-beta isoforms in the epithelium adjacent to the wound, epidermal appendages, and the cells and matrix of the granulation tissue. At this time, transforming growth factor-beta(3) isoform was the most abundant. Most notably, the epidermis adjacent to the wound was intensely immunoreactive for all transforming growth factor-beta isoforms 1 day after injury. However, the migrating epithelium, derived from both the hair follicles and the wound margins, was completely devoid of immunoreactive transforming growth factor-beta until reepithelialization was complete. Within the inflammatory exudate, there was a distinct band of leukocytes that was immunoreactive for transforming growth factor-beta(2) and -beta(3) 1 day after injury and 1 day later for transforming growth factor-beta(1). Although transforming growth factor-beta(1) and -beta(2), latent transforming growth factor-beta(2), transforming growth factor-beta(3), and latent transforming growth factor-beta(3) immunostaining was present in the numerous fibroblasts and other dermal cells, latent transforming growth factor-beta(1) was only associated with the extracellular matrix. In general, immunoreactivity remained high until day 7 after wounding and slowly subsided over time. However, by day 21, immunostaining had not returned to normal and the original wound was replete with immunoreactive fibroblasts and a dense, immunostained extracellular matrix. Thus, although the dynamic presence of transforming growth factor-beta isoforms exemplifies its positive role in the wound repair process, its persistence together with its known potent effects on matrix accumulation, supports its role in scar formation.

Using a newly developed Doppler probe, we have found that a standard suture anastomosis in a rat femoral artery is accompanied by significant (30-60%) cross-sectional area stenosis, which dissipates to baseline levels within 24 hours. We hypothesized that spasm, deposition of coagulation products, or the suture technique itself was responsible. Topical vasodilators (papaverine, sodium nitroprusside, lidocaine) and intravenous thromboxane A2 synthetase inhibitor and receptor blocking agent (Ridogrel, 4 mg/ml), anticoagulants heparin and SC4992 (an experimental platelet inhibitor/arginine-glycine-aspartic acid analogue), were administered. No drug had any significant effect on preventing postoperative stenosis. Varied suture bites affected stenosis measurements. Scanning electron microscopy and light microscopy displayed "bunching" of vessel wall in the suture ties. This was confirmed with methyl methacrylate corrosion casts and microangiography. "Sham" anastomoses also produced stenosis, which was relieved when sutures were removed. We conclude that suture anastomosis of small vessels is accompanied by significant cross-sectional stenosis caused by the physical action of tensioned sutures. This effect dissipates over a 24-hour postoperative period. The mechanism behind these changes and the clinical importance of this effect are still under investigation.

Recent developments in surgery and basic science research offer aesthetic surgeons the prospect of scarless repair. Studies in fetal wound healing provide both cellular and molecular models of optimal tissue healing without scar formation. Furthermore, craniofacial surgeons may one day operate on cleft lip, cleft palate, and other congenital malformations in utero. Cytokine research has begun to unravel possibilities for modulating the wound-healing inflammatory response in hopes of limiting scar formation. This article presents research on these developments and comments on their possible applications to aesthetic surgery.

Facial asymmetry in hemifacial microsomia presents reconstructive problems of bone and soft tissue. In most cases, this is managed by skeletal reconstruction followed by microvascular free tissue transfer for patients requiring soft tissue augmentation. We present here our experience using customized parascapular free flaps with extensions of dorsal thoracic fascia, which yields esthetically satisfying results.

Wound contraction is an important component of healing but, in the extreme, may lead to excessive scar formation and pathological wound contracture. Fetal rabbit wounds heal without contraction or scarring, whereas excisional fetal sheep wounds have been shown to contract, but no scarring or pathological wound contracture is noted. We used an in vitro model, the fibroblast-populated collagen lattice, to study the ability of fetal fibroblasts to coordinate contraction of a collagen matrix and the modulating effects of epidermal growth factor and transforming growth factor-beta 1 on this contraction. With increasing gestational age, fibroblasts increased the degree of collagen lattice contraction. Epidermal growth factor inhibited contraction by fetal fibroblasts, whereas transforming growth factor-beta 1 stimulated it. These findings suggest that while intrinsic differences between fetal and adult fibroblasts exist, polypeptide growth factors may operate at the site of tissue repair to alter cell phenotype. Further work is underway to delineate the role of soluble protein factors responsible for the absence of scarring and contracture seen in the fetal wound.

The cyclic tetradentate tertiary amine, 1,4,8,11-tetramethyl-1,4,8,11-tetraazacyclotetradecane (Me 4 [14]aneN 4 ) reacts with alkali metal salts in THF to form [M(Me 4 [14]aneN 4 ) (SCN)], M = Li, Na and [Li (Me 4 [14]aneN 4 )(H 2 O)]X, X = Cl, Br. These compounds have been characterized by elemental analysis, IR, 7 Li, 1 H and 13 C NMR spectroscopy. The complexes adopt a five-coordinate structure in which all four methyl groups of the macrocycle are magnetically equivalent. Frequency shifts in the IR spectra of the thiocyanato complexes indicate that the nitrogen end of the SCN − ligand is coordinated. A water molecule occupies the fifth coordination site in the complexes isolated as halide salts.