Two Articles on Bone Biology

There are two good articles worth reading on bone biology and physiology in June 2012 issue of Journal of Plastic and Reconstructive Surgery. 

The first one is a good review of the basics, blood supply, cell types, bone matrix, bone formation, bone growth, and bone remodeling.  The second article then uses the first to discuss clinical correlates.

Bone Biology and Physiology: Part I. The Fundamentals; Buck, Donald W. II; Dumanian, Gregory A.; Plastic & Reconstructive Surgery. 129(6):1314-1320, June 2012; doi: 10.1097/PRS.0b013e31824eca94

Bone Biology and Physiology: Part II. Clinical Correlates; Buck, Donald W. II; Dumanian, Gregory A.; Plastic & Reconstructive Surgery. 129(6):950e-956e, June 2012; doi: 10.1097/PRS.0b013e31824ec354

Fat Grafting to the Breast—more article reviews

Catching up on some of my journals that have been stacking up, one PRS journal had four articles relevant to fat grafting.  If this topic is of interest to you, all four articles are worth the read but especially the second (which discusses the first) and third (great discussion on how fat survives or doesn’t).

1. Mammographic Changes after Fat Transfer to the Breast Compared with Changes after Breast Reduction: A Blinded Study; Rubin, J. Peter; Coon, Devin; Zuley, Margarita; Toy, Jonathan; Asano, Yuko; Kurita, Masakazu; Aoi, Noriyuki; Harii, Kiyonori; Yoshimura, Kotaro; Plastic & Reconstructive Surgery. 129(5):1029-1038, May 2012; doi: 10.1097/PRS.0b013e31824a2a8e

The study compared 27 women with normal preoperative mammograms who were then treated with fat grafting to the breast to a control group of 23 women who had breast reductions.  The preop and postop mammograms (done 12 months after surgery) were read by 8 academic breast imaging radiologists in a blinded fashion.  This is one of those articles where “reading between the lines” is important.  Keep these findings in mind as we move on to the next article:   scarring (85.6% in reduction group, 17.6% in fat grafting), calcification requiring surgery (1.6% R, 4.6$ F), and mass or distortion warranting biopsy (13.6% R, 2.8% F)

Here’s the authors conclusion

…..Lipoaugmentation of the breast has been controversial, however, due to concerns regarding its interference with mammography and cancer surveillance. We have demonstrated that when compared with a widely accepted surgical procedure of the breast, reduction mammaplasty, lipoaugmentation with autologous stem cell enrichment produces lower rates of radiographic abnormalities and a more favorable Breast Imaging Reporting and Data System score.

2.  Discussion: Mammographic Changes after Fat Transfer to the Breast Compared with Changes after Breast Reduction: A Blinded Study; Spear, Scott L.; Al-Attar, Ali; Plastic & Reconstructive Surgery. 129(5):1039-1041, May 2012; doi: 10.1097/PRS.0b013e31824a29ef

Dr. Spear has written a very thoughtful review which I wish I could just copy and paste here for you to read, but alas.  This one paragraph gives you a good overview of his concerns (the bold highlights are mine):

There are a number of interesting issues raised by this article. First, what is the ideal control or comparison group? Are patients who have had breast reduction surgery the best control? Second, although multiple radiologic abnormalities are evaluated in this study, the major concern with lipoaugmentation is the development of suspicious calcifications,¹⁰,¹¹,¹⁴ and more attention could have been focused on that specific question and the almost three-fold higher incidence of this finding in lipoaugmentation patients. Third, the findings of the article raise significant questions as to where the fat is actually injected—that is, around versus into the breast parenchyma. Fourth, the study employs radiologists who are specifically trained in breast imaging, which might not reflect the skill sets of radiologists found at most diagnostic imaging centers across the United States today. In addition, even among this highly trained group of radiologists, intergrader variation was high. Finally, this study uses a lipoaugmentation technique (creating stromally enriched adipose tissue) that is presumed to concentrate stem cells; this protocol is not a widely used method, and it is not relevant to the main objective of the study.

3.   The Fate of Adipocytes after Nonvascularized Fat Grafting: Evidence of Early Death and Replacement of Adipocytes; Eto, Hitomi; Kato, Harunosuke; Suga, Hirotaka; Aoi, Noriyuki; Doi, Kentaro; Kuno, Shinichiro; Yoshimura, Kotaro; Plastic & Reconstructive Surgery. 129(5):1081-1092, May 2012; doi: 10.1097/PRS.0b013e31824a2b19

This study focused on the early phase (0=14 days) of the healing process after nonvascularized fat-grafting.  Adipocytes are most susceptible to death under ischemic conditions, although adipose-derived stromal cells can remain viable for 3 days.  The article includes a great figure (#6) which graphically illustrates the three zones of ischemia for fat grafts.  Think of a sphere with the 1st zone being on the outside:  1) “surviving zone” is the most superficial zone, is less than 300 μm thick, both adipocytes and adipose-derived stromal cells (ASCs) survive here, 2) “regenerating zone,” thickness varies depending on the microenvironmental conditions such as vascularity of and attachment to the surrounding tissue, in this zone adipocytes die as early as day 1, but adipose-derived stromal cells survive and provide new adipocytes to replace the dead ones, and 3) the most central zone is the “necrotic zone,” where both adipocytes and adipose-derived stromal cells die, no regeneration is expected, and the dead space will be absorbed or filled with scar formation.

4.  Discussion: The Fate of Adipocytes after Nonvascularized Fat Grafting: Evidence of Early Death and Replacement of Adipocytes; Pu, Lee L. Q.; Plastic & Reconstructive Surgery. 129(5):1093-1095, May 2012; doi: 10.1097/PRS.0b013e31824a2b4b

This article discusses article 3 and starts like this:

Fat grafting remains one of the most controversial procedures in plastic surgery because there is no standardized technique used by plastic surgeons to harvest, process, and place fat grafts. In addition, and most importantly, how the fat grafts survive after they are transplanted in vivo remains unclear and needs to be determined. The present study was conducted by Dr. Kotaro Yoshimura's group from the University of Tokyo, one of the most active teams in the field of fat grafting and adipose stem/stromal/progenitor cell (adipose-derived stromal cell) research. The study, composed of two parts, is another example of an important and well-conducted study in understanding the mechanism of how fat grafts survive after transplantation. ….. most adipocytes in the graft site begin to die on day 1 and only some of the adipocytes located within 300 μm of the tissue edge would survive. The number of proliferating cells increases from day 3, and increases in viable adipocyte areas can be detected from day 7.

And gives this recommendation:

Although the present study is well conducted, with sound and contemporary methodology, I would encourage the authors to perform a long-term in vivo study, such as 2 to 3 months in the same animal model, which may be equivalent to approximately 6 to 12 months in humans..

