6 Nerve Regeneration Under The Influence of Pedot.11

Volume 127, Number 5 (Supplement) PSRC Abstract Supplement
www.PRSJournal.com 9
1
THE USE OF ACELLULAR DERMAL
MATRIX IN BREAST AND ABDOMINAL
WALL SURGERY: A META-ANALYSIS
OF OUTCOMES AND RISK FACTORS
PREDICTIVE OF COMPLICATIONS
Presenter: Oluwaseun A. Adetayo, MD
Authors: Adetayo OA, Salcedo SE, Gupta SC
Loma Linda University Medical Center
Introduction: The use oI acellular dermal matrix (ADM)
has gained acceptance in breast and abdominal wall
reconstructions. Despite its widespread use, there is currently
a wide variation oI reported outcomes in the literature.
The current study defnitively elucidates the outcome rates
associated with ADM use in breast and abdominal wall
surgery and identifes signifcant risk Iactors predisposing to
the development oI complications.
Methods: A literature search was conducted using the
Medline database (PubMed, U.S. National Library oI
Medicine) and The Cochrane Library. A total oI 464 articles
were identifed, oI which 53 were eligible based on the
study`s inclusion and exclusion criteria. A meta-analysis was
perIormed with the Iollowing endpoints oI interest: incidence
oI seroma, cellulitis, inIection, wound dehiscence, implant
Iailure, and hernia recurrence. The eIIect oI certain risk Iactors
such as smoking, radiation, chemotherapy, and diabetes on the
development oI these complications is also evaluated.
Results: A majority oI the studies were retrospective (68.6).
Mean Iollow-up was 15.2 months (SD + 10.1 months). The
overall risk oI complications associated with ADM use were
as Iollows: seroma Iormation: 8; cellulitis: 5.1; wound
inIection: 16.1; wound dehiscence: 8.1; breast implant
Iailure: 6.1; hernia: 27.6; and abdominal bulging: 28.1.
Risk oI inIection despite the administration oI antibiotics was
36.4 in abdominal cases compared to 9.1 in breast cases.
Radiation resulted in a signifcant diIIerence in the rates oI
cellulitis (p0.021) and chemotherapy was associated with a
higher incidence oI seroma Iormation (p0.014).
Conclusion: This study is the frst to evaluate the overall
outcome rates associated with ADM use by conducting a
meta-analysis oI published data. This will aIIord physicians
a single comprehensive source oI reIerence when undergoing
inIormed consent discussion with patients. In addition,
awareness oI the Iactors predictive oI complications will
enable physicians to identiIy patients at high risk prior to
surgery.
2
RECONSTRUCTION OF PLANTAR HEEL
DEFECTS WITH PLANTARIS MEDIALIS
NEUROVASCULAR ISLAND FLAPS
Presenter: Sammy Al-Benna
Authors: Al-Benna S, Steinstraesser L, Steinau HU,
Hauser J, Tillkorn D, Merwart B
BG University Hospital Bergmannsheil Ruhr University
Bochum
Introduction: SoIt tissue deIects oI the heel are diIfcult to
repair and treatment oIten causes problems because oI the
anatomical structures oI the Ioot`s Iunction in bearing the
entire weight oI the body. Flaps taken Irom the non-weight
bearing area oI the sole have normal quality oI the plantar
skin, which has fbrous septa with reduced fexibility. In view
oI the quality oI the skin and subcutaneous tissue and the
quality oI the nerve supply, plantaris medialis neurovascular
island faps have been used to cover small- to middle-
sized heel deIects. The aim oI this study was to determine
the indication and clinical outcome oI plantaris medialis
neurovascular island faps used Ior the reconstruction oI
plantar heel deIects.
Materials and Methods: 15 consecutive patients with plantar
heel deIects who received treatment at our institution between
2002 and 2009 were analyzed retrospectively. Patient data
analyzed included epidemiological, clinical and management
details, sensation, and development oI recurrence.
Results: Mean age oI the patients was 42.3+12.3 years
(mean+sd). 69 were male and 31 were Iemale. Plantar
heel deIects were secondary to trauma in 33, pressure sores
in 27 tumours in 20 and osteomyelitis in 20. Patients
had a mean oI 0.8 risk Iactors (e.g. BMI~30, smoking,
diabetes mellitus). Flap survival was 100 in 12/15 patients
and partial in 3/15 patients. There were no fap losses. Other
complications included fap in 20, secondary split skin
graIting aIter debridement was perIormed in 13.3 and
haematoma evacuation in 6.7. AIter a Iollow-up oI 59+29.4
months, there were no Iurther reports oI recurrent heel deIects.
Discussion: Plantaris medialis neurovascular island faps
should be included in the armamentarium Ior plantar heel
reconstruction to provide durable closure oI small to middle-
sized plantar heel deIects. These faps are limited in width and
cannot always cover large deIects, particularly aIter excision
oI malignant tumours.
Plastic and Reconstructive Surgery May 2011 Supplement
10
3
CHARACTERIZATION OF
BIOMECHANICAL FORCES DRIVING
REGIONAL AND DIMENSION-SPECIFIC
SCAR FORMATION IN THE RED DUROC
PIG USING FINITE ELEMENT METHODS
Presenter: Satoshi Akaishi, MD
Authors: Akaishi S, Wong VW, Bhatt KA, Vial IN,
Dauskardt RH, Longaker MT, Gurtner GC
Nippon Medical School
Introduction: The role oI mechanical Iorces in pathologic
scarring has been suspected Ior centuries, and current anti-
scar treatments have therapeutic benefts that may be mediated
through modulation oI the mechanical wound environment.
Mainstays oI scar treatment such as silicone sheeting and
compression bandages rarely account Ior regional diIIerences
in skin biomechanics, thus potentially resulting in inconsistent
clinical outcomes.
Methods: We characterized region-specifc diIIerences in
skin biomechanical properties (thickness, Young`s modulus,
peak stress) in the red Duroc pig, a large animal model known
to Iorm human-like scars. To create a biologic environment
similar to high tension human wounds, we developed both
incisional and excisional wound models using a Iorce-
modulating polymer device to control local wound tension
during repair. Scar Iormation was assessed aIter eight weeks
oI injury and was correlated with predicted mechanical stress
states based on fnite element methods (FEM). Region-
specifc wounds were simulated with FEM to predict pro-
fbrotic mechanical Iorces.
Results: Red Duroc skin demonstrated thickness values
ranging Irom 2-6mm and Young`s modulus ranging Irom
7-41MPa at 1/sec strain. Peak stresses varied Irom 3-18MPa
at 1/sec strain. Application oI the Iorce-modulating polymer
device produced local skin strains oI 20 and eIIectively
modulated fbrotic phenotype on both gross and histologic
examination. When applied directly overlying closed wounds,
the stress-shielding eIIect signifcantly reduced scar Iormation
compared to unshielded wounds. Increasing wound tension
Iollowing excisional wound closure positively correlated with
local strains ranging Irom 4-15.
Conclusion: These fndings clearly demonstrate that skin
biomechanical properties vary dramatically depending on
regional and wound dimension-specifc diIIerences. Future
generation devices and polymers that mechanically modulate
the wound environment should be precisely tailored using
computer-based models Ior specifc anatomic areas and
wounds to better control local biomechanics and eIIect a
regenerative outcome.
4
AGE-RELATED DECLINE IN CITED2
EXPRESSION LEADS TO INCREASED
SENESCENCE OF TENDON-DERIVED
STEM/PROGENITOR CELLS
Presenter: Takintope Akinbiyi, MS, MD
Authors: Akinbiyi T, Eckstein DA, Xu L, Taub PJ,
Sun H
Mount Sinai School of Medicine
Introduction: The inherent defcits in tendon healing seen
in aged populations can adversely aIIect the outcome oI the
surgical repair oI tendons. Previous studies suggest that this
age-related decline in healing may be due to a reduction in
the number and activity oI tendon-derived stem/progenitor
cells (TSPCs), cells responsible Ior maintaining tenocyte
populations. The mechanism leading to this decrease is
unknown. The transcription Iactor CITED2 is a potent
suppressor oI cell senescence, in which p14ARF plays a
critical role. We recently Iound that CITED2 is strongly
expressed in young TSPCs, but its levels decline with age.
In this study, we hypothesized that the age-related decline
in CITED2 levels allow Ior TSPC senescence resulting in
decreased tendon healing with age.
Methods: Biceps brachii tendons (Young: age 40; Aged
~ 60) and TSPCs were isolated and cultured. CITED2
knockdown- P0 TSPCs were transIected with CITED2
shRNA, or scramble shRNA (control) using OligoIectamin
(Invitrogen) per the manuIacturer`s protocol. GFP () cells
were sorted by fow cytometry. RT-PCR- Total RNA was
isolated (Qiagen RNeasy Minikit) and a two-step RT-PCR was
perIormed. Western Blot- Protein extracts were separated by
SDS-PAGE, blotted onto nitrocellulose membranes, probed
with specifc antibodies and detected by chemiluminescence.
Results/Discussion: Morphology. With age, TSPCs adopted
a more fattened morphology with increased relative surIace
area (young 1.0+0.29, aged 1.16+0.29; p0.05), characteristic
oI senescent cells. Cited2 expression. With age, both mRNA
(young 1.0+0.073, aged 0.76+0.049; p0.05), and protein
expression oI Cited2, a Iactor known to maintain cell
morphology and proliIeration, were reduced. Cited2 protects
against senescence. When Cited2 expression was knocked
down in young TSPCs, expression oI the senescence Iactor
p14ARF increased to levels observed in TSPCs Irom aged
individuals. These results strongly suggest Cited2 suppresses
senescence in human TSPCs and its age-related decline
may be responsible Ior impaired tendon healing in aged
populations.
5
DOES LIPOSUCTIONING OF THE
ABDOMEN AFFECT COSMETIC
ABDOMINOPLASTY OUTCOME?
Presenter: Shannon D. Armstrong, MD
Authors: Armstrong SD, Neaman KC, Baca M,
Vanderwoude DL, Renucci JD, Albert M
GRMEP Michigan State University
Objective: The purpose oI this study is to explore whether
combining liposuction and abdominoplasty to achieve a better
cosmetic outcome impacts the saIety oI abdominoplasty.
Methods: A retrospective review was conducted oI 1008
consecutive patients who underwent abdominoplasty Irom
January 1998 to December 2008 at a six surgeon plastic
surgery practice. Surgeon operative technique, patient
comorbidities, concomitant procedures and complications
were recorded. Average age was 44 (18-76), average BMI was
25 (19-46) the majority oI patients were Iemale 977 (96.9).
Results: A total oI 950 (94.2) Iull abdominoplasties were
perIormed, 58 (5.8) mini-abdominoplasties were perIormed.
OI those 469 (46.5) had liposuction oI the abdominal
fap and 555 (55.1) had liposuction oI the fanks. The
total complication rate Ior all patients was 32.6, major
complication rate was 18.2 and minor complication rate was
31.9. The most common major complication was seroma
requiring aspiration or surgical evacuation in 15.7. The most
common minor complication was seroma that required no
intervention in 15.4. Liposuction oI the fanks or liposuction
oI the abdomen both had signifcantly higher rates oI total
complications, major complications and minor complications,
as well as revision rate compared to abdominoplasty alone.
Summary: This study, the largest retrospective study oI
cosmetic abdominoplasty to date, shows that liposuction oI
the abdominal fap or oI the fanks signifcantly increases
total complication rate, major complication rate, minor
complication rate and revision rate. Plastic surgeons should
be aware oI the potential outcomes oI combining liposuction
with abdominoplasty when perIorming concomitant
liposuction to achieve a potentially better cosmetic outcome.
6
NERVE REGENERATION UNDER THE
INFLUENCE OF PEDOT
Presenter: Ziya Baghmanli, MD
Authors: Baghmanli Z, Urbanchek MG, Wei B,
Shim BS, Martin DC, Cederna PS
University of Michigan
Objective: 3,4 polyethylenedioxythiphene (PEDOT) is
a conductive polymer being tested Ior neural-machine
interIaces. Two polymerization methods have been described:
dry (yields highly conductive, stiII product), wet (yields less
conductive, soIt product). We tested Ior eIIects oI dry or
wet PEDOT on regenerating nerves. The goal is to optimize
a material Ior better conduction within the interIace while
preserving nerve viability.
Methods: A 15 mm rat peroneal nerve gap was reconstructed
with various materials (n8 per group): Sham, AutograIt,
Decellularized nerve (DN), dry PEDOT polymerized DN
(dry PEDOT), wet PEDOT polymerized DN (wet PEDOT)
and Gap (gap was not reconstructed). AIter 90 days oI
recovery, histological nerve specimens taken Irom midgraIt
were assessed and scored with use oI a modifed version oI
a previously described scoring system. Quantitative analysis
was done as well. Axons were identifed and the Iollowing
data were collected: neural area (m
2
), percent neural area (),
axon counts, and axon density (axon/m
2
). EMG and muscle
Iorce were also measured.
Results: All nerves successIully regenerated under the
infuence oI PEDOT. Dry PEDOT had high action potential
velocity, but lower muscle Iorce, nerve score and neural
area than autograIt. Wet PEDOT exerted similar histological
outcomes to the sham, although action potential velocity and
muscle Iorce were lower. Additionally, wet PEDOT showed
better histological outcomes than dry PEDOT, as neural area
and axon density were similar to autograIt, the gold standard.
Conclusion: Peripheral nerve regeneration occurs in the
presence oI PEDOT. Favorable histological outcomes with
wet PEDOT confrm some advantages Ior this method.
Mechanical obstruction is a possible explanation or the
observed poorer histology outcomes with dry PEDOT. On
the other hand, dry PEDOT aIIorded Iaster conduction due
to the polymer. As a result, wet PEDOT is qualitatively and
quantitatively superior to dry PEDOT though the cost is some
compromise in conductivity.
12
7
POST-OPERATIVE ENOXAPARIN DOES
NOT INCREASE RISK FOR RE-OPERATIVE
HEMATOMA IN PLASTIC SURGERY
PATIENTS: PRELIMINARY RESULTS OF
THE PSEFS VENOUS THROMBOEMBOLISM
PREVENTION STUDY (VTEPS)
Presenter: Steven H. Bailey, MD
Authors: Bailey SH, Pannucci C, Dreszer G,
Fischer CF, Jaber C, Jaber RM, Hamill JB,
Hoxworth RE, Kalliainen LK, Rubin JP,
Pusic AL, Wilkins EG
UT Southwestern Medical Center
Background: VTEPS primary goal is to evaluate
whether post-operative enoxaparin alters rates oI venous
thromboembolism (VTE) in adult plastic surgery patients.
Survey research has demonstrated that the potential risk oI re-
operative hematoma is a major barrier to surgeons providing
enoxaparin prophylaxis.
Methods: The VTEPS Network consists oI Iour academic
institutions. In 2009, centers implemented a clinical protocol
Ior VTE prophylaxis. Prophylactic-dose enoxaparin was
initiated 6-8 hours aIter surgery and administered daily Ior the
duration oI inpatient stay. Historic controls included 2006-
2008 patients who received no enoxaparin but were admitted
aIter surgery. We perIormed a mid-term analysis to examine
rates oI re-operative hematoma stratifed by receipt oI post-
operative enoxaparin and procedure type.
Results: We identifed 1614 historic control patients who
received no enoxaparin. When compared to patients having
non-breast surgery, breast reconstruction patients (1.58
vs. 4.52, p0.002) and breast reduction patients (1.58
vs. 8.81, p0.001) were signifcantly more likely to have
re-operative hematoma. We compared 1614 historic control
patients to 1006 patients who received post-operative
enoxaparin. For patients who did or did not receive post-
operative enoxaparin, re-operative hematoma rates were
not signifcantly diIIerent in the overall patient population
(3.38 vs. 3.16, p0.757) or in subgroup analyses Ior
breast reconstruction (4.41 vs. 4.52, p0.946), breast
reduction (9.38 vs. 8.81, p0.917), or non-breast plastic
surgery (2.53 vs. 1.58, p0.163). Using multivariable
logistic regression, age, BMI, receipt oI intra-operative
heparin product, receipt oI intra- or post-operative aspirin,
microsurgical procedure, total operative time, or receipt oI
post-operative enoxparin were not independently associated
with re-operative hematoma.
Conclusion: Post-operative enoxaparin prophylaxis does
not signifcantly increase re-operative hematoma rate in the
overall patient population or breast surgery subgroups. Further
research on enoxaparin Ior VTE prevention is necessary.
8
EFFECT OF HYDROGEN SULFIDE
THERAPY ON NEUTROPHIL ACTIVATION
IN THE CONTEXT OF ISCHEMIA-
REPERFUSION INJURY
Presenter: Carissa Ball, BS
Authors: Ball C, ReiIIel AJ, Chintalapani S,
Spector JA, King MR
Cornell University
Introduction: Ischemia-reperIusion injury (IRI) is a poorly
understood phenomenon that aIIects many medical and
surgical disciplines. Ischemia leads to an upregulation in
endothelial P-selectin and intercellular adhesion molecule-1
(ICAM-1) expression, resulting in neutrophil recruitment to
sites oI injury. PSGL-1, L-selectin, and beta 2 integrins on
neutrophils interact with, respectively, endothelial P-selectin,
sialyl Lewis-x decorated glycoprotiens, and ICAM-1 during
transient neutrophil rolling and frm adhesion along the blood
vessel wall. Excessive neutrophil recruitment and tissue
infltration is thought to contribute to damage associated with
IRI. This work aims to understand how hydrogen sulfde, a
gasotransmitter shown to mitigate the damage caused by IRI,
aIIects neutrophil adhesion protein expression.
Methods: Neutrophils were isolated Irom human peripheral
blood, extracted, washed and suspended in HBSS. Some
neutrophils were incubated in 10 uM NaHS. Neutrophils were
labeled with monoclonal antibodies against PSGL-1, LFA-1,
Mac-1 alpha, L-selectin and beta 2 integrin CBRM1/5 epitope
and analyzed by fow cytometry. Isolated neutrophils were
treated with NaHS as above and briefy activated with IL-8 or
IMLP, labeled Ior L-selectin and PSGL-1, and analyzed using
fow cytometry.
Results: The administration oI 10 uM NaHS has no eIIect
on adhesion protein expressing in resting neutrophils.
NaHS treatment signifcantly aIIects the extent oI L-selectin
shedding Irom cells by 1.8 Iold and 2.5 Iold Iollowing
exogenous activation by IMLP and IL-8 (p0.05).
Conclusions: NaHS administration results in the
downregulation oI L-selectin expression in activated human
neutrophils. This may lead to a reduction in neutrophil
extravasation and tissue infltration and may partially account
Ior the protective eIIects oI NaHS seen in the setting oI IRI.
Furthermore, these are the frst data to demonstrate changes in
neutrophil gene expression induced by HS and may serve to
guide potential therapeutic interventions in the Iuture.
9
EFFECTIVENESS OF TOPICAL
IMMUNOSUPPRESSANTS IN PREVENTION
AND TREATMENT OF REJECTION IN FACE
ALLOTRANSPLANTATION
Presenter: Bahar Bassiri Gharb, MD
Authors: Bassiri Gharb B, Rampazzo A, Madajka M,
Altuntas SH, Cwykiel J, Siemionow MZ
Cleveland Clinic
Background: Employment oI topical immunosuppressants
has been anecdotally reported Ior treatment oI rejection in
composite tissue allotransplantation. The aim oI the present
study was to evaluate the eIIectiveness oI topical Clobetasol
and Tacrolimus in prevention and treatment oI rejection in a
Iace transplant model.
Methods: Sixty-Iour hemiIace allotransplants, between ACI
(RT1a) donors to Lewis (RT1l) recipients, were perIormed in
8 groups: groups 1 and 2 represented controls receiving no
treatment (1), or only systemic treatment with Cyclosporin-A
and anti- +-TCR Antibody Ior 7 days (2). Groups 3 and 4 were
treated with topical Clobetasol (3) or Tacrolimus (4) only.
Groups 5 to 8 received 7 days systemic immunosuppression,
Iollowed on day 8 (groups 5, 6) or at the frst sign oI rejection
by topical treatment (groups 7, 8).
Skin biopsies and blood samples and lymphoid organs were
taken. Flow Cytometry analysis was perIormed to monitor
rejection and chimerism (CD3, CD4, CD8, CD45, CD11,
CD25, +-TCR, -TCR, ACI). The infammatory infltrate was
characterized by immunostaining Ior CD4, CD8, CD11 and
CD86.
Results: Topical treatment increased the survival oI the
allograIt in all groups. Maximal survival was obtained in
groups 4-8. However a high incidence oI local complications
related to the application oI Clobetasol was evidenced:
FACS analysis showed systemic depletion oI lymphocytic
populations and increase oI CD11 cells. Spleen and thymus
were atrophic. In the Tacrolimus group the lymphocytic
populations were preserved and no local or systemic
complications were observed.
Conclusions: In our hemi-Iace transplantation model topical
treatment with Clobetasol although eIIective in treating
rejection is associated with systemic absorption and high local
complication rate, thereIore should be employed with caution.
Topical Tacrolimus could represent an adjunct to systemic
therapies prolonging allograIt survival without systemic
eIIects.
10
OPTIMAL TIMING OF DELAYED FREE
LOWER ABDOMINAL FLAP BREAST
RECONSTRUCTION AFTER POST-
MASTECTOMY RADIATION THERAPY
Presenter: Donald Baumann, MD
Authors: Baumann D, Crosby M, Selber J, Sacks J,
Garvey P, Villa M, Adelman D, Robb G
MD Anderson Cancer Center
Purpose: In women diagnosed with locally advanced breast
cancer, breast reconstruction with a lower abdominal fap is
typically deIerred until all oncologic care, including post-
mastectomy radiation therapy (PMRT), has been delivered.
The purpose oI this study was to determine the optimal
timing oI delayed lower abdominal fap breast reconstruction
Iollowing PMRT by evaluating the association between
interval duration and postoperative complications.
Methods: We reviewed a prospectively maintained database
oI DBR perIormed between July 2005 and December 2009.
Patients were classifed as having undergone reconstruction
within 12 months oI PMRT (Group I) or 12 months or
more aIter PMRT (Group II). Recipient site complications
were compared between groups including microvascular
thrombosis, partial fap loss, total fap loss, Iat necrosis,
inIection, wound dehiscence and seroma.
Results: One hundred eighty-nine patients were identifed,
82 patients (43.4) Group I and 107 patients (56.6) Group
II. The median Iollow-up was 302 days in Group I and II, 11
days in Group II, (p0.087). Ninety-Iour patients (49.7)
underwent msTRAM faps, 80 patients (42.3) DIEP faps,
and 15 patients (7.9) SIEA faps. There was no diIIerence
in fap distribution or recipient vessels between groups. The
total fap loss rate was 2.6 with all fap losses occurring in
Group I (p 0.014). A total oI 49 patients (26) experienced
at least one postoperative recipient site complication; Group I
patients trended towards a higher incidence oI microvascular
thrombosis, inIection and wound dehiscence. As a result the
re-operation rate was higher in Group I (14.6 vs. 4.7, p
0.022).
Conclusions: Patients who underwent DBR aIter 12
months oI PMRT developed Iewer complications, including
microvascular thrombosis and total fap loss, than those who
underwent DBR within 12 months oI PMRT. Allowing an
interval oI 12 months between the completion oI PMRT and
delayed abdominal Iree fap breast reconstruction will likely
minimize complications and optimize outcomes in Iree fap
breast reconstruction in patients receiving PMRT.
14
11
THE IMPORTANCE OF HOSPITAL
CASE-VOLUME FOR OUTCOMES IN
AUTOLOGOUS FREE-TISSUE BREAST
RECONSTRUCTION
Presenter: Mazen I. Bedri, MD
Authors: Bedri MI, Villegas C, Rosson GD
Mercy Medical Center
Objective: To determine iI increased hospital volume is
associated with improved short-term outcomes Ior patients
undergoing breast reconstruction using autologous Iree-tissue
transIer.
Background: Literature in several surgical subspecialties
demonstrates that high-volume centers oIten realize improved
outcomes with respect to more complex procedures. Public
data on breast reconstruction using Iree-tissue transIer has
recently become available, allowing Ior a more directed
analysis and comparison oI outcomes across institutions.
Methods: Analysis oI hospital data Irom all acute care
hospitals in Maryland (via the Health Services Cost Review
Commission database) identifed all patients who underwent
breast reconstruction using autologous Iree-tissue transIer
Irom October 1, 2008 through December 31, 2009. Hospitals
were categorized as either low-volume centers (LVCs, 1 to
30 cases) or high-volume centers (HVCs, ~30 cases) based
on the number oI patient admissions to perIorm Iree-TRAM,
DIEP, SIEA, and GAP faps over the time period. Multiple
regression analysis was used to study the relation between
hospital case-volume and outcomes including in-hospital
complication rates, length oI stay, and total hospital charges.
Results: Among 374 hospital admissions Ior breast
reconstruction using Iree-tissue transIer, 79 were accounted
Ior by the two HVCs, with the remaining 21 distributed over
19 other hospitals. HVCs were more likely to utilize DIEPs
or GAPs, while LVCs demonstrated preIerence Ior DIEPs
and Iree TRAMs. HVCs had lower in-hospital complication
rates than LVCs (24.8 vs 43.8, p0.001), and were 60
less likely to have complications aIter adjustment Ior case-
mix and patient characteristics (OR0.40, p0.001). Patients
at HVCs also had shorter lengths oI stay than those at LVCs
(3.7 days vs 4.4 days, p0.001), and were 77 less likely to
have prolonged stays aIter adjustment (OR0.23, p0.001).
No diIIerences were Iound in total hospital charges across
institutions.
Conclusion: Hospital case-volume is signifcantly associated
with decreased complication rates and length oI stay.
12
A COST ANALYSIS OF THE USE OF
ACELLULAR DERMAL MATRIX
IN IMPLANT-BASED BREAST
RECONSTRUCTION
Presenter: Catherine de Blacam, MB BCh
Authors: de Blacam C, Momoh AO, Colakoglu S,
Slavin SA, Tobias AM, Lee BT
Beth Israel Deaconess Medical Center
Background: The use oI acellular dermal matrix (ADM) as
an adjunct to implant- based breast reconstruction is becoming
commonplace. Although there may be improvement in the
overall cosmetic outcome, recent reports show an increase
in complications associated with ADM use. Randomized
outcomes data is lacking and the cost implications have not
been addressed in the literature to date.
Methods: Medicare reimbursement costs were calculated
Ior the Iollowing procedures: tissue expander/implant alone
(TE/I), tissue expander/implant with ADM (TE/I ADM) and
single stage implant with ADM (SSI ADM). Probabilities
oI complications Ior each procedure were derived Irom the
published literature. These fgures were combined to calculate
the total expected cost oI the three procedures.
Results: The most expensive procedure at baseline was TE/I
ADM ($12,597.78), Iollowed by TE/I alone ($12,276.18)
and SSI ADM ($5,423.02). When published results were
combined, a higher incidence oI most complications was
observed in ADM- based procedures. Incorporating the total
probability oI complications into the cost analysis resulted
in an increase in the excess cost oI ADM- based procedures
(TE/I ADM, $13,123.94; TE/I, $12,506.32; SSI ADM,
$5,841.84).
Conclusions: Single stage implant with ADM breast
reconstruction carries the lowest cost based on Medicare
reimbursement; however, not all patients are suitable
candidates. The use oI ADM with a tissue expander/implant
reconstruction increases the cost compared to tissue expander/
implant alone. With the increasing Iocus on health care costs,
it is important that plastic surgeons are aware oI the cost
implications oI using ADM products.
13
THE LATERAL INFRAMAMMARY
INCISION FOR NIPPLE-SPARING
MASTECTOMY: OUTCOMES FROM
OVER 50 IMPLANT-BASED BREAST
RECONSTRUCTIONS
Presenter: Keith M. Blechman, MD
Authors: Blechman KM, Levovitz C, Karp NS,
Choi M
New York University School of Medicine
Purpose: Nipple-sparing mastectomy (NSM) is rapidly
gaining popularity as its saIety and eIfcacy continue to be
supported. NSM decreases scar burden and leaves the nipple-
areola complex (NAC) intact, aIIording superior aesthetics
compared to traditional skin-sparing reconstructions. The
lateral inIrammammary Iold (LIMF) incision provides
adequate access and eliminates anterior scar, making this
incision cosmetically preIerable to other approaches. Here we
present our experience with NSM through a LIMF incision,
with immediate implant-based reconstruction, which to our
knowledge is the largest reported series using this type oI
incision.
Methods: We retrospectively reviewed 51 consecutive nipple-
or areola-sparing mastectomies via a LIMF incision Irom June
2008 to October 2010 that underwent immediate implant-
based reconstruction, with or without use oI a tissue expander.
Breasts were lightly tumesced, and sharp dissection was
preIerred to avoid electrocautery injury to the mastectomy
fap. Intraoperative subareolar biopsies were perIormed.
Three-dimensional (3D) photographs were obtained prior
to mastectomy and aIter reconstruction was complete. 3D
parameters included volume, antero-posterior projection, and
ptosis (defned by the distance Irom a set superior point to the
inIerior breast pole).
Results: Average age was 44 years. Mean Iollow-up time
was 1 year. All mastectomies were bilateral except one.
Therapeutic mastectomy was perIormed in 44 oI patients,
and Ior prophylaxis in 56. Tissue expansion was used in
76 oI patients, and Alloderm was used in 80. Fat graIting
was perIormed iI contour deIormities remained aIter placing
the permanent implant. NAC survival reached 94. One
patient required a salvage latissimus dorsi fap. 3D analysis
demonstrated larger (196 vs 248 cc), more projected (80 vs 90
mm), and less ptotic breasts (146 vs 134 mm) (p0.01).
Conclusions: Excellent outcomes can be achieved Iollowing
NSM through a LIMF incision using immediate expander/
implant reconstruction. NAC survival is reliable. NSM
reconstruction via this approach can create larger, more
projected, and less ptotic breasts.
14
COMPLICATIONS ASSOCIATED WITH
RADIATION IN TISSUE EXPANDER BREAST
RECONSTRUCTION WITH HUMAN
Presenter: Andrew L. Blount, MD
Authors: Blount AL, Armstrong SD, Lineberry K,
Do VH, Cullen WT, Ford RD
Grand Rapids Medical Education and Research Center
Objective: Tissue expander (TE) breast reconstruction with
human acellular dermal matrix (HADM) is commonly used
in immediate, post-mastectomy breast reconstruction. Few
reports exist correlating the eIIects oI radiation in TE/HADM
reconstructions. The purpose oI our study is to examine our
complication rate in patients receiving therapy with these
combined modalities.
Methods: Post-mastectomy breast reconstructions with TE/
HADM were examined in a consecutive retrospective Iashion
Irom the database oI the senior surgeons (RDF, WTC).
Patients were examined over a three-year period. Patient
groups were divided into those receiving radiation at any time
point, with subdivisions Ior preoperative and postoperative
radiation. Exclusion criteria Ior the study included delayed
and secondary breast reconstruction.
Results: Over the three-year period, 287 TE/HADM breast
reconstructions were perIormed in 175 patients. Average age
was 49 years and average BMI was 26.2. kg/m
2
. The overall
complication rate was 34. Major complications occurred
in 12 and included partial mastectomy fap necrosis (8)
and explantation (4.1). The minor complication rate was
22, representing grade I-IV capsular contracture, seroma,
inIection requiring antibiotics, and hematoma. OI 175
total patients, 42 had radiation therapy, 23 preoperative, 17
postoperative and 2 with both preoperative and postoperative.
Preoperative radiation was signifcantly associated with
fap necrosis (p 0.003), wound dehiscence (p 0.048),
and explantation (p 0.001). Postoperative radiation was
signifcantly associated with grade III/IV capsular contracture
(p 0.013). Signifcant increase in inIection requiring
antibiotics was associated with any radiation exposure (p
0.049).
Conclusion: Preoperative and postoperative radiation are
signifcant risk Iactors Ior TE/HADM breast reconstructions,
with increased rates oI fap necrosis, wound dehiscence,
explantation, and inIection. While an essential part oI multi-
modality cancer care, increases in these complications should
be expected in this patient population.
16
15
BLOCKADE OF OSTEOPONTIN WITH A
SPECIFIC RNA APTAMER INHIBITS
PRO-FIBROTIC FIBROBLAST FUNCTIONS
Presenter: JenniIer Bond, PhD
Authors: Bond J, Hunter CL, Kuo PC, Levinson H
Duke University Medical Center
Background: Osteopontin (OPN) is a secreted
phosphoprotein that interacts with cell surIace receptors,
+v3 and CD44, and extracellular matrix elements. Previous
in vivo studies have demonstrated that knockdown oI OPN
with siRNA reduces dermal fbrosis. RNA aptamers are
short (12-30nt) single-stranded RNA sequences with stable
3D-conIormations that specifcally bind target proteins with
high aIfnity. The novel RNA aptamer, OPN-R3 blocks OPN
signaling and inhibits cancer growth and metastasis. It is
unknown how OPN exerts its pro-scarring aIIects and what
therapeutic role OPN-R3 may have in preventing dermal
fbrosis.
Methods: Human scar tissue was stained Ior OPN and CD44.
OPN-R3 was evaluated in vivo Ior its inhibitory eIIects on
an excisional mouse wound healing model. Human dermal
fbroblasts (HF) were explanted Irom 4 diIIerent donors
undergoing elective procedures. HF migration was analyzed
with Boyden chambers. ConIocal microscopy was used to
assess HF Iocal adhesion length. Adhesion was measured by
incubating fuorescently stained HF on OPN coated plates.
The proliIerative activity oI HF was measured using a MTS
assay. Free foating collagen lattices were utilized to assess
HF contractility.
Results: Immunohistology staining oI human scar tissue that
shows OPN expression was increased during the infammatory
phase oI wound healing. The expression oI CD44 was
increased in scar tissue during the remodeling phase and
expression levels returned to normal surrounding tissue aIter
the remodeling phase. Preliminary data shows that OPN-R3
attenuates wound healing in vivo. OPN did not induce a
signifcant increase in Iocal adhesion length compared to
controls (p~0.05). HF adhesion, migration, proliIeration
and contraction signifcantly increased in response to OPN
and this eIIect was suppressed by the addition oI OPN-R3
(p0.05).
Conclusions: OPN exerts pro-scarring eIIects by increasing
cellular migration, adhesion, proliIeration, and contractility oI
HF. OPN-R3 may be useIul Ior contractures.
16
GENE EXPRESSION PROFILE IN
NON-SYNDROMIC METOPIC
CRANIOSYNOSTOSIS
Presenter: Chelsea Britt
Authors: Britt C, Olivares-Navarrete R, Hyzy SL,
Williams JK, Schwartz Z, Boyan BD
Georgia Institute of Technology
Background: Craniosynostosis, premature suture
closure, results in restricted skull growth. Non-syndromic
craniosynostosis and its molecular mechanisms are poorly
understood. Metopic synostosis, one oI the less common non-
syndromic Iorms, results in trigonocephaly. We hypothesized
that cells in Iused sutures express higher levels oI osteogenic
genes and produce paracrine Iactors that stimulate osteoblastic
diIIerentiation oI mesenchymal stem cells (MSCs). To test
this, we compared osteogenesis-related signaling pathways
in cells isolated Irom normal bone (NB), patent sutures
(PAT), and Iused (FUS) sutures Irom human craniosynostosis
patients.
