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The aim of this article is to provide a template for building and sustaining a microsurgical breast reconstruction practice in a private practice setting. The target audience including residents, microsurgical fellows, and reconstructive microsurgeons were currently employed in an academic setting, and reconstructive microsurgeons were currently employed in a private group entity. We present five pillars that initiate, support, and sustain a successful practice in microsurgical breast reconstruction. The five key concepts are (1) establishing a practice vision and culture, (2) obtaining funding, (3) assembling staff, (4) negotiating insurance and other contracts, and (5) striving for efficiency and sustainability. These concepts have been at the core of Plastic, Reconstructive and Microsurgical Associates of South Texas-a private practice eight-physician group based in San Antonio, Tex.-since its inception. However, these concepts have evolved as the practice has grown and as the economic landscape has changed for reconstructive microsurgeons. In the article, we will present what we have done well, what we could have done better, and some pitfalls to avoid.

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BACKGROUND: There are many approaches to pain control in reduction mammaplasty. Preoperative bupivacaine regional blocks control pain relatively inexpensively ($0.07/mL), but last only 8 hours. A liposomal bupivacaine formulation lasts 72 hours but can be costly ($17.21/mL). Orthopedic and thoracic operations have demonstrated that dexamethasone ($0.44/mL) plus bupivacaine can prolong analgesia. The authors conducted a double-blind, randomized, controlled trial to determine whether dexamethasone plus bupivacaine regional block improves postoperative pain control, reduces inpatient narcotic use, and improves patient satisfaction. METHODS: Female patients were randomized into control and experimental groups. Both groups received preoperative modified block of the pectoral nerves: bupivacaine plus saline (control group) or bupivacaine plus dexamethasone (experimental group). Postoperative pain regimens were standardized. Vital signs, pain scores, narcotic consumption, and antiemetic use were recorded throughout the hospitalization. Quality-of-life surveys were distributed at the first postoperative visit. RESULTS: Fifty-one patients completed the study: 25 control and 26 experimental group patients. The experimental group averaged lower pain scores, although there was no statistically significant difference overall or at each 4-hour interval. Postoperative narcotic use was significantly lower in the experimental group (mean, 23.2 oral morphine equivalents versus 36.6 oral morphine equivalents per patient; P = 0.026). There were no differences in 4-hour interval vital signs, antiemetic use, or length of stay. Survey results showed enhanced quality of life in the experimental group, but this was not statistically significant. CONCLUSIONS: The addition of dexamethasone to bupivacaine in the preoperative modified block of the pectoral nerves block before bilateral reduction mammaplasty resulted in significantly less narcotic consumption in the hospital. This can be a cost-effective adjunct for postoperative pain control. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

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BACKGROUND: Sternal wound infections are a rare but life-threatening complication of cardiothoracic surgery. Prior literature has supported the use of negative pressure wound therapy to decrease sternal wound infections and promote healing. This study sought to determine whether closed incision negative pressure therapy reduced wound infection and improved outcomes in cardiothoracic surgery. METHODS: A retrospective cohort study was performed including all adult patients who underwent nontraumatic cardiothoracic surgery at a single institution between 2016 and 2018 (n = 1199). Patient characteristics, clinical variables, and surgical outcomes were compared between those who did and did not receive incisional negative pressure wound therapy intraoperatively. Multivariable logistic regression analysis determined factors predictive or protective of the development of complications. RESULTS: Incisional negative pressure wound therapy was used in 58.9% of patients. Patients who received this therapy were older with statistically higher rates of hyperlipidemia, statin, and antihypertensive use. The use of negative pressure wound therapy was found to significantly reduce rates of both wound infection (3.0% vs 6.3%, P = 0.01) and readmission for wound infection (0.7% vs 2.6%, P = 0.01). After controlling for confounding variables, negative pressure wound therapy was found to be a protective factor of surgical wound infection (odds ratio, 0.497; 95% confidence interval, 0.262-0.945). CONCLUSIONS: In the largest population studied to date, this study supported the expanded use of negative pressure therapy on sternal wound incisions to decrease infection rates.

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Tissue expanders are known adjuncts in ventral hernia repair, used in a staged approach where tissue closure or coverage of the defect is preferred but inadequate. Placement of tissue expanders in the correct tissue plane can be difficult, especially in thin patients or with loss of domain. This case series describes a technique in which tissue expander placement is facilitated by ultrasound-guided hydro-dissection, following the placement of a transversus abdominis plane (TAP) block. In short, after induction of anesthesia, the same needle used for the ultrasound-guided TAP block can be repositioned by the anesthesiologist to instill tumescent solution into the fascial plane between the internal and external oblique muscles. This allows for identification of the fascial planes in the ensuing operation. Our technique may prove to be an alternative tool in the placement of tissue expanders for ventral hernia repair, or in other procedures requiring device placement.