Related Posts
Fat Injections for Breast Augmentation (November 6, 2008)
Complications After Autologous Fat Injections to the Breast – an Article Review (April 2, 2009)
Recent NPR Stories on Plastic Surgery (June 3, 2009)
ASPS Task Force Updates Position on Fat Grafting  (August 13, 2009)
Risks of Fat Grafting in Breast Cancer Patients (November 22, 2010)
Update: Stem Cells and Fat Grafting (May 11, 2011)

Panniculectomy Prior to Renal Transplantation -- an Article Review

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.


There is an interesting article in the current edition of the Plastic & Reconstructive Surgery Journal (December 2011). The focus of the article is a small subset of renal patients who need kidney transplants but whose abdominal panniculus excludes them due. A significant panniculus creates an infrapannicular area prone to increased moisture, skin maceration, and elevated bacterial counts, predisposing the patient to postoperative wound infections, necrosis, and dehiscence. Not good for anyone, but really not for someone on immunosuppression.

The article discusses the use of abdominal panniculectomy in these patients in preparation for the transplant. Nine patients , 3 men and 6 women, with a mean age of 54.5 years and a mean BMI 28.3 are the focus of the article. The focus is not a cosmetic abdominoplasty but a functional panniculectomy, most often of just the lower abdominal excess skin and not addressing the area above the umbilicus.

It must be remembered that this is a high-risk group by definition: ESRD, requiring a kidney transplant. Mean length of hospital stay of 1.75 days. No one required blood transfusions. All patients were followed postoperatively for 3 months. Complications included an abscess and a skin dehiscence treated with local wound care.




REFERENCE
Panniculectomy in Preparation for Renal Transplantation: A New Indication for an Old Procedure to Reduce Renal Transplantation–Associated Wound Complications; Kuo, Jennifer H.; Troppmann, Christoph; Perez, Richard V.; Wong, Michael S.; Plastic & Reconstructive Surgery. 128(6):1236-1240, December 2011; doi: 10.1097/PRS.0b013e318230c7b8Abstract

DVT Prophylaxis – Two Articles

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.


There were two articles regarding deep venous thrombosis prevention in the November 2011 issue of the Plastic and Reconstructive Surgery Journal.  Both are worth reading.  I have supplied the full references below with links.

From the second article:

Between 1 and 7 percent of surgeons have personally experienced a venous thromboembolism–related patient death after high-risk plastic surgery.  Plastic surgeons' self-reported practice patterns indicate a disparity between clinical understanding and clinical practice. The majority of surgeons can identify patients at high risk for postoperative venous thromboembolism. However, examination of their self-reported practice patterns indicates that a substantial proportion of surgeons (>50 percent) provide inadequate levels of venous thromboembolism prophylaxis for high-risk patients.  In addition, surgeons recognize modifiable venous thromboembolism risk factors (such as oral contraceptive use) but may fail to modify those factors before surgery. 

“Never event” is a poor descriptor for venous thromboembolism, as it implies that all events are potentially preventable. Breakthrough venous thromboembolism events routinely occur in the face of rigorous protocols and criterion-standard prophylaxis, as has been reported in the plastic surgery, orthopedic surgery, and general surgery literature. We observed multiple breakthrough events in the Venous Thromboembolism Prevention Study enoxaparin group, although the distinct causes of these events remain unclear. Unrecognized hypercoagulability has been identified as a major contributor to venous thromboembolism risk.  Venous Thromboembolism Prevention Study data support the belief that a prior personal history of venous thromboembolism is an important risk factor as well (Table 3).

Venous thromboembolism represents a financial burden for patients and payers. The mean cost of hospitalization for an index deep venous thrombosis event is over $20,000.   Previous work has shown that enoxaparin is a cost-effective method of venous thromboembolism prevention.  In July of 2010, the U.S. Food and Drug Administration approved production of enoxaparin in generic form, which should result in substantially decreased costs to patients.

For a complete overview of venous thromboembolism in plastic surgery, we refer readers to two excellent reviews that have recently been published by Miszkiewicz and colleagues and Venturi and colleagues. These reviews built on the foundation of several outstanding reviews and consensus statements published previously.

I added the references mentioned in the last paragraph to the section below.  DVT prevention is important.  It can be done safely.  It needs to be done.


Related Posts:
Deep Venous Thrombosis Prevention  (June 19, 2007)
DVT Prevention (June 4, 2008)
Prevent Pulmonary Thromboembolism – an Article Review (February 23, 2009)
DVT Screening and Prevention (February 3, 2010)

REFERENCES

1.  Changing Practice: Implementation of a Venous Thromboembolism Prophylaxis Protocol at an Academic Medical Center; Pannucci, Christopher J.; Jaber, Reda M.; Zumsteg, Justin M.; Golgotiu, Vlad; Spratke, Lisa M.; Wilkins, Edwin G.; Plastic & Reconstructive Surgery. 128(5):1085-1092, November 2011; doi: 10.1097/PRS.0b013e31822b67ff

2.  Postoperative Enoxaparin Prevents Symptomatic Venous Thromboembolism in High-Risk Plastic Surgery Patients; Pannucci, Christopher J.; Dreszer, George; Wachtman, Christine Fisher; Bailey, Steven H.; Portschy, Pamela R.; Hamill, Jennifer B.; Hume, Keith M.; Hoxworth, Ronald E.; Rubin, J. Peter; Kalliainen, Loree K.; Pusic, Andrea L.; Wilkins, Edwin G.; Plastic & Reconstructive Surgery. 128(5):1093-1103, November 2011; doi: 10.1097/PRS.0b013e31822b6817

3.  Miszkiewicz K, Perreault I, Landes G, et al.. Venous thromboembolism in plastic surgery: Incidence, current practice and recommendations. J Plast Reconstr Aesthet Surg. 2009;62:580–588.

4.  Venturi ML, Davison SP, Caprini JA. Prevention of venous thromboembolism in the plastic surgery patient: Current guidelines and recommendations. Aesthet Surg J. 2009;29:421–428.

5.  McDevitt NB. Deep vein thrombosis prophylaxis. American Society of Plastic and Reconstructive Surgeons. Plast Reconstr Surg. 1999;104:1923–1928.

6. Davison SP, Venturi ML, Attinger CE, Baker SB, Spear SL. Prevention of venous thromboembolism in the plastic surgery patient. Plast Reconstr Surg. 2004;114:43E–51E.

7. Young VL, Watson ME. The need for venous thromboembolism (VTE) prophylaxis in plastic surgery. Aesthet Surg J. 2006;26:157–175.

Additional Benefits to Reduction Mammoplasty

Updated 3/2017 -- all links removed (except to my own posts) as many no longer active.

This article (full reference below) on the additional benefits an individual gains from having a reduction mammoplasty (RM) has been published online ahead of print.  The authors performed a systemic review of the literature focusing on functional outcomes after RM with regard to physical and psychological symptom improvement.