Methods: Osteoblasts were isolated Irom NB, PAT, or FUS
Irom three metopic craniosynostosis cases. Osteoblasts were
characterized by cell number, alkaline phosphatase specifc
activity (ALP), and osteocalcin (OCN). Expression oI
integrins and Wnt and BMP pathway molecules was measured
by real-time quantitative PCR. To determine the eIIect oI
osteoblasts on surrounding progenitor cells, osteoblasts
were co-cultured with human MSCs. AIter seven days, the
osteoblasts were removed and cell number, ALP, and secreted
Iactors analyzed in the MSCs. Data are mean+SEM (n6/
condition, ANOVA and BonIerroni`s Student`s t-test).
Results: FUS osteoblasts had higher ALP and OCN than NB
or PAT cells. In FUS osteoblasts, levels oI DKK1 mRNA
were higher and ?-catenin lower than NB and PAT osteoblasts,
indicating reduced canonical Wnt signaling in FUS sutures.
BMP4 levels were higher in FUS cells than PAT or NB cells.
ITGA5 and ITGB1 expression increased in PAT cells in
comparison with NB or FUS cells. MSCs co-cultured with
FUS osteoblasts had increased ALP, and produced more OCN,
osteoprotegerin, VEGF, TGF?1, BMP2, and BMP4 than
MSCs cultured with NB or PAT cells.
Conclusions: Cells isolated Irom Iused sutures in non-
syndromic craniosynostosis present a more diIIerentiated
osteogenic phenotype. These cells produce an osteogenic
environment that induces osteoblastic diIIerentiation in
MSCs. Gene expression analysis suggests that BMP4, ITGA5,
ITGB1, and DKK1 may play an important role aIIecting
metopic suture Iate.
17
ROLE OF RAC PROTEIN IN ISCHEMIA-
REPERFUSION TREATED WITH
HYPERBARIC OXYGEN
Presenter: John P. Brosious, MD
Authors: Brosious JP, Stephenson LL, Wang WZ,
Zamboni WA
University of Nevada School of Medicine
Introduction: Hyperbaric oxygen (HBO) has been shown
to have benefcial eIIects on tissue exposed to ischemia-
reperIusion (IR). It has been shown that HBO prevents
CD18 cell surIace polarization and subsequent adhesion oI
neutrophils to the endothelium, likely through cytoskeletal
rearrangement. The Rho Iamily oI G-proteins has been
implicated in many cytoskeletal Iunctions in various cell lines.
The objective oI this study was to determine the role oI Rac, a
member oI the Rho Iamily, in the HBO treatment oI IR.
Methods: Male Wistar rats were randomly assigned to
one oI three groups: 1) Nonischemic Control, 2) Ischemia
ReperIusion (IR), and 3) IR-Hyperbaric Oxygen Treatment
(IR-HBO). The gracilis muscle fap was isolated and
raised on its vascular pedicle. A vascular clamp was placed
across the Iemoral artery and vein Ior 4 hrs oI gracilis fap
ischemia, HBO consisted oI 100 O
2
at 2.5 ATA during the
last 90 min oI ischemia. 'Activated plasma Irom the fap
circulation Iollowing 15 min reperIusion was reacted with
donor neutrophils. These neutrophils, as well as neutrophils
harvested directly Irom fap circulation, were measured Ior
active Rac protein using G-LISA assay (Cytoskeleton, Inc).
Data is reported as Mean /- SEM ng Rac per 0.25ug total
protein. Statistical comparison was by ANOVA with p value
0.05 accepted as signifcant.
Results: Ischemia reperIusion caused a signifcant decrease
in Rac protein activity (Nonischemic Control 57.80 /- 11.04
vs. IR 12.59 /- 4.32, p 0.05) in donor activated neutrophils,
while HBO revealed an increase toward normal levels oI
activated Rac (IR-HBO 30.66/-12.96).
Conclusions: These results suggest that the benefcial eIIects
oI HBO may involve rac reactivation Iollowing an IR-induced
Rac inhibition.
18
Abstract Withdrawn
18
19
TOPICAL SIRNA AND PROGENITOR
CELL MOBILIZATION REDUCE AGE-
RELATED REACTIVE OXYGEN SPECIES
ACCUMULATION AND ACCELERATE
HEALING IN THE SENESCENT WOUND
Presenter: Parag Butala, MD
Authors: Butala P, Knobel D, CrawIord JL,
Szpalski C, Marchac A, Sultan SM,
Wetterau M, Davidson EH, Saadeh PB,
Warren SM
New York University Langone Medical Center
Introduction: Impaired wound healing in elderly contributes
to signifcant biomedical burden. Our lab has previously
introduced the Hutchinson-GilIord Progeria Zmpste24-/-
mouse as a model oI senescent wound healing, and we now
explore therapeutic strategies to reduce reactive oxygen
species and accelerate wound healing.
Methods: 48 8-week Zmpste24-/- mice underwent 6mm
dorsal cutaneous wounding and were either treated with
topical p53 siRNA post-wound days 1, 7, and 13 or with
nonsense siRNA as control. As a secondary arm, mice were
treated either with the progenitor cell mobilizing agent
AMD3100 (10mg/kg i.p. daily Ior 14 days) or saline and
wounds Iollowed until closure. Wounds were harvested
Ior quantitative RT-PCR, ELISA, fow cytometry, and
immunohistochemistry on days 7, 10, and 20.
Results: Zmpste24-/- mice treated with p53 siRNA healed
wounds by day 14 + 2.2, and treatment with AMD3100 led to
wound closure by day 20 + 3.0 compared to day 35 + 3.5 Ior
controls. RT-PCR demonstrated p53 siRNA and AMD3100
treatment decreased pro-apoptotic Iactors BAX and p53
(Iold change 0.3 + 0.16, p0.05 and 0.1 + 0.07, p0.05,
respectively) and increased vasculogenic Iactors VEGF, HIF-
1, and SDF (Iold change 2.3 + 0.3, p0.05, 3.1 + 0.4, p0.05,
and 3.3 + 0.5, p0.05, respectively). ELISA Ior VEGF, SDF,
and p53 on days 7, 10, and 20 corroborated RT-PCR fndings.
Reactive oxygen species (ROS) were Iound to be markedly
decreased with siRNA and AMD3100 treatment (9.1ng/mL
+ 0.4 and 14.2ng/mL + 0.1 vs. 19.6ng/mL + 1.1, p0.05).
Flow cytometry Ior circulating endothelial progenitor cells
showed increases with both siRNA and AMD3100 treatment
at day 10 (5.1 + 0.1 and 5.0 + 0.8 vs. 1.1 + 0.9, p0.05).
Immunohistochemistry Ior CD31, PCNA, ROS, p53, and
caspase-3 confrmed quantitative data.
Conclusion: This is the frst demonstration oI the treatment
oI a mouse model oI senescent wound healing. We
characterize a vasculogenic and ROS dysIunction rescued
via diIIering pathways using topical siRNA and progenitor
cell mobilization. We believe this study highlights potential
therapies Ior the study oI senescent wound healing.
20
ROLE OF THROMBOLYTIC AGENTS FOR
MICROVASCULAR FREE FLAP SALVAGE
Presenter: Eric I. Chang, MD
Authors: Chang EI, Mehrara BJ, Festekjian JH,
DaLio AL, Crisera CA
UCLA Medical Center
Background: Vascular thrombosis with fap loss is the most
dreaded complication oI microvascular Iree tissue transIer.
Thrombolytic agents such as tissue plasminogen activator
(TPA) have been used clinically Ior Iree fap salvage in cases
oI pedicle thrombosis. Yet, there is a paucity oI data in the
literature validating the beneft oI their use.
Methods: A retrospective review oI the breast reconstruction
Iree fap database was perIormed at a single institution
between the years oI 1991-2010. The incidence oI vascular
complications (arterial and/or venous thrombosis) was
examined to determine the role oI adjuvant thrombolytic
therapy in fap salvage. Pathologic examination was used
to determine the incidence oI Iat necrosis aIter secondary
revision procedures.
Results: Seventy-Iour cases were identifed during the
study period. In 41 cases, revision oI the anastamoses was
perIormed alone without thrombolytics with 38 cases oI
successIul fap salvage (92.7). In 33 cases, anastamotic
revision was perIormed with adjuvant thrombolytic therapy,
and successIul fap salvage occurred in 28 oI these cases
(84.8). Thrombolysis did not appear to signifcantly aIIect
fap salvage. Interestingly, only two oI the salvaged faps
that had received thrombolysis developed Iat necrosis while
eleven oI the non-thrombolysed faps developed some amount
Iat necrosis (7.1 vs. 28.9, p0.05).
Conclusions: The decreased incidence oI Iat necrosis may be
attributed to dissolution oI thrombi in the microvasculature
with the administration oI thrombolytics. Although the use oI
adjuvant thrombolytic therapy does not appear to impact the
rate oI fap salvage, their use may have secondary benefts on
overall fap outcomes.
21
TEMPORAL CHANGES IN GENE
EXPRESSION REGULATING MOUSE
POSTERIOR FRONTAL SUTURE FUSION
Presenter: Regina Chang
Authors: Chang R, Hermann CD,
Olivares-Navarrete R, Williams JK,
Boyan BD, Schwartz Z
Introduction: Craniosynostosis is the premature closure
oI cranial sutures during development. Mice are a well
established model Ior suture Iusion, because the posterior
Irontal (PF) suture Iuses during development while the
remaining sutures stay open. The objective oI this study was
to identiIy genes at key developmental points that regulate PF
suture Iusion.
Materials: Bone Irom the PF suture was harvested Irom
C57Bl/6J male mice on days: 6, 12, 20, and 25. These time
points were correlated to the key developmental time points
oI PF suture Iusion based on our previous work using a snake
algorithm to quantiIy bone Iormation by microCT. Day 6 is
beIore and day 12 is at the beginning oI suture Iusion. Day
20 is when the suture has Iused with osteoid but not begun
mineralization. Day 25 is at the midpoint oI mineralization,
beIore the suture reaches its adult state. RNA Irom the suture
was extracted (RNA Irom three mice were pooled per sample)
and ran on osteogenic PCR arrays. Selected genes Irom the
PCR array showing greater than 3 Iold change were confrmed
using real-time PCR with additional intermediate time points,
days 9 and 16.
Results: Genes associated with chondrocyte maturation,
ColXa1, COMP, and Col2a1 showed a strong peak on day
12. BMP inhibitors displayed distinct expression profles:
sclerostin peaked at day 12, gremlin1 increased over time
until day 25, and BMP3 decreased aIter day 9. BMP2 and
BMP4 expression slightly decreased between days 9 and
20 Iollowed by an increased on day 25. Genes related to
osteoblast diIIerentiation, OCN and Runx2, gradually
increased up to day 25.
Conclusions: The expression oI chondrocyte maturation
markers during peak suture Iusion suggests that PF suture
Iusion occurs via endochondral ossifcation. The diIIerent
discrete time points oI BMP inhibitor expression indicate that
they may each be involved in regulating diIIerent phases oI
suture Iusion. The decrease in BMP2 and BMP4 during the
period oI suture Iusion, suggests that they may not play a
central role in suture Iusion. Expression oI genes associated
with osteoblast diIIerentiation is correlated to the bone
mineralization that occurs aIter suture Iusion.
22
SUTURELESS MICROVASCULAR
ANASTOMOSIS USING
THERMOREVERSIBLE POLOXAMERS
Presenter: Edward I. Chang, MD
Authors: Chang EI, Galvez MG, Glotzbach JP,
El-Itesi S, Hamou CD, Rajadas J, Fuller G,
Longaker MT, Gurtner GC
Stanford University
Introduction: The ability to perIorm microvascular
anastomosis Ior Iree tissue transIers and digital replants is
tedious, time consuming, and requires a skilled microsurgeon.
While a myriad oI devices have simplifed these complex
operations, all the current devices introduce Ioreign materials
which stimulate a Ioreign body reaction predisposing such
anastomoses to stenosis or thrombosis. We propose a novel
sutureless technique using poloxamers.
Materials and Methods: Rheological studies determined
the Iormulation oI P407/BSA to obtain a phase transition
temperature at 39C. Anastomoses were perIormed on Fisher
rat aortas using P407/BSA (n30) and 10-0 nylon sutures
(n30). CT and MR angiograms, ultrasound Doppler, burst
strength assays, histology, SEM were perIormed at designated
timepoints Irom 6 weeks to 2 years.
Results: A Iormulation oI 16.5 P407 and 0.25 BSA
achieved a phase transition temperature oI 39C and was used
Ior all subsequent experiments. Sutureless anastomoses were
completed more eIfciently than the hand sewn technique
(8.1 + 2.4 min vs. 47.3 + 5.0 min, p0.05) with equivalent
burst strengths (~1200 mm Hg, p~0.05). CT and MR
angiograms demonstrated equivalent patency in end-to-end
anastomoses; however, end-to-side anastomoses could not be
perIormed using traditional techniques (p0.001). Doppler
analysis demonstrated equivalent patency, vessel diameter,
and fow (116.1 mL/sec vs. 107.2 mL/sec, p~0.05) between
sutureless and hand-sewn anastomoses. Histology and SEM
demonstrated dramatically decreased infammation and
fbrosis at early time points and at 2 years. Infammatory cell
quantifcation demonstrated Iewer CD68 cells at later time
points in the poloxamer cohort (p0.001)
Conclusions: Sutureless anastomosis can be perIormed
reliably, more eIfciently, and with less intimal damage than
hand-sewn anastomosis. Poloxamer employed during the
anastomosis can provide sustained delivery oI anti-thrombotic
agents simultaneously to Iurther preserve graIt patency.
This technology oIIers a promising alternative to sutured
anastomosis and may have a proIound impact on the feld oI
reconstruction.
20
23
Abstract Withdrawn
24
PRETREATMENT OF VITAMIN D3
AMELIORATES LUNG AND MUSCLE
INJURY INDUCED BY REPERFUSION OF
BILATERAL FEMORAL VESSELS IN A RAT
MODEL
Presenter: JianXun Chen, MD
Authors: Chen JX, Shih PK, Cheng CM
Kaohsiung Medical University Hospital
Background: Peripheral arterial occlusive disease (PAOD)
is a challenge in peripheral vascular disease. Clinical
observations show reperIusion oI occluded vessels may cause
compartment syndrome or remote organ injury. Less well
known is the role oI vitamin D3 in tissue injury; thereIore, we
attempted to determine whether vitamin D3 could alleviate
local and remote organ injury induced by reperIusion oI
occluded vessels in animal models.
Methods: Twenty-Iour male Sprague-Dawley rats were
randomized into Iour groups: saline sham, saline I/R,
vitamin D3 sham, and vitamin D3 I/R group. AIter
pretreatment Ior 5 d, the animals designed to I/R injury were
subjected to 3 h oI ischemia induced by bilateral Iemoral
arteries clamp, Iollowed by reperIusion oI the vessels Ior
3 h on d 6. LeIt lung and leIt anterior tibial muscle tissue
were harvested Ior wet/dry weight ratio and histopathologic
analysis. Blood was collected Ior analysis oI urea nitrogen
(BUN), creatinine (Cr), aspartate aminotransIerase (AST),
alanine aminotransIerase (ALT), tumor necrosis Iactor-alpha
(TNF-), interleukin-6 (IL-6), ionized calcium levels, and
heme oxygenase-1 (HO-1).
Results: Compared with the saline sham group, there was
a signifcant increase in plasma IL-6 level in both saline
I/R and vitamin D3 I/R groups and muscle, lung wet/dry
weight ratio in the saline I/R group (P 0.05). Compared
with the saline I/R group, there was a signifcant decrease
in plasma IL-6 level, muscle and lung wet/dry weight ratio
in both vitamin D3 sham and vitamin D3 I/R groups, and
leukocyte HO-1 expression in vitamin D3 sham group (P
0.05). Compared with the vitamin D3 sham group, there
was a signifcant increase in plasma IL-6 levels in the vitamin
D3 I/R group, and leukocyte HO-1 expression in vitamin
D3 sham group (P0.05). BUN, Cr, AST, ALT, TNF-,
ionized calcium levels did not diIIer signifcantly among the
groups.
Conclusions: Pretreatment oI vitamin D3 ameliorates the
systemic IL-6 levels, lung and muscle injury induced by
ischemia Iollowed by reperIusion oI bilateral occluded vessels
in a rat model.
25
PROPRANOLOL CAUSES CYTOTOXICITY
IN HEMANGIOMA CELLS THROUGH
DOWNREGULATION OF VEGF-RELATED
PROTEINS AND DECREASED PI3/AKT
PHOSPHORYLATION
Presenter: Harvey Chim, MD
Authors: Chim H, Miller E, Gliniak C, Gosain AK
Case Western Reserve University
Background: Propranolol has been Iound to be eIIective
in treatment oI hemangiomas oI inIancy. However, its
mechanism oI action is as yet unknown.
Methods: Hemangioma endothelial cells at P3 or P4
were isolated Irom resected proliIerative and involuting
hemangiomas through explant culture Iollowed by CD31
dynabead selection. Cells were exposed to varying
concentrations oI propranolol ranging Irom 0.3uM to 300uM
Ior up to 4 days. RT-PCR was used to analyze mRNA
expression Ior VEGF, FGF-2, MMP-2, MMP-9, MMP-1,
FGF-2, IL6, MCP-1, HIF-1a, VEGF, VEGFR1, VEGFR2.
Secretion oI VEGF, bFGF and MMP-2 and expression
oI HIF-1a was assayed. MTS assay, apoptosis caspase,
endothelial cell migration, tubulogenesis assay with matrigel
were perIormed. Phosphorylation oI PI3/Akt and ERK 1/2
was assayed. Flow cytometry Ior VEGF-R2 and FGF-R2
was perIormed. Quantifcation oI microvessel density using
subcutaneous nude mouse matrigel model was done in 2
groups with cells either exposed to diIIerent propranolol
concentrations or mice given diIIerent IP doses.
Results: HIF-1a, MCP-1 and FGF-2 mRNA were
downregulated with increased propranolol, with increased
dose dependent protein. VEGF, MMP-2, MMP-9, MMP-
1, VEGFR1 and VEGFR2 mRNA were upregulated with
decreased secretion oI VEGF and MMP-2 protein. With
increasing propranolol, there was dose dependent decreased
cell proliIeration on MTS assay with increased apoptosis,
stepwise decrease in migration at 30uM and 100uM
propranolol and cessation oI tubule Iormation at 300uM
dosage Ior both proliIerative and involuting cells, with
shorter tubules in involuting cells. Total PI3/Akt and ERK 1/2
expression was decreased with increasing propranolol, with
phosphorylation oI PI3/Akt decreased at dosage oI 200uM
and 300uM. Quantifcation oI microvessel density showed
statistically signifcant decrease in density at IP injections oI
10 mg/kg and 2 mg/kg compared to control mice.
Conclusions: These results suggest a mechanism oI action
Ior propranolol on hemangiomas through inhibiting secretion
oI VEGF and related angiogenesis proteins, causing a direct
cytotoxic eIIect and subsequent apoptosis.
26
NASAL CONTOURING: CALCULATED AND
PREDICTABLE TIP ELEVATION WITH
CEPHALIC ALAR TRIM
Presenter: Saeed Chowdhry, MD
Authors: Chowdhry S, Hazani R, Drury B, Yoder E,
Cooperman R, Little JA, Wilhelmi BJ
University of Louisville
Introduction: Three maneuvers are known to eIIect nasal
tip rotation in nasal contouring procedures. The cephalic
alar trim is a powerIul method Ior achieving tip elevation.
Previous studies and texts provide aesthetic guidelines Ior
nasolabial (NLA). OIten, surgeon experience determines the
degree oI cephalic alar cartilage resection to achieve optimal
results. This study analyzes the change in tip elevation with
measured cephalic resections oI the alar cartilage. This can
aid the surgeon in predicting the amount oI cephalic alar trim
required Ior the desired tip elevation.
Methods: Ten Iresh cadaveric dissections were perIromed in
order to determine the change in NLA aIter cephalic trim oI
the alar cartilage. Closed rhinoplasty technique was perIormed
using marginal and intercartilaginous incisions to expose the
alar cartilage. Caliper measurements oI the alar cartilages
were recorded. Serial cephalic alar trim was perIormed in 25
percent increments. A true lateral photograph was obtained
beIore and aIter each serial excision. NLA measurements were
obtained using a digital goniometer Ior digital photo analysis.
Results: 10 Iresh cadavers were used Ior the study. The mean
initial NLA was 106 /-2.00. The mean alar cartilage width
was 9.45mm /-1.38mm. Serial 25 cephalic reductions in
alar cartilage height resulted in a mean total NLA change oI
7.4, 12.9, 19.6, respectively. The mean incremental change
in NLA was 6.47 /-1.25.
Conclusion: The NLA is an essential aesthetic Ieature oI the
nose and Iacial profle. The cephalic trim is a key maneuver
in eIIecting the NLA. Each 25 cephalic alar resection
correlates with an average change in the nasolabial angle
oI 6.47. This study demonstrates that tip elevation can be
directly increased depending on the percentage oI cephalic
alar rim resection. Knowledge oI the cephalic trim to NLA
relationship can aid in achieving desired tip elevation in nasal
contouring procedures.
22
27
EARLY POSTOPERATIVE
OUTCOMES ASSOCIATED WITH THE
ANTEROLATERAL THIGH FLAP IN
SMOKERS WITH COVERAGE OF
TRAUMATIC GUSTILO IIIB FRACTURES
OF THE LOWER EXTREMITY
Presenter: Michael R. Christy, MD
Authors: Christy MR, Lipschitz A, Christian M,
Shridharani S, Magarakis M, Rodriguez E,
Manson P
The R Adams Cowley Shock Trauma Center and The
University of Maryland
Purpose: Free muscle transIer with skin graIt has been
regarded as the gold standard Ior complex wound coverage
oI the lower extremity. More recently Iree perIorator faps
have been popularized. Applying this concept to the lower
extremity, the anterolateral thigh (ALT) fap has become
a Irequently used Iree fap Ior restoration oI soIt-tissue
deIects involving the distal lower extremity. The objective
oI this study is to evaluate the rate oI early postoperative
complications associated with the ALT Iasciocutaneous (FC)
or adipocutaneous (AC) Iree fap Ior coverage oI high-energy
traumatic open Iractures oI the lower extremity and explore
related patient risk Iactors.
Methods: A retrospective chart review oI 74 consecutive
patients undergoing Iree tissue transIer Ior lower extremity
limb coverage was perIormed. Data analyzed included:
age, gender, smoking status at the time oI injury, medical
risk Iactors Ior atherosclerosis (diabetes, hypertension, and
hypercholesterolemia) and the ASIF/OTA classifcation oI
the Iracture and soIt tissue defcit. Fischer`s exact test was
perIormed to identiIy risk Iactors associated with greater
morbidity.
Results: 74 patients were identifed with a lower extremity
Gustilo IIIb injury. 26 (35) oI patients were smokers
and 48 (64) were non smokers. 34 (46) deIects were
reconstructed using adipocutaneous (AC) faps and 40 (54)
were reconstructed using Iasciocutaneous (FC) faps. The
most Irequent complication was partial fap loss or superfcial
epidermolysis 4 (5.4). This was Iollowed by hematoma 3
(4.1) and continued osteomyelitis at 6 months 3 (4.1).
Fischer`s exact test was perIormed showing that patients who
smoked and had other risk Iactors Ior atherosclerosis were
signifcantly more at risk Ior complications (p 0.001).
Conclusion: In this review smokers and those with risk
Iactors Ior atherosclerosis have a signifcantly increased
risk oI fap complications. This retrospective analysis is a
preliminary investigation into the saIety and eIfcacy oI the
ALT Iasciocutaneous or adipocutaneous fap to reconstruct
high-energy open Iractures oI the lower extremity.
28
IMPACT OF PRIOR IPSILATERAL CHEST
WALL RADIATION ON PEDICLED TRAM
FLAP BREAST RECONSTRUCTION
Presenter: Yoon Chun, MD
Authors: Chun Y, Verma K, Sinha I, Rosen H,
Lipsitz SR, Hergrueter C, Wong J, Pribaz JJ
Brigham and Womens Hospital
Background: Many breast cancer patients interested in
pedicled transverse rectus abdominis myocutaneous (TRAM)
fap have undergone prior ipsilateral chest wall radiation.
Previous treatment Irequently includes breast conservation
therapy, mantle radiation, or prior post-mastectomy radiation.
Many reconstructive surgeons avoid basing the TRAM on
the previously irradiated superior epigastric pedicle in this
subset oI patients. This study was perIormed to compare the
complication rates between TRAM faps based on previously
irradiated pedicle vs. TRAM faps based on non-irradiated
pedicle to assess the impact oI prior ipsilateral chest wall
radiation on pedicled TRAM faps.
Methods: The authors perIormed a retrospective analysis oI
consecutive pedicled TRAM faps perIormed over an 8-year
period. A total oI 302 pedicled TRAMs were divided into two
groups: TRAMs based on a previously irradiated superior
epigastric pedicle (N76) and TRAMs based on a non-
irradiated superior epigastric pedicle (N226). Demographic
inIormation, co-morbidities, oncologic data, neoadjuvant
therapy, and complications were collected Ior comparison.
Results: 215 patients underwent 302 pedicled TRAM fap
reconstructions (128 unilateral and 87 bilateral). 76 TRAMs
were based on a previously irradiated superior pedicle due
to prior chest wall radiation ipsilateral to the fap, and 226
TRAMs were based on a non-irradiated pedicle. There was
no statistically signifcant diIIerence in the rate oI fap-related
complications between the previously irradiated group vs.
non-irradiated group including fap loss (1.3 vs. 0.4,
p0.418), partial fap loss (4.0 vs. 2.2, p0.416), inIection
(1.3 vs. 1.8, p0.789), and Iat necrosis (15.8 vs. 9.7,
p0.164). However, there was a statistically non-signifcant
trend towards higher reoperation rate in the previously
irradiated group compared to the non-irradiated group (26.3
vs. 16.4, p0.056).
Conclusion: Prior ipsilateral chest wall radiation is not
associated with signifcant fap-related complications and may
not be a contraindication Ior considering pedicled TRAM fap
breast reconstruction as an option.
29
RE-ASSESSMENT OF THE MICHIGAN
HAND QUESTIONNAIRE USING
CONFIRMATORY FACTOR ANALYSIS
Presenter: Bryan Chung, MD, PhD
Authors: Chung B, Morris SF
Dalhousie University
Introduction: The Michigan Hand Questionnaire is a 63-item
measurement tool used widely to assess six dimensions oI
hand health`. The exploratory Iactor model used to reduce
generated items to the existing number oI items proposed
that each item on the MHQ loads on a single latent Iactor
(e.g. pain, work). However, the exploratory model has not
been confrmed in a separate population Irom the original
development sample, nor has the relationship between Iactors/
subscales been explored. The purpose oI this study was to
assess the validity oI current Iactor model and to propose a
new Iactor model which might better explain the relationship
between items and Iactors/subscales.
Methods: All patients attending the Plastic Surgery Clinic
between September 2008 and October 2009 at the QEII
Health Sciences Centre in HaliIax, Nova Scotia with a hand
complaint were asked to complete a copy oI the MHQ.
Patients who were splinted or had K-wire fxation were not
eligible Ior this study. Confrmatory Iactor analysis was used
to assess the ft oI the current Iactor model.
Results: There were 116 subjects who completed Iull versions
oI the MHQ. The goodness-oI-ft oI each Iactor model are
summarized. The goodness oI ft statistics Ior the complete
exploratory model were: Chi-squared1796.67, CFI0.93,
SRMR0.59. Initial confrmatory analysis indicates that
several items load on at least two other Iactors/subscales, with
improvement in measures oI goodness oI ft.
Conclusion: The data in this study suggests that the
goodness-oI-ft oI the original proposed Iactor structure
is poor to moderate. Each oI the MHQ items does not
necessarily measure only a single discrete latent Iactor
(corresponding to one oI the subscales). The validity oI the
MHQ might be strengthened by combining redundant items
with use oI the MHQ as a single global hand score with a
Iactor structure to allow Ior analysis oI component sub-Iactors
(e.g. pain, work ability, activities oI daily living). Such a
proposed Iactor structure will be presented.
30
SHIFTING CELLULAR REDOX BALANCE:
TOPICAL SILENCING OF KEAP1
INCREASES ANTIOXIDANT CELLULAR
PROTECTION, IMPROVING DIABETIC
WOUND HEALING
Presenter: Oriana Cohen, BA
Authors: Cohen O, Patel M, Layliev J, Wetterau M,
Szpalski C, Knobel D, Ceradini DJ,
Warren SM, Saadeh PB
Introduction: Increased levels oI reactive oxygen species
(ROS) have been implicated in delayed diabetic wound
healing. The transcription Iactor NrI2 and its key repressor
Keap1 play a critical role in the protection against oxidative
stress. We hypothesized that in the hyperglycemic state,
inactivation oI Keap1 repression oI NrI2 would increase
transcriptional activation oI antioxidant genes, and thereby
improve diabetic wound healing.
Methods: Silencing RNA (siRNA) to Keap1 was generated
and assayed Ior knockdown in 3T3 fbroblasts by RT-PCR
and Western blotting. Activation oI antioxidant gene NQO-
1 expression was quantifed by RT-PCR. Using a diabetic
murine excisional wound model (db/db), siRNA to Keap1
was topically applied and wounds were assessed over 30
days Ior epithelialization, granulation tissue Iormation,
neovascularization, and ultimately, wound closure. Gene
expression was assessed by RT-PCR and Western blot. Paired
t-test determined statistical signifcance (p0.05).
Results: Keap1 silencing in 3T3 cells resulted in 63.5 +
0.36 knockdown oI Keap1 mRNA compared to nonsense
controls. This resulted in a 12.25 Iold increase in antioxidant
gene NQO-1 expression. In diabetic animals, Keap1 silenced
wounds were completely epithelialized at day 10 compared
to nonsense treated wounds, which demonstrated 1328 +
259m oI epithelial gap. They had increased granulation
tissue area (197,148 + 3,525.2 vs. 53,165 + 1,360 m
2
) and
neovascularization (61 vs. 18 CD31cells/hpI). Expression oI
NQO-1 was increased by Keap1 silencing 1.8 Iold at day 10,
and indicators oI ROS end products were decreased compared
to controls (2.3 vs. 4.5 ng/mL). This was ultimately associated
with accelerated clinical wound closure oI Keap1 silenced
wounds (21 vs. 27 days).
Conclusion: This study demonstrates the eIIectiveness
oI targeted topical silencing oI Keap1, a key regulatory
element in the broad anti-oxidant gene expression pathway,
in improving diabetic wound healing. This provides strong
evidence that the altered redox balance inherent to the
hyperglycemic state accounts Ior delayed wound healing in
diabetes.
24
31
THREE HUNDRED THIRTY-ONE
CONSECUTIVE IMMEDIATE SINGLE
STAGE IMPLANT RECONSTRUCTIONS
WITH ACELLULAR DERMAL MATRIX
IN 211 PATIENTS: INDICATIONS,
COMPLICATIONS, TRENDS, AND PATIENT
SATISFACTION
Presenter: Amy S. Colwell, MD
Authors: Colwell AS, Damjanovic B, Zahedi B,
MedIord-Davis L, Austen WG
Massachusetts General Hospital
Background: Immediate single stage implant breast
reconstruction with acellular dermal matrix (ADM) optimizes
aesthetics by preserving the mastectomy skin envelope. We
report the largest series oI single stage implant reconstructions
with ADM in the literature and describe indications,
complications, trends, and patient satisIaction.
Methods: Retrospective review oI three surgeon`s
experience was perIormed Ior immediate single stage implant
reconstruction with ADM and tissue expander reconstruction
without ADM.
Results: Two hundred-eleven patients (average 49 yo, range
27-81) had 331 implant reconstructions using AlloDerm
Iollowing nipple-sparing (66) or skin-sparing (265)
mastectomy Ior cancer (216) or prophylaxis (115). The
number oI single stage implant reconstructions increased
Irom 7 in 2006 to 116 in 2009. The percentage perIormed
Ior prophylaxis increased Irom 29 to 41. FiIty-one
patients had radiation. Indications Ior immediate implant
reconstruction included small to moderate sized breasts, a
healthy skin envelope, and patient desire to be a similar or
smaller size. Total complications (13.6) included 10 (3.02)
inIections requiring IV antibiotics, 5 (1.6) seromas, and 30
(9) reconstructions with skin necrosis requiring operative
revision (3 with implant loss and 5 with wound dehiscence).
Tissue expander reconstruction without ADM had a similar
total complication rate oI 17.7 (158 reconstructions):
9 (5.7) inIections, 3 (1.9) seromas, and 16 (10)
reconstructions with skin necrosis (3 with tissue expander
loss and 5 with wound dehiscence). A higher complication
rate occurred in the surgeons` frst year perIorming single
stage implant reconstruction 21.4 compared to subsequent
years 10.9 (p0.02). Both groups oI patients showed a
high degree oI satisIaction with breasts as measured by the
Breast-Q.
Conclusion: Immediate single-stage implant reconstruction
using AlloDerm oIIers a saIe, aesthetically pleasing
reconstruction with a low complication rate and high degree
oI patient satisIaction.
32
COMPARISON OF VRAM AND ORAM
FLAPS FOR PELVIC AND PERINEAL
RECONSTRUCTION
Presenter: Patrick D. Combs, MD
Authors: Combs PD, Mathes DW
University of Washington
Background: Wound complications aIter perineal and groin
obliterative procedures are a signifcant cause oI morbidity,
particularly Iollowing chemoradiation therapy. Vertical rectus
abdominis myocutaneous (VRAM), and increasingly oblique
rectus abdominis myocutaneous (ORAM) faps have been
used to fll potential dead space and bring healthy tissue into
the deIect. This study compares complications and outcomes
oI patients who underwent perineal or groin reconstruction
using VRAM or ORAM faps.
Methods: All patients who underwent immediate
reconstruction oI perineal, pelvic, or groin deIects using
VRAM (n49) or ORAM (n22) faps over the past ten
years at the University oI Washington Medical Center were
retrospectively reviewed. Patient, disease, and obliterative
procedure characteristics, as well as donor and recipient-
site complications were compared between the two groups.
Statistical analysis was perIormed using Student`s t test Ior
continuous and Fisher`s exact test Ior categorical variables.
Results: There were no statistically signifcant diIIerences in
major or minor donor site complication rates, major or minor
recipient site complication rates, need Ior augmented Iascial
closure, need Ior additional faps, fap loss, readmission, or
reoperation rate between the two groups.
Conclusions: Immediate reconstruction oI perineal or groin
deIects with ORAM faps results in similar complication
rates to reconstruction with VRAM faps. ORAM fap
reconstruction oI these wounds is a reasonable and saIe
alternative to VRAM fap reconstruction.
33
DIGITAL IMAGE SPECKLE CORRELATION
(DISC) ANALYSIS AS A PROSPECTIVE
QUANTITATIVE CLINICAL OUTCOMES
METRIC FOR COSMETIC TREATMENT
WITH BOTULINUM TOXIN TYPE A
Presenter: Nicole Conkling, BA, BS
Authors: Conkling N, Phillips BT, Bhatnagar D,
RaIailovich M, Wang ED, Melendez MM,
Khan SU, Bui DT, Dagum AB
Stony Brook University Medical Center
Introduction: The eIIects oI Botulinum toxin (BT) treatment
on Iacial musculature have previously relied upon subjective
patient-reported outcomes. In this study, we successIully
quantifed the initial Iacial muscle paralysis and duration oI
eIIect oI BT treatment by DISC analysis.
Methods: BT injections were dosed to cosmetic eIIect in
the Iorehead, glabellar, and crow`s Ieet areas. Photos were
taken oI patient volunteers beIore and aIter treatment and at
subsequent time points using a head stabilizer. The patients
were photographed raising eyebrows, Irowning, blinking, and
with the Iace at rest. DISC soItware was then used to calculate
the magnitude oI the contractile Iorce oI the Iacial muscles.
