bluuebunny/crossref_metadata_2025_split huggingface dataset:
Implant-Based Breast Reconstruction: Hot Topics, Controversies, and New Directions
Authors: Frey Jordan D. , Salibian Ara A. , Karp Nolan S. , Choi Mihye 
Published: July 2019

Learning Objectives:
After studying this article, the participant should be able to: 1. Evaluate appropriate patients best suited for one- or two-stage alloplastic breast reconstruction. 2. Discuss and apply the unique advantages and disadvantages of scaffold use and different implant types in breast reconstruction to maximize outcomes. 3. Develop a plan for patients undergoing implant-based breast reconstruction requiring postmastectomy radiation therapy. 4. Analyze the evidence with regard to antibiotic prophylaxis in implant-based breast reconstruction. 5. Recognize and critique novel technical and device developments in the field of alloplastic breast reconstruction, enabling appropriate patient selection.

Summary:
Implant-based, or alloplastic, breast reconstruction is the most common method of breast reconstruction in the United States. Within implant-based reconstruction, many techniques and reconstructive strategies exist that must be tailored for each individual patient to yield a successful reconstruction. Not unexpectedly, many hot topics and controversies in this field have emerged, including stages of reconstruction, use of scaffolds, permanent implant type, strategies for postmastectomy radiation therapy, and antibiotic prophylaxis. In addition, there has been an evolution in technical and device development in recent years. Therefore, plastic surgeons must be on the forefront of knowledge to approach implant-based breast reconstruction in an evidence-based fashion to best treat their patients.
Genetic Testing for Breast Cancer Susceptibility Should Be Offered before Unilateral Abdominally Based Free Flap Breast Reconstruction
Authors: Dayan Erez , Chittenden Anu , Garber Judy E. , Wo Luccie , Caterson Stephanie A. , Carty Matthew J. , Erdmann-Sager Jessica 
Published: July 2019

Background:
Pathogenic mutations have been identified in approximately 10 percent of patients who present with breast cancer. Notably, failure to identify deleterious genetic mutations has particular implications for patients undergoing abdominally based breast reconstruction, as the donor site can be used only once. The authors sought to determine: (1) how many patients underwent genetic testing before unilateral abdominally based free flap breast reconstruction; (2) how often deleterious mutations were detected after abdominally based free flap breast reconstruction; and (3) the cost-effectiveness of expanding genetic testing in this patient population.

Methods:
The authors retrospectively identified all patients who underwent unilateral abdominally based free flap breast reconstruction at Brigham and Women’s Hospital/Dana-Farber Cancer Institute between 2007 and 2016. Chart review was performed to collect relevant demographic and clinical data. Relevant hospital financial data were obtained.

Results:
Of the 713 who underwent free flap breast reconstruction, 160 patients met inclusion criteria, and mean follow-up was 5.8 years. Three patients (1.9 percent of 160) underwent contralateral surgery after completing reconstruction, two of whom had BRCA2 and one with ATM mutation. One hundred eleven patients met National Comprehensive Cancer Network guidelines for genetic testing, but of those only 55.9 percent (62 patients) were tested. Financial data revealed that testing every patient in the cohort would result in a net savings of $262,000.

Conclusions:
During a relatively short follow-up period, a small percentage of patients were diagnosed with pathogenic mutations and underwent contralateral mastectomy and reconstruction. However, because of the costliness of surgery and the decreased cost of genetic testing, it is cost-effective to test every patient before unilateral abdominally based free flap breast reconstruction.
The Analgesic Effects of Liposomal Bupivacaine versus Bupivacaine Hydrochloride Administered as a Transversus Abdominis Plane Block after Abdominally Based Autologous Microvascular Breast Reconstruction: A Prospective, Single-Blind, Randomized, Controlled Trial
Authors: Ha Austin Y. , Keane Grace , Parikh Rajiv , Odom Elizabeth , Tao Yu , Zhang Li , Myckatyn Terence M. , Guffey Ryan 
Published: July 2019