The authors performed a systematic review of the English literature using PUBMED for the period between 1977 to 2010. Studies were chosen that addressed the physical and psychological benefits of RM using a validated questionnaire.

The authors note that nearly eighty thousand breast reductions
were performed in 2009.  For insurance coverage in the United States a woman seeking breast reduction must have complaints of physical symptoms (ie neck pain, upper back pain, inframammary rashes, etc). 

The authors of this article choose to look at the other benefits a reduction mammoplasty can have:

Even less common are investigations on the effect of RM on weight loss, exercise, and eating behavior.  Women with large breasts often find exercising difficult due to public scrutiny and physical constraints. They may even develop eating disorders in an attempt to match their breast size to the rest of their body. ……..Women with macromastia often have
diminished self-esteem, poor psychosexual function, depression, and anxiety.

I want to applaud them for their article.  There are 52 article in their reference list.  Table I is a breakdown of 6 articles on physical symptoms/improvements.  Table II is a reference does the same for 8 articles on the effects of reduction mammoplasty on exercise, weight and eating behaviors.  Table III does the same for 5 articles on the effects of reduction mammoplasty on psyche.  Table IV summarizes 3 articles on the effects of reduction mammoplasty on appearance.

The results of their summary:

Women who undergo RM have a functional improvement in musculoskeletal pain, headaches, sleep, and breathing. Psychological benefits are vast and include improved self esteem, sexual function, and quality of life, as well as less anxiety and depression. Following RM, women appear to exercise more and have a reduction in eating disorders.

This is what I saw over my 21 years of practice in taking care of these women.
……
Related post: 
Reduction Mammoplasty (December 19, 2007)
……
REFERENCE

Additional Benefits to Reduction Mammaplasty: A Systemic Review of the Literature; Singh, Kimberly A.; Losken, Albert; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 November 2011; doi: 10.1097/PRS.0b013e31824129ee

Never Too Old to Donate?

Updated 3/2017-- all links removed as many no longer active.

I happened to see this press release from American Society of Nephrology via Eurekalert regarding an article in an upcoming issue of the Clinical Journal of the American Society Nephrology (CJASN) advocating the safety of kidney donation in individuals over 70 years old.  The press release does note that kidneys from these elderly donors do not last as long as those from younger living donors.

Currently, as noted on the University of Maryland Medical Center website:

Donors need to be between the ages of 18 and early 70s and can include parents, children, siblings, other relatives, and friends. An ideal donor should have a genuine interest in donating and a compatible blood type with the recipient.

Donors should be in good general health. Donors do not need to be genetically related. Typically, someone who has cancer, diabetes, kidney disease, heart disease, liver disease, sickle cell disease, HIV or hepatitis will not qualify to be a donor. However, these diseases are not all absolute contraindications to donation. Every donor will be considered on an individual basis.

Many individuals over 70 years of age are ineligible simply due to chronic illnesses.   This recent article (full reference below) is a result of a study done by John Hopkins University School of Medicine. 

Jonathan Berger, MD, Dorry Segev, MD, PhD , and their colleagues studied 219 healthy adults over the age of 70 years who donated kidneys and compared them with healthy elderly individuals who were not organ donors.  The surgeries were done at 80 of the 279 transplant centers in the United States.

The researchers found that among recipients of older live donor allografts, graft loss was significantly higher than matched 50-to 59-year-old live donor allografts (subhazard ratio [SHR] 1.62, 95% confidence interval [CI] 1.16 to 2.28, P = 0.005) but similar to matched nonextended criteria 50-to 59-year-old deceased donor allografts (SHR 1.19, 95% CI 0.87 to 1.63, P = 0.3).

Mortality among living kidney donors aged ≥70 was no higher than healthy matched controls drawn from the NHANES-III cohort.

I don’t have full access to the article (only the abstract).  I wonder how old the oldest donor was (ie 72? or 82?).  I wonder if the risk is different for the 70-75 age group vs the 75-80 age group.

Living Donors Online: FAQ (kidney donation)

REFERENCE

Living Kidney Donors Ages 70 and Older: Recipient and Donor; Jonathan C. Berger, Abimereki D. Muzaale, Nathan James, Mohammed Hoque, Jacqueline M. Garonzik Wang, Robert A. Montgomery, Allan B. Massie, Erin C. Hall, and Dorry L. Segev;  Outcomes CJASN October 27, 2011 CJN.04160511; published ahead of print October 27, 2011, doi:10.2215/CJN.04160511 (full article is not open access)

Prophylactic Mastectomy in BRCA Carriers: Can the Nipple Be Preserved? (an article review)

Updated 3/2017 -- photos and all links removed as many no longer active.

The entire article is available via open access (full reference below).  Women with the BRCA gene (both 1 and 2) often elect to have prophylactic mastectomy to reduce their risks of developing breast carcinoma.  This is even more so for the contralateral breast when a primary is found.  Skin-sparing mastectomies (SSM) and nipple-sparing mastectomies (NSM) greatly improve the cosmetic results for women undergoing reconstruction.  Traditionally, the NAC has been removed due to concerns of possible tumor recurrence or development of a new primary in the remaining breast tissue of the NAC. 

The article notes "numerous retrospective studies have shown a wide range(0-58%) of nipple involvement by tumor in mastectomy specimens." 

This retrospective study involves a small cohort of 33 patients (25 BRCA1, 8 BRCA2) who underwent mastectomy between March 1987 and June 2009 treated at Mayo Clinic.  The entire nipple-areolar complex (NAC) was excised and evaluated histologically.  There was a total of 62 NACs available for evaluation. [TDLS = terminal duct lobular units]

Sixty-two NACs from 33 women (25 BRCA1, 8 BRCA2) were studied. TDLUs were present in 15 (24%) NAC specimens. No evidence of atypical hyperplasia, carcinoma in situ, or invasive carcinoma was found in any of the 33 prophylactic mastectomy specimens. Among the 29 breasts with cancer and available tissue, 2 (7%) had malignant findings and 1 (3%) had atypia in the NAC. One woman who underwent bilateral mastectomy for bilateral invasive carcinoma had one nipple with tumor within lymphatics, and her contralateral nipple had atypical lobular hyperplasia. A second woman had ductal carcinoma in situ involving a single major lactiferous duct..

They conclude the probability of premalignant or malignant lesions in the NAC of BRCA carriers is low overall.  It must be remembered that it is higher (10%) in the subgroup of women undergoing therapeutic mastectomy.  It may be safe for select women with BRCA mutations to have a nipple sparing procedure, but she and her physicians (oncologist and surgeon) should have a frank discussion about her individual case.