We corroborated our quantitative analysis with patient-
reported data using the validated FLO-11 Questionnaire and
SPA Measure.
Results: The analysis (n4 patients) demonstrated substantial
Iacial muscle paralysis beginning at 1 week and varying
degrees oI recovery by 8 weeks, depending upon the
individual muscle group. In Patient 1, the Irontalis muscle
showed more dramatic initial paralysis at 1 week, but also
more rapid recovery, while the eIIect on the glabellar region
took at least 2 weeks to reach its maximum paralysis, which
was greater in magnitude and slower to recover. Despite the
demonstrated near recovery oI the paralyzed muscles, patient
perception oI eIIect only began to decrease slightly at the
8-week time point as measured by FLO-11 (Irom 90.9 at week
4 to 82.7 at week 8) and no change in SPA.
Conclusions: DISC analysis provides a sensitive, non-
invasive measure oI Iacial muscle dynamics, and has the
potential to serve as an objective metric Ior plastic surgeons
administering BT injections, enhancing clinical judgment
in tailoring treatment to individual patients. Additional
applications oI this technology include monitoring recovery
Iollowing nerve repair, or quantiIying prospective outcomes
data Ior Iacial transplant recipients.
34
DOES IMMEDIATE BREAST
RECONSTRUCTION AFFECT SURGICAL
SITE INFECTION? DATA FROM THE
NATIONAL SURGICAL QUALITY
IMPROVEMENT PROGRAM (NSQIP)
Presenter: Melinda A. Costa, MD
Authors: Costa MA, Nguyen TJ, Shahabi A,
Hernandez AM, Vidar EN, Davis GB,
Chan LS, Wong AK
Keck School of Medicine of the University of Southern
California
Introduction: Surgical site inIections (SSI) are a source oI
signifcant postoperative morbidity and cost. To date, there is
little data regarding whether immediate breast reconstruction
aIIects the incidence oI SSI in mastectomy patients.
Methods: Using the National Surgical Quality Improvement
Program (NSQIP) database, all Iemale patients undergoing
mastectomy, with or without immediate reconstruction, Irom
2005 - 2008 were identifed. Only clean procedures were
analyzed. The primary outcome was incidence oI SSI within
30 days oI operation. Stepwise regression analysis was used to
identiIy risk Iactors associated with SSI. Multivariate logistic
regression analysis was used to determine rate oI SSI while
adjusting Ior risk Iactors associated with SSI.
Results: A total oI 32,855 mastectomies were perIormed
during the study period; 6,289 had immediate breast
reconstruction and 26,566 did not. The incidence oI SSI was
3.6 (95 CI: 0.31-0.41) in patients undergoing mastectomy
and reconstruction and was 2.5 (95 CI: 0.23-0.27) in
patients undergoing mastectomy alone. AIter adjustment
Ior risk Iactors, individuals undergoing mastectomy with
reconstruction were 1.32 times as likely to develop SSI than
those with mastectomy without reconstruction (95 CI: 1.1-
1.6, p0.004). Statistically signifcant (p0.05) independent
risk Iactors Ior SSI include preoperative BMI oI 35 or more
(OR: 3, 95 CI: 2.5-3.7), diabetes mellitus on insulin (OR:
2.9, 95 CI: 2.3-3.8), ASA class 3 or greater (OR: 1.78, 95
CI: 1.6-2), and intraoperative red blood cell transIusion oI
2 or more units (OR: 2.6, 95 CI: 1.1-6.6). Postoperative
risk Iactors include urinary tract inIection (OR: 6.6, 95
CI: 4-11), wound dehiscence (OR: 13, 95 CI: 8.4- 21.7),
pneumonia (OR: 5.8, 95 CI: 2.2-15), and return to operating
room (OR: 3.3, 95 CI: 2.9-3.9).
Conclusion: Immediate breast reconstruction is associated
with a minimal increase in risk oI SSI in patients undergoing
mastectomy. Further study is indicated to characterize this
risk, including how type oI reconstruction aIIects risk oI SSI
in the mastectomy patient population.
26
35
MESH HERNIORRHAPHY REVERSES
INTERNAL OBLIQUE MUSCLE ATROPHY
AND PARTIALLY RESTORES ABDOMINAL
WALL COMPLIANCE
Presenter: Eric J. Culbertson, MD
Authors: Culbertson EJ, Xing L, Wen Y, Franz MG
Objectives: Mechanically unloading skeletal muscle causes
atrophic changes and fbrosis. Our previous work using a
rat model demonstrated that incisional herniation Iollowing
laparotomy induces oblique muscle atrophy and fbrosis
resulting in decreased compliance aIter 35 days. The current
study tests iI these abdominal wall changes persist to 70 days,
and iI abdominal wall compliance and atrophy is restored
Iollowing mesh hernia repair.
Methods: A rat model oI chronic incisional hernia was used.
Midline incisional hernias were repaired on post-operative
day (POD) 35 with polypropylene mesh (n8) and compared
to controls oI unrepaired hernias (n8) and sham repairs that
underwent primary repair at the initial laparotomy and did not
Iorm hernias (n8). All rats were sacrifced on POD 70. Intact
abdominal wall strips were cut perpendicular to the wound Ior
tensiometric analysis. Internal oblique muscles (IOMs) were
harvested Ior fber type analysis.
Results: No hernia recurrences occurred in the mesh repair
group. Unrepaired abdominal walls demonstrated signifcantly
greater stiIIness and increased breaking strength, yield load
and yield energy compared to the sham repair group. Mesh-
repaired abdominal walls demonstrated a trend toward an
intermediate mechanical phenotype 35 days aIter repair.
Hernia Iormation was associated with increased IOM type
IIa muscle fber composition compared to sham (17.8 vs.
10.3, P 0.01), a shiIt consistent with muscle atrophy. Mesh
repair restored type IIa fber composition to that oI the sham
group (9.10 vs. 10.3, P ~0.05).
Conclusions: We confrmed that ventral herniation reduces
abdominal wall compliance and induces IOM atrophy and
Iound that this adaptation persists at 70 days. Polypropylene
mesh incisional herniorrhaphy only partially restores
abdominal wall compliance and reduces toughness Iollowing
hernia Iormation, but reverses IOM muscle fber type changes
associated with atrophy. The elastic properties oI the mesh
contribute to abdominal wall mechanical Iunction, and
optimization oI mesh physical characteristics should account
Ior total abdominal wall compliance.
36
THERAPEUTIC POTENTIAL OF EX-
VIVO FUSED CHIMERIC CELLS IN
PROLONGING VASCULARIZED SKIN
ALLOGRAFT SURVIVAL
Presenter: Joanna Cwykiel, MSc
Authors: Cwykiel J, Klimczak A, Jundzill A,
Siemionow M
The Cleveland Clinic
Introduction: Cell-based therapies are new strategies
developed to minimalize the negative impact oI liIe-long
immunosuppression. The aim oI this study was to test the
in vivo eIIect oI supportive therapy oI ex-vivo Iused donor-
recipient chimeric cells Ior CTA transplantation under short-
term protocol oI anti- +TCR/CsA.
Materials and Methods: Seventeen transplantations oI
vascularized skin allograIt (VSA) between ACI (RT1a)
donors and Lewis (RT1l) recipients were perIormed in 3
groups. Group 1 (n5) did not receive treatment. Groups 2
(n5) and 3 (n7) were treated with 7 day anti- +TCR/CsA
protocol. Additionally, in group 3, the immunosuppressive
protocol was augmented with a supportive cellular therapy
oI ex-vivo Iused donor-recipient chimeric cells (DRCC:
2-3x10
6
cells) delivered intraosseously. Karyotyping, PCR,
immunofuorescence and CFU assays were utilized to
characterize the DRCC phenotype. Flow cytometry was
perIormed to assess the presence oI chimerism in the blood oI
the recipient.
Results: Immunofuorescence proved the creation oI
DRCC, which morphologically resembled heterokaryon and
synkaryon types oI cell Iusion. Moreover, polyploidy oI the
Iused chimeric cells was confrmed by karyotype analysis
and PCR analysis Ior the presence oI donor and recipient
MHC class II. ProliIerative potential oI DRCC was validated
by CFU assay. The supportive role oI the adoptive transIer
oI Iused cells was confrmed in experimental animals by
prolonged survival oI VSA up to 86 days compared to animals
under only short-term immunosuppression (allograIt survival
up to day 61). The presence oI donor-origin cells in the
peripheral blood oI recipients confrmed eIfcacy oI -TCR/
CsA protocol and Iacilitation oI chimerism induction.
Conclusions: We created and characterized ex vivo Iused
DRCC. Ex vivo created chimeric cells had a benefcial
eIIect and prolonged survival oI CTA. Extended survival oI
VSA was associated with the presence oI chimerism in the
recipients` blood. This novel concept oI chimeric cell adoptive
transIer could have a universal use Ior extending survival or
even inducing tolerance in human organ and CT.
37
A FIRST GENOME-WIDE ASSOCIATION
STUDY IN DUPUYTRENS DISEASE
IDENTIFIES 9 SUSCEPTIBILITY LOCI AND
SUGGESTS A MAJOR ROLE FOR WNT-
SIGNALLING
Presenter: Guido H. Dolmans, MD
Authors: Dolmans GH, Werker PM, Hennies HC,
Furniss D, Festen EA, Franke L,
van der Vlies P, WolIIenbuttel BH, Giele H,
OphoII RA, Wijmenga C
University Medical Center Groningen
Background: Dupuytren`s disease (DD) is a benign
fbromatosis oI the hand and fngers, oIten leading to disabling
extension defcits oI the fnger joints. We hypothesize that
the susceptibility to DD is infuenced by multiple genetic and
environmental Iactors. To identiIy DD susceptibility genes
to Iurther our understanding oI the pathogenesis oI DD, a
genome-wide association study was perIormed.
Methods: We perIormed a genome-wide association study in
960 Dutch DD cases and 3,117 controls. The top 35 associated
single nucleotide polymorphisms (SNPs) were replicated
in three independent replication sets, compromising 1,365
DD cases and 8,445 controls Irom Germany, the UK and the
Netherlands.
Results: We initially observed genome-wide signifcance Ior
8 SNPs at three loci. AIter replication and joint analysis oI
2,325 DD cases and 11,562 controls 11 SNPs Irom 9 diIIerent
loci showed genome-wide signifcance. Five DD loci contain
genes known to be involved in the WNT signaling pathway.
Conclusions: This study implicates 9 diIIerent loci involved
in susceptibility to DD. The presence oI WNT signaling
pathway genes in fve oI the 9 loci suggests that this pathway
is likely a key player in the fbromatosis process observed in
DD.
38
BONE REGENERATION IN DISTRACTION
OSTEOGENESIS DEMONSTRATES
SIGNIFICANTLY INCREASED
VASCULARITY IN COMPARISON TO
FRACTURE REPAIR IN THE MURINE
MANDIBLE
Presenter: Alexis Donneys, MD, MS
Authors: Donneys A, Tchanque-Fossuo CF,
Farberg AF, Deshpande SD, Buchman SB
University of Michigan Medical School
Background: Tissue analysis oI bone regenerate has
suggested an intense vascular response aIter mandibular
distraction osteogenesis (DO). QuantiIying and
3-dimensionally (3-D) imaging this vascular response could
be oI immense clinical import in eIIorts to advance the utility
oI bone regeneration and repair. Conventional quantifcation
oI vascular responses has heretoIore Iocused on inexact,
cumbersome measurements oI blood fow and histological
vessel counting. Utilizing Micro-Computed Tomography aIter
vessel perIusion we posit that quantitative vascular metrics
will be signifcantly higher in mandibular DO compared to
those observed in Iracture repair (FxR) aIter bony union.
Methods: Sprague-Dawley rats underwent mandibular
osteotomy and external fxator placement. A DO group (n9)
underwent a 5.1 mm distraction, while a FxR group (n12)
had a 2.1 mm fxed gap set. 40 days aIter surgery Microfl
was perIused into the vasculature and imaging ensued.
Radiomorphometrics Ior vascularity were analyzed within
the region oI interest (ROI). Independent samples-t test were
perIormed with statistical signifcance at p0.05
Results: Stereological analysis demonstrated statistically
signifcant increases in the distracted vasculature compared
to Iracture repair: Vessel volume Iraction (54 vs. 28, p
0.030), and vessel number (0.86 mm-1 vs. 0.50 mm-1,
p 0.014). 3-D imaging is also shown, demonstrating the
enhanced vascular response oI DO in comparison to FxR.
Conclusion: We report robust and quantifable increases
in vascular density in DO compared to FxR. Our fndings
support a signifcant distinction between the mechanisms
controlling bone repair during Iracture healing, Irom
the regenerative processes oI mandibular DO. A better
understanding oI the diIIerences between the two types oI
bone Iormation may enable clinicians to selectively optimize
therapeutic outcomes in the Iuture.
28
39
ANALYSIS OF CRANIAL NEURAL CREST
CELLS DURING PALATOGENESIS
Presenter: Max Dougherty, BA
Authors: Dougherty M, Kamel G, Hickey G,
Grimaldi M, Ethier R, Liao EC
Background: In all vertebrates, cranial neural crest cells
(CNCC) Iollow stereotypic patterns oI migration to Iorm
cranioIacial structures. In particular, anterior stream oI
migrating CNCC Iorms the palate (ethmoid plate in fsh).
We generated a transgenic animal (sox10:kaede) whose
neural crest cells are labeled with kaede, a green fuorescent
protein that can be selectively converted to red with targeted
UV light. This model allows us to precisely analyze CNCC
migration throughout embryogenesis. Study oI CNCC
migration perturbed by over-expression or knockdown oI
genes regulating cranioIacial development, such as mirn140
and Wnt9a, uncovers the mechanism oI action oI these genes
on cellular morphogenesis.
Methods: The sox10:kaede transgenic animal was generated
using Tol2 transposase mediated germline integration.
Progeny oI Iounder transgenic zebrafsh were used Ior the
photoconversion experiments. Specifc regions oI neural
crest cells were labeled at 10 somites and at 23 hours post
Iertilization by targeted irradiation with 403 nm light using
a conIocal microscope. Embryos were photographed at the
time oI photoconversion and Iollowed through embryogenesis
to track cellular movements. Wnt9a morpholino or mirn140
duplex RNA were injected at the one-cell stage and Iate-
mapping experiments were carried out.
Results: Preliminary work on wild-type embryos has
demonstrated the utility oI this model in tracking cellular
movements. We confrm that the kaede reporter protein is
expressed in CNCC cells. Wnt9a knockdown and mirn140
overexpression have unique eIIects on CNCC migration,
where movement to populate pharyngeal arch and subsequent
cranioIacial structures are deranged.
Conclusions: The sox10:kaede transgenic line provides a
reliable model Ior CNCC Iate-mapping. We are able to utilize
this system to uncover the morphogenetic mechanism oI two
genes that regulate CNCC migration, Wnt9a and mirn140.
These studies illustrate the advantage oI the zebrafsh model
Ior application in the study oI cranioIacial development,
where complex cellular movements are highly choreographed
at molecular and spatiotemporal levels.
40
THE EFFECT OF LOW INTENSITY
ULTRASOUND ON PROLIFERATIVE GENE
EXPRESSION IN TENDON-DERIVED STEM
CELLS
Presenter: Donna A. Eckstein, BA
Authors: Eckstein DA, Guha D, Akinbiyi T, Taub PJ,
Zhang H, Sun H
Mount Sinai School of Medicine
Background: Ultrasound (US) has been used Ior treatment
oI tendon injuries, however its mechanism is unknown.
Prior studies have shown that US benefts tendon healing
by increasing cell proliIeration and collagen synthesis,
however these fndings have been inconsistent. Low Intensity
Ultrasound (LOFU) is a Iorm that removes the thermal
component Iound at higher intensities while preserving
the mechanical eIIect. We investigated the eIIect oI LOFU
on tendon stem progenitor cells (TSPCs), cells with selI-
renewal and pluripotent capabilities important Ior tendon
homeostasis and repair. Recent studies suggest TSPCs
exhibit changes with age including reduced Cited2, a potent
suppressor oI senescence, reduced BMI1, a regulator oI
proliIeration, and increased p16, a proliIeration inhibitory
gene. Characterization oI changes in these genes will provide
insight into the mechanism oI US therapy used to optimize
tendon healing aIter surgery.
Methods: Biceps brachii tendons were obtained Irom patients
(Young: 36; Old: 74) and TSPCs were isolated and cultured.
The cells were untreated or treated with LOFU at 2W, 5W, or
10W at a Irequency oI 1Hz Ior 150 seconds with a duty cycle
oI 20. RNA was extracted at 2 hours and 4 hours. RT-PCR
was perIormed to assess Cited2, BMI1, MEL18, and p16.
Results/Discussion: At 2 and 4 hours, young TSPCs showed
increased expression oI Cited2 with increased intensity
US, however aged TSPCs showed a delayed response, with
Cited2 increasing at 4 hours, but relatively unchanged at 2
hours. A similar pattern was seen with BMI1 and MEL18,
another proliIeration promoting gene, with young TSPCs
showing early increases and aged TSPCs showing a delayed
increase. p16 was decreased in young TSPCs, but unchanged
or increased in aged TSPCs. These results suggest that US
may infuence tendon healing by inhibiting senescence and
stimulating proliIeration oI TSPCs via up regulation oI
Cited2, BMI1, and MEL18 and down regulation oI p16. The
study also shed light on the potential Ior US use to reverse
the eIIect oI aging at a cellular level in skeletal tissues such as
tendon.
41
ADIPOSE DERIVED STEM CELLS
PROLIFERATE AND DIFFERENTIATE ON
HUMAN ACELLULAR DERMIS
Presenter: Nazanin Ehsani, BS
Authors: Ehsani N, Slack G, Fan K, Kruger E,
Tabit C, Zuk P, Bradley J
University of California Los Angeles
Background: Tissue expander/implant breast reconstruction
is oIten perIormed with an allogeneic dermal substitute
like Alloderm Ior improved inIramammilary Iold contour.
When early postoperative radiation is necessary, rapid tissue
incorporation oI the graIt is benefcial. As a means Ior Iaster
incorporation, we studied implantation oI adipose derived
stem cells (ASC) onto Alloderm with regard to penetration,
proliIeration and diIIerentiation.
Methods: Alloderm was pretreated with 70 ethanol, soaked
in media then seeded with ASCs (2x10
5
) isolated Irom
lipoaspirate. ASC-seeded Alloderm constructs were grown in
control, adipogenic or osteogenic media. At 0, 2, 7, 14, 21 and
28 days the specimens were harvested. H&E, DAPI, and SEM
imaging studies were perIormed at each timepoint to assess
cell attachment, proliIeration and migration with cell viability,
location and number at various matrix depths over time. RT-
PCR was perIormed Ior Osteocalcin, Alkaline phosphatase,
Osteopontin, Bone Sialoprotein (BSP), BMP-2 hCBFA-1,
Adipsin, and PPAR gamma expression. Histological analysis
was perIormed using Von Kossa and Oil-red-O staining
protocols.
Results: ProliIeration increased Irom 2 to 7 days (16 to 55
mean per hpI) then stabilized by week 6. Migration showed
25 penetration at one week and Iull penetration by week 6.
SEM confrmed ASC attachment and viability with cellular
microvilli and interdigitation within the matrix. In adipogenic
media, there was an increase in Oil-red-O staining at day 14
and PPARG gene expression was elevated (~15 Iold) by 4
weeks compared with controls. However, in osteogenic media,
Von Kossa staining had only late calcium deposition by Days
21 and 28. BSP and BMP-2 expression was undetectable.
There was variability in expression oI hCBFA-1 and alkaline
phosphatase. ASC expression oI osteocalcin was higher in
osteogenic media at later timepoints (3, 4 weeks; p0.05).
Conclusion: When adipose derived stem cells are seeded
onto an acellular dermal matrix, they penetrate, proliIerate,
and express markers oI adipogenic diIIerentiation. Osteogenic
expression occurs late and is more variable.
42
THERAPEUTIC POTENTIAL OF FGF-2
FOR HYPERTROPHIC SCARS/KELOIDS:
UPREGULATIONS OF MMP-1 AND HGF
EXPRESSION
Presenter: Hitomi Eto, MD
Authors: Eto H, Suga H, Kato H, Doi K,
Yoshimura K
University of Tokyo
Background: Although hypertrophic scar (HTS) and keloid
are challenging problems, their pathogenesis has not been
well understood.
Methods: Samples were obtained Irom 9 patients (6 Iemales
and 3 males, age: 17-62) who underwent surgical resection
oI HTSs (including keloid). Real-time PCR was perIormed
to analyze gene expressions oI Iresh tissues (hypertrophic
scar and surrounding normal skin) and cultured fbroblasts
obtained Irom each samples. Therapeutic eIIects oI FGF-2
on HTS-derived fbroblasts and related signaling pathways
were examined using real-time PCR. HTS animal models
were prepared by transplanting human HTS into subcutis oI
nude mice, and therapeutic eIIects oI injection oI control-
released FGF-2 were evaluated by macroscopic examination,
histological analysis, western blotting, and quantifcation oI
collagen contents.
Results: Gene expression oI MMP-1 was lower in HTS tissue
than control skin, while type 1 and 3 collagen and TGF- were
elevated. However, these diIIerences diminished in cultured
fbroblasts Irom both tissues. Administration oI FGF-2
markedly increased gene expressions oI HGF and MMP-1
both in HTS-derived and control fbroblasts. Inhibitors oI
ERK or JNK pathway diminished the upregulation oI HGF
and MMP-1 by FGF-2. In vivo studies indicated that FGF-2
treatment resulted in less weight and less collagen contents
oI HTS tissue. Histologically, FGF-2-treated HTS had less
density oI collagen fbers and the tissue margin became
unclear. By western blotting, we confrmed that FGF-2-treated
HTS showed signifcantly higher MMP-1 protein level than
control.
Discussion: DiIIerences in gene expressions between HTS
and normal skin diminished in cultured fbroblast, suggesting
importance oI in-vivo microenvironmental Iactors in
pathogenesis oI HTS. This study also revealed that decreased
expression oI MMP-1 is an important transcriptional change
in HTS, and its reversal by FGF-2, presumably via both ERK
and JNK signaling pathways, could be a new therapeutic
approach. The eIfcacy oI treatment using control-released
FGF-2 was demonstrated by the in vivo study.
30
43
THE INNOVATIVE ROLE OF SWEAT
GLAND STEM CELLS ON DERMAL
REGENERATION AFTER THERMAL
INJURY
Presenter: Lars H. Evers, MD
Authors: Evers LH, Salem H, Mailaender P
University of California- San Diego
Introduction: Recently glandular derived stem cells had
shown their promising potential as a source oI pluripotent
stem cells as an alternative to embryonic origin. Adult
glandular stem cells derived Irom sweat glands (SGSC) are
able to diIIerentiate into various somatic cell types, such as
skin. Yet, their potential role in skin regeneration especially
aIter thermal injury remains to be elucidated.
Methods: Glandular stem cells Irom human axillary sweat
glands were generated. A burn mouse model was created.
40 mice (nu/nu) received a 20 TBSA partial thickness
dorsal scald burn. Study group (n20) received application
oI PBS and sweat gland stem cells |5x10
5
cells| in the zone
oI stasis in the burn wound, control group (n20) received
application oI PBS. 7 and 14 days (subgroups) aIter injection,
wound areas were harvested and analyzed with respect to
epithelialization, vascularization, apoptosis and wound
closure. In a second approach (n20) sweat gland stem cells
were seeded on a three dimensional Collagen/Elastin-Matrix
as a scaIIold. This scaIIold replaced a Iull thickness burn
wound with close contact to the zone oI stasis.
Results: ProliIeration was tested showing the survival oI the
cells. The healing area and regeneration rate was increased in
the group used the SGSC-seeded wound area. Vascularization
rate showed a signifcant increase in the SGSC-wound area.
Morphology and immunohistochemistry showed new skin-
like structures in the healing wound bed. SGSC were detected
in the regenerated tissues, apoptosis was reduced. In the
second approach, regeneration rate and vascularization were
signifcantly improved in the study group.
Conclusions: This study showed Ior the frst time that sweat
gland stem cells are able to improve the dermal regeneration
aIter thermal injury with or without a scaIIold-matrix. These
results could Iorm a base Ior Iurther clinical applications Ior
devastating burned patients.
44
EVOLUTION OF BREAST
RECONSTRUCTION PARADIGMS
DRIVEN BY INCREASE IN NUMBERS OF
BILATERAL MASTECTOMY
Presenter: LinLin Gao, BS
Authors: Gao LL, Smith BL, Liao EC
Background: We investigated whether the national trend
oI increasing prophylactic bilateral mastectomy cases is
associated with changes in reconstructive approach. Since
breast cancer treatment per annum cost is in excess oI $4-
$6 billion, cost analysis oI prophylactic mastectomy and
reconstructive methods is especially pertinent in the current
health care climate.
Methods: We present a large single-institution case series
that included all cases oI breast cancer surgical treatment. We
examined cases Irom a 10 year period: 1999 - 2004 (period
A), and 2005 -2010 (period B). The patients were identifed
using a clearinghouse database populated by inIormation
Irom electronic medical records. We designed a macro to
automatically cull patient characteristics oI interest, with
100 specifcity and 97 sensitivity. Data was analyzed
using SAS
9.2 Ior statistical signifcance Ior proportions oI

two populations and Chi-square test on the distribution oI
procedures.
Results: Percentage oI patients treated with bilateral
mastectomy doubled in period B and were on average 8 years
younger than those receiving unilateral reconstruction (p
0.001). Bilateral mastectomy patients were more likely to
undergo reconstruction compared to unilateral, in both periods
A and B (p0.001). There was an increase in reconstruction
with AlloDerm and silicone implant during period B
(p0.001). For autologous reconstruction, there was a shiIt to
decrease donor site morbidity Irom period A to B, where there
was a decrease in pedicled TRAM as the DIEP procedure
was introduced in period B and accounted Ior 20 oI all
autologous methods (p0.001).
Conclusions: With increasing cases oI bilateral mastectomy,
new reconstructive procedures were implemented to keep
pace with the demand oI reconstruction, both in terms oI
overall volume, and to decrease donor site morbidity Ior
autologous methods. These signifcant changes in practice
paradigms, both in oncologic treatment and associated
reconstructive methods, need to be Iurther evaluated with cost
analysis to elucidate eIIect on our local and national health
care system.
45
PERFUSION-RELATED COMPLICATIONS
ARE SIMILAR FOR FLAPS HARVESTED
ON MEDIAL OR LATERAL BRANCH
DEEP INFERIOR EPIGASTRIC ARTERY
PERFORATORS
Presenter: Patrick B. Garvey, MD
Authors: Garvey PB, Salavati S, Feng L, Butler CE
The University of Texas MD Anderson Cancer Center
Background: The deep inIerior epigastric artery (DIEA)
medial branch appears to better perIuse tissue across the
midline in comparison to the lateral branch in anatomic
studies. We hypothesize that perIusion-related complications
in unilateral DIEP and MS FTRAM faps will be less when
based on medial compared to lateral branch perIorators.
Methods: OI 2043 consecutive Iree fap breast
reconstructions perIormed over 10 years, we compared
only unilateral DIEP or MS FTRAM faps harvested Irom
a single DIEA branch. Flap harvest patterns were classifed
as hemifaps, zone 3 faps, and total faps. Fat necrosis and
partial fap necrosis was determined by physical examination
on a regimented Iollow-up schedule and radiographic and/
or pathologic confrmation. Unicovariate and multicovariate
regression analyzed the eIIect oI patient and reconstruction
characteristics on outcomes.
Results: We included 228 patients: 120 (52.6) medial and
108 (47.4) lateral branch faps. Mean Iollow-up was 30.1
months. Zone 3 faps (79.8) were most common, Iollowed
by hemifaps (15.4), and total faps (4.8). Overall Iat
necrosis and partial fap necrosis rates were 14.5 and 6.1
respectively. Multi-covariate logistic regression analysis
demonstrated an association between patients with any co-
morbidity and the development oI Iat necrosis (OR2.88,
95 CI Ior OR 1.34-6.15; p0.007) and partial fap necrosis
(OR2.41, 95 CI Ior OR: 1.18-4.95; p0.016) but showed
medial and lateral branch faps to have similar rates oI Iat
necrosis (14.3 vs. 20 respectively; p0.3719) and partial
fap necrosis (7.1 vs. 5.9 respectively; p0.7271). MS
FTRAM and DIEP Iat necrosis (14.5 vs. 18.0; p0.6039)
and partial necrosis (4.4 vs. 7.5; p0.5576) were also
similar.
Conclusions: We Iound perIusion-related complications to
be similar between medial vs. lateral DIEA branch faps in
this largest study to-date comparing these groups. We suggest
surgeons primarily base their decisions regarding DIEA
branch harvest on the perIusion quality oI the perIorators,
without overestimating the theoretic beneft oI medial branch
perIorator harvest.
46
Abstract Withdrawn
32
47
GENE EXPRESSION PATTERNS OF HUMAN
ADIPOSE-DERIVED STROMAL CELLS
CORRELATE WITH FACS SORTING
PARAMETERS FOR PROSPECTIVE
ISOLATION OF SUBPOPULATIONS
Presenter: Jason P. Glotzbach, MD
Authors: Glotzbach JP, Levi B, Januszyk M,
Wong VW, Sorkin M, Chen J, Suga H,
Stanford University
Background: Human adipose-derived stromal cells (hASCs)
have shown tremendous promise Ior tissue engineering
and regenerative medicine applications, but the optimal
prospective isolation strategy Ior these cells is not known.
Using single cell analysis, we have previously characterized
transcriptionally defned heterogeneous subpopulations
within hASCs, but the correlation oI these subpopulations
with sorting parameters must be defned to allow selection oI
hASC subpopulations Ior therapeutic use.
Methods: hASCs were isolated Irom lipoaspirate specimens
using standard techniques. Cells were sorted by FACS using
multiple combinations oI surIace antigen expression profles.
Expression oI 200 gene targets was analyzed by quantitative
RT-PCR within multiple cell aggregates as well as across
individual cells Irom each sorted subpopulation.
Results: Using a novel fdelity score developed Ior this
purpose and defned as overall expression divided by
transcriptional variability, we correlated expression patterns
Ior each subpopulation with the FACS sorting parameters
used Ior isolation. Subpopulation gene expression patterns
clearly correlated with sorting parameters. For example,
the subpopulation defned as CD45- demonstrated a
markedly diIIerent distribution oI fdelity scores as
compared with the CD45-/CD31-/CD34 population. These
distributions demonstrate increasing homogeneity within
each subpopulation, which would be expected based on
the increasingly stringent sorting parameters. We observed
consistently higher fdelity oI expression with increasingly
stringent sorting strategies, suggesting that each subpopulation
can be defned by their transcriptional signatures in addition to
surIace antigen expression.
Conclusions: By correlating transcriptionally defned hASC
subpopulations with sorting parameters Ior prospective
isolation, selection oI hASCs targeted Ior specifc tissue
engineering applications will be Ieasible. Using this method,
diIIerent hASC isolation strategies can be systematically
tested Ior correlation with transcriptional signatures and
screen Ior potential use in specifc tissue engineering
application.
48
NEGATIVE PRESSURE WOUND THERAPY
FOR AT RISK SURGICAL CLOSURES:
A PROSPECTIVE RANDOMIZED
CONTROLLED TRIAL
Presenter: Jesse Goldstein, MD
Authors: Goldstein J, Masden D, Endara M, Xu K,
Steinberg J, Attinger C
Georgetown University
Background: Few options exist to aid healing Iollowing
surgical closure in at risk patients. Recently the use oI
negative pressure wound therapy (NPWT) on surgical
incisions has been proposed. We perIormed a prospective
randomized controlled trial comparing NPWT to standard dry
dressings on surgical incisions.
Methods: All participants undergoing primary wound closure
at a busy reIerral center were randomized to either NPWT
or a dry occlusive dressing over their incision at the end oI
surgery. All dressings were removed at post-op day 3 and
evaluated routinely in clinic. Endpoints included post-op
inIection, wound dehiscence and reoperation. Multivariate
regression and Kalpan-Meyer analyses were perIormed.
Results: 43 patients were randomized to receive dry dressings
and 50 to NPWT (N 93). Average Iollow up time was
133 days. The majority oI closures occurred in the lower
extremities with the lower leg the most common (54),
Iollowed by Ioot (18), thigh (17) and trunk (11). There
were no signifcant diIIerences between the two groups with
regards to pre-op co-morbidities or operative details. 6.8 oI
the NPWT group and 13.5 oI the control group developed
wound inIections (p0.46). There was no diIIerence in time
to develop inIection between the groups. For patients who
developed inIection, Ioot wounds occured earliest (17 days),
Iollowed by leg (29 days), and trunk (65 days) (p0.01).
There was no signifcant diIIerence in the incidence oI
dehiscence between the NPWT and control group (36.4 vs.
29.7; p0.54). Mean time to dehiscence was 33 days Ior
NPWT and 60 days Ior controls, but this was not signifcant
(p0.45). Similar to post-op inIection, Ioot wounds dehisced
earliest (22 days), Iollowed by leg (33 days) and trunk wounds
(66 days) (p0.0001). Overall, 35 oI the control group and
40 oI the NPWT group had a wound inIection, dehiscence
or both. OI these, 9 in the NPWT group (21) and 8 in the
control group (22) required reoperation.
Conclusions: There is no observable beneft to NPWT with
regard to inIection or dehiscence when applied to at risk
surgical closures.
49
THE HOST IMMUNE RESPONSE FAILS
TO PREVENT KLEBSIELLA PNEUMONIAE
FROM RAPIDLY FORMING BIOFILM IN
THE RABBIT DERMAL ULCER WOUND
MODEL
Presenter: Anandev N. Gurjala, MD, MS
Authors: Gurjala AN, Geringer M, Galiano RD,
Mustoe TA, Leung KP
Northwestern University
Objective: The establishment oI bacterial bioflm in wounds
is a key event: once bioflm is present, it is extremely diIfcult
to eliminate, and proven to impair wound healing leading to
the development oI chronic wounds. The objective oI this
study was to determine how many bacteria it takes to establish
bioflm in wounds.
Methods: Full thickness dermal punch wounds were created
in the ears oI New Zealand white rabbits, and inoculated with
increasing concentrations oI planktonic Klebsiella pneumonia
bacteria, ranging Irom 10
2
through 10
7
bacteria per wound. It
was hypothesized that lower bacterial concentrations would
be eliminated by host deIenses, and that higher bacterial
concentrations would overcome the host immune response.
Results: Imaging oI the wound surIace by electron
microscopy, quantifcation oI bacterial number by viability
counts and qPCR, and analysis oI neutrophil counts, however,
yielded opposite than expected results. By 96 hours post
inoculation, even the lowest 10
2
concentration oI bacteria had
proliIerated to a level oI 10
7
CFU/ml per wound, Iorming
Iully mature bioflm. Higher inocula, however, proliIerated
only minimally, peaking at between 10
7
and 10
8
CFU/ml.
Neutrophil response was minimal to lower inocula, increasing
in accord with bacterial proliIeration, but ultimately proving
inadequate to eliminate the inIection. Neutrophil response
to higher inocula on the other hand was more rapid, and
appeared to limit proliIeration to a ceiling oI 10
8
. Repetition
oI these experiments in a compromised ischemic rabbit model
yielded a higher bacterial ceiling oI 10
9
CFU/ml per wound.