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The superficial inferior epigastric artery (SIEA) flap and the deep inferior epigastric perforator (DIEP) flap have been increasingly adopted for breast reconstruction; however, each have its own set of advantages and disadvantages. In the select subset of patients that cannot tolerate minimal abdominal fasciotomy that occurs with DIEP harvest and do not have adequate pedicle length that often occurs after SIEA harvest, we suggest another option for abdominally-based free flap breast reconstruction. Here, we describe the formation of a composite perforator based on the pedicle of the retro-rectus deep inferior epigastric vessels and the superficial inferior epigastric vessels, known as a superficial and deep inferior epigastric artery (SADIE) flap, which allows for a more compatible anastomotic size match than the SIEA and elongation of the vascular pedicle with minimal dissection of the anterior rectus fascia. Our patient is a 36 year-old female (BMI = 24) with a history of breast cancer who subsequently underwent skin-sparing mastectomy with tissue expander, chemotherapy, and eventual superior and deep inferior epigastric artery (SADIE) composite flap. The patient had an uncomplicated postoperative course at 6-month follow-up with excellent cosmesis. This modification in surgical technique has not been previously described in the literature and represents a suitable option for those desiring breast reconstruction, but have short pedicle length at harvest and cannot tolerate abdominal fasciotomy.

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The success of microvascular reconstruction depends on many factors. Although many factors cannot be dictated by a surgeon, the success of anastomosis can be maximized by honing skill with performing anastomoses. However, size discrepancy of vessels remains a common challenge, given the lack of an ideal technique. In this study, the authors introduce their experience in using composite deep inferior epigastric arterial and venous grafts to overcome the vessel size and pedicle length discrepancy in lateral thigh and superficial inferior epigastric artery (SIEA) flaps. Of the 1095 flaps performed, the authors identified a total of 12 flaps (one lateral thigh flap and 11 SIEA flaps) on nine patients for breast reconstruction. The authors used deep inferior epigastric vessels to act as interposition grafts between the internal mammary artery and flap pedicle. For the SIEA flaps, the authors anastomosed the SIEA system to the deep inferior epigastric arterial system, checked the viability of the flap, and then transferred the flap to the internal mammary artery and flap pedicle. For the SIEA flaps, the authors anastomosed the SIEA system to the deep inferior epigastric arterial system, checked the viability of the flap, and then transferred the flap to the internal mammary artery system in three patients. In the last five patients, the authors anastomosed the deep inferior epigastric vessels to the internal mammary artery system first, and then transferred the SIEA flap. For the lateral thigh flap, the authors anastomosed grafts to the internal mammary artery system first as well. There were no flap losses or fat necrosis. Although the authors' outcomes are limited to only breast reconstruction, they believe this method could be expanded to different types of reconstruction, especially reconstruction of the head and neck.

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Periocular necrotizing fasciitis is a rare, but potentially blinding, or even fatal disease. The authors report a case of a 44-year-old man who presented with quiescent bilateral periocular and facial necrotizing fasciitis. The patient was treated with antibiotics and surgical debridement, followed by negative-pressure wound therapy (NPWT), until the wound bed was thought to be healthy enough to support bilateral upper eyelid full-thickness skin grafts. NPWT appeared to decrease local edema; speed reperfusion and granulation tissue formation; and served to stabilize the skin grafts against the wound bed, while not causing any ocular complications. NPWT can be a safe and effective adjunct treatment for periocular necrotizing fasciitis.

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Anatomical study has proven vital to the understanding and improvement of rejuvenation techniques of the face and neck. The microscopic septa responsible for individual facial fat compartments are also present in the neck. The authors' anatomical studies of the neck, including supraplatysmal and subplatysmal elements, have influenced their surgical and nonsurgical techniques. Careful muscular resuspension and modification of both deep and superficial fat compartments can lead to impressive and lasting aesthetic outcomes. The authors present their algorithm and approach to both surgical and noninvasive methods for aesthetic neck contouring. The discussion contained here is augmented by video footage of injected, fresh cadaver dissection that highlights the anatomical relationships of neck fat compartments discussed in this article.

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Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.

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With limited downtime and immediate results, facial filler injections are becoming an ever more popular alternative to surgical rejuvenation of the face. The results, and the complications, can be impressive. To maximize safety during injections, the authors have outlined general injection principles followed by pertinent anatomy within six different facial danger zones. Bearing in mind the depth and the location of the vasculature within each zone, practitioners can tailor their injection techniques to prevent vessel injury and avoid cannulation.