REFERENCE

Prophylactic and Therapeutic Mastectomy in BRCA Mutation Carriers: Can the Nipple Be Preserved?; Carol Reynolds, Jennifer A. Davidson, Noralane M. Lindor, Katrina N. Glazebrook, James W. Jakub, Amy C. Degnim, Nicole P. Sandhu, Molly F. Walsh, Lynn C. Hartmann and Judy C. Boughey; Annals of Surgical Oncology Volume 18, Number 11, 3102-3109, DOI: 10.1245/s10434-011-1908-8

Parents and Their Child’s Genital Ambiguity

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

There is more information in the Science Daily news article than the journal article abstract (full access is not free):  Parents Feel Shock, Anxiety and the Need to Protect Children With Genital Ambiguity

Parents of babies born without clearly defined male or female genitals experience a roller-coaster of emotions, including shock, anxiety and the need to protect their child, according to a study in the October issue of the Journal of Advanced Nursing.  …….

I never had to walk a family through this as a practicing physician.  As a medical student, we had a patient which led to much discussion. 

Early surgical decisions raised strong emotions in some parents. Sian was anxious about whether she had done "the right thing," but Anne described a documentary that suggested that parents shouldn't be allowed to make decisions about genital surgery as "ridiculous."

I tend to agree with Anne.  Parents should be in on all the decisions being made.

Reconstructive genital surgery made it easier for some parents to protect and bond with their child. Medical evidence about whether the child was predominantly male or female, and how they looked, guided the parents' decisions when it came to surgery. But one mother who learnt that her child had both male and female internal organs described the news as a "double whammy."

It’s a tough diagnosis for families to have to deal with and ongoing support and care is important.  


REFERENCE

Searching for harmony: parents’ narratives about their child’s genital ambiguity and reconstructive genital surgeries in childhood; Caroline Sanders, Bernie Carter, Lynne Goodacre;  Journal of Advanced Nursing, 2011; 67 (10): 2220 DOI: 10.1111/j.1365-2648.2011.05617.x (abstract free, full article is not)

Reconstruction of the Burned Hand – an article review

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Going through a stack of journals that have piled up, I noticed a nice little article (full reference below) discussing reconstruction of the burned hand.  It’s a short, seven page article full of information.

Early treatment and aggressive management are critical to restoring optimal hand function following burn injury. It has been shown that an early, multidisciplinary approach to the care of the burned hand has led to a successful outcome in 97 percent of patients with superficial injuries and 81 percent of patients with deep dermal burns.

Early treatment is important for the best outcomes with burned hands.  If there is any question of degree or severity, refer hand burns to a burn center or specialist.

The article notes the various burned hand deformities can be classified into the following categories:

(1) hypertrophic burn scars and burn scar contractures

(2) claw deformity

(3) web space deformity

(4) the severely burned hand which may involve
many deformities simultaneously

The article discusses each of these malformations individually along with their management and reconstructive options.  This article is worth your time to read and reread.

REFERENCE

Reconstruction of the Burned Hand; Kreymerman, Peter A.; Andres, Lewis A.; Lucas, Heather D.; Silverman, Anna L.; Smith, Anthony A.; Plastic & Reconstructive Surgery. 127(2):752-759, February 2011; doi: 10.1097/PRS.0b013e3181fed7c1

Bariatric Surgery Should Come Before Breast Reduction

Updated 3/2017-- all links removed (except to my own posts) removed as many no longer active. 

Many women with large breast and weight issues seek breast reduction.  I was taught to encourage them to lose weight first.  Now there is a very small study that backs this up  (full reference below).

The American Society of Plastic Surgeons issued a press release entitled “Breast Reduction and Bariatric Surgery—Which Should Be Done First?” and provided the answer “ Final Results May Be Better When Weight Loss Comes First.”  I agree, but find it odd that such a small study was published.  There should have been more patients included.

Jeffrey A. Gusenoff, MD, and colleagues reviewed two groups of patients who sought consultation for body contouring surgery August of 2008 and February of 2010 after massive weight loss (defined as a weight loss of greater than 50 pounds).

Group I (n=15) included any patients who underwent reduction mammoplasty for symptomatic macromastia before massive weight loss.  Group II (the control group, n=14) included any patients who did not undergo breast surgery before massive weight loss.

The patients were given a prospective phone survey to assess self-ratings of breast appearance before and after breast reduction and after massive weight loss, ability to exercise, which would have preferred to have first—massive weight loss or breast reduction surgery—and what they would recommend to a friend.

Of the 15 patients (7.9%) in group I, 14 completed the survey (93%). 

For group I, all patients felt the appearance of their breasts improved after reduction (p < 0.001) but felt appearance worsened or stayed the same after weight loss (p = 0.003).

Seventy-one percent of patients were able to exercise more and 64 percent were able to lose weight on their own because of their reduction. ……..

Ten patients (71 percent) would recommend that a friend lose weight before breast reduction surgery. …

For group II, 79 percent of patients felt the appearance of their breasts worsened or stayed the same after massive weight loss (p = 0.03). ……

All 14 patients (100 percent) would recommend losing weight before undergoing breast surgery.

Even though I tend to agree that patients should loss weight prior to breast surgery.  It is much easier to achieve the cosmetic goals of the patient if she is at or near her goal weight.  Otherwise, the surgeon and patient are left to guess at how her skin will retract with weight loss and how much deflation or loss of volume will occur.

I wish the study had ask how many of the Group I patients desired an augmentation as part of their revision. 

Eleven patients (79 percent) felt a secondary lift following massive weight loss should be covered by insurance, and seven patients (50 percent) plan on having revision breast surgery.

They noted it with Group II patients

Eleven patients (79 percent) wished their breasts currently appeared different, with eight (57 percent) desiring lifted breasts, seven (50 percent) desiring general reshaping, two (14 percent) desiring reduced breasts, and two (14 percent) desiring larger breasts.

I have augmented four patients over my 21 years of practice who had previous breast reductions prior to losing weight (one was mine).  This should be included in the discussion as well as the high probability that a revision to reshape or re-lift the breasts will be needed if the reduction is done prior to the (massive) weight loss.

Related posts:
Reduction Mammoplasty (December 19, 2007)
Breast Reduction: Safe in the Morbidly Obese?—Article Review  (August 25, 2008)
Tennis Star Brings Breast Reduction Surgery into Press (June 4, 2009)
Impact of Obesity on Breast Surgery Complications – article review  (June 16, 2011)


REFERENCE

Reduction Mammaplasty, Obesity, and Massive Weight Loss: Temporal Relationships of Satisfaction with Breast Contour; Coriddi, Michelle; Koltz, Peter F.; Gusenoff, Jeffrey A.; Plastic & Reconstructive Surgery. 128(3):643-650, September 2011; doi: 10.1097/PRS.0b013e318221da6b

Kids and Boxing

I can’t say I am a fan of boxing, but I can appreciate the discipline required both mentally and physically.  The American Academy of Pediatrics has recently (full reference below, free access) issued a policy statement on participation of children and adolescents in the sport of boxing (bold emphasis is mine).