Conclusions: These results provide new insight into the
interaction between host and bacteria, demonstrating a
surprising ease with which even extremely low numbers oI
bacteria can rapidly establish bioflm in wounds, and that
although unable to eliminate bioflm Iormation, the host
response is able to contain it. These fndings challenge the
conventional 10
5
paradigm, and Iurther support the clinical
signifcance oI bioflms in the pathogenesis oI chronic
wounds.
50
FGF TOGETHER WITH COLLAGEN
CARRIER FOR CALVARIAL DEFECT
REPAIR
Presenter: Bo Han, PhD
Authors: Han B, Zhi Y, Nimni M, Urata M
University of Southern California
Background: Bone deIects repair remains a major concern in
reconstructive surgery. Many growth Iactors and their scaIIold
have been attempted to solve the problem. Acidic fbroblast
growth Iactors FGF-1 is known to promote cell growth and
diIIerentiation. It can stimulate the proliIeration oI osteogenic
cells and chondrocytes, and also promote angiogenesis.
Methods: Rat calvarial deIect model was used to evaluate the
healing oI experimental bone deIects using porous collagen
scaIIolds and FGF-1. A 8-mm diameter critical size deIect
(CSD) was made in the calvarial bone oI each 24 rat. The
animals were divided into Iour treatment groups: 1) scaIIold
only; 2) scaIIold with 0.1ug oI FGF-1; 3) scaIIold with 1.0
ug oI FGF-1; 4) scaIIold with 1.0 ug oI FGF-1. Each test
article was placed in calvarial deIect created on the plate oI
parietal bone with a specially designed drill bit. Incisions
were closed with surgical staple. Post-operatively, animals
were observed daily Ior general health. All animals were
euthanized at 28 days. Harvested tissues were fxed in neutral
buIIered Iormalin. SoIt x-ray radiography and microCT
analysis were perIormed on the fxed explants. Samples
were then decalcifed and processed Ior histological analysis.
New bone Iormation was measured radiologically and
histomorphologically.
Results: Among all test groups, the strongest bone Iormation
was observed collagen with 1.0g FGF-1. New bone Iormation
in scaIIold alone, 0.1ug FGF, and 10 ug FGF groups also
showed moderate new bone Iormation.
Conclusions: In conclusion, osteoconductive collagen
scaIIold together with mitogenic and angiogenic Iactor FGF
enhanced calvarial bone repair. However, control the release
and dose oI growth Iactor appears to be critical Ior tissue
repair and regeneration application.
34
51
IMMUNOMODULATORY PROPERTIES OF
A NOVEL MESENCHYMAL STEM CELL -
HYDROGEL SCAFFOLD
Presenter: Summer E. Hanson, MD, MS
Authors: Hanson SE, King SN, Kim J, Thibeault SL,
Hematti P
University of Wisconsin School of Medicine and Public Health
Background: During the past several years, mesenchymal
stromal/stem cells (MSCs) have rapidly moved Irom in
vitro and animal studies into clinical trials as a therapeutic
modality potentially applicable to a wide range oI disorders.
It has been proposed that ex vivo culture expanded MSCs
have immunomodulatory properties that may play a role
in the physiologic infammatory response oI their resident
tissue, in addition to the ability to diIIerentiate into multiple
tissue lineages. Since MSCs play a signifcant part in
matrix deposition and tissue support through their many
physiological roles, there is increasing interest in their
potential use Ior adipose tissue engineering, particularly in
conjunction with extracellular matrix-based scaIIolds such as
hyaluronic acid (HA).
Methods: Given the potential reparative and infammatory
roles oI MSCs and macrophages in wound healing, our
group compared the eIIect oI MSCs on monocyte-derived
macrophages in the presence oI an HA hydrogel scaIIold. We
used a unique 3D co-culture system with MSCs encapsulated
in the hydrogel and peripheral blood mononuclear cells plated
in direct contact with the MSC-gel construct to investigate
the immunophenotype oI macrophages vital to tissue healing.
In particular, we looked at the expression oI surIace markers
associated with an alternatively activated or anti-infammatory
macrophage including CD14, CD16, CD206, and HLA-DR.
Results: Both MSCs and macrophages cultured on the
HA-hydrogel were viable and able to be recovered Irom the
construct. There was a signifcant diIIerence in the phenotype
observed between macrophages cultured on the HA scaIIold
compared to tissue culture polystyrene (p0.01). Macrophages
cultured on gels with MSCs expressed lower CD 16 and
HLA-DR with higher expression oI CD206, indicating the
least infammatory profle overall. Furthermore, there was no
change in the expression oI standard mesenchymal surIace
markers on MSCs cultured in the presence oI the biomaterial.
Conclusion: We show a unique immunophenotype oI an
alternatively macrophage when cultured with an MSC-
hydrogel construct which may have a potentially signifcant
role in tissue repair.
52
COST COMPARISON OF OPEN
FASCIECTOMY VERSUS PERCUTANEOUS
NEEDLE APONEUROTOMY FOR
TREATMENT OF DUPUYTRENS
CONTRACTURE
Presenter: Fernando A. Herrera, Jr, MD
Authors: Herrera FA, Suliman A, Benhaim P,
Meals R, Mitchell S
Purpose: Dupuytren`s disease is a result oI thickening oI the
palmar Iascia resulting in cords, nodules and contractures oI
the fngers and joints. Standard surgical treatment consists
oI open Iasciectomy oI the involved cords. This results in
large incisions in the hand and a relatively long recovery
process. The less invasive Needle Aponeurotomy technique
was devised to correct the contractures by dividing the
cords within the hand while avoiding the large incisions and
extensive recovery and rehabilitation required with traditional
surgery. This purpose oI this study is to compare the cost
oI each surgery and compare immediate outcomes to one
another.
Materials and Methods: Retrospective chart review was
perIormed identiIying all patients receiving open Iasciectomy
Ior primary treatment oI symptomatic Dupuytren`s contracture
at a single institution Irom 2008-2010 (Group 1). A matched
cohort group treated with Percutaneous Needle Aponeurotomy
Ior Dupuytren`s contracture during the same time period
was selected (Group 2). Using ICD-9 codes, fnancial, and
medical records were reviewed and, age, pattern oI disease,
improved at the time oI surgery, immediate complications,
and the cost oI the procedures were identifed and compared
among the 2 groups. Statistical analysis was perIormed using
paired t-test.
Results: Twenty-Iour patients ft the inclusion criteria Ior the
open Iasciectomy group. Mean age was 60 years Ior Group
1 (36 to 80). Twenty-two were male, the remainder were
Iemale. Mean percent improved postoperatively was 100 at
the MP, and 94 at the PIP. Mean age was 65 years Ior Group
2 (41 to 79). Twenty-one were male. Mean percent improved
postoperatively was 100 at the MP, and 96 at the PIP.
There were 2 complication in Group 1 (wound dehiscence,
nerve injury), and no complications in Group 2. Mean cost Ior
Group 1 was $11,240, mean cost Ior Group 2 was $4,657. The
diIIerence in cost between groups was statistically signifcant
(P 0.001).
Conclusion: The use oI percutaneous needle aponeurotomy is
not only less invasive but is signifcantly decreased in overall
cost.
53
OUTCOMES OF TISSUE EXPANDER
BREAST RECONSTRUCTION IN
PATIENTS WITH PRE-RECONSTRUCTION
RADIATION
Presenter: Elliot M. Hirsch, MD
Authors: Hirsch EM, Seth AK, Kim JY,
Dumanian GA, Mustoe TA, Fine NA
Northwestern Memorial Hospital
Background: Although the eIIects oI post- breast
reconstruction radiation are well known, the eIIects oI
pre-reconstruction radiation on tissue expander breast
reconstruction are not well documented in the literature. This
study evaluates the complication rates Ior immediate (ITER)
and delayed (DTER) tissue expander breast reconstruction in
women with pre-reconstruction radiation.
Methods: The charts oI 48 patients who previously underwent
lumpectomy/radiation later Iollowed by completion
mastectomy/ITER or mastectomy/radiation with DTER Irom
August 1999 - July 2008 were retrospectively reviewed. Only
patients with acceptable skin appearance aIter radiation were
oIIered expander reconstruction. Average Iollow-up was 47
months. Complications that occurred in non-radiated breasts
and complications unrelated to radiation were excluded.
Fisher`s exact test and student`s t-test were used Ior statistical
analysis.
Results: Forty-two patients underwent primary ITER,
with 30 patients completing secondary expander to implant
exchange. The overall ITER complication rate was 79,
with an explantation/conversion to fap rate oI 38. Six
patients underwent DTER, and all completed secondary
expander to implant exchange. The DTER explantation/
conversion to fap rate and overall complication rate were
both 17. This diIIerence in complications between the two
groups was statistically signifcant (p0.05). No diIIerence
in complication rates was observed based on age, smoking
status, BMI, or timing between radiation and surgery
(p~0.05).
Conclusions: The eIIects oI radiation may not be apparent
prior to immediate reconstruction, which may allow patients
to undergo tissue expander breast reconstruction who would
not otherwise be eligible. This explains the signifcantly
higher complication rate among ITER patients. Approximately
40 oI these patients undergo explantation/conversion to
fap, which is similar to established data Ior post-mastectomy
radiation and prosthetic reconstruction. As evidenced by the
DTER group, the procedure can be perIormed with a low
complication rate in patients without adverse responses to
radiation.
54
A SYSTEMATIC REVIEW AND META-
ANALYSIS OF COMPLICATIONS
ASSOCIATED WITH ADM-ASSISTED
BREAST RECONSTRUCTION
Presenter: Goretti Ho, MD
Authors: Ho G, Shahabi A, Nguyen TJ, Hwang BH,
Chan LS, Wong AK
Keck School of Medicine of the University of Southern
California
Background: The use oI acellular dermal matrix (ADM) has
increased in implant-based breast reconstruction. Multiple
published studies evaluate the outcomes oI its use in breast
reconstruction with no consensus on the rate oI associated
complications. The purpose oI this study is to conduct a
systematic review to address the rate oI complications with
the use oI ADM by pooling power Irom all oI the available
studies to date.
Methods: The initial keyword-generated literature search
on English-language articles using MEDLINE and a manual
search up to July 2010 yielded 61 citations. Two levels oI
screening identifed 17 relevant studies. Seven outcome
rates were analyzed. Six studies with both ADM and non-
ADM treatment groups were used Ior the meta-analysis. A
random eIIects model with 95 confdence intervals was
used to evaluate statistical heterogeneity among the studies.
Heterogeneity was measured using the I2 statistic, and Ior
analyses with high inter-group heterogeneity, a sensitivity
analysis was done to evaluate a more homogenous group.
Results: Six studies reporting both the ADM and non-ADM
outcomes were used in the meta-analysis to calculate the
estimated pooled odds ratio oI the Iollowing complications:
seroma, cellulitis, inIection, hematoma, skin fap necrosis, and
reconstructive Iailure. ADM-assisted breast reconstructions
were Iound to be 3.7 times as likely to experience a seroma;
twice as likely to be complicated by cellulitis and hematoma;
and 3.5 times as likely to become inIected. Additionally,
ADM-assisted reconstructions were 4.3 times more likely to
result in reconstructive Iailure. Seventeen studies reporting
ADM-assisted breast reconstruction outcomes were used
to estimate pooled complication rates. The results Ior the
complications are as Iollows: seroma, 6.9; cellulitis 2.1;
inIection 5.65; skin fap necrosis 10.9; hematoma 1.34;
capsular contracture 0.58.
Conclusion: This analysis suggests that ADM-assisted breast
reconstructions exhibit a higher rate oI complications when
compared to traditional musculoIascial faps.
36
55
DO MEDICAL STUDENTS OBTAIN AN
APPRECIATION FOR THE SCOPE OF
PLASTIC SURGERY? THE UNIVERSITY OF
UTAH EXPERIENCE
Presenter: Linh A. Ho, BS
Authors: Ho LA, Mendenhall SD, Hopkins PN,
Agarwal CA, Agarwal JP
University of Utah School of Medicine
Background: The versatile nature oI plastic surgery can cause
conIusion as to what is encompassed by this broad specialty.
Medical education serves to guide career choices and begins
to build a Iramework Ior appropriate reIerral patterns.
The degree to which students gain an appreciation Ior the
breadth oI plastic surgery Irom their education is unknown.
The purpose oI this study was to objectively measure this
understanding.
Methods: Medical students at the University oI Utah were
given an online survey consisting oI 24 clinical scenarios
with the task oI selecting one or more appropriate surgical
subspecialties to manage the problems listed. Additionally,
students indicated their level oI training and whether they
had prior clinical exposure to plastic surgery or other surgical
subspecialties. Data was analyzed using chi-square and
multiple logistic regression.
Results: 230 oI 408 students responded to the survey (57, 60,
62, and 51 Ior class years 1-4 respectively). While students
generally chose at least one acceptable surgical specialty Ior
reIerral (90 oI the time), plastic surgery was only selected in
54 oI the scenarios. This did not improve over the 4 years oI
medical school (p0.31), but signifcantly improved with prior
exposure to plastic surgery in the Iorm oI a clinical rotation
or shadowing experience (p0.0001). Areas oI relatively
poor association with plastic surgery (50) included hand
injuries, mandible Iractures, skull deIormities, deviated
septum, and pressure sores.
Conclusion: This study indicates a need Ior improvement oI
medical education in a way that would increase exposure to
the feld oI plastic surgery. Early appreciation Ior this diverse
specialty could potentially infuence career choices and
increase reIerrals to plastic surgeons Irom Iuture physicians.
56
ALTERING THE GLIAL SCAR
FIBRONECTIN MATRIX TO PROMOTE
REGENERATIVE HEALING
Presenter: Henry C. Hsia, MD, FACS
Authors: Hsia HC, Zheng HH, Corbett SA
Princeton University/Robert Wood Johnson Medical School
Introduction: Following spinal cord injury (SCI), a dense
connective tissue matrix comprised oI fbronectin (FN)
flls the injury site. Cells secrete FN as a disulfde-bonded
dimer that binds to the +5 1 integrin receptor. Integrin-FN
interactions allow unIolding oI the soluble protein and its
assembly into a detergent-insoluble fbrillar matrix that
serves as the template Ior the deposition and assembly oI
other fbrillar proteins, including collagen. In this Iashion,
the dysregulation oI FN assembly could increase the fbrous
scarring that is a major impediment to neuronal regeneration
Iollowing SCI. ThereIore, an understanding oI both the
cellular mechanics oI FN fbril Iormation and its regulation
in astrocytes Iollowing injury could contribute to therapeutic
strategies designed to modulate scar Iormation and promote
regeneration.
Methods: Human astrocytes were cultured on 3-D collagen
matrices to recapitulate the in vivo quiescent state. To induce
an activated state, astrocytes were treated with TGF-? and
expression oI vimentin and GFAP, markers associated with
the activated injury phenotype in vivo, were detected by
immunoblotting oI cell lysates. In parallel experiments, FN
was added to TGF-? treated and control cells to determine
the eIIect on +5 1 receptor recycling via an integrin
internalization assay using surIace-labeled biotin.
Results: Astrocytes cultured on collagen gel in the absence
oI TGF-? express FN but do not incorporate it into a matrix.
When astrocytes are activated, there is a dramatic increase in
matrix assembly. In the absence oI FN and TGF-? treatment,
degradation oI +5 1 receptor was observed, which was
abrogated in the presence oI FN or aIter TGF-? treatment.
Conclusion: Activation oI an injury state in astrocytes via
TGF-? results in altered ability to assemble a FN matrix.
Internalization oI +5 1, involved in matrix assembly,
depends on activation but can also be altered by FN
alone. Modifcation oI the local microenvironment alters
astrocyte ability to produce scar matrix, which has important
implications Ior developing treatments to promote neuronal
regeneration aIter injury.
57
PROTOCOL MANAGEMENT OF LATE
STAGE PRESSURE ULCERS: A 5-YEAR
RETROSPECTIVE STUDY OF 101
CONSECUTIVE PATIENTS WITH 179
ULCERS
Presenter: Kristen A. Hudak, MD
Authors: Hudak KA, Simonelic K, Larson DL
Medical College of Wisconsin
Purpose: Pressure ulcers aIIect over a million adults, costing
up to $40,000 per episode. Despite recurrence rates oI 12
to 82, no standard protocol exists. While some require
adequate preoperative nutrition, others propose a two-stage
process oI debridement, intravenous antibiotics, Iollowed
by reconstruction. Our institution has a single surgeon and
standard protocol: surgery and immediate reconstruction
regardless oI nutrition, intra-operative bone culture to guide
postoperative antibiotic use, and hospital admission Ior 3
weeks fat bed rest prior to a graduated sitting schedule.
Methods: A fve-year retrospective chart review was
perIormed on consecutive surgically treated pressure ulcers.
A search oI billing records by CPT identifed 101 patients
with 179 ulcers. Data abstracted included demographics,
co-morbidities, location and stage oI ulcers, treatment history
with outcomes and laboratory data.
Results: Patients were 79 male, 70 white, 34 smokers
with a mean age oI 49.4 years. OI the 179 ulcers, 49.7 were
ischial, 26.8 sacral, and 19 trochanteric. 87.7 oI ulcers
were stage 4. Primary closure was perIormed on 45.8 with
the remainder receiving fap closure. There was no correlation
between positive bone cultures and recurrence (p0.93).
Overall recurrence rate was 16.8 with mean recurrence at
435.9 days. New ulcer occurrence was 14.5. Complication
rate was 17.3, with suture-line dehiscence most common.
There was an increase in prealbumin and albumin Irom
admission to discharge (p0.0001). The admission prealbumin
(p0.2) and albumin (p0.43) did not correlate with
recurrence. The mean Iollow-up was 629 days.
Conclusion: The use oI a standard clinical pathway Ior
pressure ulcer treatment improves long-term outcomes and
the validity oI our protocol is supported by low recurrence
and complication rates. Contrary to traditional belieIs,
nutritional data does not predict outcome; with defnitive
closure increasing nutritional markers signifcantly. Intra-
operative bone cultures are the most valid method to diagnose
osteomyelitis; results should not delay defnitive treatment.
58
ACCELERATED PORCINE WOUND
HEALING AFTER TREATMENT WITH
ALPHA-GAL NANOPARTICLES
Presenter: Zachary M. Hurwitz, MD
Authors: Hurwitz ZM, Ignotz R, Lalikos JF, Galili U
University of Massachusetts Medical School
Introduction: Anti-Gal is the most abundant antibody
in humans, constituting ~1 oI immunoglobulins. The
-gal glycolipid, while absent in humans, is present in
most other mammals. Anti-Gal/-gal interaction activates
complement and induces rapid recruitment oI macrophages.
We hypothesize that early recruitment and activation oI
macrophages in acute wounds will accelerate healing.
Methods: EIfcacy oI a-gal nanoparticle treatment was
studied in 1,3 galactosyltrasIerase knockout pigs. Like
humans, these pigs lack -gal epitopes and produce anti-Gal
antibodies. -gal nanoparticles were created, comprised oI
phospholipids, cholesterol and ~10
15
/mg -gal glycolipid
epitopes (GalA1-3Gal1-4GlcNAc-R). When bound by anti-
Gal, these epitopes stimulate macrophages. Full-thickness
wounds (20x20mm) with tattooed borders were created on the
back oI pigs. Dressings impregnated with 10mg or 100 mg/
mL oI -gal nanoparticles or with saline (control) were used.
Wound surIace area was measured every 3-4 days during
dressing changes and compared with control using a paired
T-test. Upon harvest, each wound was sectioned and examined
by H&E microscopy.
Results: Epidermal regeneration was Iaster in wounds treated
with -gal nanoparticles than in controls. On histology, treated
wounds displayed many more macrophages and increased
angiogenesis than control wounds in the same pig. On day
10 (n8), the mean control wound measured 73.3 mm
2
while
10mg and 100mg treated wounds had means oI 47mm
2
(p
0.039) and 31.7mm
2
(p 0.0009), respectively. On day 13
(n5), the mean control wound was 23mm
2
while 10mg and
100mg treated wounds had means oI 5.4mm
2
(p 0.027) and
2.3mm
2
(p 0.001), respectively.
Conclusion: -gal nanoparticle treatment oI acute wounds
increases early local macrophage action and is associated
with accelerated angiogenesis and wound-healing in pigs
that lack -gal. As humans lack -gal and express high titers
oI anti-Gal antibodies, this treatment may exhibit a similar
eIIect in the clinical setting. Future studies will examine the
specifc eIIects oI -gal immunomodulation in this model and
potentially on chronic wounds.
38
59
A 3D MORPHOMETRICAL EVALUATION
OF THE EXACT EFFECTS OF BOTULINUM
TOXIN ON THE PERIORBITAL
STRUCTURES.
Presenter: Niklas Iblher, MD
Authors: Iblher N, Stark BG
University Medical Center Freiburg
Introduction: Botulinum toxin injections Ior wrinkle
reduction is one oI the most popular aesthetic procedures
perIormed today and has been savely applied in a vast amount
oI cases all over the world. Yet the exact eIIects on the
periorbital structures in general and the brow and lid positions
and movement are only scarcely scrutinized in a reproducible
systematic manner.
Material and Methods: In a prospective trial 30 Iemale
patients were treated with botulinum toxin type A Ior either
only the glabella region (15 patients) or the glabella region
and Irontalis muscle (15 patients). The applied injection
technique was based on a standardized 5 point scheme Ior the
glabella and a 6 point scheme Ior Irontalis muscle. Besides
regular photo documentation 3D morphometrical scanning
with a mobile 3D surIace scanner (Artec) was perIormed. The
documentation was perIormed pre-injection, aIter 2 weeks, 3
months, 6 months and 9 months. From the 3D scans natural-
sized 3D models including the surIace structure and the photo-
texture were rendered. In these models the exact position and
curvature oI the brow and the eyelid dimension and position
was measured.
Results: For the frst time realistic, geodesic 3D-surIace
measurements can be presented to show not only the exact
eIIects on the periorbital structures and brow position but also
the diIIerence between treatments oI only the glabella and oI
combined treatment oI the glabella and the Irontalis muscle.
The exact intraindividual changes over the course oI time
until total resolution oI muscle paralysis are presented.
60
TRANSIENT RECEPTOR POTENTIALS IN
HUMAN HYPERTROPHIC SCAR
Presenter: Hisako Ishise, MD
Authors: Ishise H, Kawai K, Fujiwara T,
Nishimoto S, Kakibuchi M
Hyogo College of Medicine
Introduction: Hypertrophic scarring represents an
amplifcation oI the wound healing process that results in
overdeposition oI collagen. This process tends to occur in
areas undergoing repetitive mechanical stretch stimulations,
such as the elbows and knees. Interestingly, hypertrophic
scarring is considered unique to humans. However, the link
between mechanical stretch and collagen deposition is still
unknown. Calcium is an intracellular signaling molecule
that plays an important role in the wound healing process.
Calcium infux into cells is mediated by calcium channels,
and it is thought that mechanical stretch Iorces lead to an
up-regulation oI calcium channels. In the present study, we
investigated an ion channel group called Transient-Receptor-
Potential (TRP), which has been associated with hypertrophic
cardiomyopathy. The TRP superIamily is subcategorized into
Iour groups: TRPC, TRPV, TRPM and PKD. We analyzed the
gene expression levels oI each oI these homologues in both
hypertrophic and normal scarring.
Methods: Both hypertrophic and normal scar samples were
collected Irom human subjects and the gene expression
level oI each TRP homologue was examined using RT-PCR.
Additionally, linear wounds were created on the dorsum oI
mice and the skin was mechanically stretched by excising
ventral skin and suturing the wound edges together. The
resulting scars on the dorsum were harvested and the gene
expression levels oI the TRP homologues were analyzed using
RT-PCR.
Results: In humans, the gene expression level oI the TRPC5
homologue was elevated in hypertrophic scars relative to
normal scars. In mice, mechanically stretched scars did not
show elevated levels oI the TRPC5 homologue.
Conclusion: In humans, hypertrophic scarring is mediated
by increased levels oI the TRPC5 homologue. Blocking
calcium infux through this ion channel could potentially
modulate wound healing in a Iavorable way. Investigating the
mechanisms underlying TRPC5 expression in both human and
animal models could provide valuable insight into the process
oI hypertrophic scarring and highlight potential therapeutic
approaches.
61
EXOGENOUS RHBMP-7 INCREASES
EXPRESSION OF ENDOGENOUS
INHIBITORS DURING DISTRACTION
OSTEOGENESIS: AN ALTERNATIVE
PATHWAY TO ACCELERATE BONE
FORMATION
Presenter: Ali Izadpanah, MD
Authors: Izadpanah A, Alsalmi L, Hamdy RC,
Lessard ML
McGill University
Introduction: Distraction osteogenesis (DO) is a common
technique Ior bone lengthening. We had previously shown
that exogenous rhBMP-7 during DO in wild type mice leads
to an up-regulation oI osteogenesis at medium dose oI 4g/kg
and a down-regulation at higher doses at mid-consolidation.
However, there are no studies investigating the fnal eIIect oI
exogenous rhBMP-7 at the end oI consolidation.
Purpose: We sought to determine the eIIect oI rhBMP-7
during DO at the end oI consolidation and to Iurther identiIy
the possible mechanisms oI such eIIects.
Materials and Methods: DO was applied to the right
tibia oI 52 adult wild type mice. Distractions began aIter a
latency period oI 5 days at a rate oI 0.2 mm/12h Ior 2 weeks.
On the frst day oI distraction, animals were injected with
rhBMP-7 at Iour diIIerent doses oI 0 g/kg (controls), 2g/
kg, 4g/kg and 20g/kg. Animals were sacrifced at day
51 (end oI consolidation). Specimens were examined using
radiology, micro-CT, static histomorphometry, histology, and
immunohistochemistry.
Results: There was a gradual statistically signifcant
decrease in osteogenic eIIect oI rhBMP-7 at higher doses
Ior both amount and quality oI bone Iormed (13.69+8.92N,
13.12+4.17N, and 8.82+5.94N Ior ultimate Iorce and
20.37+8.26, 18.04+8.73, and 12.47+7.95 Ior BV/
TV Ior 2g/kg, 4g/kg and 20g/kg respectively).
Immunohistochemical analysis showed a parallel increase in
expression oI endogenous inhibitors (Noggin, and Chordin)
and other endogenous osteogenic BMPs.
Conclusion: High doses oI rhBMP-7 had an inhibitory eIIect
on DO with the greatest fnal eIIect to be seen at the lowest
administered dose oI 2g/kg at the end oI consolidation.
Observed eIIects were diIIerent than our previously seen
osteogenic eIIect oI medium dose (4g/kg) to be the utmost
at day 34 (mid-consolidation). Our immunohistochemical
analysis demonstrates a plausible explanation; upon
increasing administered doses oI exogenous rhBMP-7, there
is an upregulation oI endogenous inhibitors (Noggin and
Chordin) and a possible competitive inhibition oI common
receptors Ior other endogenous BMPs such as BMPs-2, and 4.
62
AUTOMATED DETECTION OF WOUND
AREA IN A STENTED EXCISIONAL MODEL
OF MURINE WOUND HEALING
Presenter: Michael Januszyk, MD
Authors: Januszyk M, Rustad KC, Major MR,
Wong VW, Glotzbach JP, Gurtner GC
Stanford University
Introduction: Gross wound closure represents the single most
ubiquitous endpoint Ior clinical and preclinical investigations;
however, considerable variation among observer
measurements Irequently leads to poor precision and reduced
statistical power. To address this issue, we have developed an
automated computer method to detect and quantiIy regions oI
wound pathology, using a murine model oI wound healing.
Methods: Twenty-fve mice (C57BL/6) were subjected to a
stented excisional model oI wound healing developed by our,
and evaluated at regular intervals using digital photography.
In total, 350 images were collected in our database, each
independently converted to 8-bit vectors in both RGB
and HSV space. Linear discriminant analysis (LDA) was
employed to develop an image flter Ior initial registration
oI each stented ring, which was used to circumscribe the
wound mask. Each mask was then automatically divided into
an array oI 16x16-pixel regions oI interest (ROIs), which
were designated as either 'wound or 'no wound based on
the degree oI overlap with the 'gold standard wound area
as manually outlined by a senior plastic surgeon. A set oI 21
gray-level-histogram-based an texture-based Ieatures was
computed in each ROI. A two-layer neural network (NN)
with a sigmoid neural transIer Iunction was used to partition
the Ieatures space to distinguish between 'change and 'no
change ROIs. We randomly assigned 75 oI the images
to the 'training set and used the remaining 25 to test the
method.
Results: Step-wise Ieature selection was used to identiIy a
subset oI 13 Ieatures, which were merged through the NN
to partition the ROIs into two groups. The perIormance was
evaluated by receiver operating characteristic (ROC) analysis.
When applied to the training set, the method achieved a
sensitivity oI 97 at a specifcity oI 98.3, with an area
under the ROC curve oI 0.99. The trained neural network
was then applied to the test set, and achieved an average
diIIerence in wound area oI 2.3, representing a signifcant
improvement over that oI blinded surgical residents markings
wound boundaries under otherwise identical conditions.
40
63
HYDROGEN SULFIDE PROTECTS AGAINST
IRI THROUGH THE JAK-STAT PATHWAY IN
AN IN VIVO MODEL OF IRI
Presenter: Natalia Jimenez, BA
Authors: Jimenez N, ReiIIel AJ, Henderson PW,
Millet YH, Chu S, Spector JA
Weill Cornell Medical College
Introduction: Hydrogen sulfde (HS) has been shown to
conIer protection against ischemia-reperIusion injury (IRI)
in various in vitro and in vivo models. Although our lab has
previously shown that HS administration results in activation
oI the JAK-STAT (stress response) pathway in murine
myotubes, we sought to validate these fndings in an in vivo
model oI muscle IRI.
Methods: 24 C57/BL6 mice were treated with IV saline or a
dose oI HS suIfcient to raise the blood stream concentration
by 10uM. AIter 20 min, mice underwent 3h oI unilateral
tourniquet-induced hindlimb ischemia. Animals were
sacrifced aIter 30s, 5, 15, and 30 min oI reperIusion, the
gastrocnemius muscles were harvested bilaterally, and protein
extracted Ior western analysis. Additionally, 12 C57/BL6 mice
received a 40g/g IP dose oI AG490 (a JAK2 inhibitor), 10uM
HS, AG490HS, or saline. AIter 3h oI hindlimb ischemia and
3h oI reperIusion, muscle was harvested and a TUNEL assay
perIormed.
Results: There is a 2-Iold increase in STAT1 and 3
phosphorylation in HS-treated mice within 30s oI reperIusion
which does not return to baseline levels by 30 min. There
was no change in STAT phosphorylation in non-HS treated
ischemic and all non-ischemic tissue. With JAK2 inhibition,
the apoptotic index (AI) oI AG490-treated and non-treated
ischemic mice were similar (13.4 1.7 v.11.4 2.0,
p0.34), while mice treated with HS alone demonstrated a
signifcantly lower AI (5.1 1.6) compared to the non-
treated ischemic controls (p0.02). Finally, the AI oI mice
treated with AG490HS was 13.3 2.2, signifcantly
greater than that oI mice treated with HS alone (p0.001), and
unchanged Irom non-treated ischemic controls (p0.53).
Conclusion: HS activates the JAK-STAT pathway in the
setting oI IRI. Furthermore, inhibition oI JAK-STAT abolishes
the protective eIIect oI HS, thereby confrming that HS
conIers protection, at least in part, via this pathway. These
data provide Iurther crucial insight into understanding the
mechanisms by which HS provides protection and may serve
to Iacilitate Iuture implementation oI HS as a pharmacological
agent Ior the mitigation oI IRI.
64
PERI-OPERATIVE CORTICOSTEROID USE
IN TRAM FLAP DECREASES LENGTH OF
HOSPITAL STAY
Presenter: XiLin Jing, MD
Authors: Jing XL, Houin H, Siddiqui A
Henry Ford Hospital
Objective: Breast cancer is the most common site-specifc
cancer and a leading cause oI death Ior women. Breast
reconstruction oIIers quicker recovery and improved
selI-image. The pedicled transverse rectus abdominis
musculocutaneous (pTRAM) fap is the workhorse oI
autologous option Ior many plastic surgeons. Post-operative
recovery parameters include healing and return to normal
activities. Pain impacts a patient`s ability to avoid various
peri-operative complications and resume activities oI daily
living. Post-surgical swelling and infammatory response
also negatively impact recovery. The use oI steroid has been
studied in neurosurgery, otolaryngology and cranioIacial
surgery to mitigate these eIIects. The utility oI peri-operative
steroids in pTRAM surgery remains an area oI debate.This
study is a retrospective review oI our experience with peri-
operative corticosteroid use in TRAM fap patients.
Methods: A retrospective review was conducted oI patients
who had undergone breast reconstruction with pedicled
pTRAM faps between 2005 and 2009. Demographic data,
length oI hospital stay, and complication rate were complied.
The results oI six surgeons were included. All patients were
Iollowed Ior at least 18 months.
Results: Our study had a cohort oI 117 patients: control
group included 81 pTRAM fap patients. Steroid group
had 36 patients who received a single dose oI 250 mg oI
methylprednisolone aIter induction, then every 6 hours Ior
24 hours. Average hospital stay Ior the control group was 4.8
days; steroid group was 3.2 days, p 0.001. InIection rate Ior
the control group was 9; steroid group was 6, p0.567.
Need Ior surgical revision was 25 Ior both groups. Hospital
stay was the only statistically signifcant fnding.
Conclusion: pTRAM faps are an important and eIIective
treatment Ior breast reconstruction. In our review, steroids
shorten the length oI stay Ior pTRAM fap patients by
almost 2 days. At the dose used, there was no increase in
peri-operative complications. We believe that peri-operative
steroid use is saIe and may be benefcial towards better patient
satisIaction and outcome.
65
MISREPRESENTATION OF SCHOLARLY
WORKS BY INTEGRATED PLASTIC
SURGERY APPLICANTS: IS IT REALLY AN
ISSUE?
Presenter: Steven J. Kasten, MD
Authors: Kasten SJ, Phillips J, Murphy MA
Background: Many authors report alarming rates oI Ialse
or questionable claims oI scholarly achievement amongst
residency applicants, including Chung et al., who recently
reported 38 oI publications Irom plastic surgery applicants
Irom the 2009 match could not be verifed. We simultaneously
conducted a similar investigation Irom an older data set, with
the hypothesis that the percentage oI citations claimed by
many authors to be Ialse was erroneously high due to Iailure
oI an adequate search or prolonged time Irom submission to
publication Ior many journals.
Methods: Applications received via the Electronic Residency
Application System to the University oI Michigan Integrated
Plastic Surgery Residency Program Ior the 2007 match
season were reviewed two years aIter being submitted by the
applicants. Scholarly works listed as published, accepted, or in
press, including journal articles, abstracts and book chapters,
were investigated. Those listed as submitted were excluded.
An exhaustive search was conducted that included Google,
Ovid MedSearch, PubMed, a physical search Ior the journals
in our medical library, and phone calls to regional societies.
Results: Our sample represented 60 oI all applicants in the
2007 integrated plastic surgery match. 102 applicants cited
342 scholarly works. OI these, 311 (91) were verifed. OI
the remaining 9, 20 citations (6) by 9 applicants (4)
could not be verifed, and 11 (3) by 9 applicants (4) were
confrmed as Iraudulent or Ialse.
Conclusions: The majority (91-97) oI integrated
plastic surgery applicants are truthIul regarding scholarly
achievement. Some citations that couldn`t be confrmed
even by our exhaustive search may not be Ialse; we could
confdently say only 3 didn`t exist. Listing a citation
as 'submitted, when it has been, is not dishonest. It is
understood that not all submissions are ultimately published.