Background:Postoperative pain control after abdominally based autologous microvascular breast reconstruction is critical to functional recovery, patient satisfaction, and early discharge. The transversus abdominis plane block using 0.25% bupivacaine hydrochloride has been shown to be effective, but it is limited by a short duration of effect. Liposomal bupivacaine is a recently U.S. Food and Drug Administration–approved preparation of bupivacaine that can provide up to 72 hours of pain relief. The purpose of this randomized, controlled trial was to compare the analgesic efficacy of liposomal bupivacaine and conventional bupivacaine.Methods:This study was a prospective, single-blind, randomized, controlled trial of 44 patients undergoing abdominally based autologous breast reconstruction between June of 2016 and February of 2018 performed by a single surgeon. Each patient was randomized to receive either 266 mg of liposomal bupivacaine or 75 mg of conventional bupivacaine to the transversus abdominis plane at the conclusion of the reconstruction procedure. All patients were managed postoperatively according to an enhanced recovery protocol.Results:In our study of 44 patients, 22 patients received a transversus abdominis plane block with conventional bupivacaine and 22 patients received liposomal bupivacaine. There were no significant differences with regard to any outcome measure. No differences were found in total opioid consumption (p= 0.98), Quality of Recovery-15 scores (p= 0.72), pain scores (p= 0.39), or length of stay (p= 0.20).Conclusion:In the setting of a robust enhanced recovery after surgery protocol, liposomal bupivacaine does not confer advantages over conventional bupivacaine when used as single injections in transversus abdominis plane blocks after abdominally based microvascular breast reconstruction.CLINICAL QUESTION/LEVEL OF EVIDENCE:Therapeutic, II.
What Happened after the Poly Implant Prothèse Recall? A Prospective Cohort Study of 808 Implants into the Predictive Value of Implant Rupture on Postexchange Complications
Authors: Kappos Elisabeth A. , Fitzgerald Éilis , Haug Martin D. , Quaba Omar , Quaba Awf 
Published: July 2019

Background:
Problems with a variety of breast implants have emerged with consequences for patients’ health and safety. The authors’ goal was to follow up on their Poly Implant Prothèse patients after their implant exchange.

Methods:
This single-center, single-surgeon, prospective cohort study lasted from 2012 until 2017. Implant size, implantation interval, surgical details, and complications were registered. The Clavien-Dindo classification was used to grade postoperative complications. Logistic regression was used to investigate whether rupture, interval between implantation and explantation, and new implant size were predictors of postexchange complications.

Results:
The authors explanted 808 implants in 404 patients. The rupture rate was 30.9 percent per patient and 20.2 percent per implant. The capsular contracture rate at the time of exchange was low, with 1.86 percent of implants and 2.7 percent of patients; 97.8 percent of patients elected implant exchange and only 2.2 percent just wanted their implants removed. The mean follow-up after implant exchange was 5.2 years, with the last mandatory outpatient appointment usually being scheduled 6 to 12 months after implant exchange. The authors found that 74 patients (18.3 percent) and 124 implants (15.3 percent) had postexchange complications, the majority of them minor (83 percent Clavien-Dindo grade I). Patients with a ruptured implant at the time of exchange were significantly more likely to develop postexchange complications than were patients without rupture.

Conclusions:
This is the first study providing such a complete long-term postexchange follow-up of a single surgeon’s Poly Implant Prothèse implant cohort. Implant rupture at the time of exchange had a high predictive value for postexchange complications in the authors’ series of 808 implants and 404 Poly Implant Prothèse recall patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
An In Vitro Model Assessing the Penetration of Hyaluronidase through Optic Nerve Dura for Management of Hyaluronic Acid Facial Filler Embolism
Authors: Adulkar Namrata , Cheng Charles , Lee Lawrence , Rasmussen Steve , Dolman Peter J. , Yin Vivian T. 
Published: July 2019

Background:
Blindness from ophthalmic or central retinal artery embolism is one of the most devastating complications of cosmetic filler facial injections. A proposed therapy to mitigate visual loss is prompt retrobulbar injection of hyaluronidase into the retrobulbar space. Despite Zhu et al. showing a lack of evidence and very limited published literature for reversing visual loss with this intervention, it is still widely accepted as a treatment for filler-related emboli. The purpose of this study was to evaluate the penetration of hyaluronidase through optic nerve dura using an in vitro model.

Methods:
At study conclusion, five 1-cm-long segments of fresh optic nerve were obtained and injected with highly crosslinked hyaluronic acid filler, then ligated on both ends in a watertight fashion. The sections were immersed in three concentrations of hyaluronidase solution for 24 hours. Histopathologic examination of the specimen was performed to assess the presence of filler.