Thousands of boys and girls younger than 19 years participate in boxing in North America. Although boxing provides benefits for participants, including exercise, self-discipline, and self-confidence, the sport of boxing encourages and rewards deliberate blows to the head and face. Participants in boxing are at risk of head, face, and neck injuries, including chronic and even fatal neurologic injuries. Concussions are one of the most common injuries that occur with boxing. Because of the risk of head and facial injuries, the American Academy of Pediatrics and the Canadian Paediatric Society oppose boxing as a sport for children and adolescents. These organizations recommend that physicians vigorously oppose boxing in youth and encourage patients to participate in alternative sports in which intentional head blows are not central to the sport.

I would tend to agree that children should be encouraged to participate in sports that have less risk of concussion injury.

Related posts:
Cauliflower Ear  (September 21, 2007)
Mangled Ear--a badge of honor?  (August 4, 2008)
Hematoma of Ear (Boxer's Ear) – 1908 TX  (October 14, 2009)


REFERENCES

Policy Statement—Boxing Participation by Children and Adolescents; American Academy of Pediatrics, Council on Sports Medicine and Fitness, Canadian Paediatric Society, and Healthy Active Living and Sports Medicine Committee; Pediatrics 2011; peds.2011-1165; published ahead of print August 28, 2011, doi:10.1542/peds.2011-1165

Pressure Treatment of Auricular Keloids

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I have written of keloid treatment (general, not site specific) previously.  I have always tried to include pressure treatment as part of the plan when treating keloids of the ear lobe.   This pressure treatment came in the form of pressure earrings  -- clip-on, disc-shaped. 

The recent article (full reference below) in the Archives of Facial Plastic Surgery journal introduces a new pressure device which looks like it will work better than what has been available (photo credit) 

and as can be seen in this photo the upper ear can be treated with pressure which has not been possible with the clip earrings. (photo credit)

These devices were custom made which makes them more expensive than off-the-shelve pressure earrings and may make them difficult to get if no one is available in your area to make them.

From the article:

Pressure therapy was popularized in the 1970s after clinicians noticed that pressure stockings used over lower extremity burns caused scars to mature faster with decreased erythema and thickness.  Pressure causes localized hypoxia, resulting in fibroblast degeneration and disintegration owing to decreased intercollagenous cohesion and increased collagenase activity.

Furthermore, pressure has been shown to shorten scar formation time, reorient collagen fibers within the scar to become parallel to skin surface, increase hyaluronic acid levels, and decrease chondroitin sulfate levels, all of which help to flatten the initially elevated scar tissue and reduce recurrence rates.

According to various reviews and guidelines, pressure therapy is a long-standing therapeutic option for keloids, producing thinning and pliability. Although the precise biomolecular mechanism of compression is not understood, success rates of at least a partial reduction of derailed scars, from 60% to 85%, have been reported from a monotherapeutic regimen of pressure therapy. The combination of surgery with postoperative pressure treatment showed good response rates of about 90% to 100%, especially after excision of auricular keloids. ………

Overnight use of the new pressure device seems to be an effective extension of established auricular keloid therapy, with additional potential for prophylaxis of recurrence. Preliminary work was presented and intended to produce a demonstration of an optimized treatment modality. Analysis of this therapeutic regimen based on a larger sample size, and long-term follow-up will be the substance of a future report.

REFERENCE

Auricular Keloids: Combined Therapy With a New Pressure Device; Gregor M. Bran, Jörn Brom, Karl Hörmann, Boris A. Stuck; Arch Facial Plast Surg. 2011;Published online August 15, 2011. doi:10.1001/archfacial.2011.57

Management of Latex Allergic Surgical Patient

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

A couple of nice articles recently on latex allergy have crossed my path – one in a journal I subscribe to (Aesthetic Surgery Journal) and the other via twitter and @Allergy  (Ves Dimov, M.D., blogs at Allergy Notes).  I’ve put both full references below.

Latex allergy became widely recognized in the late 1980s and early 1990s.  The increase in latex allergies cases is felt to be associated with the increase use of latex gloves and implementation of universal precautions (now known as standard precautions) in the 1980s.

Management of possible or confirmed latex allergic patients begin with history and suspicion:

All patients who present for surgical procedures or exams which require latex gloves (pelvic exam, dental exams, etc) should be questioned about possible latex allergy.

Patients at highest risk include those who have a history of multiple surgeries (especially for urogenital abnormalities which may require frequent urinary catheterizations), allergic disease, or spina bifida, or who are employed in occupations with inherent latex use (ie, healthcare workers).

If an individual patient notes a history of food allergies (atopy), pay special attention if those foods include banana, kiwi, avocado, or stone fruits like cherries or peaches which are associated with latex allergy.

Regardless of the cause, the presence of hand dermatitis is a risk factor for developing latex allergy among healthcare workers

Confirmation of latex allergy is achieved through laboratory testing.  Dr. Dimov has a nice post which explains this:  Latex Allergy - ACAAI Video

Confirmation should be done if there is time.  If not, then proceed as if the patient is latex allergic.

Here’s my check list:

1.  When I schedule the procedure, I inform the facility so they can prepare using their own check list (ie special cleaning of room and anesthesia equipment, pulling of latex free supplies, labeling room as latex-free, etc).

2.  I schedule latex-sensitive/allergic patients as the first case of the day.  This assumes it is an elective case and not an emergency.

3.  If I need girdles or other postoperative garments, I make sure they are latex-free when I order them.

……

The second article (the one from Dr. Dimov) takes a look at hospital policies which ban the use of natural rubber latex (NRL) devices and whether they may be an overreaction.

Their conclusions (bold emphasis is mine):

With the reduced incidence of allergic reactions, the availability of specific and sensitive testing for the selection of low-allergen gloves, competitive costs and lower environmental impact, NRL remains an excellent choice of material for medical gloves and should continue to be used.

In recent years, a number of high profile institutions have moved to a totally NRL-free environment, including gloves. However, the evidence within Europe demonstrates that the many benefits of NRL can be retained by purchasing low-allergen, low-protein and powder-free gloves, thereby reducing the risk of type I and type IV sensitization as well as allergic reactions.

NRL gloves are characterized by a high level of barrier performance for staff and patients, good comfort allowing staff to perform safely and efficiently, and competitive pricing in a period of economic difficulty. NRL is an environmentally sustainable material, which is also naturally biodegradable, enabling hospitals to meet their ‘green’ purchasing requirements.

Finally, compared with various synthetic materials, NRL is generally better accepted by the clinicians. There will, of course, be a continuing requirement for synthetic gloves for known latex-allergic patients and staff, and for these purposes several options are currently available. In conclusion, we believe that a sensible balance requires a mix of latex and synthetic gloves.

