Implications of Aging in Plastic Surgery

Summary:. Given the rapidly aging population, investigating the effect of age on plastic surgery outcomes is imperative. Despite this, the topic has received relatively little attention. Furthermore, there appears to be little integration between the basic scientists investigating the mechanisms of aging and the plastic surgeons providing the majority of “antiaging” therapies. This review first provides a description of the effects and mechanisms of aging in 5 types of tissue: skin, adipose tissue, muscles, bones and tendons, and nervous tissue followed by an overview of the basic mechanisms underlying aging, presenting the currently proposed cellular and molecular theories. Finally, the impact of aging, as well as frailty, on plastic surgery outcomes is explored by focusing on 5 different topics: general wound healing and repair of cutaneous tissue, reconstruction of soft tissue, healing of bones and tendons, healing of peripheral nerves, and microsurgical reconstruction. We find mixed reports on the effect of aging or frailty on outcomes in plastic surgery, which we hypothesize to be due to exclusion of aged and frail patients from surgery as well as due to outcomes that reported no postsurgical issues with aged patients. As plastic surgeons continue to interact more with the growing elderly population, a better appreciation of the underlying mechanisms and outcomes related to aging and a clear distinction between chronological age and frailty can promote better selection of patients, offering appropriate patients surgery to improve an aged appearance, and declining interventions in inappropriate patients

A Prospective Multicenter Study of a Weekly Application Regimen of Viable Human Amnion Membrane Allograft in the Management of Nonhealing Diabetic Foot Ulcers

Background:. Diabetic foot ulcers (DFUs) pose a significant clinical challenge for providers and patients, and often precede devastating complications such as infection, hospitalization, and amputation. Therefore, advanced treatment options are needed to facilitate the healing of chronic DFUs and improve outcomes in this high-risk population. Cryopreserved viable human amnion membrane allograft (vHAMA) has shown great promise in the treatment of recalcitrant DFUs as a supplement to standard of care (SOC). Placental grafts are rich in extracellular matrix proteins, growth factors, and cytokines, which can induce angiogenesis and dermal fibroblast proliferation, resulting in accelerated healing. Methods:. In this prospective, multicenter single arm trial, 20 patients with nonhealing DFUs received weekly application of vHAMA, in addition to SOC, for up to 12 weeks. The primary study endpoint was proportion of healed wounds at 12 weeks. Secondary endpoints included proportion of wounds healed at 6 weeks, time to heal, and percentage area wound reduction. Subjects were evaluated for ulcer healing and assessed for adverse events at every treatment visit. Results:. At study conclusion, 85% of patients receiving vHAMA healed. Ten wounds healed (50%) by 6 weeks, and 17 wounds (85%) healed by 12 weeks. The mean time to heal was 46.6 days (95% CI: 35.1–58.0), and the average number of vHAMAs used was 5.4 (SD: 3.25). The mean PAR was 86.3% (SD: 40.51). Conclusions:. Aseptically processed, cryopreserved vHAMA should be considered as a safe and effective option for DFUs refractory to SOC therapy

Cutaneous Breast Radiation-associated Angiosarcoma: Anterior Chest Wall Reconstruction Options Following Extra-radical Resection

Background:. Radiation-associated angiosarcoma (RAAS) of the breast is a rare complication following breast irradiation with high rates of recurrence and death. To improve survival, we have advocated for an extra-radical resection where the entire irradiated skin and subcutaneous tissue is excised. This results in very large chest defects for which we describe our reconstructive experience. Methods:. We performed a retrospective review of patients diagnosed with RAAS and treated with extra-radical resection followed by immediate reconstruction between 1999 and 2017. We analyzed reconstructive options, complications rates, length of stay, and operative times. Results:. Extra-radical resections were performed in 35 patients. We reconstructed these large defects with abdominal advancement flaps with split-thickness skin grafting in 25 patients and added a pedicled latissimus dorsi or omental flap in the 10 other patients. Skin grafts took well over the irradiated pectoralis major muscle with a median take rate of over 90%. Average operative times were 150 minutes for those treated with an abdominal advancement flap and skin grafting with a median length of stay of 5 days for all patients. Conclusion:. Large anterior chest soft-tissue defects caused by extra-radical resections leaves defects too large to be covered by traditional breast reconstruction flaps. Abdominal advancement, latissimus dorsi muscle, and omental flaps along with skin grafts can be safely performed while leaving other traditional options open for future breast reconstruction