We should give applicants the beneft oI the doubt, and the
opportunity to confrm their claims when we cannot. It is
likely that reported data on impropriety in applicants to other
specialties are also erroneously high.
66
THE UTILITY OF LABORATORY AND
NUTRITIONAL ASSESSMENT OF MASSIVE
WEIGHT LOSS PATIENTS UNDERGOING
BODY CONTOURING SURGERY
Presenter: Sumesh Kaswan, MD
Authors: Kaswan S, Messing S, GusenoII JA
University of Rochester
Introduction: With the increasing use oI bariatric surgery,
there has been an increase in the number oI patients presenting
Ior body contouring surgery. Pre-operative assessment oI
nutrition and use oI laboratory data in this population has been
emphasized; however, the utility oI such measures remains
to be determined. We investigated whether pre-operative
nutritional and laboratory evaluation is useIul in predicting
complications in the massive weight loss population (~50lbs).
Methods: 211 patients were identifed. All patients were
evaluated by a dietician and variables collected included age,
sex, BMI indices, weight loss method, time since weight loss,
presence oI dumping syndrome, dietary protein intake, use
oI vitamins and presence oI co-morbidities. Laboratory data
included a complete blood count, comprehensive metabolic
panel and coagulation profle. Complications were noted Ior
patients who underwent body contouring surgery. Univariate
and multivariate logistic regression analyses were perIormed
to determine the association oI aIorementioned variables and
complications.
Results: OI the 211 patients, 75 had body contouring
procedures. 175 (83) had a laboratory evaluation,
including all 75 patients who had body contouring surgery.
The incidence oI abnormal laboratory results ranged Irom
1-71, with a low globulin being most common (71).
The incidence oI abnormal lab results was higher in patients
who had a higher delta BMI (p0.03), had bariatric surgery
vs selI weight loss (p0.01) and presence oI co-morbidities
(p0.001). OI the 75 patients who had body contouring
surgery, 40 had one or more complications. The incidence
oI complications was higher in patients who had low
dietary protein intake (p0.04), low serum protein (p0.01),
low globulin (p0.05) and the presence oI co-morbidities
(p0.02).
Conclusion: Given the high incidence oI abnormal laboratory
results, routine laboratory evaluation along with a detailed
nutritional assessment is needed Ior massive weight-loss
patients undergoing body contouring surgery. This will help
identiIy patients at a higher risk oI developing complications
and ultimately improve outcomes.
42
67
LONGTERM IN-VIVO TUMORIGENIC
ASSESSMENT OF HUMAN CULTURE-
EXPANDED ADIPOSE STROMAL/STEM
CELLS
Original Presenter: Adam J. Katz, MD, FACS
New Presenter: Zoe MacIsaac
Authors: Katz AJ, Shang H, MacIsaac Z,
Parker A
University of Virginia Health System
Introduction: Adipose Stromal/Stem Cells are the subject oI
extensive research studies around the world, and have entered
into clinical trials Ior a number oI indications. Theoretically,
cell therapies may give rise to tumors directly (as is the case
with ESCs), and/or indirectly by supporting the viability and
growth oI 'micro-tumors already present in the surrounding
microenvironment. The objective oI this study was to evaluate
the direct long term tumorogenic and migratory behavior oI
culture-expanded human ASCs.
Methods: Human ASCs were isolated per standard
protocols and culture-expanded in adherent monolayer
culture. Cells were then Iormed into 3-D spheroids and
maintained in suspension culture Ior at least 2 weeks prior
to implantation. Nude mice were injected subcutaneously
with 150 ASC spheroids, each composed oI 40,000 ASCs.
Six control animals did not receive cell injections. Animals
were monitored Ior 12 months Ior signs oI systemic illness
and/or gross tumor growth and thereaIter various organs
were harvested and evaluated Ior gross appearance, weight,
and tumor Iormation. Select organs were evaluated Ior the
presence oI human cells using PCR detection oI a human-
specifc marker.
Results: OI the cell-injected animals, 11/12 animals survived
the entire year oI the study, whereas only 3/6 acellular
controls survived that period. Moreover, all cell treated
animals maintained there weight over the 12 month period,
with no signifcant diIIerence Irom control animals. There was
no gross evidence oI any tumor Iormation either at the sight oI
injection, or in any oI the organs harvested. PCR analysis oI
lung and spleen tissue harvested aIter sacrifce did not show
any evidence oI the migration/presence oI human cells.
Conclusion: These results provide strong evidence that
human culture-expanded ASCs do NOT generate tumors or
migrate systemically aIter implantation in vivo at relatively
high doses, and when Iormulated as 3-D organoids composed
oI cells and selI-generated ECM.
68
UMBILICAL CORD MESENCHYMAL
STEM CELL-DERIVED CARTILAGE ON
NANOFIBER-SUPPORTED SCAFFOLDS
FOR MICROTIA REPAIR
Presenter: Christian KauIIman, MD
Authors: KauIIman C, Dahl J, Caballero M,
Madan G, Pappa A, van Aalst JA
University of North Carolina at Chapel Hill
Introduction: Microtia is a congenital deIormity in which
the external ear is small and abnormally shaped. The current
surgical approach utilizes rib cartilage to reconstruct the
microtic ear; this results in a reasonable likeness oI the
external ear, but is not deIormable like a normal ear. A great
deal oI eIIort has been directed toward generating tissue-
engineered cartilage that has the ability to provide structural
support and deIormability similar to that oI endogenous ear
cartilage. To date, this work has not resulted in clinically
usable ear cartilage implants. Importantly, both strategies are
limited by the non-deIormability oI the cartilage.
Methods: We propose to develop a nanofber-based
cartilage implant that will provide the structural support and
deIormability necessary to generate a more normal external
ear. To do so, human umbilical cord mesenchymal stem cells
(hUCMSCs) were seeded on polycaprolactone (PCL) and
D, L-lactide-co-glycolic acid (PLGA) nanofber scaIIolds
and treated Ior 21 days with chondrogenic growth Iactors.
Cultures were subjected to biochemical, quantitative PCR,
and histologic analyses.
Results: Results indicate that hUCMSCs cultured on PLGA
scaIIolds have a signifcantly higher glycosaminoglycan
content, diIIerentiation index, and Collagen X RNA
expression compared to cells grown in the absence oI
nanofber scaIIolds. Histologic evaluation oI the hUCMSC
derived cartilage demonstrated positive staining with both
Alcian Blue and Toluidine Blue.
Conclusions: These data suggest that hUCMSC-derived
cartilage grown on a PLGA nanofber substrate results in
more mature tissue engineered cartilage that may be useIul in
the generation oI a deIormable cartilage implant Ior microtia
reconstruction.
69
SERUM-DERIVED NANOPARTICLES CAN
CAUSE CALCIUM-MEDIATED CUTANEOUS
WOUND CONTRACTION
Presenter: Kenichiro Kawai, MD, PhD
Authors: Kawai K, Larson BL, Carre AL,
Longaker MT, Lorenz HP
Hyogo College of Medicine
Introduction: Serum-derived nanoparticles (NPs), previously
known as nanobacteria, are small particles that are composed
oI a protein core surrounded by a hydroxyapatite shell. NPs
are able to bind ions, proteins, and other organic molecules
present in the surrounding environment. These small entities
can act as calcium mediators and it has been hypothesized that
they can disrupt calcium homeostatsis in vivo. NPs have been
associated with several calcium-mediated disease processes,
such as kidney stone Iormation, atheroscloerosis, and cancer
metastasis. In the present study, we generated NPs and
investigated their ability to mediate cutaneous wound repair.
Methods: NPs were grown on collagen-coated culture
dishes in alpha-MEM media supplemented with 20 FBS
under varying conditions. SEM imaging oI the NPs was
perIormed and their ionic composition was analyzed via
EDX spectroscopy. The eIIect oI NPs on wound repair was
tested on open cutaneous wounds in mice. Immediately aIter
injury, mice received an intravenous injection oI 100ul oI
normal saline or 100ul oI NPs. The rate oI wound closure was
quantifed and the serum calcium levels were Iollowed. In
vitro analysis oI nanoparticle-mediated eIIects was assessed
by FPCL, calcium uptake, and BrdU assays.
Results: Treatment with NPs decreased wound size in
all experimental mice (p0.05). A statistically signifcant
improvement in the wound healing was seen as early as 1
hour post-injury. In vitro analysis demonstrated that NPs
cause contracture oI fbroblast populated collagen lattices in
a dose-dependent manner. Treatment with NPs also increased
the rate oI fbroblast proliIeration and increased fbroblast
calcium uptake in vitro.
Conclusion: NPs can acutely decrease wound size via
contracture. We hypothesize that the contraction eIIect is
mediated by the release oI calcium, which occurs when NPs
reach the low pH oI the acute wound microenvironment. In
this study we have demonstrated that NPs have a therapeutic
beneft, which could have important implications Ior the
treatment oI large open wounds.
70
POST-MASTECTOMY BREAST
RECONSTRUCTION AFTER PREVIOUS
LUMPECTOMY AND RADIATION
THERAPY: ANALYSIS OF COMPLICATIONS
AND SATISFACTION
Presenter: Ibrahim Khansa
Authors: Khansa I, Colakoglu S, Curtis MS, Yueh JH,
Ogunleye A, Tobias AM, Lee BT
Beth Israel Deaconess Medical Center
Background: Lumpectomy and radiation therapy (breast
conservation therapy, BCT) is a common treatment Ior early
stage breast cancer. However, many oI these patients will
require a subsequent salvage mastectomy and reconstruction
aIter a loco-regional recurrence. This study examines
whether prior BCT leads to higher rates oI complications
and dissatisIaction with subsequent mastectomy and breast
reconstruction.
Methods: All women at an academic institution undergoing
initial breast reconstruction were identifed (1999-2006).
Women who had undergone prior BCT were compared to
women without prior BCT. A questionnaire adapted Irom
the Michigan Breast Reconstruction Outcomes Survey was
administered. Rates oI complications, as well as general and
aesthetic satisIaction, were compared between the two groups.
Multiple logistic regression was used to analyze the eIIects
oI prior BCT, age, reconstruction type, and time between
radiation and reconstruction.
Results: Overall, 532 women underwent 802 reconstructions,
oI which 113 women (137 reconstructions) had prior BCT.
Prior BCT did not correlate with higher complication
(OR1.18, p0.437), lower general or aesthetic satisIaction
(OR0.89, p0.658; OR0.95, p0.850; respectively);
however, there was an increased rate oI mastectomy skin fap
loss (12.4 vs. 6.8, p0.024). Increasing age was the most
signifcant risk Iactor Ior complications and dissatisIaction.
Conclusion: Radiation in the setting oI BCT did not
increase overall rates oI complications or dissatisIaction
with subsequent breast reconstruction in our patient
population. These patients, however, had a higher incidence
oI mastectomy skin fap loss. These fndings are important
Ior preoperative counseling and intraoperative planning in
patients with prior lumpectomy and radiation.
44
71
THE APPLICATION OF SUBCUTANEOUS
TALC IN PANNICULECTOMIES AND
SUBCUTANEOUS ADVANCEMENT FLAPS
WITH CONCOMITANT HERNIA REPAIR
REDUCES DRAIN DURATION AND POST-
OPERATIVE WOUND COMPLICATIONS
Presenter: David A. Klima, MD
Authors: Klima DA, Getz SB, BrintzenhoII RA,
Carpenter CL, HeniIord BT
Carolinas Medical Center
Introduction: Wound complications in patients undergoing
large ventral hernia repairs requiring extensive tissue
dissection and panniculectomy (OVHR/PAN) occur in 18-
50 oI procedures. This study evaluates a novel technique
involving the application oI talc to subcutaneous tissue oI
OVHR/PAN patients in order to decrease the rate oI wound
complications.
Methods: Demographics, peri-operative data, and long-
term outcomes oI patients undergoing concomitant OVHR/
PAN were evaluated with a prospectively collected surgical
outcomes database at our institution Irom 1999-2010. Patients
were divided into two groups; one oI which did not receive
talc (NOTALC) and one oI which had subcutaneous talc
applied prior to closure (TALC).
Results: 180 patients met criteria Ior study inclusion, with
74 in the TALC group and 106 in the NOTALC group.
Demographics were statistically similar between TALC and
NOTALC groups (p0.05) and included mean age (55.7/-
13.2 v 53.5/-11.6 years) ASA scores (2.6/-0.66 v 2.5/-0.5),
and tobacco use (21 v 21). BMI was signifcantly less in
the TALC group (33.6/-8.9 v 37.3/-8.8 kg/m2, p0.03),
but deIect size was signifcantly larger (258/-195 v 213/-
281cm2, p0.02). The TALC group had a signifcant decrease
in the rate oI seromas requiring intervention Irom 20.8 to
2.7 (p0.001), cellulitis Irom 39.6 to 20.5 (p0.007)
and need Ior oral antibiotics Irom 36.8 to 23.3 (p0.05).
The TALC group also had a signifcantly earlier drain removal
Irom 25.6/-19.1 to 14.6/-7.0 days (p0.001). When BMI
was controlled Ior, the rate oI seromas requiring intervention,
cellulitis, oral antibiotics and drain duration remained
statistically signifcant (p0.05).
Conclusions: The subcutaneous application oI talc Ior
OVHR/PAN patients demonstrated decreased rate oI post-
operative cellulitis, need Ior oral antibiotics, drain duration
and seroma Iormation requiring intervention. These
diIIerences held true aIter controlling Ior BMI and despite
larger deIect sizes. The use oI subcutaneous talc in patients
undergoing large ventral hernia repair is a promising agent to
help decrease wound complications.
72
HYPERGLYCEMIA AND ISCHEMIA IN
DIABETES: STRESSORS IMPLICATED IN
DYSFUNCTIONAL HEALING
Presenter: Denis Knobel, MD
Authors: Knobel D, Cohen O, CrawIord JL, Butala P,
Layliev J, Wetterau MT, Warren SM,
Saadeh PB
Introduction: Both hyperglycemia inherent to diabetes
and ischemic wounds are associated with increased cellular
stress refected, in part, by elevated levels oI reactive oxygen
species (ROS). The relationship between elevated ROS and
poor diabetic healing is poorly elucidated. We hypothesized
that reducing ROS with N-acetylcysteine (NAC), an ROS
scavenger, would mitigate the molecular derangements
associated with diabetes and improve diabetic healing.
Methods: Paired 6-mm stented wound were created on
diabetic mice (db/db). NAC was prepared in an agarose-gel
matrix (5, 40, 600 mM) and topically applied on post-surgery
day 1 and every-other day thereaIter. An agarose-only matrix
served as control. Mice were observed over 30 days Ior
closure. Samples harvested were evaluated Ior ROS levels
with an 8-OHdG ELISA and 8-OHdG immunofuorescence.
Expression oI both vasculogenic mediators and the pro/
anti-oxidant genes PUMA and MnSOD were quantifed by
both ELISA and RT-PCR. Furthermore, the pro-apoptotic
mediators p53 and Caspase-3 were assessed by ELISA and
immunohistochemistry (IHC). ANOVA determined statistical
signifcance (p0.05).
Results: Dose oI 40 mM NAC consistently accelerated
wound closure compared to the control, 5 and 600 mM NAC
preparations (17 + 1 days vs. 27 + 1 days). Mice treated with
40 mM NAC displayed superior ROS scavenging evident
by decreased staining Ior 8-OHdG correlating with a 50
reduction in 8-0HdG. RT-PCR demonstrated a 67 decrease
in pro-oxidant gene PUMA expression and 36 increase
in anti-oxidant gene MnSOD. This decrease in ROS nearly
doubled protein levels oI the vasculogenic mediator VEGF,
and caused a 3.5 Iold increase in SDF-1 gene expression
compared to controls. This led to a 4-Iold increase in
circulating EPCs. Moreover, NAC treatment resulted in a 43
decrease in protein expression oI the pro-apoptotic mediator
p53 with decreased Caspase-3 staining.
Conclusion: This study illustrates that local reduction oI
ROS improves diabetic healing and was associated with the
reversal oI the vasculogenic and pro-apoptotic derangements
associated with these wounds.
73
BREAST IMPLANT PROCEDURES
PERFORMED UNDER CONSCIOUS
SEDATION: A SIX-YEAR EXPERIENCE IN
461 PATIENTS
Presenter: Jason H. Ko, MD
Authors: Ko JH, Heyer KS, Mustoe TA
Northwestern University
Purpose: Breast implant procedures are typically perIormed
using either IV sedation with local anesthesia or general
anesthesia; however, there is an increased interest in the use
oI conscious sedation (CS) in plastic surgery. We examined
the saIety and eIfcacy oI breast implant procedures perIormed
under CS over a 6-year period.
Methods: Between 2002 and 2008, 461 consecutive patients
underwent breast implant procedures perIormed by the senior
author under CS using pre-operative IV diazepam, along with
intra-operative midazolam, Ientanyl, and local anesthetic.
One hundred twenty oI these patients underwent breast
augmentation mammaplasty, using a dual-plane technique
and meticulous administration oI local anesthesia to minimize
intra-operative pain. This subset oI breast augmentation
mammaplasty patients was selected out, and the dosages oI
conscious sedation medications were recorded.
Results: Baseline patient characteristics, in addition to post-
operative complications were recorded. When comparing
breast augmentation mammaplasty procedures during the
early years oI the study (Years 1-3) to those perIormed
more recently (Years 4-6), higher pre-operative doses oI
diazepam (p0.01) were given in recent years, resulting
in signifcantly decreased total dosages oI intra-operative
Ientanyl (p0.0001), in turn leading to subjectively smoother
operations and decreased times in the recovery room. There
were no signifcant diIIerences between the early and late
years in terms oI midazolam dosages. None oI the 461
patients in this study required unplanned conversion to deep
sedation or general anesthesia.
Conclusion: Our study demonstrates that breast implant
procedures can be perIormed both saIely and eIIectively under
CS without requiring conversion to deeper anesthesia. More
recently, higher doses oI pre-operative diazepam allowed Ior
administration oI more eIIective amounts oI local anesthesia,
thereby decreasing Ientanyl doses and reducing nausea
and vomiting. We believe that CS is the preIerred method
oI anesthesia Ior most patients undergoing breast implant
procedures.
74
GENE MODIFICATION OF MUSCLE FLAPS
USING NOVEL RECOMBINANT ADENO-
ASSOCIATED VIRAL VECTORS
Presenter: Ergun Kocak, MD, MS
Authors: Kocak E, Carruthers KH, Miller MJ,
During MJ
The Ohio State University
Background: Widespread application oI gene therapy has
been limited by several Iactors with one oI the most important
being that systemic gene therapy methods do not allow Ior
specifc targeting oI tissues. Methods aimed at improving this
specifcity are needed to achieve clinically applicable gene
therapy treatment regimens. Recent reports have described
the delivery oI genes into muscle faps Ior local production oI
gene products. These studies have relied on time consuming
methods that use ex vivo perIusion oI isolated tissues that are
transIerred as microvascular Iree faps. We set out to develop
a method Ior gene modifcation oI fap tissues that would yield
sustainable production oI gene products but would be less
time consuming than existing protocols.
Methods: The viral vector used Ior gene delivery in these
experiments is a novel adeno-associated virus (AAV) that is
unique to our laboratory. We have shown that recombinant
rAAVrec2 not only has a marked increase in yields, but also
has a signifcant improvement in tissue tropism compared to
the more classical AAV serotypes. The rAAVrec2 vector was
used to deliver the gene Ior green fuorescence protein (GFP).
The tissues that were gene modifed were pedicled pectoralis
muscle faps in wild-type C57BL/6 mice. Gene therapy
was delivered by direct injection oI muscle faps. Tissues
were collected at 5 weeks post injection oI viral vector and
histologically examined.
Results: Direct injection oI muscle faps was carried out
reliably in our experiments and added minimal additional
time to the fap procedures. Analysis oI the injected muscle
fap tissues demonstrated GFP production that was observed
histologically by both direct fuorescence microscopy and
immunofuorescent staining. In contrast, GFP was not
detected in tissues that were not directly injected with vector,
indicating that the inIection oI tissues stayed local to the fap.
Conclusions: Using novel recombinant adeno-associated viral
vectors, we have developed a method Ior gene delivery into
muscle faps that is minimally time consuming and applicable
to pedicled fap transIers.
46
75
MICRORNA-1 AND MICRORNA-206
IMPROVE HUMAN SATELLITE CELL
DIFFERENTIATION IN VITRO: A NOVEL
APPROACH FOR TISSUE ENGINEERING
OF SKELETAL MUSCLE
Presenter: Merel Koning, MD
Authors: Koning M, Harmsen MC, Bank RA,
Werker PM
University Medical Center Groningen
Introduction: Facial paralysis is a physically, psychologically
and socially disabling condition. Innovative treatment
strategies based on regenerative medicine, in particular tissue
engineering oI skeletal muscle Irom human satellite cells,
are promising Ior treatment oI patients with Iacial paralysis.
However, the eIfciency oI satellite cell diIIerentiation in vitro
is suboptimal. MicroRNAs are involved in various critical
Iunctions, including the regulation oI cellular proliIeration
and diIIerentiation. We hypothesize that microRNA-1
and microRNA-206 can modulate human satellite cell
diIIerentiation.
Methods: To investigate this, we isolated and cultured
human satellite cells Irom muscle biopsies. Using qRT-PCR,
we frst showed that microRNA-1 and microRNA-206 are
robustly induced in diIIerentiating satellite cells. Gain-oI-
Iunction approach was used to investigate microRNA-1
and microRNA-206 potential in human satellite cell
diIIerentiation.
Results: AIter transIection, microRNA-206 was Iound
to upregulate the myogenic regulator Iactor MYOD1,
compared to the microRNA-scrambled control. Furthermore,
microRNA-1 and microRNA-206 transIected satellite
cells exhibited a decreased nuclear staining Ior Pax7, and
an increased nuclear staining Ior MyoD1. Finally, alpha-
sarcomeric actin and myosin expression by satellite cells and
myotubes was enhanced.
Conclusion: ThereIore, we conclude that microRNA-1
and microRNA-206 can improve human satellite cell
diIIerentiation. It represents a potential novel approach Ior
tissue engineering oI human skeletal muscle Ior the beneft oI
patients with Iacial paralysis.
76
POST-MASTECTOMY BREAST
RECONSTRUCTION VERSUS
MASTECTOMY ALONE: A COMPARATIVE
ASSESSMENT OF QUALITY OF LIFE USING
PATIENT REPORTED SATISFACTION,
BODY IMAGE AND SEXUAL WELL-BEING
Presenter: DziIa S. Kpodzo, MD
Authors: Kpodzo DS, Antony A, Damjanovic B,
Chretien Y, Austen WG, Colwell AS
Purpose: Mastectomy alone (MA) alters a woman`s sense
oI Iemininity and sexuality and contributes to diminished
quality oI liIe (QOL). Breast reconstruction (BR) has the
potential to ameliorate the physical and psychological burden
oI mastectomy alone by restoring the breast mound and a
patient`s sense oI selI. However, research to date on patient
satisIaction and sexuality have not provided consistent data.
We report comparative quality oI liIe assessment in patients
with mastectomy alone and mastectomy Iollowed by breast
reconstruction, which may be a powerIul adjunct to guide
treatment recommendations.
Methods: The Breast-Q instrument, a validated outcome
specifc survey designed to measure QOL in 6 domains, was
administered to a retrospective cohort oI patients having
mastectomy between 2005-2008. Survey results were scored
and compared using a two-tailed T-test.
Results: Seventy-fve patients with MA completed the
survey Ior a response rate oI 52. The average age was 61,
the average BMI 27, and the race was primarily Caucasian.
Seventy-nine percent had a college education while 64 had
an income greater than $40,000. In comparison, 164 patients
with BR completed the survey Ior a higher response rate oI
76 (p0.001). This group was younger (average age 50,
p0.001), more educated (72 with a college education,
p0.002), and had more patients (87) earning over $40,000
per year (p0.0001), but was similar in ethnicity and BMI. In
quality oI liIe domains, patients with BR had higher scores
on satisIaction with breasts (p0.0002) and psychosocial well
being (p0.01). Sexual well-being scores were lower than
other satisIaction scores in both groups; however, patients
with BR had signifcantly higher scores than MA (p0.0001).
Conclusion: Breast reconstruction improves patient reported
quality oI liIe in satisIaction with breasts, overall psychosocial
well-being, and sexual well-being compared with mastectomy
alone. This data may be invaluable in counseling women on
the benefts oI breast reconstruction Ior cancer treatment and
prophylaxis.
77
OSCILLATING CULTURES ACCELERATE
MINERALIZATION OF HMSCS ON 3D TYPE
I COLLAGEN SCAFFOLDS: IMPLICATIONS
FOR BONE TISSUE ENGINEERING
BIOREACTOR DESIGN
Presenter: Erwin A. Kruger, MD
Authors: Kruger EA, BischoII DS, Huang WR,
Rudkin GR, Yamaguchi DT, Miller TA
VA Greater Los Angeles Healthcare System
Introduction: We have recently demonstrated that
three-dimensional (3D) scaIIold materials have distinct
mineralization profles in the human mesenchymal stem
cell (HMSCs) niche. Type I collagen scaIIolds mineralize
Iaster and to a greater extent than synthetic materials in
static cultures. Since biomechanical conditions are known
to up-regulate osteogenic gene expression, we hypothesized
that dynamic culture conditions would enhance HMSC
mineralization on type I collagen scaIIolds. We investigated
the extent oI HMSC mineralization on collagen scaIIolds in
static vs. dynamic conditions.
Methods: HMSCs were seeded on type I collagen scaIIolds
at 250,000 cells/scaIIold and subjected to either static or
oscillating, dynamic culture conditions (on laboratory
shaker at 85 cycles/min) at 37C, 5 CO
2
. Both cultures
were subjected to diIIerentiation medium (containing
dexamethasone, ?-glycerol phosphate, and ascorbic acid).
Osteogenic markers (ALP, BSP, OCN, Col I) were analyzed
by RT-PCR in static vs. dynamic cultures at 0, 7, 14, and 28
days. At 28 days, static vs. dynamic scaIIolds were analyzed
Ior mineralization by micro-CT and histology.
Results: Micro-CT analysis noted a 3200-Iold increase in
percent mineralization/volume in dynamic vs. static cultures
conditions. Dynamic conditions showed a 7-Iold decrease in
total volume compared to static cultures. Histology sections
showed denser matrix, more cell clusters, and higher alizarin
red S staining oI mineral in dynamic vs. static conditions. RT-
PCR Ior all osteogenic markers (ALP, BSP, OCN, Col I) were
down-regulated by 4 weeks (p0.05) in dynamic vs. static
cultures, inversely correlating with increased mineralization.
Conclusion: Our fndings suggest that biomechanical Iorces
play a signifcant role in mediating mineralization oI HMSCs
on type I collagen scaIIolds. Furthermore, osteogenic gene
expression tapers with increased mineral deposition. This
highlights collagen-based scaIIolds as promising matrices
Ior human bone tissue engineering and implies a need Ior the
rational design oI bioreactors towards a clinically useIul ex
vivo bone graIt substitute.
78
COST ANALYSIS OF RIGID STERNAL
FIXATION VERSUS MODIFIED WIRE
TECHNIQUES FOR PRIMARY STERNAL
CLOSURE OF HIGH RISK STERNOTOMY
PATIENTS
Presenter: JenniIer H. Kuo, MD
Authors: Kuo JH, Quan E, Young N, Wong MS
UC Davis
Background: Postoperative sternal wound inIections (PSWI)
cause signifcant morbidity, and can be a potentially lethal
complication Iollowing cardiac surgery. Rigid sternal fxation
(RSF) with titanium plates has been shown to reduce PSWI in
high-risk patients. Although it bestows greater sternal stability,
the higher initial cost oI titanium plates has continued to deter
wide-spread acceptance and use. This study evaluates the
cost oI care oI high risk sternotomy patients who underwent
RSF compared to those who underwent sternal closure with
modifed wire techniques (MWT).
Methods: A retrospective single institution review oI 33
patients who underwent RSF and 45 high risk sternotomy
patients who underwent MWT Ior primary sternal closure,
over a 4 year period (2006-2009) was conducted. High risk
was defned as e3 historical risk Iactors: obesity, diabetes,
COPD, renal Iailure, cardiac bypass time ~2 h, and transverse
sternal Iractures, requiring retention sutures or a Robicsek
weave Ior reinIorcement oI sternal closure. All physician and
hospital charges related to their operation were included.
Results: Patients who underwent RSF were similar to MWT
patients in age (59 vs 64 years, p0.06) and BMI (34 vs 36
kg/m
2
, p0.25). Overall incidence oI PSWI in RSF patients
was 6, and 28.9 (p 0.02) in MWT patients. The average
hospital cost per complication Ior the RSF cohort was $1,057
vs. $51,083 Ior their MWT counterparts.
Conclusion: This study provides a detailed cost analysis oI
rigid sternal fxation vs. modifed wire techniques Ior primary
closure in high risk sternotomy patients. Despite the initial
higher cost oI titanium plates, RSF aIIords an overall lower
cost oI care Ior this patient population. The lower cost oI care,
in addition to the lower incidence oI postoperative sternal
wound inIections, suggests rigid sternal fxation as the best
option Ior sternal closure in high risk sternotomy patients.
48
79
IDENTIFICATION OF CD109 AS
A REGULATOR OF CUTANEOUS
INFLAMMATION IN VIVO
Presenter: JeanPhilip Lacroix
Authors: Lacroix J, Vorstenbosch J, Lighter M,
Philip A
Plastic Surgery Research McGill University
Background: Persistent infammation and excessive
extracellular matrix (ECM) production are major hallmarks
oI wound healing pathologies such as hypertrophic scars and
keloids. Although upregulation oI TGF-? expression at the
wound site is critical Ior the chemotactic accumulation oI
immune cells and ECM synthesis, excessive TGF-? activity
can lead to persistent infammation and abnormal scarring.
Our group has recently reported the identifcation oI CD109
as a novel TGF-? co-receptor and negative regulator oI
TGF-? signaling and responses. Thus, we hypothesized that
by increasing CD109 expression in the skin in vivo, it may
be possible to downregulate TGF-? signaling and reduce
infammation, alleviating progression oI fbrosis.
Objective: To determine whether CD109 regulates cutaneous
infammation in vivo, using a transgenic mouse model
overexpressing CD109 in the epidermis.
Methods: Cutaneous infammation was induced by
intradermal injection oI 50 g lipopolysaccharide (LPS) or
vehicle control, in transgenic mice overexpressing CD109 in
the epidermis and their wild-type littermates. Infammatory
response was determined at 24h and 48h post-injection by
evaluating the number oI macrophages and neutrophils by
immunohistochemistry, and by analyzing the expression oI
pro-infammatory cytokines (IL-1+, TNF-+) and chemokines
(MIP-1+, MIP-2+, MCP-1) by qRT-PCR.
Results: Transgenic mice display decreased neutrophil
and macrophage infltration in the skin aIter LPS injection,
when compared to wild-type littermates, identiIying the
anti-chemotactic property oI CD109. In addition, a marked
reduction in the expression oI the pro-infammatory cytokines
IL-1+, TNF+ and chemokines MCP-1, MIP-1+ and MIP-
2+ was observed both 24h and 48h post-LPS injection
(p0.05), providing Iurther support that CD109 decreases the
infammatory responses.
Conclusions: Our fndings demonstrating that CD109
decreases the infammatory responses in the skin in vivo
suggest that CD109 may have potential therapeutic value Ior
the treatment oI infammatory and fbrotic skin disorders such
as keloids and hypertrophic scarring.
80
ACCELERATED VASCULARISATION
AND IMPROVED BONE FORMATION IN
CRITICAL-SIZE BONE GRAFTS BY VEGF-
EXPRESSING BMSC IN A RABBIT MODEL
Presenter: Rene Largo, MD
Authors: Largo R, KmpIen A, Haerschnitz O,
KlarhIer M, Gueven S, Scherberich A,
Martin I, Heberer M, Banf A, SchaeIer DJ
University Hospital of Basel
Introduction: InsuIfcient vascularization is the main obstacle
to the generation oI bone constructs Ior critical-size deIects.
The combination oI tissue engineering and fap preIabrication
in a rabbit model led to bone growth to a depth oI 1.8 mm, but
necrosis in the deeper core (Scheufer 2008). Here, we test the
hypothesis that increased angiogenic stimulation Irom within
constructs by VEGF can signifcantly accelerate vascular
ingrowth and improve bone Iormation.
Methods: Bone marrow stromal cells (BMSC) Irom
NZWrabbits were transduced with a retroviral vector
expressing rbVEGF165 linked to a truncated version oI
rbCD4 as a cell surIace marker. Cells were seeded in critical-
size HA-scaIIolds, which were wrapped in a panniculus
carnosus fap and implanted ectopically. The kinetics oI
construct perIusion was assessed by angio-MRI at week 1,
4 and 8. Morphometric analysis oI the induced bone tissue
was perIormed by micro-CT on explanted constructs aIter 8
weeks. Bone Iormation and vascularization were quantifed
histologically.
Results: Transduced BMSC were purifed by FACS based on
CD4 expression. Six rabbits were implanted with autologous
BMSC-loaded scaIIolds (nave, VEGF-expressing or control
vector-transduced). Angio-MRI demonstrated improved
perIusion oI VEGF-expressing constructs already 1 week
aIter implantation compared with controls. Micro-CT showed
40.7 greater bone Iormation (p0.01) and twice thicker bone
ingrowth into construct core by VEGF-expressing BMSC 3.1
mm versus 1.6 mm).
Conclusions: VEGF expression by genetically-modifed
BMSC leads to accelerated vascularization oI critical-
size bone graIts and signifcantly thicker bone Iormation,
suggesting that the combination oI cell and gene therapy
approaches is a promising novel strategy Ior eIfcient bone
regeneration
81
STEM CELL THERAPY IMPROVES BONY
HEALING
Presenter: John Layliev, MD
Authors: Layliev J, Marchac A, Butala P, Szpalski C,
Henderson R, Sagepin F, Weinstein A,
Saadeh PB, Warren SM
New York University Medical Center
Introduction: Despite bone repair being a relatively rapid
and eIfcient process, many patients Iail to heal their Iractures.
Since an adequate blood supply is essential Ior osteogenesis,
we hypothesize that endogenous stem cell mobilization will
improve bony healing, especially when administered in
conjunction with a chemotaxis enhancing drug.
Methods: A circular critical size 3-mm cranial deIect was
made in the right parietal bones oI 6 week old FVB mice.
Mice were separated into Iour groups. One group (n30)
received daily subcutaneous AMD3100 (10mg/kg) injection
beginning on postoperative day 3 and continuing Ior 14
days. The second group (n30) received daily injection
oI a chemoattractant. The third group (n30) received
administration oI both drugs. The Iourth group (n30)
received subcutaneous saline injection. Skulls were harvested
at 4 weeks, 8 weeks, and at 12 weeks. Flow cytometry was
used to quantiIy the amount oI progenitor cells in peripheral
blood obtained via intracardiac puncture. Immunofuorescent
CD31 and osteocalcin staining oI skull specimens was
perIormed to assess Ior vascularity and osteoblastic activity.
Microcomputed tomography was used to assess bony
regeneration.
Results: Flow cytometry demonstrated increased progenitor
cell levels in the AMD3100 group (11.33+0.64 vs.
6.07+1.25 at day 7, p0.01; and 8.03+1.50 vs.