 

REFERENCES
Recognition and Management of the Latex-Allergic Patient in the Ambulatory Plastic Surgical Suite;  Deborah Accetta and Kevin J. Kelly; Aesthetic Surgery Journal July 2011 31: 560-565, first published on June 1, 2011 doi:10.1177/1090820X11411580
Latex Medical Gloves: Time for a Reappraisal; Palosuo T, Antoniadou I, Gottrup F, Phillips P; Int Arch Allergy Immunol 2011;156:234-246 (DOI: 10.1159/000323892)

Review of NSAIDs Effects & Side Effects for Arthritis Pain

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

Recently I gave in and went to see a rheumatologist after more than 3 months of intense morning stiffness and swelling of my hands (especially around the PIPs and MCPs) and wrists which improved during the day but never went away.  It had gotten to the point where I could no longer open small lid jars (decreased strength), do my push-ups or pull ups (pain and limited wrist motion), and OTC products (Tylenol, Advil, etc) weren’t working.  I can’t take Aleve due to the severe esophagitis it induces.  I didn’t want to write a prescription for my self-diagnosed (without) lab arthritis.

BTW, all the lab work came back negative with the exception of a slightly elevated sed rate and very weakly positive ANA.  The rheumatologist was impressed with the swelling, pain, and stiffness and was as surprised as I by the normal lab work.  He thinks (and I agree) that I am in the early presentation of rheumatoid arthritis.  He wrote a prescription for Celebrex and told me to continue with the Zantac I was already taking (thanks to the Aleve).  The Celebrex is helping.

So I was happy to see this article (full reference below) come across by twitter feed.  H/T to @marcuspainmd: Useful review of NSAIDs effects & side effects for arthritis pain http://cot.ag/oHxQDX

A major disadvantage of NSAID use is the gastrointestinal side effects. These range from abdominal pain, nausea, diarrhea, and dyspepsia to more serious events, such as gastric or duodenal ulcers, anemia, and bleeding, or perforated ulcer. These side effects are due to the simultaneous inhibition of COX-1 and COX-2.

As many as 25% of chronic NSAID users will develop ulcer disease
2%–4% will bleed or perforate, especially those who have been designated as being in a high-risk category
The overall risk for these complications in patients taking NSAIDs was approximately 2.4.

High-risk patients are those with a history of complicated peptic ulcer disease or multiple (at least two) risk factors; moderate-risk patents are those with one to two risk factors, ie, age 65 years, high-dose NSAID therapy, previous history of an uncomplicated ulcer, concurrent use of aspirin (including low-dose), corticosteroids, or anticoagulants; and low-risk patients are those with no risk factors.

The two methods employed to prevent the development of peptic ulceration and mucosal injury in patients taking NSAIDs:

(1) prophylaxis with a proton pump inhibitor or a prostaglandin analog (such as misoprostol) or high-dose histamine 2-receptor antagonist (H2RA)
(2) with substitution of a traditional NSAID by a COX-2 inhibitor
The article on ulcer formation in COX-2 (Celebrex) vs NSAIDS:

Goldstein et al14 determined gastroduodenal damage
from endoscopy after 4, 8, and 12 weeks of treatment with celecoxib 200 mg twice daily or naproxen 500 mg twice daily in 537 patients with osteoarthritis or rheumatoid arthritis.

The cumulative incidence of gastric and duodenal ulceration for celecoxib was 9% and for naproxen was 41%. In the group that received celecoxib, the occurrence of ulcers was significantly associated with a number of factors, including H. pylori positivity, concurrent aspirin usage, and a history of ulcers.

It’s a really nice review article and is open source.



REFERENCES
Combination therapy versus celecoxib, a single selective COX-2 agent, to reduce gastrointestinal toxicity in arthritic patients: patient and cost-effectiveness considerations;  Marina Scolnik, Gurkirpal Singh; Open Access Rheumatology: Research and Reviews 2011:3 53–62

Timing of Radiotherapy in Implant-Based Breast Reconstruction

 Updated 3/2017-- all links (except to my own posts) removed as many no longer active.

As Jackie Fox, Dispatch From Second Base, writes the choices after getting diagnosed with breast cancer can be overwhelming.  These choices (dependent on type and stage of breast cancer, desire for reconstruction, treatment needed, etc) can make the timing tricky when it comes to radiotherapy and reconstruction choices. 

The current issue of Plastic and Reconstructive Surgery Journal (first reference below) seeks to shed some light on the question of timing in implant-based breast reconstruction.

The authors looked at three populations  who received implant-based reconstruction from October of 2003 to October of 2007, a total of 257 patients (mean age, 49 years) were prospectively involved in this study.  All patients underwent a two-stage immediate breast reconstruction with subpectoral temporary expanders (ST 133; Allergan, Inc., Irvine, Calif.) and permanent implants (ST 410-510; Allergan).  Median followed up was 50 months.

• The first population (group 1, n = 109 patients) was made up of women affected by early-stage breast cancer with extensive nodal involvement that required postmastectomy radiotherapy and adjuvant chemotherapy.  This group received radiation on permanent implants (radiotherapy plus permanent implants).
• The second population (group 2, n = 50 patients) was made up of patients with locally advanced breast cancer who preoperatively were candidates for radiotherapy and who received chemotherapy before surgery.  This group  received radiation during the expansion phase of STE (radiotherapy plus tissue expanders).
• A third population (n = 98 patients) who did not receive radiotherapy was included as a control group.

The estimate of the totally failed reconstruction rate was the principal endpoint of this study. Capsular contracture rates and patients' and surgeons' subjective evaluations were the secondary endpoints.

Highlights of the study:

The totally failed reconstruction rate was significantly higher in group 2, with 40% (20/50) of unsuccessful reconstructions, compared with 6.4% (7/109) in group 1 and 2.3% (2/98)  in the control group (p < 0.0001).

Half (10/20) the failed reconstructions in group 2 involved those stopped at the first stage with removal of temporary expander for extrusion (5 cases) or infection (5 cases).

The other half of the failed reconstructions in group 2 occurred during the second stage and were converted to flap surgery --  2 due to extrusion, 3 due to infection, and 5 due to poor results (e.g., asymmetry, Baker grade IV capsular contracture).

The 7 failures in group 1 were due to severe capsular contracture (5), wound dehiscence (1), and an infection that required implant removal (1).

The incidence of Baker grade IV capsular contracture rate was significantly higher for group 1 (10.1%) and group 2 (13.3%) compared with the control group which did not receive any radiation (0%),  p = 0.0001).

The shape assessment performed by the surgeons demonstrated a higher incidence of good results in group 1, although the highest value was still reported in the control group (group 1, 58.7 %; group 2, 30.8 %; control group, 74.2 %; p = 0.0009).

The estimate of patients' opinions demonstrated a higher prevalence of good results in group 1 in comparison with group 2, although as with the surgeons assessment it was highest in the control group (good opinion: group 1, 52.2%; group 2, 46.2%; and control group, 68.1%; p = 0.04)

The study authors conclusions:

This study demonstrated that a higher total failure rate affects breast reconstructions that undergo irradiation during tissue expansion. For this reason, we suggest that if tissue expansion can be performed during postoperative chemotherapy, chest wall irradiation should be delivered on permanent implants. The second surgical step can be scheduled 3 weeks after the end of chemotherapy, and the irradiation should not begin more than 3 weeks later. Patients whose need for radiotherapy is not known preoperatively can, in this way, improve their surgical outcome.