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BACKGROUND: Local ischemia before the development of recipient circulation may contribute to the highly variable long-term results of fat grafting. Remote ischemic preconditioning before adipose procurement augments the retention of fat grafts and limits subsequent liposclerosis. However, there is no literature examining what role remote ischemic preconditioning has on the fat graft recipient site. METHODS: Subcutaneous adipose tissue from transgenic mice expressing green fluorescent protein/luciferase was injected into skin folds of wild-type mice. Donors and recipients experienced intermittent temporary hindlimb tourniquet application before harvest and transfer, respectively. The viability of the transferred tissue was examined over 28 days by luciferin bioluminescence and subsequent histologic analysis. RESULTS: There was a difference in bioluminescence at days 0, 14, and 28. The remote ischemic preconditioning donor or recipient mouse-alone groups demonstrated an approximately 2- to 3-fold increase in bioluminescence. Donor and recipient remote ischemic preconditioning had a 9-fold increase in bioluminescence. Histologic analysis at 28 days confirmed the presence of donor adipocytes, and they were gradually replaced by recipient inflammation and scar tissue. However, the amount of interstitial fibrosis was substantially less in the remote ischemic preconditioning groups. These findings were more pronounced when remote ischemic preconditioning was used for both donor and recipient mice. CONCLUSIONS: Remote ischemic preconditioning has the ability to increase the viability of donor adipocytes and limit interstitial fibrosis. More specifically, remote ischemic preconditioning treatment of both donated adipose tissue and recipient wound beds demonstrates the greatest overall adipose cellular viability and native architecture.

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Fat grafting has highly variable long-term results. Research efforts to improve the reliability of fat grafting are limited by inefficient methods for evaluation of fat engraftment. In this work, we describe a novel animal model for the quantitative evaluation of fat grafting using in vivo bioluminescence of adipocytes from luciferase-expressing mice. Subcutaneous adipose tissue from GFP and luciferase-expressing FVB mice were obtained. The samples were homogenized, decanted, and injected into the dorsal skin folds of wild-type FVB mice. Viability of the transferred tissue was examined over a 28-day time period with quantitative bioluminescence after luciferin injection. All animals demonstrated viable adipose transfer with bioluminescence detectable on days 0, 1, 7, 14, and 28. This animal model may be used for noninvasive, longitudinal studies for quantification of the fat engraftment process.

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BACKGROUND: Implant-based techniques represent the most common form of breast reconstruction. However, substantial postoperative pain has been associated with implant-based breast reconstruction. OBJECTIVE: The objective of this study is to evaluate immediate postoperative pain in implant-based breast reconstruction. METHODS: We reviewed 378 patients who underwent implant-based reconstruction between January 2004 and December 2012. Each patient's visual analog scale (VAS) score, pain medication, and patient-controlled analgesia (PCA) attempts were used to assess in-hospital postoperative pain. We evaluated timing of reconstruction post mastectomy, tissue expander (TE) designed fill volume, TE initial fill volume, and single-stage immediate implant (II) versus TE reconstruction. RESULTS: No significant differences in pain parameters were noted between the immediate and delayed postmastectomy reconstruction cohorts. TEs with larger (>300 cc) designed volumes required significantly more narcotic use (p = 0.02) and PCA attempts (p < 0.01). Narcotic use was higher in the larger (>250-cc) TE initial fill group starting on postoperative day 2, but overall differences in VAS score and PCA attempts were not significant. Morphine equivalence (p < 0.01) and non-opioid oral analgesic use (average p = 0.03) of the TE cohort were significantly higher than those of the II cohort. CONCLUSION: Patients undergoing TE-based implant reconstruction show greater analgesic use than those with single-stage II-based reconstruction. This may indicate a higher immediate postoperative pain in TE procedures than in II procedures. Furthermore, higher initial fill and designed volume of TE require more morphine equivalence postoperatively. These findings may warrant further preoperative discussion for better pain management and patient satisfaction.