3.23+1.33 at day 14, p0.05). Calvarial deIects oI
AMD3100-treated mice harvested at 4 weeks demonstrated
increased vascularity (3.07+0.91 vs. 5.44+1.89, p0.01)
and osteoblastic density (1.96+0.54 vs. 3.36+0.52,
p0.01) compared to controls. AMD3100-treatment
signifcantly improved bony regeneration on microcomputed
tomography at weeks 8 (34.78+11.49 vs. 50.28+11.47,
p0.017) and 12 (36.01+5.66 vs. 61.85+11.45, p0.001)
compared to controls.
Conclusions: Treatment with an endogenous cell mobilizer
results in an increased number oI circulating progenitor cells
leading to increased vascularity at bony healing sites. A dense
vascular bed leads to increased bone density. Collectively,
endogenous stem cell therapy enhances new bone Iormation.
82
COMPOSITE TISSUE
ALLOTRANSPLANTATION IN SWINE
ACROSS A FULL MHC BARRIER USING
A MIXED HEMATOPOIETIC CHIMERISM
PROTOCOL
Presenter: Angelo A. Leto Barone, MD
Authors: Leto Barone AA, Torabi R, Randolph MA,
Duran-Struuck R, Hawley RJ, Horner BM,
Matar A, Crepeau R, Albritton A,
Mallard C, Tang Y, Tena A, Scalea JR,
Kurtz JM, Huang CA, Sachs DH,
Cetrulo CL
Harvard Medical School Massachusetts General Hospital
Introduction: Composite tissue allotransplantation (CTA)
is currently limited by acute and chronic rejection, and the
morbidity oI immunosuppression. Using MHC-defned
miniature swine, we have investigated various approaches
to achieve CTA acceptance across both minor and major
histocompatibility (MHC) barriers. The aim oI this study was
to induce stable mixed chimerism across a Iull MHC barrier
through bone marrow transplantation (BMT) to Iacilitate
long-term acceptance oI a simultaneously transplanted CTA.
Methods: CTA/BMT were perIormed across a Iull MHC
barrier (swine leukocyte antigen SLAccSLAdd). Recipients
underwent low-dose (100cGy) total body irradiation, T-cell
depletion with CD3-Immunotoxin and a 45-day course oI
Cyclosporine (CyA). A gracilis myocutaneous CTA was
transplanted along with BMT. CyA was maintained between
400-800 ng/mL Ior 30 days and tapered oII by day 45. Flap
viability was assessed daily by clinical exam and serial
biopsies. Chimerism and serum alloantibody against donor
MHC were assessed by fow cytometry, and immunoresponse
was measured by in vitro assays. Control animals did not
undergo the conditioning regimen and received CTA.
Results: Controls receiving a CTA without conditioning
rejected all components oI the fap by day 6 post-
transplantation (PTD6). In the frst experimental animal no
detectable chimerism was observed. All components oI the
fap appeared viable up to PTD43. The epidermis sloughed
by PTD45, and was Iollowed by loss oI all components
oI the fap by PTD71. In the second experimental animal
myeloid chimerism was observed. All components oI the fap
are accepted up to PTD43 in this animal and monitoring oI
additional timepoints is ongoing, as immunosuppression is
tapered.
Conclusion: We are currently developing a clinically-relevant
concomitant CTA/BMT transplant strategy in a preclinical
large animal model. The conditioning regimen used in our
can prolong survival oI a CTA across a Iull MHC barrier.
Improved T-cell depletion and increased bone marrow cell
doses Iavorable to production oI transient or stable mixed
chimerism are under investigation.
50
83
NOVEL REGULATION OF HUMAN ADIPOSE
DERIVED STROMAL CELL OSTEOGENESIS
THROUGH NOGGIN KNOCKDOWN AND A
BMP-2 SLOW RELEASING SCAFFOLD
Presenter: Benjamin Levi, MD
Authors: Levi B, Nelson ER, Li S, Hyun J,
Glotzbach J, Brown K, Lee M,
Longaker MT
Stanford University
Introduction: There remains a pressing need Ior a suitable
alternative to currently available techniques Ior bone tissue
repair. We have previously demonstrated the osteogenic
potential oI human adipose derived stromal cells (hASCs),
however, we believe we can enhance hASC osteogenic
capability by modulating the BMP pathway in vitro and in
vivo. We hypothesize that by knocking down noggin on a
genetic level, we can increase the osteogenic capability oI
hASCs and that along with a novel bmp loaded biomimetic
scaIIold, we can greatly improve skeletal tissue engineering.
Methods: hASCs were harvested Irom lipoaspirate oI 5
Iemale patients. AIter 48 hrs in vitro expansion, the cells
were transIected with Noggin shRNA. Gene and protein
knockdown were confrmed. Osteogenesis was assessed
by staining and qRT-PCR. Cells were seeded on an
osteoinductive scaIIold with or without BMP and implanted
into a 4mm critical size calvarial deIect in athymic mice. In
vivo calvarial deIect healing was assessed by microCT and
histology.
Results: hASCs with confrmed noggin knockdown displayed
signifcantly enhanced osteogenic diIIerentiation in vitro as
compared to control, shown by an up-regulation oI alkaline
phosphatase activity, mineralization and numerous gene
markers (RUNX2, OCN and BMPR1B, *p0.05). This
enhanced osteogenesis was observed in vivo as well, as
calvarial deIects seeded with noggin knock down cells had
signifcantly increased boney healing when compared to those
seeded with control hASCs defned as calcifcation on Micro
CT analysis and histology (*p0.05). BMP loaded scaIIolds
Iurther enhanced in vivo healing oI hASCs in a calvarial
deIect.
Conclusion: We demonstrate that hASCs can be enriched Ior
a more osteogenic subpopulation by manipulating the BMP
pathway. By removing a BMP inhibitor, we have created
a population oI hASCs that possess superior osteogenic
potential in vitro and in vivo. Creating a hASC population
that demonstrates a robust ability to diIIerentiate along an
osteogenic lineage, we hope to optimize the potential utility oI
cell-based therapies in skeletal regeneration.
84
ELONGATED CELL MORPHOLOGY
AND UNIAXIAL MECHANICAL
LOADING CONTRIBUTE TO TENOCYTE
MICROENVIRONMENTAL NICHE
Presenter: Jie Li, MD, PhD
Authors: Li JL, Zhu J, Zhang WJ, Zhou GD, Cao YL,
Liu W
Shanghai 9th Peoples Hospital Shanghai Jiao Tong University
School of Medicine
Introduction: Tendon niche is important Ior maintaining
the phenotype and Iunction oI tenocytes resided in the niche.
However, it remains unclear what Iactors contribute to this
particular niche environment. We hypothesize that elongated
morphology and the paralleled uniaxial mechanical loading
are the primary niche Iactors.
Methods: Primary porcine tenocytes oI newborn pigs were
cultured respectively on culture dish (Group A), smooth
(Group B) and microgroove silicone membrane (Group
C, Iorcing cells in an elongated morphology) and were
mechanically loaded either parallel with or perpendicular to
microgroove direction Iollowed by RT-PCR and quantitative
PCR to examine gene expression oI tenocyte marker
tenomodulin and others in triplicate samples.
Results: With passage, cells became spread on groups A
and B and dediIIerentiated because oI the lost expression
oI tenomodulin and collagen I. In contrast, Group C cells
were Iorced elongated and could maintain the expression
oI both molecules with signifcant diIIerence to other two
groups (p0.05). Interestingly, dediIIerentiated tenocytes
became rediIIerentiated with regained expression oI both
molecules aIter switching to microgroove culture condition
(p0.05). Further study revealed that mechanical stretch also
signifcantly enhanced the expression oI tenomodulin and
collagen I comparing to non-stretched cells (p0.05). Only
the mechanical loading paralleled to the axis oI elongated
tencoytes could signifcantly enhance the expression, while
mechanical loading perpendicular to the axis signifcantly
reduced expression oI both molecules. Further mechanism
study revealed that either enIorced elongated cell morphology
or paralleled loading led to increased level oI RhoA-GTP and
reduced ROCK activity. Moreover, artifcial RhoA activation
with LPA and artifcial inhibition oI ROCK with Y-27632
enhanced the expression oI tenomodulin and collagen I.
Conclusion: This study verifes the newly proposed
hypothesis regarding key Iactors Ior mimicking tenocyte
niches, which is currently employed to transdiIIerentiate
dermal fbrolasts or diIIerentiate MSCs into tenocytes.
85
CD4-CD8- DOUBLE NEGATIVE
REGULATORY T CELL BASED THERAPY
PERMITS PERMANENT ENGRAFTMENT IN
MOUSE CTA MODEL
Presenter: ChengHung Lin, MD
Authors: Lin CH, Ng TW, Zhang D, Zhang WS,
Brandacher G, Lee WP, Zheng XX
University of Pittsburgh Medical Center
Background: Composite tissue allotransplantation (CTA)
can restore appearance, Iunction and dignity to the deIormed
patient. But CTA requires high-dosed immunosuppressive
drugs, which can cause severe side eIIects. Regulatory cell-
based therapy may wean patients oII immunosuppressants. In
our previous report, ex vivo CD4 T-cells converted CD4-
CD8- double negative regulatory T cells (DN Tregs), which
regulate allo- and auto- immune responses, signifcantly
prolong islet allograIt survival. In this study, we explore the
DN Treg-based therapy in mouse CTA model.
Materials and Methods: We tested the DN Treg-based
therapy (5 x 10
6
) with a short course oI low-dosed
immunosuppressant, rapamycin (0.6 mg/kg/day Ior 28 days),
in an MHC completely mismatched mouse heterotopic
CTA model (DBA/2 to C57BL/6). Antilymphocyte serum
(ALS) and/or IL-2/Fc Iusion protein were also used in the
experimental groups in conjunction with DN Tregs and
rapamycin.
Results: DN Tregs and rapamycin had a synergistic eIIect
on decreasing both CD4 and CD8 T cell proliIeration
and increasing apoptosis detected by signifcantly induced
Annexin V staining Ior both CD4 and CD8 T cells in
vivo. In mouse CTA model, the single transIer oI DN Tregs
plus 28-day IL-2/Fc and low-dosed rapamycin treatment
signifcantly prolonged hindlimb allograIt survival in
comparison with untreated group (MST 46 days vs. 10 days,
p0.0026) and IL-2/Fc plus rapamycin treated group (MST
46 days vs. 32 days, p0.0064). Moreover, the addition oI
ALS to DN Tregs, rapamycin and IL-2/Fc treatment could
achieve permanent engraItment in mouse CTA model (~ 100
days). Macrochimerism was detected 30 days aIter hindlimb
osteomyocutaneous fap transplantation. Moreover, signifcant
increase oI CD4Foxp3 Tregs was Iound over the period oI 3
months post transplantation.
Conclusion: Using ex vivo CD4 T-cells converted DN Tregs
is a highly potent and antigen specifc induction method.
Our results in mouse CTA model support the concept and
the Ieasibility oI potentially utilizing this novel cell-based
therapeutic approach Ior the prevention oI composite tissue
allograIt rejection.
86
SPATIALLY CONTROLLED DELIVERY
OF NEUROTROPHIC FACTORS IN SILK
FIBROIN-BASED NERVE CONDUITS FOR
PERIPHERAL NERVE REPAIR
Presenter: YenChih Lin, PhD
Authors: Lin YC, Ramadan MH, Philips BJ,
Tupaj M, Kaplan DL, Sivak W, Rubin JP,
Marra KG
University of Pittsburgh
Background: Long gap peripheral nerve damage remains
a clinical challenge. One approach is to maximize the
delivery oI neurotrophic Iactors, such as glial cell line-
derived neurotrophic Iactor (GNDF), in the distal region oI a
peripheral nerve wound. The aim oI our study was to evaluate
the eIfcacy oI silk fbroin-based nerve guides containing a
uniIorm distribution compared to a higher concentration oI
GDNF in the distal portion oI a critical-sized rat sciatic nerve
deIect model.
Methods: Three groups oI silk conduits were prepared: (1)
Silk conduits with empty silk microspheres, (2) Silk conduits
with GDNF-loaded silk microspheres uniIormly distributed
in the conduit wall, and (3) Silk conduits with GDNF-loaded
silk microspheres with the highest GDNF concentration at the
distal end. The guides were sterilized, hydrated and cut at 1.7
cm. Eight guides in each group were implanted in a 1.5 cm
male Lewis rat sciatic nerve deIect. The rats were Iollowed Ior
six weeks, then the nerve graIts were explanted, harvested and
fxed Ior histological analysis.
Results: Nerve tissue stained with the Schwann cell S-100
antibody demonstrated a signifcantly increased density oI
Schwann cells in both GDNF-treated groups compared to
the control group. Higher GDNF-distribution at the distal
end treated animals possessed a higher density oI PGP 9.5
protein in middle conduit than compared to GDNF uniIorm-
treated animals. As expected, no signifcant diIIerences in
gastrocnemius calI muscle weights were observed at this early
time point.
Conclusion: Silk-based nerve conduits possess optimal
mechanical and degradative properties, rendering them
potentially useIul in peripheral nerve repair. This study
demonstrates that novel, porous silk fbroin-based nerve
conduits, inIused with GDNF in a controlled, spatial
distribution, represent a potentially viable conduit not only Ior
Schwann cell migration and proliIeration but also Ior axonal
regeneration in the repair oI peripheral nerves.
52
87
GRADED NERVE MODULATION USING A
BIOMEMS DEVICE
Presenter: Samuel Lin, MD
Authors: Lin S, Song YA, Rabie AN, Ibrahim AM,
Han J, Lin SJ
Beth Israel Deaconess Medical Center Harvard Medical
School
Background: Neuropathic pain and neuromuscular synkinesis
with recovery oI an injured nerve remains a complex issue.
Currently there is no eIIective strategy Ior inhibiting nerve
signals that is graded or reversible. A neural prosthetic device
that can block nerve impulse progression may allow Ior pain
control in a more eIfcient and physiological method. For this
purpose, we have attempted to modulate the concentrations
oI K, Na, Mg2 ions around the sciatic nerve in-situ to
induce reversible inhibitory conditions Ior motor activities as
an initial model. This method lends itselI to a miniaturization
in the Iorm oI an small bioMEMS (Microelectro-mechanical
Systems) implantable device Ior localized selective nerve
blocking.
Materials and Methods: Sciatic nerves oI 10 Irogs (Rana
Catesbeiana) were utilized Ior in-vitro electrochemical local
nerve inhibition via modulation oI the concentration oI
K, Na and Mg2 ions around the nerve in-situ using the
ion-selective electrodes (ISE). Action potentials and muscle
contractions were recorded as outputs oI the graded nerve
blocking with a diIIerential amplifer and a Iorce transducer.
Results: Depleting K ions Ior 5 minutes at a depletion
current oI 100nA-1A and applying a pulse train oI
electrical stimuli Irom 4 A to 15 A caused muscle twitch
amplitude decrease compared to the non-depleted condition
by approximately 50. AIter reversing the polarity and
injecting K ions Ior 5 min. at i100nA, no muscle response
could be recorded even at signifcantly higher current pulses
above 18 A. Interestingly, this blocking eIIect, however,
was reversible. AIter perIusing Ringer`s solution on the
blocking site and waiting Ior about 10 minutes, the nerve was
responsive again.
Conclusions: We demonstrate an electrochemical, local
nerve inhibition method via an active control oI ion
concentration along the nerve is potentially Ieasible. An
implantable low-power neural prosthetic device Ior treatment
oI chronic painIul conditions may provide a platIorm Ior
the management oI neuropathy and Iacial nerve synkinesis
resulting Irom trauma.
88
PATTERNS OF ANTIBIOTIC USE
AND SURGICAL SITE INFECTION
IN AUTOLOGOUS BREAST
RECONSTRUCTION
Original Presenter: Daniel Z. Liu, MD
New Presenter: Janelle A. Dubbins, MD
Authors: Liu DZ, Dubbins JA, Mathes DW
University of Washington
Background: InIection rates Ior surgical treatment oI breast
cancer are documented at 3-15, higher than average Ior a
clean surgical procedure. Pre- and postoperative antibiotics
have been Iound to be useIul in lowering inIection rates in
other surgical groups, yet there is no current consensus on
postoperative prophylactic antibiotic use in autologous breast
reconstruction.
Methods: A retrospective review oI consecutive patients with
autologous breast reconstruction between September 2006
and September 2010 was perIormed. Specifc risk Iactors Ior
autologous reconstruction were reviewed, including American
Society oI Anesthesiologists class, obesity, smoking, medical
comorbidities, irradiation, and chemotherapy history. Data
were collected on the type and duration oI prophylactic
antibiotics. The incidence oI surgical site inIections (SSI) was
measured using Centers Ior Disease Control and Prevention
criteria.
Results: Two hundred and fIty-six patients with 360 breast
Iree faps who received both preoperative and postoperative
prophylactic antibiotics were analyzed. The overall SSI rate
was 17.8 (46 oI 256 patients). SSI was correlated with
increased age, tobacco use, prior radiation, and immediate
reconstruction. The duration oI postoperative antibiotic use
did not diIIer statistically in those patients who developed SSI
(6.4 days versus 7.6 days, p 0.24). Eighty-six (34) patients
received only 24 hours oI postoperative antibiotics, while
170 (66) patients received more than 24 hours oI antibiotics
Ior a median duration oI 10 days. There was no statistically
signifcant diIIerence in the overall SSI rate in those who
received more than 24 hours oI antibiotics (14 versus 24,
p 0.055).
Conclusions: There was no reduction in the overall SSI
rate among those who received postoperative antibiotic
prophylaxis Ior more than 24 hours. Due to potential adverse
events related to prolonged antibiotic use, this practice is
not recommended in the autologous breast reconstruction
population.
89
COMPARISON OF AAV-DS-VEGF AND
AAV-SS-VEGF: EFFICACY OF IN VITRO
TRANSGENE EXPRESSION AND IN VIVO
ISCHEMIC FLAP SURVIVAL
Presenter: PY Liu, MD
Authors: Liu PY, Avanessian B, Ma QZ, DurIee H,
Tang YQ, Wang XT
Roger Williams Medical Center
Introduction: Conventional recombinant adeno-associated
virus (rAAV) vectors are single-stranded DNA vectors,
which need conversion to double-stranded DNA prior
to transcription, thus delaying expression oI transgene.
Previously, we reported that rAAV-VEGF gene transIer to
rat ischemic faps improved fap survival when injected two
weeks beIore fap elevation. Here we compare the transgene
expression eIfcacy oI single-stranded (SS) and double-
stranded AAV (DS) mediated human VEGF gene transIer
and the eIfciency in enhancing ischemic fap survival when
injected one week beIore fap elevation, as well as in vitro
work demonstrating superiority oI the DS-AAV-VEGF in
producing protein, inIecting target cells, and enhancing cell
motility.
Materials and Methods: 293 cells were transduced with
AAV-DS-VEGF or AAV-SS-VEGF. Non-treatment was as
control. The supernatant was harvested at day 3 and 7 Ior
human VEGF ELISA. Primary DB/DB and DBm fbroblasts
were transduced with AAV-DS-VEGF and AAV-SS-VEGF
(MOI100, n4). Non-treatment was as control. Day 3
supernatant was harvested Ior ELISA analysis. We perIormed
in vitro wound healing assay by scratching transduced cells
and recording the healing Ior 48 hours using an IncuCyte
system.
AAV-SS-VEGF and AAV-DS-VEGF (n10) constructs were
injected into the dorsae oI rats. The controls received saline
or AAV-SS-GFP injection. One week later, a fap oI 10 cm x 3
cm was raised. One week post-surgery, we evaluated the fap
viability and harvested the injected and surviving fap tissues
Ior histology.
Results: Both AAV-SS-VEGF and AAV-DS-VEGF-treated
293 cells produced more VEGF than control at all MOIs. AAV-
DS-VEGF -treated cell supernatant had higher expression than
AAV-SS-VEGF supernatant at all MOIs tested. AAV-DS-
VEGF very signifcantly improved fap survival (57.2+5.5)
compared to saline group (48+5.1) and AAV-SS-GFP
group (45.9+6.3, p 0.01, both comparisons).
Conclusion: AAV-DS-VEGF produces higher and earlier
transgene expression than AAV-SS-VEGF, and improves fap
survival compared to controls or AAV-SS-VEGF in a time
interval that may enhance clinical relevance.
90
THE SAFE BREAST AUGMENTATION LIFT:
THE 360-DEGREE CIRCUMFERENTIAL
PEDICLE
Presenter: Kevin LuItman, MD
Authors: LuItman K, OBrien M, Hazani R, Rao A,
Wilhelmi BJ
Introduction: The breast augmentation mammoplasty liIt
may be one oI the most challenging procedures in plastic
surgery. This procedure has several potential complications
including nipple loss, nipple dennervation, asymmetry,
implant malposition, implant exposure, and persitent ptosis.
Failure to preserve nipple circulation and innervation can
result Irom maintaining the nipple on an unreliable pedicle
which is worsened with simultaneous implant insertion. The
aim oI this project is to describe a technique, 360-degree
pedicle liIt, that can be used inconjunction with augmentation
to reduce the risk Ior nipple compromise complications.
Methods: This is a retrospective review oI 28 augmentation
mammoplasty liIt procedures in sixteen patients using a newly
described 360-degree circumIerential pedicle and inverted
T pattern skin scar. With the 360-degree pedicle, the nipple
is preserved with a de-epithelialized 360 circumIerential
pedicle and the implant is placed inIeriorly through a small
incision away Irom the pedicle to the nipple. Four oI these
patients underwent unilateral breast implant and mastopexy
as a symmetry procedure Ior reconstruction. The other twelve
were bilateral cosmetic breast augmentation liIt procedures.
The average patient age was 40.1 years.
Results: All sixteen oI these patients had 28 nipples survive
and normal sensation. None oI these patients developed
implant exposure or inIections. None oI these patients
required an additional procedure with a range oI 6 months to
3 years Iollow-up. The range oI implant size was 200-500cc
with and average size oI 350cc. In this review 20 oI the breast
implants were silicone and 8 were saline.
Conclusion: The 360-degree circumIerential pedicle can
provide the most reliable arterial perIusion, venous drainage,
and preservation oI sensation to the nipple in breast augment
liIt procedures. This 360-degree technique is a rational
modifcation to optimize nipple preservation and sensation.
54
91
NERVE GAP REPAIR WITH ALLOGENIC
EPINEURAL TUBES SUPPORTED WITH
BONE MARROW STROMAL CELLS (BMSC)
THERAPY AS AN ALTERNATIVE TO
AUTOGRAFT REPAIR
Presenter: Maria Madajka, PhD
Authors: Madajka M, Mendiola A, Brzezicki G,
Mendiola A, Siemionow M
Cleveland Clinic
Introduction: We introduced novel conduits oI allogenic
epineural tube, flled with autologous or allogenic BMSC.
Epineural tube has low immunogenic potential as it lacks
the Schwann cells responsible Ior rejection. Bone Marrow
Stromal Cells (BMSC) are immunologically neutral and can
provide neurotrophic Iactors supporting axon growth.
Materials and Methods: 72 epineural tubes were transplanted
across MHC barrier, without immunosuppression, to bridge
20 mm nerve gap deIects in 3 groups. Group 1: the tube
was flled with saline, Groups 2 and 3 with isogenic and
allogenic BMSC, respectively. 18 autograIts served as
controls. Nerve regeneration was evaluated by somatosensory
evoked potentials, muscle weight, histomorphometry and
immunostaining at 6, 12 and 24 weeks post transplantation.
Results: Nerve regeneration was present in all groups.
Overall, saline flled conduits perIormed inIeriorly to BMSC
supported constructs, as evidenced by lower wet muscle
ratios and histomorphometric measures. Nerve repair with
epineural/BMSC conduits, especially with isogenic BMSC,
yielded comparable or better results (muscle reinnervation at
12 weeks) to autograIt repair.
Conclusion: Allogenic epineural conduit combined with
local BMSC supportive therapy is a promising alternative to
autograIt repair with the elimination oI toxic immunotherapy.
92
RECOVERY OF SENSATION IN THE
RECONSTRUCTED BREAST
Presenter: Michael Magarakis, MD
Authors: Magarakis M, Venkat R, Dellon LA,
Bellamy J, Vaca E, Manahan MA,
Edwards C, Rosson GD
Johns Hopkins School of Medicine
Background: Return oI sensation aIter breast reconstruction
in patients that had undergone radiation therapy with
or without concomitant fap neurotization has not been
thoroughly studied. We sought to evaluate the return oI
sensation aIter breast reconstruction and identiIy Iactors that
may predict a suboptimal sensation recovery.
Methods: Thirty-seven patients (74 breasts), with deep
inIerior epigastric artery perIorator (DIEP) fap (n27) or
implant-based reconstruction (n29) with a minimum post-
operative interval oI 18 months, were included in the study.
Our primary outcome was mean static and moving pressure
(gm/mm
2
), as perceived by the patients, measured by the
Pressure-Specifed Sensory Device (PSSD) in 9 areas oI the
breast.
Results: The non-neurotized DIEP fap skin had a poorer
mean static (67.3 gm/mm
2
vs. 45.6 gm/mm
2
) and moving
(45.8 gm/mm2 vs. 23.6 gm/mm
2
) sensation compared to
the inner quadrants oI the skin overlying the implants.
Multivariate analysis adjusting Ior BMI, chemotherapy,
time since surgery and timing oI reconstruction (immediate,
staged or delayed), while accounting Ior within person
correlations showed that in the absence oI radiation, implants
are associated with better sensation (static, p0.0001; moving,
p0.0001) compared to DIEP faps. Radiation therapy was
Iound to negatively aIIect sensation recovery among implant-
based reconstructions in an independent manner (static,
p0.002; moving, p0.014). A subgroup analysis oI DIEP
faps (neurotized |n6| vs non-neurotized |n21|) showed
that in the absence oI radiation, neurotization was associated
with better static (60.6 gm/mm
2
vs 77.2 gm/mm
2
) and moving
sensation (30.9 gm/mm
2
vs 59.2 gm/mm
2
) in the DIEP fap
skin island.
Conclusion: In the absence oI radiation, skin territories
overlying implants are associated with a better sensation
recovery compared to DIEP faps. Neurotization, in the
absence oI radiation therapy, appeared to improve sensation
in DIEP faps. Radiation inhibited sensation in implant-based
reconstruction. Prospective studies are warranted to Iurther
evaluate the sensation recovery in breast reconstruction.
93
SAFETY OF RHYTIDECTOMY IN THE
ELDERLY
Presenter: Esteban Marten, MD, MPH
Authors: Marten E, Langevin CJ, Kaswan S, Zins JE
Cleveland Clinic
Purpose: The purpose oI our study was to evaluate the saIety
oI IaceliIt surgery in an elderly population. Specifcally,
is chronologic age an independent risk Iactor leading to a
higher complication rate in the elderly patient undergoing
rhytidectomy surgery?
Methods: We retrospectively reviewed consecutive IaceliIts
(216 patients) perIormed by a single surgeon at our institution
over a three-year period. Patients were then divided into two
groups, under age 65 (148 patients) and age 65 and older (68
patients). Co-morbidities, operative details, and complications
were compared using statistical analysis.
Results: The average age was 70.0 years in the elderly group
and 57.6 years in the younger group. When compared to
the patients under age 65, elderly patients were more likely
to have a higher ASA score and to have had a prior IaceliIt
(41.2 vs. 17.6, p0.001, Fisher Exact Test). The elderly
underwent just as many extended SMAS dissections (73.5
vs. 83.8, p0.077), major adjunctive procedures (69.2 oI
patients vs. 84.6, p0.10) and minor adjunctive procedures
(27.9 oI patients vs. 28.4, p0.58, Cochran-Mantel-
Haenszel Exact Test), yet they had slightly shorter operative
times. The elderly had complication rates comparable to
those oI younger patients (2.9 vs. 2.0 major, p0.65 and
5.9 vs. 6.1 minor, p0.99, Fisher Exact Test). However,
there were non-signifcant trends towards higher major
complication rates in patients age 70 and older (Relative Risk
2.74, Confdence Interval (0.5, 14.96), p0.24) and higher
minor complication rates in patients age 75 and older (RR
2.28, CI (0.50, 10.39), p0.29, Poisson Regression Model).
There were no deaths in either group.
Conclusions: In our series oI careIully selected elderly
patients age 65 and older, IaceliIt complication rates were not
statistically diIIerent when compared to a younger control
group. Our data suggest that chronologic age alone was not
an independent risk Iactor Ior IaceliIt surgery. Further studies
are needed to defne whether a chronologic age limit Ior saIe
IaceliIt surgery beyond age 65 exists.
94
DIMENSIONAL CONSIDERATIONS FOR
OPERATIVE REPAIR OF THE FRACTURED
PEDIATRIC ORBIT
Presenter: Matthew Martin, MD
Authors: Martin M, Rechner B
Grand Rapids Medical Education Partners
Objective: Orbital depth has been measured in adults and
is known to be about 45mm. Knowledge oI this distance
helps prevent violation oI the optic nerve during orbital
Iracture repair, avoiding the potentially grave consequence
oI postoperative vision loss. However, the distance to this
anatomic landmark has not previously been elucidated in
pediatric patients. Consequently, the present study establishes
such distances to Iacilitate saIer exploration and Iracture
reduction in the pediatric orbit.
Methods: The present study is an IRB-approved,
retrospective analysis oI maxilloIacial and sinus CT scans oI
patients aged 1 month to 18 years at Helen DeVos Children`s
Hospital in Grand Rapids, Michigan. CT scans were stratifed
by patient age into 14 groupings. 30 CT scans per age group
(420 scans in total) were analyzed. Data points included
patient age, sex, and mean orbital depth, as measured Irom the
inIerior orbital rim to the optic canal.
Results: Mean orbital depth was 28.9 mm in inIancy, which is
64 oI the established adult distance. Mean orbital depth was
85 oI the established adult distance by 3 years oI age (38.5
mm), and 95 oI the established adult distance by 8 years oI
age (42.9 mm).
Conclusion: In this series, orbital depth averages 64 oI the
established adult value in inIancy, and 95 oI the established
adult value by age 8. It is our hope that a more clear
understanding oI orbital depth will help Iacilitate the saIest
possible exploration and operative repair in pediatric orbital
Iractures.
56
95
POST-MASTECTOMY RECONSTRUCTION
PREFERENCES IN THE PRE- AND POST-
BARIATRIC SURGERY POPULATIONS
Presenter: Marissa R. Matarrese, MD
Authors: Matarrese MR, Hendrickson V, GusenoII JA
University of Rochester Medical Center
Background: Women have several options Ior post-
mastectomy breast reconstruction. Signifcant research
has been done to ascertain the psychological and cosmetic
outcomes oI women who have undergone various
reconstruction methods, but no studies have addressed these
issues in the bariatric population. This study examines how
educating Iemale pre- and post-bariatric patients about the
potential complications oI breast reconstruction while still
obese changes their desire Ior immediate versus delayed
reconstruction.
Methods: Women without a prior diagnosis oI breast cancer
who were considering bariatric surgery or who had undergone
bariatric surgery were surveyed regarding their preIerences
Ior post-mastectomy reconstruction. Outcomes included
preIerence Ior immediate versus delayed reconstruction, most
appealing Iorm oI reconstruction, and their likelihood oI
undergoing immediate reconstruction iI it involved a higher
complication rate or additional surgery to correct skin laxity.
Results: 86 women were surveyed, 37 who had undergone
bariatric surgery and 49 who were considering bariatric
surgery. In both groups, most patients preIerred immediate
over delayed reconstruction but were unsure oI what kind
oI reconstruction they would want (implant vs autologous).
InIorming women that obesity increases the rate oI wound
healing complications did not signifcantly change their
desire Ior immediate reconstruction. However, inIorming
them that additional surgery may be required to revise their
reconstruction iI they lost weight Iollowing reconstruction
signifcantly increased the percentage oI women who were
willing to delay reconstruction (p0.0001).
Conclusion: Women who have undergone or are considering
bariatric surgery are more likely to delay post-mastectomy
breast reconstruction iI they are educated on the potential Ior
revision surgery iI they continue to lose weight. Interestingly,
inIorming the same women oI the increased risk oI wound
healing complications iI they undergo breast reconstruction
while obese does not discourage them Irom considering
immediate breast reconstruction.
96
LONG-TERM TOLERANCE TO COMPOSITE
TISSUE ALLOGRAFT IS DEPENDENT ON
ADMINISTRATION OF BONE MARROW
BUT NOT DURABLE DONOR CELL
CHIMERISM
Original Presenter: David W. Mathes, MD
New Presenter: JeII Chang, MD
Authors: Mathes DW, Chang J, Hwang B,
Miwongtum T, Graves S, Storb R
University of Washington Medical Center
Purpose: The use oI composite tissue allograIts (CTA) has
become a clinical reality with the successIul transplantation
oI hand, abdomen, and partial Iace. However, the survival oI
these transplants is dependent on immunosupression. The
purpose oI this experiment was to develop a large animal
model Ior the simultaneous transplantation oI HSC and CTA
using our established mixed chimerism protocol. We also
sought to examine the role oI the HSC inIusion in our mixed
chimerism protocol.
Methods: 4 simultaneous transplants were perIormed across
a MHC matched, minor mismatch barrier. All dogs received
200 cGy oI radiation on the day oI transplant. They then
underwent a CTA transplant (myocutaneous rectus fap) with
intraoperative injection oI HSC. 2 Dogs underwent the same
protocol except without any HSC inIusion. All dogs were
treated with post-graIting immunosuppression (35 days oI
cyclosporine and 28 days oI Mycophenolate MoIetil). The
animals were Iollowed Ior donor chimerism in the peripheral
blood. The allograIts underwent routine biopsies and Iollowed
clinically. Finally, they were Iollowed Ior the levels oI FoxP3,
TGF-B, IL-10, Granzyme B expression in the CD3 cell
populations derived Irom their peripheral blood, transplant
muscle and transplant skin.
Results: All oI the experimental animals have demonstrated
long-term tolerance to their CTA allograIt (497, 467, 465, and
354 days aIter transplant). Only 3 oI the 4 dogs has detectable
donor chimerism. One dog lost donor cell chimerism at 10
weeks post-transplant but remained tolerant to the allograIt.
The level oI Foxp3 decreased in the peripheral blood but
was stable in both the skin and muscle. The two dogs that
underwent the transplant protocol minus the HSC rejected
their transplant 40 to 45 days aIter cessation oI post-graIting
immunosuppression.
Conclusion: This study demonstrates simultaneous
transplantation oI HSC and CTA is Ieasible and leads to
tolerance to both the skin and muscle and is dependent on the
adminstration oI the HSC at the time oI transplant. However,
tolerance in this model is not dependent on the persistence oI
donor cell chimerism.
97
MEDICAL STUDENT PERCEPTIONS OF
PLASTIC SURGEONS AS HAND SURGERY
SPECIALISTS: THE UNIVERSITY OF UTAH
EXPERIENCE
Presenter: Shaun D. Mendenhall, BA
Authors: Mendenhall SD, Hopkins PN, Agarwal JP
University of Utah
Background: Many people are unIamiliar with the role oI
plastic surgeons in hand surgery. The reason Ior this is likely
multiIactorial including stereotypes conveyed by popular
media, the diminishing presence oI plastic surgeons in
hand surgery, and poor medical student education. OI these
Iactors, the latter is oI particular importance because medical
education serves to guide career choices and begins to build
Iramework Ior appropriate reIerral patterns. This study
explores medical student perceptions about hand surgery.
Methods: Students oI the Univ oI Utah SOM were given an
online survey consisting oI 24 clinical scenarios, 8 oI which
were specifc to hand surgery. Students chose who would best
manage each scenario Irom 10 surgical specialties listed. They
indicated their level oI training and whether they had clinical
exposure to plastic surgery or other surgical subspecialties.