REFERENCES

Outcome of Different Timings of Radiotherapy in Implant-Based Breast Reconstructions; Nava, Maurizio B.; Pennati, Angela E.; Lozza, Laura; Spano, Andrea; Zambetti, Milvia; Catanuto, Giuseppe; Plastic & Reconstructive Surgery. 128(2):353-359, August 2011; doi: 10.1097/PRS.0b013e31821e6c10

BreastCancer.org:  When Is Radiation Appropriate?, last updated August 6, 2008

Is Prophylactic Mastectomy Worth It?

Updated 3/2017--  all links (except to my own posts) removed as many no longer active. 

There is a recent article which asks this question (full reference below).  I think it is a question which must be answered on an individual basis.  

For someone like me, the answer would be no.  I have no family history or personal history of breast cancer.  I have small, more dense than fatty breast, but have always had normal mammograms.  I have never had any lesions which needed biopsy.

For an individual woman with a strong family history of breast cancer (especially genetically proven, BRCA1 and BRCA2) and a person history of breast cancer (ie right mastectomy for lobular carcinoma), then it is easy to say “Yes, a prophylactic left mastectomy would be worth it for you.”

In between these two examples is the gray area, and this article doesn’t necessarily make the gray area any clearer.

There is plenty of evidence that prophylactic mastectomy lowers the risk of breast cancer in the high–risk population in at least 95%.

The authors of the June 2011 Aesthetic Plastic Surgery Journal article performed a retrospective study by reviewing the records of all their patients (n=52) who underwent prophylactic mastectomy within a 25-year period to look at the aesthetic and long-term oncologic outcomes, complications, and patient satisfaction.

Of the 52 patients, 40 had the surgery on one side only (contralateral prophylactic mastectomy) and 12 had bilateral (bilateral prophylactic mastectomy), giving a total of 64 prophylactic mastectomies.

Of the 52 patients/ 64 mastectomies, there was 1 (1.56%) case of unexpected breast cancer in the mastectomy specimens.

Two thirds (42/64) were subcutaneous prophylactic mastectomies and the other third (22/64) were simple total prophylactic mastectomies.

Most of their patients chose to have reconstruction with implants (58/64 = 90.62%) while the other 6 (9.37)  chose to use autologous tissue --  5 (7.81%) received latissimus dorsi flaps with implants and 1 (1.56%) had a TRAM flap.

The complications included 4 (6.25%) breasts that developed capsular contracture, 2 (3.12%) cases of hematoma, and 1 (1.56%) infection.

More than 90% of the patients reported being either highly (39/52) or partially satisfied  (10/52).  Only 3/52 reported being unsatisfied. The authors report an overall aesthetic index of 8.8.

There were no deaths among their patients, nor any new development of breast cancer during the time period.

Related posts
Women Don’t Regret Prophylactic Mastectomy (May 5, 2011)

Prophylactic Mastectomy (January 28, 2009)

Advances in Nipple-Sparing Mastectomy – an article review (April 27, 2011)

Are Patients Making Good Decisions About Breast Reconstruction? (February 28, 2011)

REFERENCE

Prophylactic Mastectomy: Is It Worth It?; Jose Abel de la Peña-Salcedo, Miguel Angel Soto-Miranda, Jose Fernando Lopez-Salguero; Aesthetic Plastic Surgery, Volume 35 (3), June 2011;  DOI: 10.1007/s00266-011-9769-x

American Cancer Society:  What are the risk factors for breast cancer?

More on Implant-Related ALCL of the Breast – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

Last week @prsjournal tweeted

Pre-print Article: Patient Death Attributable to Implant-Related Primary Anaplastic Large Cell Lymphoma of the B... http://bit.ly/o9lQ1f

The title definitely caught my eye.  I have finally read it and re-read it.
Here’s the abstract:

Implant-related primary anaplastic large cell lymphoma (ALCL) of the breast is a rare clinical entity. With increasing attention being paid to this disease, most cases reported to date in the literature have demonstrated indolent clinical courses responsive to explantation, capsulectomy, chemotherapy and/or radiotherapy.

We describe a case of bilateral implant-related primary ALCL of the breast that proved refractory to both standard and aggressive interventions, ultimately resulting in patient death secondary to disease progression. We situate this case in the context of the current state of knowledge regarding implant-related primary ALCL of the breast and suggest that this entity is generally, but not universally, indolent in nature.

The story of implant-related ALCL is far from being completely written.  This article notes (as did the recent FDA report) most investigations performed to date suggest an association between breast implants and primary ALCL of the breast.  The specifics regarding this relationship remain poorly defined.

A review of all reported cases of implant-related primary ALCL of the breast demonstrates no obvious correlation with implant fill type (silicone vs. saline), surface morphology (smooth vs. textured), implant position (subpectoral vs. subglandular), or indication for implant placement (cosmetic vs. reconstructive).

The FDA notes (bold emphasis is mine):

ALCL is a very rare condition; when it occurs, it has been most often identified in patients undergoing implant revision operations for late onset, persistent seroma. Because it is so rare and most often identified in patients with late onset of symptoms such as pain, lumps, swelling, or asymmetry, it is unlikely that increased screening of asymptomatic patients would change their clinical outcomes. The FDA does not recommend prophylactic breast implant removal in patients without symptoms or other abnormality.

……..

The FDA is requesting health care professionals report all confirmed cases of ALCL in women with breast implants to Medwatch, the FDA’s safety information and adverse event reporting program. Report online or by calling 800-332-1088.

Related posts:

More on Link Between Breast Implants and ALCL (April 25, 2011)

ALCL and Breast Implants – an article review (March 9, 2011)
ALCL and Breast Implants (January 31, 2011)
Breast Implants and Lymphoma Risk (June 29, 2009)


REFERENCE

Patient Death Attributable to Implant-Related Primary Anaplastic Large Cell Lymphoma of the Breast: A Case Report and Review of the Literature; Carty, Matthew J.; Pribaz, Julian J.; Antin, Joseph H.; Volpicelli, Elgida R.; Toomey, Christiana E.; Farkash, Evan A.; Hochberg, Ephraim P.; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 19 July 2011; doi: 10.1097/PRS.0b013e318221db96

Modification of Square Face

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

Recently an article in the Archives of Facial Plastic Surgery (full reference below) led to a Reuters news by Genevra Pittman:  Face too square? There's a surgery for that

The journal article is from China where the surgical procedure to modify a square face to a more oval face is done much more commonly than in the United States.  The Reuters article includes quotes from two U.S. surgeons:  Dr. Jeffrey Spiegel, chief of facial plastic and reconstructive surgery at the Boston University School of Medicine, and Dr. Ross Clevens, a cosmetic surgeon in Melbourne, Florida.