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BACKGROUND: Variable results associated with fat grafting have been attributed to local trauma, inconsistencies in transfer, and ischemia before the development of recipient circulation. Remote ischemic preconditioning is an inexpensive noninvasive technique that has been used in animal models and multicenter clinical trials to protect organ systems. In this work, the authors describe a novel animal model for analyzing the efficacy of fat grafting, and investigate the effect of remote ischemic preconditioning on volume retention. METHODS: Subcutaneous adipose tissue samples from green fluorescent protein/luciferase-expressing FVB mice were obtained with or without pretreatment with a temporary hind-limb tourniquet. The samples were injected into the dorsal skin folds of wild-type FVB mice. The viability of the transferred tissue was examined over a 28-day period with quantitative bioluminescence after luciferin injection. Transferred tissue was also explanted for histologic analysis. RESULTS: The remote ischemic preconditioning group had significantly increased bioluminescence at days 0, 1, and 28. Histologic analysis at day 28 confirmed the presence of vascularized adipose in both groups. However, significant amounts of interstitial fibrosis were found in the control group, whereas substantially less was found in the remote ischemic preconditioning group. The remote ischemic preconditioning group retained a substantially greater amount of green fluorescent protein, suggesting increased survival of donor adipocytes. CONCLUSIONS: In this work, the authors describe a novel animal model for quantitative evaluation of fat grafting using in vivo bioluminescence of adipocytes from luciferase-expressing mice. The authors also demonstrate that remote ischemic preconditioning increases the viability of fat transfer and decreases interstitial fibrosis.

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BACKGROUND: Women who undergo mastectomy and breast reconstruction are shown to express more pain than those who undergo mastectomy alone. The authors evaluated postoperative pain outcomes following breast reconstruction. METHODS: Patients undergoing primary implant-based (n = 1038) or flap-based (n = 837) reconstructions from 2004 to 2012 at the University of California, Los Angeles, were evaluated. Postoperative pain was measured using the visual analogue scale, total narcotic use, and number of patient-controlled analgesia attempts. Narcotic dosage was standardized to morphine equivalents per kilogram. The authors modeled postoperative narcotic use, patient-controlled analgesia attempts, and visual analogue scale scores over time using spline graphs for comparison between the two reconstruction methods. RESULTS: Both total narcotic use and patient-controlled analgesia attempts were higher in the implant-based group throughout the immediate postoperative period. Implant-based reconstruction patients had significantly higher visual analogue scale scores (p < 0.0001) and total narcotic use (p < 0.0001) through postoperative day 3 compared with autologous tissue-based reconstruction patients. When controlling for reconstruction method, bilateral procedures were more painful (visual analogue scale score and patient-controlled analgesia attempts, both p < 0.001). When controlling for laterality, unilateral implant-based and autologous reconstructions had comparable visual analogue scale scores (p = 0.38) and patient-controlled analgesia attempts. However, unilateral implant-based procedures required more narcotic use than unilateral autologous tissue-based procedures (p = 0.0012). CONCLUSION: Although commonly perceived as a less distressing operation, implant-based breast reconstruction may be more painful during the immediate postoperative hospitalization than abdominally based free tissue transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

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SUMMARY: We present a brief literature review of the topical immune-modulating medication Imiquimod. The treatment of periorbital melanoma in situ typically requires surgical resection. Here we discuss a case of lower eyelid melanoma in situ successfully treated non-operatively with Imiquimod.

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The development of a functional microvasculature is critical to the long-term survival of implanted tissue-engineered constructs. Dynamic culture conditions have been shown to significantly modulate phenotypic characteristics and stimulate proliferation of cells within hydrogel-based tissue engineered blood vessels. Although prior work has described the effects uniaxial or equibiaxial mechanical stimulation has on endothelial cells, no work has outlined effects of three-dimensional mechanical stimulation on endothelial cells within tubular vessel analogues. We demonstrate here that 7 days of 10% cyclic volumetric distension has a deleterious effect on the average length and density of angiogenic sprouts derived from pellets of bovine aortic endothelial cells. Although both groups demonstrated lumen formation, the sprouts grown under dynamic culture conditions typically had wider, less-branching sprout patterns. These results suggest that prolonged mechanical stimulation could represent a cue for angiogenic sprouts to preferentially develop larger lumens over cellular migration and subsequent sprout length.

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The delivery of growth factors to cellularize biocompatible scaffolds like fibrin is a commonly used strategy in tissue engineering. We characterized smooth muscle cells (SMC) proliferation and chemotaxis in response to PDGF-BB and FGF-2, alone and in combination, in 2D culture and in 3D fibrin hydrogels. While both growth factors induced an equipotent mitogenic response in 2D culture, only FGF-2 was significantly mitogenic for SMCs in 3D culture. Only PDGF-BB was significantly chemotactic in a modified Boyden chamber assay. In a 3D assay of matrix invasion, both growth factors induced an invasive response into the fibrin hydrogel in both proliferating and nonproliferating, mitomycin C (MMC) treated cells. The invasive response was less attenuated by the inhibition of proliferation in PDGF-BB stimulated cells compared with FGF-2 stimulated cells. We conclude that SMCs cultured in fibrin hydrogels have a more robust chemotactic response to PDGF-BB compared with FGF-2, and that the response to FGF-2 is more dependent on cell proliferation. Delivery of both growth factors together potentiates the chemotactic, but not mitogenic response to either growth factor alone.

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