Prospective, Randomized, Controlled, Comparative Effectiveness Trial Examining Healing, of Acellular-Reticular Human-Dermis Versus Standard Care in Treatment of Diabetic Foot Ulcers

Category: Diabetes Introduction/Purpose: One sequitur of prolonged diabetes is the development of diabetic foot ulcers (DFUs), which are often complicated by lower extremity amputation (LEA). The annual incidence of DFUs and LEAs calculated from the Medicare population is approximately 6% and 0.4% respectively. Many acellular dermal matrices have been shown to successfully heal these wounds. In this study, we examined a novel, human, acellular reticular dermis with an open, porous, uniform framework aseptically processed to retain endogenous matrix protein versus standard of care in non healing diabetic foot wounds. Methods: This study was a multicenter, randomized controlled trial in which diabetic patients having at least one non-healing neuropathic foot ulcer that failed at least 4 weeks of documented conservative care with adequate blood flow and a lack of renal failure were screened for a 2-week period. Those meeting inclusion and exclusion criteria, after 2-weeks of offloading and moist wound care if the diabetic foot ulcer (DFU) failed to reduce in area by 20% were randomized 1:1 to standard of care (SOC) or human acellular dermal tissue (HADT) applied weekly plus SOC for up to 12 weeks Results: At 6 weeks, 65% of the HADT–treated wounds had healed (13/20) compared to 5% (1/20) of the wounds that received SOC alone (adjusted p=.00028). At 12 weeks, 80% of the HADT–treated wounds (16/20) had healed compared to 20% (4/20) of the DFUs in the SOC group (adjusted p=.00036). Mean time to heal within 12 weeks was 39.6 days for the HADT group compared to 77.0 days for the SOC group (adjusted p=.00014). There was no incidence of increased adverse or serious adverse events between groups, nor adverse events related to the graft. The mean and median costs to closure in the HADT group were $1475.00 and$963.00, respectively, per healed wound Conclusion: These findings demonstrate that weekly application of acellular human reticular dermis is an effective treatment for non-healing diabetic foot wounds. Wound-size-specific pieces may allow for decreased cost to closure and wastage

Diffusion and Perfusion: The Keys to Fat Grafting

Background: Fat grafting is now widely used in plastic surgery. Long-term graft retention can be unpredictable. Fat grafts must obtain oxygen via diffusion until neovascularization occurs, so oxygen delivery may be the overarching variable in graft retention. Methods: We studied the peer-reviewed literature to determine which aspects of a fat graft and the microenvironment surrounding a fat graft affect oxygen delivery and created 3 models relating distinct variables to oxygen delivery and graft retention. Results: Our models confirm that thin microribbons of fat maximize oxygen transport when injected into a large, compliant, well-vascularized recipient site. The “Microribbon Model” predicts that, in a typical human, fat injections larger than 0.16 cm in radius will have a region of central necrosis. Our “Fluid Accommodation Model” predicts that once grafted tissues approach a critical interstitial fluid pressure of 9 mm Hg, any additional fluid will drastically increase interstitial fluid pressure and reduce capillary perfusion and oxygen delivery. Our “External Volume Expansion Effect Model” predicts the effect of vascular changes induced by preoperative external volume expansion that allow for greater volumes of fat to be successfully grafted. Conclusions: These models confirm that initial fat grafting survival is limited by oxygen diffusion. Preoperative expansion increases oxygen diffusion capacity allowing for additional graft retention. These models provide a scientific framework for testing the current fat grafting theories