Results:
The optic nerve sections were 1.1 cm (range, 0.8 to 1.2 cm). Three were immersed in 20 ml of 1500 IU/ml hyaluronidase solution and two were immersed in saline as control. After 24 hours, there was a persistence of hyaluronic acid within the optic nerves.

Conclusions:
There is a lack of evidence for penetration of optic nerve sheath by hyaluronidase. This raises question about the effectiveness of retrobulbar injection of hyaluronidase in reversing filler-related blindness. Further studies are needed before this can be adopted as the treatment of choice.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, V.
The Interplay of Mechanical Stress, Strain, and Stiffness at the Keloid Periphery Correlates with Increased Caveolin-1/ROCK Signaling and Scar Progression
Authors: Dohi Teruyuki , Padmanabhan Jagannath , Akaishi Satoshi , Than Peter A. , Terashima Masao , Matsumoto Noriko N. , Ogawa Rei , Gurtner Geoffrey C. 
Published: July 2019

Background:
Fibroproliferative disorders result in excessive scar formation, are associated with high morbidity, and cost billions of dollars every year. Of these, keloid disease presents a particularly challenging clinical problem because the cutaneous scars progress beyond the original site of injury. Altered mechanotransduction has been implicated in keloid development, but the mechanisms governing scar progression into the surrounding tissue remain unknown. The role of mechanotransduction in keloids is further complicated by the differential mechanical properties of keloids and the surrounding skin.

Methods:
The authors used human mechanical testing, finite element modeling, and immunohistologic analyses of human specimens to clarify the complex interplay of mechanical stress, strain, and stiffness in keloid scar progression.

Results:
Changes in human position (i.e., standing, sitting, and supine) are correlated to dynamic changes in local stress/strain distribution, particularly in regions with a predilection for keloids. Keloids are composed of stiff tissue, which displays a fibrotic phenotype with relatively low proliferation. In contrast, the soft skin surrounding keloids is exposed to high mechanical strain that correlates with increased expression of the caveolin-1/rho signaling via rho kinase mechanotransduction pathway and elevated inflammation and proliferation, which may lead to keloid progression.

Conclusions:
The authors conclude that changes in human position are strongly correlated with mechanical loading of the predilection sites, which leads to increased mechanical strain in the peripheral tissue surrounding keloids. Furthermore, increased mechanical strain in the peripheral tissue, which is the site of keloid progression, was correlated with aberrant expression of caveolin-1/ROCK signaling pathway. These findings suggest a novel mechanism for keloid progression.
Variation in the Desire for Cleft Revision Surgery among Children, Caregivers, and Surgeons
Authors: Ranganathan Kavitha , Kochkodan Jeanne M. , Baker Michaella K. , Matusko Niki , Bennett Katelyn G. , Shapiro Danielle N. , Warschausky Seth A. , Vercler Christian J. , Kasten Steven J. , Buchman Steven R. , Waljee Jennifer F. 
Published: July 2019

Background:
Although revision surgery is part of the reconstructive process for children with cleft lip and/or cleft palate, the indications for revision vary, and the extent to which surgeons and families agree on appearance is unclear. The authors sought to understand the extent to which children with cleft lip and/or cleft palate, surgeons, caregivers, and control observers agree on satisfaction with appearance and the desire for revision.

Methods:
Children with cleft lip and/or cleft palate (n = 100) and their caregivers (n = 100) were surveyed regarding satisfaction with appearance using the Cleft Evaluation Profile. Surgeons (n = 10) and control observers (n = 10) rated photographs of these children using questions analogous to the Cleft Evaluation Profile. General linear model repeated measures analysis of variance were used to detect significant differences between raters, with an alpha of 0.05.

Results:
The children reported greater satisfaction with appearance across all domains compared with surgeons (nose, 7.77 versus 5.51, p < 0.001; lip, 7.94 versus 5.90, p < 0.001; maxilla, 8.16 versus 6.56, p < 0.001) and general observers (nose, 7.78 versus 6.00, p < 0.001; lip, 7.80 versus 6.12, p < 0.001; maxilla, 8.16 versus 7.40, p < 0.001). Children and caregivers expressed similar degrees of satisfaction with appearance of the lip (5.48 ± 1.69 versus 5.6 ± 1.49, p > 0.5) and maxilla (6.08 ± 1.1 versus 5.8 ± 1.2, p = 0.07). There was no significant relationship between children and surgeons in terms of the desire for revision surgery (p = 0.44).