Data were analyzed using Chi-square and multiple logistic
regression.
Results: There were 230 oI 408 who completed the survey.
Over the 4 years oI training, 13-29 had clinical exposure
to plastic surgery. Students generally chose at least one
acceptable surgical specialty Ior reIerral (91-96) with
signifcant improvement over the course oI their training.
Although a prior rotation in plastic surgery signifcantly
increased the selection oI plastic surgery Ior all clinical
scenarios (23 vs 46, p0.003), the majority oI students did
not appreciate plastic surgeons to be hand surgeons.
Conclusion: Many medical students do not perceive plastic
surgeons as hand surgeons. The impact this trend may have
on the Iuture oI hand surgery Ior plastic surgeons in unknown.
However, it is possible that iI plastic surgeons don`t take
more ownership oI hand surgery by better educating Iuture
physicians that this may contribute to a decline in hand
reIerrals and a gradual phasing out oI hand surgery Ior plastic
surgeons.
98
FUNCTIONAL OUTCOMES OF REPAIR OF
2 CM RAT SCIATIC NERVE DEFECT WITH
AN ALLOGENIC TISSUE ENGINEERED
BONE MARROW STROMAL CELL
EPINEURAL CONSTRUCT
Presenter: Amanda Mendiola, MD
Authors: Mendiola A, Madajka M, Brzezicki G,
Gatherwright J, Siemionow M
Cleveland Clinic Foundation
Objective: To engineer a bone marrow stromal cell (BMSC)
epineural construct Ior nerve repair by combining the
neurotrophic eIIects oI the epineural sheath with bone marrow
stromal cells (BMSC). We hoped to create a synergistic eIIect
in vivo by combining them ex vivo prior to implantation.
Methods: A total oI 6 Iully allogenic |ACI (RT1a) to LEW
(RT1l)| stromal cell epineural constructs were created by
flling an empty allogenic epineural sheath with 3x10
6
isogenic BMSC and cultured in media Ior 10 days. 2
experimental groups had a 2 cm sciatic nerve deIect repaired
in Lewis rats. Group 1: Repair with the allogenic SCEC.
Group 2: AutograIt repair. Animals were evaluated at 6 weeks.
Nerve regeneration was assessed using SSEP, pin prick (PP),
and toe spread (TS). The SSEP results were calculated as
percentages oI the unoperated side to serve as an intra-animal
control and to account Ior diIIerent planes oI anesthesia Ior
each animal. Muscle denervation atrophy was evaluated by
gastrocnemius muscle index (GMI).
Results: Macroscopic observation revealed nerve
regeneration through the tube without any signs oI rejection.
The SCEC group showed better PP with Iull sensory recovery
at 6 weeks while the autograIt repair demonstrated an average
PP oI 2.88 at 6 weeks. At 6 weeks both groups displayed
comparable TS score oI 0.75 Ior SCEC and 1 Ior the autograIt
group. GMI calculations revealed a slightly higher score
Ior SCEC (0.34 vs 0.27). The P1 latencies were comparable
between the two groups (112.31 Ior SCEC and 111.98 Ior
autograIt). N2 latencies were similar as well. The autograIt
group exhibited higher amplitude at 68.77 than SCEC
(51.40), but the diIIerence was not signifcant.
Conclusion: The allogenic construct supported nerve
regeneration without any signs oI rejection. Although this is
preliminary data, it shows a trend that SCEC has comparable
or better Iunctional results to an autograIt. This novel
technique could be a Iuture alternative to peripheral nerve
repair.
58
99
EXTENDED POSTOPERATIVE ANTIBIOTIC
PROPHYLAXIS TO PREVENT LATE
BREAST IMPLANT INFECTIONS IN THE
IRRADIATED CHEST WALL
Presenter: Michael N. Mirzabeigi, MS
Authors: Mirzabeigi MN, Lee M, Smartt JM,
Jandali S, Sonnad SS, Serletti JM
University of Pennsylvania
Background: Previously irradiated patients can be
particularly challenging candidates Ior implant reconstruction
due to troublesome rates oI inIection. The issue oI antibiotic
prophylaxis remains controversial, and evidence-based
postoperative strategies to reduce implant inIections have not
been well-described in the literature. The purpose oI this study
is to determine the eIfcacy oI long-term trimethoprim &
sulIamethoxazole (TMP/SMX) therapy Ior preventing implant
inIections in patients with a previously irradiated chest wall.
Methods: A retrospective chart review was perIormed on all
patients undergoing implant reconstruction Irom January 2005
to December 2008. Prior to 2007, the senior author commonly
utilized short term (5-7 days) antibiotic prophylaxis Iollowing
implant reconstructions. Following this time period, the
postoperative prophylactic regimen was then amended as to
provide all patients with previous chest wall irradiation and
subsequent implant reconstruction with prophylactic TMP/
SMX Ior 30 days Iollowing implant insertion.
Results: A total oI 51 post-radiation implant reconstructions
were perIormed on 46 patients. The study population was
divided into 2 groups: 26 implant reconstructions without
extended TMP/SMX prophylaxis (control group) and
25 implant reconstructions with 30 days oI TMP/SMX
prophylaxis (TMP/SMX group). The control group had an
implant inIection rate oI 35 percent as compared to 8 percent
Ior the TMP/SMX group (p 0.021). The control group
was subdivided into 2 groups: 19 implant reconstructions
received 5-7 days oI cephalosporin prophylaxis (routine
antibiotics group) and 7 implant reconstructions received
no postoperative prophylaxis (no antibiotics group). The
routine antibiotics group had an inIection rate oI 42 percent as
compared to 8 percent Ior the TMP/SMX group (p 0.0075).
Conclusion: A month-long course oI TMP/SMX was proven
to be more eIIective than routine perioperative antibiotics in
preventing implant inIections. Extended TMP/SMX therapy
serves as an eIIective adjunctive measure Ior reducing the rate
oI implant inIections in breast reconstruction.
100
INVESTIGATION OF AN ATHYMIC MOUSE
MODEL OF HUMAN HYPERTROPHIC SCAR
FORMATION
Presenter: Moein Momtazi, MD
Authors: Momtazi M, Kwan P, Ding J, Anderson C,
Honardoust D, Goekjian S, Tredget EE
University of Alberta
Purpose: Hypertrophic scar (HSc) is a dermal
fbroproliIerative disorder that imposes signifcant Iunctional
and cosmetic limitations. Lack oI a relevant animal model is a
barrier towards better understanding the mechanisms involved
in these processes. The objective oI this study is to validate
the nude mouse animal model Ior the study oI human HSc.
Methods: There were a total oI 5 animal groups with 5
mice in each group. Groups 1 through 4 received split
thickness human skin graIts. Animals in control group 5 were
autograIted with Iull thickness nude mouse skin. Wounds
were photographed weekly to document healing. Animals
were euthanized at 30, 60, 120 and 180 days post-operatively.
At each time point, scar biopsies and normal skin samples
were harvested. Morphologic analysis was conducted
using a modifed Manchester Scar Scale to evaluate scar
images by 5 independent, blinded evaluators. Histological
analysis consisted oI skin thickness measurements and
immunohistochemistry Ior decorin expression.
Results: Macroscopically 19/20 mice (95) receiving split
thickness human skin graIts developed frm, elevated wounds
similar to human HSc that persisted at 180 days post-graIting.
Conversely, mice autograIted with Iull thickness skin
demonstrated healed wounds similar to normal nude mouse
skin. Mice graIted with human skin had an average scar score
oI 9.93 +0.13 compared to 5.92 +0.23 Ior autograIted controls
(p0.01). Histologically, these wounds are hypercellular,
hypervascular, possess an abundance oI disorganized, whorl-
like collagen fbers and express less decorin compared to
normal skin. Average HSc thickness was 540.9 +15.7 m,
compared to 157.0 +3.3 m Ior normal unwounded skin
(p0.00001). This represents an average increase in thickness
oI 347.1 +9.2 compared to normal unwounded skin and
254.0 +7.4 compared to the original split thickness human
skin graIt.
Conclusions: GraIting split thickness human skin onto
nude mice results in persistent wounds that demonstrate
morphological and histological similarity to human HSc.
ThereIore, this model is a promising technique to study HSc
Iormation.
101
ASSESSMENT OF MITOCHONDRIAL
CALCIUM (MCA2+) OVERLOAD AND
FUNCTION IN EX VIVO HUMAN SKELETAL
MUSCLE UNDERGOING ISCHEMIA AND
REPERFUSION (I/R)
Presenter: Andreas Naparus, MBBS, BSc, AICSM
Authors: Naparus A, HoIer S, Cahoon N,
McAllister S, AshraIpour H, Huang N,
Zhong T, Lipa J, Neligan P, Pang CY
Hospital for Sick Children Toronto
Introduction: There is evidence in pig skeletal muscle that
inhibition oI ATP synthesis as a result oI mCa2 overload
is the main cause oI I/R injury. This pathogenesis oI I/R
injury has yet to be verifed in the human skeletal muscle. To
this end, the aim oI this study was to assess the mCa2 and
muscle ATP content, muscle injury and muscle necrosis in ex
vivo human skeletal muscle undergoing I/R injury.
Methods: Muscle strips (1x15 mm) derived Irom human
rectus abdominis muscle biopsies were assigned to Iour
groups Ior culture in Krebs buIIer at 37C: (1) 5h normoxic
control; (2) 3h hypoxia (ischemia)/2h reoxygenation
(reperIusion); (3) cyclosporine A (CsA, 10-6M) aIter 3h
hypoxia Iollowed by 2h reoxygenation; and (4) NIM 811
(10-6M) aIter 3h hypoxia Iollowed by 2h reoxygenation. CsA
and NIM 811 are mitochondrial permeability pore inhibitors
(mPTP) known to inhibit mCa2 overload in pig skeletal
muscle. Muscle hypoxia and reoxygenation were achieved by
bubbling the buIIer with 95N/5CO
2
and 95O
2
/5CO
2
,
respectively. mCa2 content was measured by atomic
absorption spectrometry. Mitochondrial Iunction, muscle
injury and viability were assessed by measuring muscle ATP
content, LDH release and MTT reduction, respectively.
Results: AIter 3h hypoxia/2h reoxygenation, the mCa2
content increased Irom 1.04+0.08 to 1.64+0.20 g/mg prot.,
the muscle ATP content reduced Irom 11.4+1.5 to 6.0+1.3
mol/g prot., muscle LDH release increased Irom 111+13 to
211+31 U/g wet wt., and muscle MTT reduction decreased
Irom 0.75+0.06 to 0.45+0.06 OD/mg wet wt., compared with
the 5h normoxic control (n6; p 0.05). CsA or NIM 811
treatment given at the end oI 3h hypoxia kept the mCa2
content, ATP content, LDH release, and MTT reduction
similar to those oI the normoxic control assessed at the end oI
2h reoxygenation (n4-6).
Conclusion: Inhibition oI ATP synthesis as a result oI mCa2
overload causes I/R in ex vivo human skeletal muscle.
The mPTP inhibitors CsA (clinical drug) and NIM 811 are
eIIective in salvage oI ex vivo ischemic human skeletal
muscle Irom I/R injury by inhibition oI mCa
2
overload.
102
SAFETY OF PRE-OPERATIVE
ERYTHROPOIETIN IN SURGICAL
CALVARIAL REMODELING: AN 8-YEAR
RETROSPECTIVE REVIEW AND ANALYSIS
Presenter: Sanjay Naran, MD
Authors: Naran S, Cladis F, Fearon J, Bradley J,
Michelotti B, Cooper G, Cray Jr J,
Kinsella C, Katchikian H, Miller R,
Grunwaldt L, Losee J
Introduction: Calvarial remodeling is a complex, high
blood loss procedure. Preoperative erythropoiesis stimulating
agents have proven to signifcantly decrease the need Ior
blood transIusions. However, recent adult studies have
raised concern that elevating hemoglobin levels ~12.5 g/
dl may increase the risk oI thrombotic events. It was
thereIore necessary to identiIy any such risks in the pediatric
population. As such, we sought to review pediatric patients
who underwent calvarial remodeling aIter receiving
erythropoietin, determine the incidence oI any thrombotic
events, and establish that the use oI erythropoietin does not
pose the same risk oI morbidity as in adult populations.
Methods: Three major metropolitan children`s hospitals were
retrospectively reviewed Ior patients who underwent calvarial
remodeling aIter receiving pre-operative erythropoietin
Irom 2000 to 2008. Demographic and perioperative data
were collected and included postoperative outcomes such as
transIusion reactions, ulcer Iormation, pneumonia, inIection,
deep vein thrombosis, cerebrovascular accident, pulmonary
embolism, sagittal sinus thrombosis, and myocardial
inIarction.
Results: 369 patients qualifed (mean age 0.86+1.1 yrs), oI
which 56.4 were male. Erythropoietin was administered at a
dose oI 600U/kg, with an average course oI three preoperative
doses. No patients experienced major complications (i.e.
death or blindness), or any complications during the dosing oI
erythropoietin. 31 patients (8.40) experienced one or more
minor postoperative complications. There were no instances
oI any thrombotic events.
Conclusions: We Iound no complications during
erythropoietin dosing. There was no signifcant correlation
between hemoglobin levels ~12.5 g/dl and the occurrence
oI any complication. We observe zero thrombotic
postoperative complications. We thereIore estimate the risk
oI any thrombotic event in this population to be 0.81
(95 confdence). Taken together, these data suggest that
erythropoietin does not increase the incidence oI thrombotic
events in our pediatric population and remains a saIe and
benefcial preoperative therapy.
60
103
SEROMA RATES IN COSMETIC
ABDOMINOPLASTIES: DOES TECHNIQUE
REALLY MATTER?
Original Presenter: Keith C. Neaman, MD
New Presenter: Marissa E. Baca
Authors: Neaman KC, Armstrong SD,
Baca ME, Albert M,
VanderWoude DL, Renucci JD
Grand Rapids Medical Education and Research Center
Michigan State University
Introduction: Post-operative seromas are one oI the
most Irequent complications in patients undergoing
abdominoplasty. Surgeons have adopted various technical
modifcations to reduce seroma Iormation. Here we compare
the technique utilized by six plastic surgeons when perIorming
an abdominoplasty.
Methods: A retrospective review oI consecutive patients
undergoing abdominoplasty over an 11-year period was
perIormed. All surgeries were perIormed one oI six plastic
surgeons with little variation in individual technique over
the study period. Each surgeon`s patient cohort, operative
technique and post-operative complications were compared.
Results: The 1008 study patients underwent either a Iull or
mini abdominoplasty (93.2 vs. 6.8, respectively). The
most common complication was seroma Iormation occurring
in 155 patients (15.4). Risk Iactors Ior seroma Iormation
included male sex (p 0.001) and morbid obesity (p0.043).
Liposuction oI the fanks and the abdominal fap at the time
oI abdominoplasty was associated with a higher seroma
rate (p0.003). Those patients who had a seroma were more
likely to undergo a revision (p0.003). The six surgeons were
compared showing a relatively homogenous patient cohort,
although the techniques varied. Compared to the rest oI the
surgeons, surgeon A had a signifcantly higher seroma rate
(26.7). Surgeon A`s technique included abdominal fap
liposuction, high electrocautery settings and undermining to
the costal margin in a supraIascial plane. Overall duration and
number oI drains showed no increase in seroma Iormation.
Conclusion: Numerous surgical modifcations have been
proposed to reduce seroma rates. Concomitant liposuction oI
the abdomen increases fuid demands placed on the lymphatic
system potentially leading to seroma Iormation. Furthermore,
devitalization oI sub-scarpal Iat may lead to poor adherance oI
the abdominal fap to the abdominal wall and subsequent dead
space Iormation. In order to reduce seroma rates, surgeons
should avoid aggressive liposuction in conjunction with wide
undermining, particularly in high-risk patients.
104
ROLE OF GSK-3B SIGNALING IN PALATAL
OSTEOGENESIS: IN VITRO AND IN VIVO
STUDIES
Presenter: Emily R. Nelson, BS
Authors: Nelson ER, Levi B, Sorkin M, James AW,
Brugmann SA, Longaker MT
Stanford University
Introduction: Through the use oI animal models, the
molecular underpinnings oI cleIt palate are becoming
increasingly clear. The Iunction oI both Glycogen synthase
kinase-3B (GSK-3B) and Indian Hedgehog (Ihh) have
previously been shown to be necessary Ior normal cranioIacial
development. Here, we examined the potential coordinate
roles oI Hedgehog and Wnt Signaling in palatal Iusion.
Methods: Palates were isolated Irom GSK-3B null mice
and compared to wild-type littermates during diIIerent
periods oI palatal development (E9.5-E17.5). CleIting oI
the GSK-3B null mouse was confrmed via whole mount
stains. DiIIerences in gene expression were examined
between null and wild-type mice by qRT-PCR and in
situ hybridization, including proliIeration, osteogenic
diIIerentiation (Runx2, ALP, Col1a1), Wnt (Wnt 9, B-catenin,
c-myc) and Hedgehog signaling (Shh, Ihh, Ptc1, Gli1, Gli2,
Gli3). Immunohistochemistry was used to confrm that
protein expression levels matched gene expression levels oI
previously mentioned targets.
Results: By in situ hybridization and immunohistochemistry,
GSK null mutants were Iound to have increased Wnt signaling
activity compared to their wildtype littermates, shown by
an increase in Wnt 9, B-catenin, and c-myc. By in situ
hybridization and qRT-PCR, GSK null mutants also displayed
decreased hedgehog signaling activity (Shh, Ihh, Ptch1,
Gli1, Gli2), as well as decreased osteogenic gene expression
(ALP, Runx2, Ocn, Col1a). When supplemented to medium
in culture, recombinant Wnt3a was observed to decrease
hedgehog signaling activity (Ihh, Ptch1, Gli1), and when
recombinant Shh was added, an increase in ossifcation was
observed (ALP, Runx2, Ocn, Col1a) by qRT-PCR.
Conclusion: Our results suggest an essential role Ior Wnt
signaling and Ihh signaling during palatal development.
These pathways seem to be tightly regulated in that high
levels oI Wnt signaling act to inhibit Ihh signaling, suggesting
that Wnt signaling may be upstream Irom Ihh signaling in
palatogenesis. This decreased Ihh signaling observed in the
GSK null mutant leads to decreased osteogenesis during
secondary palate Iormation.
105
NORMATIVE REFERENCE PARAMETERS
OF BONE MINERAL DENSITY
DISTRIBUTION IN THE SPRAGUE DAWLEY
RAT MANDIBLE
Presenter: Noah S. Nelson
Authors: Nelson NS, Donneys A,
Tchanque-Fossuo CN, Deshpande SS,
Boguslawski MJ, Goldstein SA, Buchman SR
Background: Microcomputed Tomography (CT) is an
established method Ior quantiIying mandibular bone density
and mineralization. Although classic radiomorphometric
parameters such as Bone Mineral Density are useIul in
determining the average mineral content oI a scanned
specimen, they lack the capability oI portraying the unique
array oI mineralization densities known as the Bone
Mineral Density Distribution (BMDD). This inIormation is
particularly useIul in processes aIIecting bone turnover, such
as radiotherapy or treatment regimens designed to enhance
bone density. Its sensitivity in these scenarios is able to
demonstrate subtle changes in bone metabolism. For example,
the quality oI mineral produced can be analyzed with Mpeak,
which refects the most Irequent level oI mineral density
achieved in a sample, or Mwidth, an indicator oI the diversity
oI mineralization densities existing in a sample. Calculating
such changes would be immensely benefcial in a small
animal model with translational potential. Here we report
the utility oI BMDD in the Sprague Dawley rat mandible
and generate reIerence parameters Ior Iuture comparison in
experimental cranioIacial pathology and treatment.
Methods: 8 male Sprague Dawley rats underwent CT
imaging and mineralization histograms were produced. An
average histogram was generated Ior the group and reIerence
criteria were selected. Descriptive analysis was conducted
using PASW 18 soItware describing variances Ior each oI the
BMDD metrics.
Results: Mpeak (3444 Hounsfeld Units, SD138) and
Mwidth (2221 Hounsfeld Units SD628) are two metrics
demonstrating reliable, reproducible parameters oI BMDD
with calculated limited variance. Six other valuable
metrics quantiIying biologically signifcant events in bone
mineralization are reported.
Conclusions: Here we generate consistent parameters Ior
BMDD in the Sprague Dawley rat mandible and use this
powerIul analysis to examine the vast wealth oI inIormation
depicted in a histogram beyond consensus conventional
metrics. Moreover, we explore its role and translational
potential in cranioIacial experimentation.
106
RISK FACTORS ASSOCIATED WITH
MICROVASCULAR FREE FLAP FAILURE:
DATA FROM THE ACS-NATIONAL
SURGICAL QUALITY IMPROVEMENT
PROJECT (ACS-NSQIP)
Presenter: Thientrang J. Nguyen, MD
Authors: Nguyen TJ, Shahabi A, Vidar EN, Chan LS,
Baker RY, Schooler WG, Urata MM,
Wong AK
University of Southern California Keck School of Medicine
Background: There are numerous Iactors that may infuence
microvascular Iree fap Iailure. The ACS National Surgical
Quality Improvement Program (NSQIP) is a validated,
risk-adjusted program used to establish national outcomes
benchmarks. Using this multi-institutional database, we
sought to identiIy Iactors associated with microsurgical Iree
fap Iailure and return to the operating room.
Methods: We identifed all patients who underwent Iree fap
procedures in the NSQIP database Irom 2005-8. Univariate
analyses were perIormed to determine associations oI return
to OR and fap Iailure with the Iollowing variables oI age,
BMI, amount oI transIusion required, diabetes and smoking
status, total intra-operative time, and type oI fap procedure.
Results: From 2005-8, 320 patients underwent a
microsurgical Iree fap procedure with 370 faps. The mean
age oI the 320 patients was 52 years. OI the 370 faps, 270
(73) faps were done Ior breast reconstruction, 57 (15.4)
were myocutaneous faps, 25 (6.8) were Iree cutaneous
faps, and 18 (4.9) were Iree Iascial faps. Overall, the
incidence oI returning to the OR was 15 (56/370), (95 CI
11, 19) and the incidence oI fap Iailure within 30 days
was 6 (22/370) (95 CI 4, 8). Patients who received 3
or more units oI packed red blood cells intra-operatively were
3 times more likely to return to the OR and over 5 times more
likely to experience fap Iailure. For every hour oI increased
operative time, patients had a 10 increased risk oI returning
to the operating room and 22 increased risk oI fap Iailure.
Patients who underwent head and neck reconstructions had a
4 Iold increased risk oI fap Iailure.
Conclusions: We Iound that risk Iactors Ior fap Iailure
include increased transIusion, prolonged surgery time,
and head and neck reconstruction. The overall rates oI
fap loss was 6 and return to the OR was 15. Based on
the multi-institutional data derived Irom NSQIP hospitals
around the country, this study oIIers Ior the frst time, a
true approximation oI nationwide microvascular Iree fap
outcomes in plastic surgery.
62
107
Abstract Withdrawn
108
IMPLANT BASED BREAST
RECONSTRUCTION: REMOTE VERSUS
INTEGRATED PORT TISSUE EXPANDERS
Presenter: Michelle Obrien, MD
Authors: Obrien M, Mattingly J, Hazani R,
Augenstein AC, Wilhelmi BJ
Introduction: Recent breast cancer literature has suggested
that radiation over integrated port tissue expanders can
attenuate the radiation beam. Accordingly, some radiation
oncologists Iavor remote port tissue expanders. However,
plastic surgeons generally preIer integrated port tissue
expanders Ior technical ease oI placement and exchange. Also,
the complication risk oI remote port tissue expanders may be
higher.
Methods: We completed a retrospective review oI 107
patients that underwent breast reconstruction with tissue
expanders. Overall a total oI 170 tissue expanders were placed
in these 107 patients. There were 64 women that underwent
bilateral breast reconstruction and 43 that were unilateral.
Remote tissue expanders were used Ior 21 patients, all were
bilateral (42 remote port tissue expanders). Integrated port
tissue expanders were used in 86 patients Ior tatal oI 128
integrated port tissue expanders (42 bilateral, 44 unilateral).
Results: Complication rates were higher Ior breast
reconstruction with remote port tissue expanders (8/42
implants, 19.0) versus integrated port tissue expanders
(9/128 implants, 7.03). Complications with remote port
tissue expanders included the port turning over, kinked port
tubing, needle cut tubing leak, and inIection. InIection rates
were higher with remote port tissue expanders (5/42 implants,
11.9) versus integrated port tissue expanders (8/128
implants, 6.25). Increased risk Ior inIection with remote
ports is consistnet with the less clean location oI the port
near the axilla. When integrated port tissue expanders were
used, operative times were shorter Ior initial placement and
exchange oI the tissue expanders.
Conclusion: In this retrospective review oI immediate breast
reconstructions there was an increased risk Ior complications
with remote port tissue expanders.
109
INCREASED OSTEOBLASTOGENESIS
AND WNT/BMP GENE REGULATION
IN NON-SYNDROMIC LAMBDOID
CRANIOSYNOSTOSIS
Presenter: Rene Olivares-Navarrete, DDS, PhD
Authors: Olivares-Navarrete R, Britt C, Hyzy SL,
Williams JK, Schwartz Z, Boyan BD
Purpose: Craniosynostosis results in restricted skull
growth and increased intracranial pressure. The molecular
mechanisms oI non-syndromic craniosynostosis are poorly
understood. Lambdoid synostosis is the least common non-
syndromic craniosynostosis, occurring in 2-4 oI surgical
cases. The aim oI this study was to determine whether
osteoblasts isolated Irom Iused lambdoid sutures express
higher levels oI osteogenic genes and produce paracrine
Iactors that stimulate mesenchymal stem cells (MSCs) to
diIIerentiate into osteoblasts more than osteoblasts isolated
Irom normal bone or patent sutures.
Methods: Osteoblasts were isolated Irom normal bone
(NB), patent sutures (PAT), and Iused sutures (FUS)
in three human lambdoid craniosynostosis cases. First,
cells were characterized by responses oI cultures to 1+,
25-dihydroxy vitamin D3 (1,25D) treatment. Cell number,
alkaline phosphatase specifc activity (ALP), and osteocalcin
(OCN) were measured. Next, we measured expression oI
osteogenesis-related signaling pathways (Wnts, BMPs,
and integrins) by real-time qPCR. Finally, osteoblasts were
co-cultured with human MSCs. AIter seven days, MSC cell
number, ALP, and secreted Iactors were analyzed. Data are
mean+SEM (n6/condition, ANOVA post-hoc Student`s t-test
with BonIerroni`s modifcation).
Results: 2FUS osteoblasts had higher ALP and OCN than
cells isolated Irom NB or PAT, and were more responsive
to the osteotropic hormone 1,25D. Genes important in bone
Iormation including BMP4, FGF2, VDR, and ITGB1 were
up-regulated in FUS cells in comparison to NB and PAT cells.
PAT osteoblasts showed higher CTNNB, LRP5, DKK2, and
ITGA5 and lower RUNX2 than FUS cells. MSCs co-cultured
with FUS osteoblasts had higher ALP, OCN, OPG, VEGF,
TGF?1, BMP2, and BMP4 than MSCs co-cultured with NB or
PAT osteoblasts.
Conclusions: Cells isolated Irom Iused sutures present a
more diIIerentiated osteogenic phenotype and are more
responsive to 1,25D3. In addition, these cells produce a
microenvironment that induces osteoblastic diIIerentiation in
MSCs. We have identifed candidate Wnt and BMP Iamily
genes that may mediate suture Iusion in non-syndromic
lambdoid craniosynostosis.
110
PREVENTION OF VENOUS
THROMBOEMBOLISM WITH POST-
OPERATIVE ENOXAPARIN: PRELIMINARY
RESULTS OF THE PSEFS VENOUS
THROMBOEMBOLISM PREVENTION
STUDY (VTEPS)
Presenter: Christopher J. Pannucci, MD
Authors: Pannucci CJ, Dreszer G, Wachtman CF,
Bailey SH, Hamill JB, Rubin JP,
Kalliainen LK, Hoxworth RE, Pusic AL,
Wilkins EG
Background: Venous thromboembolism (VTE) is a major
patient saIety issue. VTEPS was designed to analyze whether
post-operative enoxaparin could prevent symptomatic VTE in
adult plastic surgery patients.
Methods: The VTEPS Network includes Iour tertiary care
Iacilities. VTEPS patient eligibility criteria include age ~
18, general anesthesia, and post-operative admission. The
previously validated Caprini risk tool was used to quantiIy
VTE risk. In 2009, sites adopted a clinical protocol. Patients
with Caprini scores ~3 received post-operative enoxaparin
prophylaxis started 6-8 hours aIter surgery and continued Ior
the duration oI inpatient stay. VTEPS control patients received
an operation between 2006 and 2008 and met eligibility
criteria as above. Historic control patients received no heparin
products or warIarin Ior 60 days aIter surgery. The primary
study outcome was symptomatic, imaging-confrmed VTE
which occurred within 60 days oI surgery.
Results: 2637 patients (1658 controls and 979 enoxaparin
patients) were analyzed. When compared to controls,
enoxaparin patients had signifcantly higher baseline VTE
risk (30 vs. 18 with Caprini score ~7, p0.001), and
longer hospital stays (57 vs. 43 with admission ~48 hours,
p0.001). Among high-risk patients with Caprini score ~7,
post-operative enoxaparin was associated with signifcant
VTE risk reduction (OR 0.36, p0.039) when controlling
Ior length oI stay ~48 hours and over 50 reduction in VTE
risk (4.59 vs. 2.02, p0.079) overall. Stratifed analysis
demonstrated notable risk reduction in patients with Caprini
~8 (10.29 vs. 4.35, p0.142), Caprini 7-8 (2.97 vs.
0.98, p0.140), and Caprini 5-6 (1.33 vs. 0.83, p0.492)
who received post-operative enoxaparin. Overall VTE rate
was not signifcantly diIIerent between control and enoxaparin
groups (1.45 vs. 1.12, p0.483).
Conclusions: Post-operative enoxaparin prevents
symptomatic VTE in high-risk plastic surgery patients, when
controlling Ior length oI stay. Future work should examine
the saIety profle oI post-operative enoxaparin in this patient
group.
64
111
ANGIOPOIETIN-1 MEDIATED EFFECTS ON
RE-EPITHELIALIZATION: IN VITRO AND
IN VIVO ANALYSIS
Presenter: Parit A. Patel, MD
Authors: Patel PA, Le LD, Crombleholme TM,
Keswani SG
University of Cincinnati and Cincinnati Childrens Hospital
Introduction: Adenoviral overexpression oI Angiopoietin-1
(AdAng-1) results in accelerated re-epithelialization.
Keratinocytes do not express Tie2, the Ang-1 receptor and we
hypothesize that Ang-1 induces downstream growth Iactors.
We employed an in vitro co-culture system and an excisional
wound healing model in TGF? null-/- and wild type (WT)
mice to examine Ang-1 wound healing eIIects.
Methods: Fibroblasts transduced with AdAng-1,
AdLacZ (MOI 20) or PBS are placed into co-culture with
keratinocytes. Neutralizing antibodies (NAbs) to Ang-1, KGF,
EGF, PDGF-B, PDGF-A, IGF-1, TGF? and TGF?1 were
added. Ki67 immunostaining oI the keratinocytes was used
to determine a proliIeration index (PI). 6mm crown wounds
treated with 1e8 PFU oI AdAng-1 AdLacZ, or 20?l PBS were
made in TGF?-/- (n15) and WT (n15). At 5 days wounds
were analyzed Ior epithelial gap, granulation tissue Iormation,
capillary density and KGF expression.
Results: In co-culture, AdAng-1 results in increased
keratinocyte PI compared to controls (Ang1 38.5 vs.
LacZ 19 or PBS 16.3). This response was completely
inhibited by NAbs to Ang1 (17.1) or TGF? (16) and
partially inhibited by NAbs to KGF (29.5) or PDGF-B
(25.6). NAbs to PDGF-A, IGF-1, TGF? or EGF had no
eIIect. AdAng-1 treated wounds in TGF?-/- mice showed
signifcantly larger epithelial gaps compared to Ad-Ang-1
treated WT mice (3.3mm+.1 vs. 2.7mm+.2, p0.01).
However, in TGF?-/- mice AdAng-1 treated wounds show
signifcantly reduced epithelial gaps (Ang-1 3.3mm+.1, LacZ
4.4+.2, PBS 4.4+.3, p0.001) and increased vessel density
compared to controls (Ang1 11.1 Caps/HPF, LacZ 4.1+.3,
PBS 4.4+.3, p0.0001). KGF immunostaining localized to
the advancing epithelial margin, was enhanced in AdAng-1
treated wounds in both TGF?-/- and WT mice.
Conclusions: The eIIects oI Ang-1 on keratinocyte
proliIeration are mediated indirectly by TGF? and KGF.
In vivo, TGF? is an important mediator oI Ang-1 eIIect on
reepithelialization, but Ang-1 also enhances KGF expression.
These results suggest that wound healing eIIects oI Ang-1
over expression are to due to dermal epidermal signaling
mediated by TGF? and KGF.
112
THE IMPACT OF THE AGE OF SURGERY
AND TYPE OF SURGICAL INTERVENTION
ON LONG-TERM NEUROPSYCHOLOGICAL
OUTCOMES IN SAGITTAL
CRANIOSYNOSTOSIS
Original Presenter: Anup Patel, MD, MBA
New Presenter: Jordan Terner
Authors: Patel A, Terner J, Travieso R,
Roginiel A, Alderman M,
Bridgett D, Losee J, Pollack I,
Kanev P, Persing J
Yale University School of Medicine
Introduction: The impact oI the age at surgery and type
oI surgical intervention in patients with single-suture
craniosynostosis on long-term neuropsychological (NP)
outcomes remains a signifcant source oI debate. This study
addresses limitations oI previous studies by employing
comprehensive, longitudinal testing to assess NP Iunction in
patients with sagittal craniosynostosis (SGC) who underwent
surgical correction.
Methods: This multi-institutional study consisted oI 33
SGC patients who were treated operatively and subdivided
as Iollows: 1) age oI surgery: treatment prior to 6 months
oI age VS aIter 6 months oI age; 2) type oI surgery: whole-
vault cranioplasty (WVC) VS strip craniectomy (SC). All
patients underwent testing evaluating various domains oI NP
Iunction using the Iollowing battery oI neurodevelopmental
instruments: Wechsler Fundamentals, WASI, Beery VMI,
BRIEF, and BASC-2.
Results: Given the limited sample size, i.e., age oI surgery:
beIore 6 months oI age (n21) VS. aIter 6 months oI age
(n12); type oI surgery: WVC (n12) VS. SC (n21)),
statistical signifcance was set at p0.10. Controlling Ior
age at surgery, patients who received SC obtained better
outcomes relative to WVC patients on Verbal IQ (p0.10).
Those undergoing WVC obtained better scores on measures
oI reading (p0.10), spelling (p0.10), and parental report oI
executive Iunction (p0.05) diIfculties. Those undergoing
surgery aIter 6 months oI age obtained lower FSIQ and
perIormance IQ scores than those who received surgery
earlier in liIe (p0.10). AIter accounting Ior FSIQ and type
oI surgery, participants older than 6 months old at the time
oI surgery perIormed worse on spelling measurements and
parental report oI executive Iunction (p0.05).
Discussion: Preliminary fndings show a trend toward
improved NP outcomes in patients treated beIore 6 months
oI age and those treated with WVC. Current studies are
underway with larger numbers oI subjects, taking into account
demographics, such as socioeconomic Iactors and maternal
education.
