Annals of plastic surgery
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Annals of plastic surgery · Jan 2014
Learning curves in abdominal wall reconstruction with components separation: one step closer toward improving outcomes and reducing complications.
Learning curves are characterized by incremental improvement of a process, through repetition and reduction in variability, but can be disrupted with the emergence of new techniques and technologies. Abdominal wall reconstruction continues to evolve, with the introduction of components separation in the 1990s and biologic mesh in the 2000s. As such, attempts at innovation may impact the success of reconstructive outcomes and yield a changing set of complications. The purpose of this project was to describe the paradigm shift that has occurred in abdominal wall reconstruction during the past 10 years, focusing on the incorporation of new materials and methods. ⋯ The overall learning curve for a specific procedure, such as abdominal wall reconstruction, can be quite volatile, especially as innovative techniques and new technologies are introduced and incorporated into the surgeon's practice. Our current practice includes primary repair myofascial flap of the components separation and the use of biologic mesh as an overlay graft, anchored to the external oblique. This process of outcome improvement is not gradual but is often punctuated by periods of failure and redemption.
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Annals of plastic surgery · Jan 2014
Transcriptional profiling of rapamycin-treated fibroblasts from hypertrophic and keloid scars.
Excess scar formation after cutaneous injury can result in hypertrophic scar (HTS) or keloid formation. Modern strategies to treat pathologic scarring represent nontargeted approaches that produce suboptimal results. Mammalian target of rapamycin (mTOR), a central mediator of inflammation, has been proposed as a novel target to block fibroproliferation. ⋯ Hypertrophic scar and keloid fibroblasts demonstrated overexpression of collagen I and III that was effectively abrogated with rapamycin. Blockade of mTOR specifically impaired fibroblast expression of the collagen biosynthesis genes PLOD, PCOLCE, and P4HA, targets significantly overexpressed in HTS and keloid scars. These data suggest that pathologic scarring can be abrogated via modulation of mTOR pathways in procollagen and collagen processing.
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Annals of plastic surgery · Jan 2014
Maximizing chemoprophylaxis against venous thromboembolism in abdominoplasty patients with the use of preoperative heparin administration.
Abdominoplasty is one of the highest risk plastic surgery procedures for venous thromboembolism complications (VTE). Current recommendations for VTE prophylaxis are sequential compression devices (SCDs) in the OR and optional use of subcutaneous heparin after surgery. Subcutaneous heparin has been shown to be safe in other surgical groups. However, the large raw surface areas and dissection involved in abdominoplasty has been a relative contraindication for preoperative chemoprophylaxis. However, the period while the patient is under general anesthesia and immediately following the procedure is likely the highest risk time period for VTEs. The purpose of this study is to determine if preoperative chemoprophylaxis is safe in these patients. ⋯ The use of preoperative chemoprophylaxis in patients undergoing abdominoplasty can be done without an increase in bleeding complications or overall complication rate. Furthermore, enoxaparin can also be used preoperatively and continued for 2 more days during the period of time of maximum immobility with easy administration for outpatients via use of a prescription home use kit.
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Intraoperative management of hemodynamic instability during microvascular flap reconstruction is often based on anecdotal experience. Randomized controlled trials are difficult to perform when overall success rates are high. This study seeks to determine current practices for management of intraoperative hypotension during microsurgical free tissue transfer. ⋯ A national survey of microsurgeons demonstrates that many would not use vasopressors to treat intraoperative hypotension regardless of their experience. Although subject to responder bias, this report, nevertheless, outlines current practice. The need to develop a scientific basis for these practices is evident.
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Annals of plastic surgery · Jan 2014
Predictive risk factors of venous thromboembolism in autologous breast reconstruction surgery.
Venous thromboembolism (VTE) can be a significant cause of morbidity and mortality in autologous breast reconstruction surgery. The aim of this study was to evaluate the effect of patient characteristics, comorbidities, payer type, reconstruction type, reconstruction timing, radiation, chemotherapy, and teaching status of hospital on VTE (deep venous thrombosis and/or pulmonary embolism) in autologous breast reconstructive surgery. ⋯ In patients undergoing autologous breast reconstruction surgery, immediate reconstruction, older than 65 years, obesity, history of chemotherapy, and chronic lung disease are all independent predictors of higher VTE. Surgeons should consider these factors and use appropriate prophylaxis to minimize the risk of VTE development.