Conclusions:
All groups expressed differing levels of satisfaction with cleft-specific aspects of appearance. Importantly, children were more satisfied than all other groups. Care must be taken to evaluate perceptions of all stakeholders before moving forward with cleft revision surgery.
A Cultured Autologous Dermo-epidermal Skin Substitute for Full-Thickness Skin Defects: A Phase I, Open, Prospective Clinical Trial in Children
Authors: Meuli Martin , Hartmann-Fritsch Fabienne , Hüging Martina , Marino Daniela , Saglini Monia , Hynes Sally , Neuhaus Kathrin , Manuel Edith , Middelkoop Esther , Reichmann Ernst , Schiestl Clemens 
Published: July 2019

Background:
The management of deep partial-thickness and full-thickness skin defects remains a significant challenge. Particularly with massive defects, the current standard treatment, split-thickness skin grafting, is fraught with donor-site limitations and unsatisfactory long-term outcomes. A novel, autologous, bioengineered skin substitute was developed to address this problem.

Methods:
To determine whether this skin substitute could safely provide permanent defect coverage, a phase I clinical trial was performed at the University Children’s Hospital Zurich. Ten pediatric patients with acute or elective deep partial- or full-thickness skin defects were included. Skin grafts of 49 cm2 were bioengineered using autologous keratinocytes and fibroblasts isolated from a patient’s small skin biopsy specimen (4 cm2), incorporated in a collagen hydrogel.

Results:
Graft take, epithelialization, infection, adverse events, skin quality, and histology were analyzed. Median graft take at 21 days postoperatively was 78 percent (range, 0 to 100 percent). Healed skin substitutes were stable and skin quality was nearly normal. There were four cases of hematoma leading to partial graft loss. Histology at 3 months revealed a well-stratified epidermis and a dermal compartment comparable to native skin. Mean follow-up duration was 15 months.

Conclusions:
In the first clinical application of this novel skin substitute, safe coverage of skin defects was achieved. Safety and efficacy phase II trials comparing the novel skin substitute to split-thickness skin grafts are ongoing.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
Microvascular Reconstruction of the Nose with the Radial Forearm Flap: A 17-Year Experience in 47 Patients
Authors: Salibian Arthur H. , Menick Frederick J. , Talley John 
Published: July 2019

Background:
Microvascular reconstruction of the nose was pioneered in China in the early 1970s using the radial forearm flap. Since then, different flaps, methods, and flap designs have been used to improve outcomes. Microvascular tissue transfer has become the first step of multistage reconstruction, which includes rebuilding the nasal framework, transferring a forehead flap for external skin coverage, and sculpting the nose for improved appearance and breathing. In this article, the authors present their long-term experience in microvascular reconstruction of the nose using the infolded radial forearm flap for full-thickness nasal defects, and a single circumferential flap for inner lining only.

Methods:
Fifty microvascular nasal reconstruction procedures were performed on 47 patients between 2000 and 2017 using the radial forearm flap. The reconstructions included total/subtotal nasal defects using a trapezoid-shaped forearm flap folded in one or two planes, and a rectangular flap positioned internally and circumferentially for lining only. The nasal defects were caused by cancer resection, trauma, infection, cocaine abuse, and failed attempts at nasal reconstruction.

Results:
Forty-seven flaps were transferred successfully for nasal reconstruction, with two immediate failures (4 percent) caused by flap insetting complications and one late loss. Forty-six patients completed the multistage nasal reconstruction. Follow-up was 1 to 17 years (average, 6 years).

Conclusion:
The radial forearm flap infolding technique is the authors’ method of choice for microvascular reconstruction of the nose because it allows placement of a primary dorsal cartilage graft for optimal vascularization, and uses the excess dorsal skin during forehead resurfacing to modify the lining inset and shape the nostrils.