Spiegel states he does the procedure described in the Archives article two to four times each week.  Clevens states “he doesn't treat many male patients who want a more "feminine" face shape.”

Xiaoping Chen, MD, International Plastic and Cosmetic Center, China, and colleagues reviewed the procedure done for nineteen men with a square face (aged 22-30 years).  The time span of the cases was not given (ie 2001 to 2010) in the article.

The procedure involves an ostectomy with resection of the mandibular angle, splitting of the lateral cortex around the mandibular angle, and reduction of the width of the chin by an intraoral approach. (photo credit)

It sometimes was necessary to resect part of a hypertrophic masseter muscle. In addition, partial buccal fat pad removal was performed in patients with prominent cheeks. When the operation was completed, the wound was irrigated; a suction tube to allow drainage was then placed and maintained for 48 to 72 hours. The patient's lower face was lightly compressed with a dressing. Antibiotics were administered for 3 to 5 days, and the sutures were removed 7 days postoperatively.

In this series of 19 patients, there were no complications.  Complications that can occur include:  microgenia, facial asymmetry, hematoma, infection, or permanent mental nerve injury.

All patients developed edema in their lower face  (tx’d with corticosteroid therapy, 10 mg/d for 3 days) and varied amounts of difficulty in opening their mouth for 1 to 2 weeks.

Results can be as dramatic as the procedure needed to achieve them  (photo credit)


The Reuters news article states, “The procedure typically takes an hour or two, and costs up to $10,000, surgeons said.”



REFERENCE

Modification of Square Face in Men; Xiaoping Chen, Jinde Lin, Jie Lin, Jian Shen, Yudan Zhou, Xuan Wu, Yanwu Xu; Arch Facial Plast Surg. 2011;13(4):244-246.doi:10.1001/archfacial.2011.47

Should Langer’s Lines be Used for Incisions?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

An old PRS journal article came to my attention recently thanks to a tweet by @prsjournal: “Most Emailed Article Langer's Lines: To Use or Not to Use: Thirty-six differently named guidelines have develope... http://bit.ly/mPR6v1”
[I’m not sure the time frame involved in the “most emailed.” Not sure if it’s for the day, the week, etc.] –
The tweeted article (first full reference below) is a short one and I would recommend it to young plastic surgeons and students.

A state of tension exists naturally in skin. For instance, wounded skin will gape, becoming elliptical instead of round. The first to notice this skin property was Dupuytren. In 1834, he encountered a corpse of a man who had stabbed himself with a round-tipped awl. Dupuytren noticed these stab wounds were elliptical instead of round. Then in 1838, Malgaigne wrote about the direction of these ellipses being different in different areas of the body. These two men did not drive home their point; Karl Langer, however, exhaustively studied the direction of these ellipses by stabbing a round-tipped awl into hundreds of cadavers. …….. but he is best remembered for his lines. ……….

In 1897, Kocher recognized the surgical importance of Langer's tension lines. He advised that surgical incisions follow these lines. However, Langer, an anatomy professor, did not intend for his lines to be used as guides for incisions. Later, Borges pointed out that Langer's lines represent lines of cleavage in cadavers and not lines of relaxed tension……….

Langer's lines are quite different from the relaxed skin tension lines of the face. These lines were described by Borges in 1962,and they are probably the most-accepted guide for incisions of the face………..

Langer's lines are almost perpendicular to Borges's relaxed skin tension lines in the areas of the scalp, forehead, glabella, midcheek, and lateral eye…………….

Cornelius Kraissl maintained that scars were least conspicuous when placed in wrinkle lines. … Kraissl recognized that wrinkles occurred perpendicular to muscle action. From this, he developed a scheme for elective incisions. However, these incisions might not be inconspicuous in patients without wrinkles or with ill-defined wrinkles. Also, wrinkle lines do not always coincide with Borges's relaxed skin tension lines. Hence, Borges's lines are the best guide for elective incisions of the face. …………….

Developed from cadavers with extremities in extension, Langer's lines are longitudinal over joints. Blocker and Hendrix recognized that Langer's longitudinal lines predisposed patients to contractures when they were used over joints. Oriented perpendicular to muscle action, Kraissl's lines have a more transverse orientation than Langer's. Accordingly, Kraissl's transverse lines of the upper extremity do not predispose patients to contracture formation. ……….

Many other factors contribute to the camouflaging of scars, including wrinkle and contour lines. Learn how to assess the direction of least tension on the wound and orient the closure accordingly.

Borges's and Kraissl's lines are better guides for elective incisions in the face and body, respectively, than Langer’s lines. Remember, they are only guidelines. (photo scanned in from 2nd reference article)

REFERENCE

1. Langer's Lines: To Use or Not to Use; Wilhelmi, Bradon J.; Blackwell, Steven J.; Phillips, Linda G.; Plastic & Reconstructive Surgery. 104(1):208-214, July 1999

2. The Selection of Appropriate Lines for Elective Surgical Incisions; Kraissl, Cornelius J; Plastic & Reconstructive Surgery. 8(1):1-28, July 1951.

3. Relaxed Skin Tension Lines (RSTL) versus Other Skin Lines; Borges, Albert F.; Plastic & Reconstructive Surgery. 73(1):144-150, January 1984.

2-Stage Ear Reconstruction – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

There is a nice article on a 2-stage ear reconstruction for microtia (full reference below) in the current issue (May/June 2011) of the Archives of Facial Plastic  Surgery journal.

I am in awe of the surgeons who can carve the 3-dimensional cartilage framework fabricated in the first stage.  This is not something I mastered but continue to read to learn (while referring this patients to others).

In the article, Yanyong Zhao, MD  and colleagues describe the 2-stage procedure they used to reconstruct the ears of 68 patients (ages ranged from 5 to 17 years).  The surgeries were done  between January 1, 2006, to December 31, 2008. Forty-eight patients were boys, and 20 were girls. Unilateral microtia was present in 66 patients and bilateral microtia was present in 2 patients.

The authors clearly describe the procedure and have added nice photos such as this one to make it even more clear (photo credit).

The first stage involves elevating the skin flap and retroauricular fascial flap in the mastoid area, then the cartilage framework is wrapped by the fascial flap from behind and covered by the skin flap from front.

In the second stage the crus, the tragus, and the conchal cavity are reconstructed. So almost all of the fine structures of ear are reconstructed.

Here is one of the photos which shows their results (photo credit)

The article is worth reading, especially for students and residents.  Even experienced surgeons may find it useful.

REFERENCE

Original Article A 2-Stage Ear Reconstruction for Microtia; Haiyue Jiang, Bo Pan, Yanyong Zhao, Lin Lin, Lei Liu, Hongxing Zhuang; Arch Facial Plast Surg. 2011;13(3):162-166; doi:10.1001/archfacial.2011.30