CLINICAL QUESTION/LEVEL OF EVIDENCE:
Therapeutic, IV.
10-Year Experience Using Inspira Implants: A Review with Personal Anecdote
Authors: Mallucci Patrick L. 
Published: July 2019

Summary:
The article summarizes the author’s experience with Inspira implants. They were first introduced into the European market in 2006. The advent of the Inspira range heralded a fundamental change in the way round implants were perceived. The comprehensive matrix, the form stability of the gels, along with sophisticated manufacturing of the shell placed them as a premium product for use in both aesthetic and reconstructive breast surgery. The same principles of precise tissue-based planning, developed for anatomical implants, were being adopted for use with Inspira, leading to more predictable outcomes with high levels of patient satisfaction.
The Science of Cohesivity and Elements of Form Stability
Authors: Gabriel Allen , Maxwell G. Patrick 
Published: July 2019

Summary:
Silicone gel implants vary in terms of gel cohesivity and form stability. Various degrees of gel cohesivity are obtained by varying the density of crosslinking between silicone polymers. Less cohesive gels are less crosslinked, are more elastic, and have a softer feel while more cohesive gels more crosslinked, are less elastic, and have a firmer feel. When a highly cohesive gel is able to maintain its intended distribution within an implant, the gel is referred to as being form stable. Thus, a form-stable implant is able to retain its designed shape and dimensions in any position. Gel cohesivity and form stability influence breast shape, softness/firmness, and in vivo implant performance and an understanding of these parameters is critical to implant selection.
Maximizing Aesthetics and Patient Selection Utilizing Natrelle Inspira Line Implants in Aesthetic Breast Surgery
Authors: Kortesis Bill G. , Bharti Gaurav 
Published: July 2019

Summary:
Aesthetic breast augmentation has recently experienced a significant boom in options available to achieve an ideal outcome. Evolving prosthetic device technology has now brought an array of implant gels, implant shells, and fill ratios to customize shape, composition/fill, and feel of the augmented breast. With the vast portfolio of currently available implants, surgeons now have a greater ability to produce tailored and desired outcomes. The Natrelle Inspira line of breast implants by Allergan Medical is a comprehensive portfolio of implants starting with the Responsive series with the softest gel, the SoftTouch series, and the fully Cohesive series. These options allow surgeons to help tailor and create the breast that patients desire.
The nonpathogenic commensal Neisseria: friends and foes in infectious disease
Authors: Dorey Robert B. , Theodosiou Anastasia A. , Read Robert C. , Jones Christine E. 
Published: July 2019

Purpose of review
Nonpathogenic commensal Neisseria are rarely considered in the clinical setting despite evidence that they can cause invasive opportunistic infections. In contrast, they may offer protection against pathogenic Neisseria, and such relationships are being actively explored in experimental studies.

Recent findings
Recent case reports are presented of invasive infection caused by nonpathogenic Neisseria in patients on novel biologic therapies. On the other hand, Neisseria lactamica, a nonpathogenic commensal, has been shown in human challenge studies to inhibit colonization by Neisseria meningitidis. Experimental mouse models have also explored the inhibitory effects of nonpathogenic Neisseria on Neisseria gonnhoreae infection. Cutting-edge advances in metagenomics and microbiomics are being used to understand the mechanisms underpinning these effects.

Summary
Clinicians should have increased awareness of nonpathogenic Neisseria. First, as new immunomodulating therapies become licenced, the interactions that maintain balance between commensals and their human hosts may be altered. Second, these bacteria are showing promise in their capacity to exclude pathogenic Neisseria species from their anatomical niches.
Usefulness of the Intersocietal Accreditation Commission (IAC) Quality Improvement Self-assessment Tool After 1 Year
Authors: Farrell Mary Beth , Lally Mary , Vermeiren Frank 
Published: July 2019

Background and objectives:
The Intersocietal Accreditation Commission (IAC) created a voluntary quality improvement (QI) tool that allows imaging facilities to self-assess and document the quality of imaging studies. This study aimed to evaluate users' perceptions of the effectiveness and usefulness of the new QI self-assessment tool.

Methods:
The IAC's QI tool evaluates 4 quality measures: test appropriateness; technical quality/safety; interpretive quality; and report timeliness/completeness. A survey was appended to the tool to assess the perceived value.

Results:
Between May 2016 and July 2017, a total of 829 facilities completed 5312 self-assessments. During that time, 936 respondents completed the survey. There was a high level of agreement that the tool is easy to use (91.8%), encouraged critical thinking (90.3%), and the activity was worthwhile (89.6%).

Conclusion:
The results show that most respondents find value in using the voluntary IAC QI Self-assessment Tool. Respondents believed tool use encouraged critical thinking, and they were satisfied with the QI self-assessment process.