113
3D-SCHWANN CELL-NEURON-
SPHEROIDS - ASSAY FOR NEURITE
SPROUTING AND MYELINATION
Presenter: Vincenzo Penna, MD
Authors: Penna V, Boyle V, Stark GB
University Medical Center Freiburg
Introduction: Experimental approaches in peripheral nerve
regeneration aim on neurite extension and myelination.
Due to the complex processes these experiments are mainly
perIormed in in-vivo situations going along with inevitable
sacrifce oI animals and long observation periods. The aim oI
this study was to evaluate whether a 3D Schwann Cell Neuron
Spheroid allows in vivo evaluation oI neurite extension and
myelination.
Methods: SCs were cultivated Irom sciatic nerves oI neonatal
rats; the neural cell culture NG108-15, a hybrid cell line
Irom mouse neuroblastoma and rat glioma was purchased.
SCNG spheroids were created and embedded in collagen.
For comparison 2D-Co-Cultures oI SC and NG cells were
cultivated on fasks. Using the microscope Axioplan (Zeiss)
and the soItware Axiovision (Zeiss) both the 2D-culture and
the 3D-culture were analyzed aIter 10 days oI incubation in
regard to neurite outgrowth and neurite length. Neuroflament
and myelin binding protein stains were perIormed.
Results: Both Co-Cultures (2D and 3D) showed considerable
neurite outgrowth aIter 10 days oI incubation. The direct
comparison oI both Co-cultures revealed a signifcantly higher
number oI neurites and signifcantly higher neurite lengths in
the SC-NG-spheroids. Furthermore myelinisation processes
could be observed only in the 3D Co-Cultures.
Conclusion: By simply transIerring a 2D into a 3D culture
with multiplication oI cell-cell contacts a signifcant increase
oI neurite reaction can be achieved. This, together with the
observed myelinisation processes could make the spheroidal
Co-culture a close-to-reality model Ior Iurther studies oI
neuroregenerative mechanisms and a possible assay Ior drug
testing.
114
GENETIC AND EPIGENETIC MECHANISMS
OF ADIPOSE TISSUE AGING
Presenter: Ivona Percec, MD, PhD
Authors: Percec I, Dierov R
University of Pennsylvania
Introduction: The molecular mechanisms responsible Ior
human aging are critically important as the world`s population
lives longer and older individuals demand a higher quality oI
liIe. The pathways resulting in tissue aging, however, have yet
to be understood, thereby limiting our insight into the aging
pathway and delaying important therapeutic interventions
in the prevention and treatment oI aging. The goal oI this
research program is to establish the genetic and epigenetic
Iactors responsible Ior human aging using human adipose
tissue as a model Ior investigation.
Methods: Subcutaneous adipose tissue samples are collected
Irom male and Iemale patients (ages 18-85), who are
undergoing aesthetic surgery by plastic surgeons at University
oI Pennsylvania. Adipocytes, stromal vascular Iraction
(SVF) and adipose-derived stem cells (ADSC) are isolated
Irom each specimen and examined in parallel. RNA and
protein expression is examined in a multi-tiered approach
that establishes molecular changes associated with aging in a
genome-wide and pathway-specifc manner.
Results: We present genome-wide RNA expression
diIIerences acquired during the aging process using
microarray chip technology in our model oI adipose tissue
aging oI purifed populations oI adipocytes, SVFs, and
ADSCs Irom human subcutaneous adipose tissues oI
diIIerent ages, clinical aging phenotypes, and anatomical
locations. Secondly, we demonstrate that the human Sirtuin
histone deacetylation genes (SIRT1-7), which are known to
be involved in longevity and adipose metabolism, regulate
adipose tissue aging in a diIIerential manner via specifc
eIIects on cell type, anatomical region and aging phenotype.
Finally, we demonstrate that Ieatures originally thought to
be specifc to brown adipose tissue (BAT) may in Iact be
responsible Ior the variance in subcutaneous adipose tissue
aging phenotypes.
Conclusions: We have established that adipose tissue is an
excellent model Ior the investigation oI human aging. By
examining molecular changes associated with aging in a
genome-wide and pathway-specifc manner, we are advancing
the understanding oI how human tissues age.
66
115
CAN INTRAOPERATIVE PERFUSION
TECHNIQUES ACCURATELY PREDICT
MASTECTOMY SKIN FLAP NECROSIS?
Presenter: Brett T. Phillips, MD
Authors: Phillips BT, Lanier ST, Conkling N,
Wang ED, Dagum AB, Ganz JC, Khan SU,
Bui DT
Stony Brook University Medical Center
Background: Intraoperative vascular imaging can assist
surgeon assessment oI mastectomy skin fap (MSF) perIusion
to predict areas oI necrosis. No head to head study has
compared alternative imaging modalities such as Indocyanine
Green (ICG) and Fluorescein Dye Angiography (FDA) Ior
this purpose.
Methods: A prospective study oI 50 immediate breast
reconstructions with tissue expanders is underway where
MSFs are evaluated intraoperatively via clinical assessment,
ICG, and FDA Iollowing expander placement. Predicted areas
oI necrosis are marked on the patient`s skin, traced onto a
transparent flm, and photodocumented. Clinical assessment
guides excision. Patients are Iollowed weekly and areas oI
actual necrosis are directly compared to areas predicted by
each method.
Results: Data is collected Ior 27 immediate breast
reconstructions (17 patients), with a mean Iollow-up oI 5.7
months (Range: 3.6-7.8). Mean patient age is 48.7 (Range:
23-74) and mean BMI is 27.6 (Range: 18.5-41.5). 6 cases oI
necrosis occurred (22.2). ICG & FDA correctly predicted
the occurrence oI necrosis in 5/6 oI cases (Sensitivity 83.3).
However, ICG & FDA overpredicted areas oI actual necrosis
by 73.8 and 86.3, respectively. OI the 21 breasts in which
necrosis did not occur, ICG predicted no necrosis in 11 Ior
a specifcity oI 52.4, while FDA predicted no necrosis in
7 Ior a specifcity oI 33.3. The negative predictive value
Ior ICG, FDA & clinical judgment were 91.7, 87.5, and
75, respectively. Retrospective quantitative analysis Ior
ICG (SpyQ) oI areas that ultimately became necrotic showed
absolute perIusion units 8.0 with 100 sensitivity and 3.7
with 100 specifcity.
Conclusions: ICG is a more sensitive and better predictor
oI MSF necrosis when directly compared to FDA. Both ICG
& FDA are better predictors oI skin necrosis than clinical
judgment. Results show a trend oI over prediction by both
methods without the use oI additional quantitative analysis.
Preliminary fndings show that areas oI skin with absolute
perIusion units 8.0 predict necrosis with 100 sensitivity
and values 3.7 with 100 specifcity.
116
MAXILLOFACIAL HARDWARE
COMPLICATIONS AND INDICATIONS FOR
SALVAGE
Presenter: Brian A. Pinsky, MD
Authors: Pinsky BA, Hernandez-Rosa J,
Villanueva NL, Factor SH, Taub PJ
The Mount Sinai Hospital
Background: From 2002 to 2006, more than 117,000 Iacial
Iractures were recorded in the US National Trauma Database.
These Iractures are commonly treated with open reduction
and internal fxation. While in place, the hardware Iacilitates
successIul bony union. However, when post-operative
complications occur, the plates may require removal prior
to bony union. Indications Ior salvage versus removal oI
maxilloIacial hardware are not well defned. A literature
review was perIormed to identiIy instances when hardware
may be salvaged.
Methods: Papers considered Ior inclusion were Iound in
the PubMed and Web oI Science databases in August 2009
with the key words maxilloIacial trauma AND (hardware
complications OR indications Ior hardware removal).
Included papers looked at human patients with only Iacial
trauma and miniplate fxation, and presented data on
complications and/or hardware removal.
Results: FiIteen articles were included. None were clinical
trials. Complication data was presented by patient, Iracture,
and/or plate without consistency. The data described 1,075
Iractures, 2,961 patients, and 2,592 plates, nonexclusive.
Complication rates varied Irom 6 to 8 by Iracture, and
6 to 13 by patient. When their data was combined, 50
oI complications were treated with plate removal; this was
consistent across the mandible, mid-Iace, and upper Iace.
All complications due to loosening, non-union, broken
hardware, and severe/prolonged pain were treated with
removal. Some complications due to exposures, deIormities,
and inIections were treated with salvage. Exposed plates
were treated with faps, plates with deIormities were treated
with secondary procedures including hardware revision,
and hardware inIections were treated with antibiotics alone
or in conjunction with soIt tissue debridement and/or tooth
extraction.
Conclusion: Well-designed clinical trials evaluating hardware
removal versus salvage are lacking. Some postoperative
complications due to exposure, deIormity, and/or inIection
may be successIully treated with plate salvage. We propose an
algorithm using this review and clinical experience.
117
THE EFFECTS OF NON-VASCULARIZED
VERSUS VASCULARIZED BONE GRAFTING
ON CALVARIAL DEFECT HEALING
Presenter: Stephanie M. Power, MD
Authors: Power SM, Holdsworth DW, Matic DB
University of Western Ontario
Background: Cranial vault reconstruction oIten creates non-
vascularized bone segments within residual calvarial deIects.
It remains unknown whether bone graIting infuences basic
mechanisms oI dural or pericranial osteogenesis. The purpose
oI this study is to compare the eIIects oI non-vascularized
versus vascularized bone graIts on calvarial healing.
Method: Bilateral 4 mm parietal deIects were created in 26
Wistar rats. Animal ethics approval was obtained. Animals
were divided into control (n6) and experimental (EXP1-
2, each n10) groups. Within all groups, an adjacent Iull
thickness crescent was leIt empty in one parietal region
(deIect side). On the contralateral side in Control, EXP1,
and EXP2 groups, crescents consisted oI native parietal bone
(sham), non-vascularized, and vascularized bone graIts,
respectively. Vascularized graIts were supplied by perIorating
dural arterioles. Serial micro-CT scans were co-registered
using anterior and posterior landmarks and regions oI interest
accounted Ior cranial vault growth over time. Bone mineral
content (BMC), density, and Iractional area were compared
within and between groups over time using parametric and
non-parametric tests. Patterns oI bone Iormation were also
compared non-parametrically between groups.
Results: DiIIerences in BMC across sides were signifcant
between groups at weeks 6 (p0.016) and 12 (p0.025). Bone
Iormation was greater within both Control and EXP2 versus
EXP1 at weeks 6 and 12 (p0.05). Healing patterns diIIered
between groups (p0.047), progressing through bone islands
within Control and EXP2 versus marginal healing on the graIt
side in EXP1.
Conclusions: Bone graIt vascularity may signifcantly
infuence calvarial healing. Bone Iormation was greater within
native parietal bone and vascularized bone graIts at later
stages with dural regeneration appearing primarily responsible
Ior deIect closure. Non-vascularized bone graIt healing was
limited to deIect margins and may thereIore inhibit dural
osteogenesis. Greater understanding oI vascular mechanisms
underlying calvarial healing may have implications Ior cranial
reconstruction.
118
CT ANGIOGRAMS FOR MICROSURGICAL
BREAST RECONSTRUCTION:
INTERSURGEON INTERPRETATION AND
APPLICATION
Presenter: Meghan A. Quigley, BS
Authors: Quigley MA, Cray JJ, Nguyen VT,
Gimbel ML, De La Cruz C
Background: Anatomical variation in the abdominal wall
vasculature has led to preoperative imaging as a tool Ior
precise planning and execution oI microsurgical breast
reconstruction. Computed tomographic angiography (CTA)
has become the gold standard modality Ior preoperative
visualization oI the abdominal vascular supply Ior msITRAM,
DIEP, and SIEA faps. CTA provides detailed 3-D inIormation
oI the epigastric system, including the location, size,
branching pattern, and intramuscular course. The use oI this
imaging modality has been shown to signifcantly reduce
operative time and Iacilitate fap design, leading many
surgeons to routinely utilize CTA Ior breast reconstruction.
However, it is yet to be determined whether there exists
signifcant intersurgeon variability in interpretation and fap
choice based on this technology. In this study, we sought
to examine the intersurgeon variability in evaluating CT
angiograms.
Methods: CT angiograms Irom 30 consecutive patients
undergoing breast reconstruction were independently
reviewed by three microsurgeons. The leIt- and right-sided
vascular supplies were evaluated in the 60 hemifaps. The
parameters assessed included the SIEA size at the origin, the
SIEV size at the superior Iemoral head, and the DIE vessel
branching pattern. Each surgeon then predicted the type oI
fap they would utilize Ior each patient.
Results: A statistically signifcant correlation Ior both SIEA
(p0.03) and SIEV size (p0.001) was observed among
the CTA interpretations. Using Fleiss` Kappa, moderate
agreement among the surgeons was Iound Ior the DIE vessel
pattern (k0.47). For the fap prediction, however, only Iair
agreement was Iound (k0.40). It was also observed that one
surgeon`s choice oI msITRAM faps was signifcantly more
Irequent than the other surgeons (p0.001).
Conclusion: There is a moderate degree oI intersurgeon
variability in evaluating the vascular anatomy in CT
angiograms. Such variability may refect the limitations oI
the CTA measuring tool as well as each surgeon`s individual
bias in fap design, which can be attributed to his surgical
experience and practice patterns.
68
119
T-REGULATORY CELLS AND TH17 CELLS
IN PERISILICONE-IMPLANT CAPSULAR
FIBROSIS
Presenter: Evelyn Rabensteiner, MD
Authors: Rabensteiner E, WolIram D, Backovic A,
Bck G, Mayer C, Parson W, Huss H,
Piza-Katzer H, Wick G
Innsbruck Medical University
Aims: The Iocus oI this study are immunological mechanisms
underlying extensive peri-silicone-implant capsule Iormation-
the most Irequent post-operative complication in patients
receiving silicone mammary implants (SMI).
Methods: We investigated on local activation oI the immune
response by phenotypical and Iunctional characterization oI
lymphocytes accumulated within the peri-implant fbrotic
tissue. Intracapsular lymphoid cells and peripheral blood
mononuclear cells (PBMCs) were isolated and analyzed
via fow cytometry. We examined the expression oI surIace
markers (CD4CD25highFoxp3), cytokine profles, and
T-cell-receptor (TCR) repertoire oI these cells. Intracapsular
Tregs were Iurther analyzed by immunohistochemistry and
Iunctional suppression assays.
Results: In comparison to peripheral circulation, the
cellular composition oI intracapsular lymphocytes showed
a predominance oI CD4 T-helper cells with a signifcant
number oI TCR gamma/delta cells. Interleukin (IL)-17, IL-6,
IL-8 transIorming growth Iactor (TGF-beta)1 and interIeron
(IFN)-gamma prevailed within the population oI intracapsular
T-cells, suggesting a TH17/TH1 weighted local immune
response. Intracapsular T-cells also displayed a restricted
TCR alpha/beta repertoire. We investigated Tregs in greater
detail. Their suppressive potential was proven in autologous
mixed lymphocyte reaction with peripheral T-cells, but they
Iailed to suppress intracapsular T-cells. Interestingly, ratios oI
intracapsular Tregs were inversely proportional to the clinical
degree oI capsular fbrosis.
Conclusion: Our results indicate that silicone implants trigger
a specifc, antigen driven local immune response through
activated TH17/TH1 cells suggesting that fbrosis is promoted
by the production oI profbrotic cytokines, and controlled by
the local Tregs.
120
DEVELOPMENT OF AN ENGINEERED EAR
USING A FIBROUS COLLAGEN SCAFFOLD
WITH EMBEDDED WIRE
Original Presenter: Mark A. Randolph, MAS
New Presenter: Xing Zhao, MD
Authors: Zhao X, Randolph MA,
Pomerantseva I, Bassett E, Zhou L,
Bichara DA, Kulig KM,
Sundback CA, Vacanti JP
Introduction: Carved autologous costal cartilage used
Ior auricular reconstruction causes morbidity and oIten
suboptimal aesthetic results. Alloplastic implants give
more consistent appearance but are subject to extrusion and
complications. Engineered cartilage can be a Ieasible option
Ior auricular repair but the greatest challenge is maintaining
the complex 3D shape oI the human auricle while avoiding
distortion and shrinkage as the scaIIold degrades and
neocartilage matures. Natural materials, like collagen, are
promising candidates but lack required strength. Our aims
were to evaluate a porous collagen scaIIold Ior cartilage
Iormation in immunocompromised and immunocompetent
animals; optimize in vitro culture conditions; and perIorm
prooI-oI-concept studies with human ear-shaped scaIIolds.
Methods: Fibrous collagen sheets were made by Kensey
Nash. Sheep auricular chondrocytes were seeded on collagen
disks, precultured statically or dynamically, and implanted
in nude mice Ior 6 wks. Upon selecting optimal culture
conditions, autologous cartilage Iormation was evaluated in
sheep. HalI size adult human ear-shaped collagen scaIIolds
were made with and without an embedded coiled titanium
wire. The ear-shaped constructs were implanted in nude
mice Ior 6 wks. Constructs were assessed by histological and
biochemical analyses.
Results: Dynamic preculture conditions improved cartilage
matrix development in vivo. Autologous cartilage engineered
in sheep aIter 6 wks resembled native sheep ear cartilage.
AIter 6 wks in vivo in mice, size change oI ear-shaped
constructs with wires was minimal (2.0 in length and 4.1
in width). Signifcant shrinkage (14.4 in length and 16.5
in width) occurred in constructs without wires. Both types
oI constructs maintained shape and demonstrated elasticity,
cartilage morphology and extracellular matrix (ECM)
deposition.
Conclusions: Flexible wire Iramework embedded within a
porous collagen scaIIold prevented shrinkage and distortion
allowing retention oI ear shape and Iormation oI neocartilage
in mice. Autologous cartilage was engineered in sheep. These
are important milestones.
121
AMIFOSTINE DEMONSTRATES
SIGNIFICANT CYTOPROTECTION IN
AN IRRADIATED MURINE MODEL
OF MANDIBULAR DISTRACTION
OSTEOGENESIS
Presenter: Elizabeth R. Razdolsky
Authors: Razdolsky ER, Tchanque-Fossuo CN,
Donneys A, Farberg AS, Deshpande SS,
Gallagher KK, Sarhaddi D, Poushanchi B,
Buchman SR
Background: Head and neck cancer (HNC) clinical
management requires adjuvant radiation (XRT) therapy. Our
previous studies have demonstrated the deleterious eIIect oI
a human equivalent dose oI radiation (HEDR) on a murine
mandibular model oI distraction osteogenesis (DO). Here,
we use quantitative histomorphometry (QHM) to objectively
measure the radio-protective eIIects oI AmiIostine (AMF) on
the cellular integrity in an irradiated and distracted regenerate.
We posit that AMF will protect osteocytes, cells critical Ior
bone regeneration and healing, Irom the damaging eIIects oI
XRT.
Methods: 16 Sprague Dawley rats were randomly assigned
into 2 groups: Group 1 (n6) and Group 2 (n10) received
a HEDR given in 5 Iractionated doses. Group 2 was given
AMF 45 minutes prior to XRT. Both groups underwent a
leIt mandibular osteotomy with bilateral fxator placement.
Distraction to 5.1 mm was Iollowed by a 28-day consolidation
period. All leIt hemimandibles were harvested, sectioned and
stained. QHM was perIormed Ior osteocyte count (Oc) and
empty lacunae (EL). Independent Samples t-test was used
Ior group comparison with p 0.05 considered statistically
signifcant.
Results: Complete bony bridging was observed in all AMF
pre-treated animals, whereas the irradiated group exhibited
some specimens with fbrous unions and incomplete bridging.
QHM analysis revealed a statistically signifcant higher Oc
compared with irradiated mandibles (69 vs. 44 osteocytes,
p0.000). There was also a corresponding decrease in the
number oI EL between the AMF-treated and irradiated groups
(4 vs. 11 EL, p0.002).
Conclusions: Our fndings demonstrate the signifcant
osseous cytoprotective capacity oI AMF on distraction in the
Iace oI XRT. The maintenance oI bone Iorming cells resulting
Irom AMF pretreatment was associated with an increase in
bony union and a complete elimination in the incidence oI
fbrous union. We posit that the demonstration oI similar
eIfcacy oI AMF in the clinical arena may allow the successIul
implementation oI DO as a viable reconstructive option Ior
HNC in the Iuture.
122
BREAST CANCER RECURRENCE
FOLLOWING POSTMASTECTOMY
RECONSTRUCTION COMPARED
TO MASTECTOMY WITH NO
RECONSTRUCTION
Presenter: Sashank K. Reddy, MD, PhD
Authors: Reddy SK, Colakoglu S, Curtis MS,
Momoh AO, Yueh JH, Ogunleye A,
Tobias AM, Lee BT
Harvard Medical School
Background: Advances in breast reconstruction aIter
mastectomy have provided surgeons with a multitude oI
reconstructive options. Concerns remain, however, about
the eIIects oI the various reconstructive methods on ultimate
oncologic outcome. While various studies have demonstrated
the saIety oI individual methods, there is a paucity oI data
examining the Iull spectrum oI reconstructive techniques.
This study compares incidence, detection, and management oI
recurrent breast cancer in a large series oI patients treated at a
single center with mastectomy alone or with mastectomy and
reconstruction.
Methods: A retrospective chart review was perIormed Ior
all patients who underwent mastectomy and all patients who
underwent immediate reconstruction Ior breast cancer or
DCIS at the Beth Israel Deaconess Medical Center between
January 1999 and December 2006. The 921 patients were
divided into two groups: mastectomy and reconstruction (n
494) and mastectomy alone (n 427). Reconstructive options
included tissue expander/ implants, latissimus, TRAM, DIEP,
and SGAP. Patients were Iollowed Ior a mean oI 4.5 years.
Data on patient demographics, reconstructive method, and
presence and nature oI recurrences were obtained.
Results: The total incidence oI recurrence - locoregional
and/or distant - was 5.9 (29/494) in patients who had
mastectomy with reconstruction and 11.5 (49/427) in
patients who had mastectomy alone (p 0.0023). The
incidence oI locoregional recurrence only was 2.2 (11/494)
in patients who had mastectomy with reconstruction and
4.0 (17/427) in patients who had mastectomy alone (p
0.1220). OI the 11 reconstructed patients with a locoregional
recurrence, all were detected by selI or clinical examination.
Median time to detection was not signifcantly diIIerent
between the two groups: 1.6 years in both (p 0.5471).
Conclusions: Reconstruction with a variety oI methods does
not adversely aIIect the incidence or time to detection oI
recurrent breast cancer. Patients with locoregional recurrences
aIter reconstruction were rare in our series and these lesions
were detected by selI or clinical examination.
70
123
BODY-CONTOURING FOLLOWING
BARIATRIC SURGERY: HOW MUCH IS
BEING DONE?
Presenter: Alyssa J. ReiIIel, MD
Authors: ReiIIel AJ, Jimenez N, Harris KD,
Millet YH, Lekic N, Dakin GF, Pomp AL,
Spector JA
Weill Cornell Medical College
Introduction: As a result oI the widespread obesity epidemic,
over 150,000 bariatric procedures are perIormed in the United
States annually. The massive weight loss that oIten ensues
can leave patients with large amounts oI excess skin and, as
a result, poor cosmesis. Despite the Irequency with which
weight loss surgeries are perIormed, most patients do not
undergo subsequent body-contouring surgery. We designed
a study to explore the reasons behind the paucity oI body-
contouring procedures in the post-bariatric surgery population.
Methods: A survey was designed to acquire data regarding
patient demographics, the amount oI pre-operative counseling
given by their bariatric surgeon regarding body-contouring
options, reIerrals to plastic surgeons, income and insurance
coverage, body-contouring procedures perIormed, and
outcome satisIaction. The survey was mailed to 501 patients
who underwent bariatric surgery by a single surgeon between
2004 and 2010. Attempts were made to contact patients via
telephone iI they did not initially respond.
Results: One-hundred seventeen patients responded
(23.3). Ninety-six (82.1) were Iemale. Over halI oI all
respondents reported an annual household income $50,000.
Insurance covered 95.7 oI bariatric procedures. Only
23.1 oI respondents report discussing body-contouring
surgery with their bariatric surgeon, either preoperatively
or postoperatively. Twelve patients (10.3) were reIerred
Ior consultation with a plastic surgeon, while only 8 (6.8)
underwent any body-contouring procedure. The most Irequent
reasons cited Ior not undergoing plastic surgery were expense
and lack oI awareness regarding surgical options.
Conclusion: The majority oI bariatric surgery patients are
unaware oI the multitude oI body-contouring procedures
available as a result oI insuIfcient pre- and post-operative
counseling. In addition, a large subset oI these patients
demonstrate an interest in Iurther pursuing such options but
cannot aIIord them. We conclude that Iurther eIIorts towards
improving patient (and surgeon) education regarding post-
bariatric body-contouring options are warranted.
124
A NOVEL ALGORITHM TO ANALYZE
CORONAL SUTURE DEVELOPMENT IN
MICE
Presenter: Megan Richards
Authors: Richards M, Hermann C,
Olivares-Navarrete R, Guldberg RE,
Skrinjar O, Williams JK, Schwartz Z,
Boyan BD
Objectives: Mice are a common model Ior studying
craniosynostosis because the posterior Irontal suture Iuses
normally while the remaining sutures stay open. We have
developed and validated an algorithm that allows us to
quantitatively assess Iusion oI the posterior Irontal suture
using micro computerized tomography (CT). However,
analysis oI the coronal suture is complicated because it
curves up to 180 degrees about all three axes. The objectives
oI this study were to develop an algorithm to reconstruct
and segment the coronal suture by CT to identiIy the key
developmental changes that occur and to correlate these
results with histology oI this tissue.
Methods: Six C57Bl/6J male mice each were euthanized on
days 6, 12, 20, 25, and 30. The skulls were scanned by CT
and processed using the developed algorithm. The algorithm
reconstructs the images so that they are perpendicular to the
coronal suture about all three axes and then segmentation is
perIormed using our previous algorithm. The reconstruction
was accomplished by creating a 3D surIace oI the skull in
order to fnd the vector normal to the surIace. The vector
tangent to the suture was Iound with a polynomial ft through
the center oI the suture. These two vectors were then used
to reconstruct an image perpendicular to the suture about all
three axes. The segmentation boundaries were analyzed to
fnd the Iollowing measurements: minimum, maximum and
mean distances between the bones, the area oI the suture, the
mass oI the suture, and the percentage oI the suture open.
Results: The results show that the minimum coronal suture
distance decreases beginning on day 12 and reaches a plateau
on day 20. The bone mass begins to increase on day 12,
but approximately 60 oI the suture remained open even
at day 30. This suggests that the coronal suture bones come
together, increase in mass, but do not Iuse. This is diIIerent
than what was seen in our previous analysis oI the posterior
Irontal suture using the same algorithm where the suture Iused
early on and then increased in mass. This algorithm has the
potential to diagnose cases oI craniosynostosis and predict the
occurrence oI re-synostosis.
125
IMMEDIATE IMPLANT PLACEMENT
VERSUS THE STAGED TISSUE
EXPANDER TECHNIQUE IN BREAST
RECONSTRUCTION
Presenter: Jason Roostaeian, MD
Authors: Roostaeian J, Clayton J, Vardanian A,
Sanchez I, Da Lio A, Lipa JE,
Festekjian JH, Crisera C
Purpose: Tissue expander based techniques are the most
common Iorm oI breast reconstruction. Skin-sparing
mastectomy techniques have Iacilitated the ability to perIorm
immediate placement oI a permanent implants. Proposed
benefts to immediate implant-based breast reconstruction
(IIBR) include less cost, time, and operations to complete
reconstruction. The purpose oI this study is to directly
compare this method to the staged tissue expander immediate
breast reconstruction (TEIBR) technique.
Methods: Patients who underwent prosthetic breast
reconstruction between 2004 and 2009 were reviewed. There
were 35 consecutive patients, 8 unilateral and 27 bilateral,
who underwent IIBR. A second group oI 50 patients, 11
unilateral and 39 bilateral underwent TEIBR. Normative
data, complication rates, revision rates, cost, number oI oIfce
visits, and total reconstructive time was compared. Aesthetic
outcomes were graded by a blinded panel using an established
4-point scoring system.
Results: Patients in both groups had similar demographics,
stage oI disease, co-morbidities, smoking and radiotherapy
exposure. At a mean Iollow-up oI 13 months, the overall
complication rate was similar in both groups 14.3 IIBR vs
14.0 TEIBR (p 0.604). The need Ior revision surgery was
also similar, 24.2 in IIBR vs 22.5 in TEIBR (p 0.805).
The mean fnal implant volume did not diIIer between the
two groups, 395+94cc in IIBR vs 376+120cc in TEIBR (p
0.286). The mean number oI oIfce visits was signifcantly
diIIerent, mean 5.0+4 vs 9.2+3 visits, p 0.001 Ior IIBR
vs TEIBR respectively. On aesthetic evaluation there was
no signifcant diIIerence noted. Surgeon`s Iee as a marker
oI overall cost per breast did diIIer, $4,000 Ior IIBR versus
$10,555 Ior TEIBR.
Summary/Conclusion: IIBR has similar complication rates,
need Ior revision, and aesthetic outcomes but less cost, oIfce
visits, and reconstructive time when compared to TEIBR. In
the appropriately selected patient, IIBR is a saIe option that
provides similar outcomes in less time and cost compared to
staged expander-based reconstruction.
126
3D CT ANGIOGRAPHY TO PREDICT
WEIGHT OF DIEP FLAP FOR BREAST
RECONSTRUCTION
Presenter: Gedge D. Rosson, MD
Authors: Rosson GD, Shridharani SM, Magarakis M,
Manahan MA, Stapleton SM, Gilson MM,
Flores JI, Basdag B, Fishman EK
Johns Hopkins University School of Medicine
Background: Three-dimensional computed tomographic
angiography can be used preoperatively to evaluate the
course and caliber oI perIorating blood vessels Ior abdominal
Iree-fap breast reconstruction. For postmastectomy breast
reconstruction, many women enquire whether the abdominal
tissue volume will match that oI the breast to be removed.
ThereIore, our goal was to estimate preoperative volume and
weight oI the proposed fap and compare them with the actual
volume and weight to determine iI diagnostic imaging can
accurately identiIy the amount oI tissue that could potentially
to be harvested.
Methods: Preoperative three-dimensional computed
tomographic angiography was perIormed in 15 patients
who underwent breast reconstruction using the deep inIerior
epigastric artery perIorator fap. BeIore each angiogram,
stereotactic fducials were placed on the planned fap outline.
The radiologist reviewed each preoperative angiogram
to estimate the volume, and thus weight, oI the fap.
These estimated weights were compared with the actual
intraoperative weights.
Results: The average estimated weight was 99.7 oI
the actual weight. The interquartile range (25th to 75th
percentile), which represents the 'middle halI oI the patients,
was 91 to 109, indicating that halI oI the patients had an
estimated weight within 9 oI the actual weight; however,
there was a large range (70 to 133).
Conclusion: Three-dimensional computed tomographic
angiography with stereotactic fducials allows surgeons to
adequately estimate abdominal fap volume beIore surgery,
potentially giving guidance in the amount oI tissue that can be
harvested Irom a patient`s lower abdomen.
72
127
DELIVERY OF MESENCHYMAL STEM
CELLS IN A BIOMIMETIC HYDROGEL
ENHANCES STEM CELL ENGRAFTMENT
AND ACCELERATES WOUND HEALING
Presenter: Kristine C. Rustad, BS
Authors: Rustad KC, Wong VW, Sorkin M,
Major MR, Glotzbach JP, Rajadas J,
Stanford University
Background: Mesenchymal stem cell (MSC)-based therapies
have demonstrated signifcant pre-clinical eIfcacy in models
oI pathologic healing. Current strategies utilize local or
systemic injection oI MSCs and are limited by suboptimal cell
engraItment. We hypothesized that delivery oI MSCs within
a dermal-like hydrogel would enhance post-implantation cell
survival and allow Ior the Iull therapeutic potential oI MSC-
based approaches to be achieved.
Methods: MSCs were harvested Irom the bone marrow
oI luciIerase/GFP mice and seeded onto biomimetic
hydrogels previously developed by our laboratory. MSC
viability was assessed via a live/dead assay and hydrogel-
induced changes in gene expression were evaluated with
qRT-PCR. Using an excisional wound model in wildtype
mice, we compared the therapeutic eIfcacy oI MSC-seeded
hydrogels, subcutaneously injected MSCs and hydrogels
alone to untreated wounds. Bioluminescence imaging was
used to compare viability oI MSCs seeded in hydrogels versus
injected MSCs. Wound histology, microvessel counts and
immunofuorescent localization oI MSCs was perIormed.
Results: MSCs showed ~90 viability within the hydrogel
Ior up to 2 weeks in vitro. MSCs exhibited a 3.9-Iold increase
in VEGF gene expression when seeded within the hydrogel
compared to standard cell culture. Wounds treated with MSC-
seeded hydrogels demonstrated accelerated healing compared
to untreated wounds at day 5 (49.3 vs 30.8 wound closure,
p0.01 Ior all days), day 7 (78.5 vs 64.0), day 9 (93.6 vs
82.0) and day 11 (100.0 vs 93.0). Bioluminescence imaging
indicated increased viability oI MSCs delivered within
hydrogels compared to injection. MSC-seeded hydrogels
demonstrated enhanced MSC engraItment and augmented
wound angiogenesis compared to subcutaneously injected
MSCs.
Conclusions: Hydrogel delivery oI MSCs improves cell
survival and engraItment in murine wounds compared to
local MSC injection. Further, our MSC-hydrogel construct
accelerates normal wound healing and promotes wound
angiogenesis. These MSC-scaIIold constructs represent a
novel strategy to maximize the therapeutic benefts oI MSCs
Ior skin regeneration.
128
LASER-ASSISTED INDOCYANINE GREEN
IMAGING OPTIMIZES THE DESIGN OF
THE ANTEROLATERAL THIGH FLAP
Presenter: Justin M. Sacks, MD
Authors: Sacks JM, Nguyen AT, Yu P, Baumann DP
Introduction: The anterolateral thigh (ALT) fap is oIten
diIfcult to design and raise secondary to variable perIorator
anatomy. In addition, handheld Doppler examination does not
always correlate to perIorator identifcation. Laser-assisted
indocyanine green (ICG) fuorescent dye angiography is a
modality that visualizes vascular perIorators to faps and
quantifes relative tissue perIusion. The purpose oI this study
was to show how ICG imaging optimizes skin paddle design
oI the ALT fap without the use oI the handheld Doppler or
landmark algorithms.
Methods: FiIteen patients with head and neck cancer deIects
were reconstructed with a Iree ALT fap using laser-assisted
ICG perIorator mapping. The mid-point oI a line between the
anterior superior iliac spine and the patella was determined
and the laser was centered over this. Indocyanine-green (12.5
milligrams) was injected intravenously and fuorescence
patterns were recorded. Optimal perIorators were chosen
using real-time imaging and SPY-Q analysis soItware. The
ALT skin paddle was centered over perIorators based on
best relative perIusion values. The hand-held Doppler was
not used to identiIy perIorators. All faps were elevated in
standard Iashion. Patient demographics, deIect characteristics,
reconstructive techniques and clinical outcomes were
assessed.
Results: FiIteen patients underwent 15 Iree-tissue transIers.
Intraoperative imaging procedures using ICG assisted in
placement oI the ALT skin paddle over one or two optimal
perIorators Ior each fap harvest. There was one partial fap
loss requiring debridement. There were no complications
related to the administration oI ICG fuorescent dye.
Conclusions: Laser-assisted ICG imaging using SPY-Q
analysis soItware provides robust intraoperative real-time
angiography. PerIorator anatomy Irom the descending
branch oI the lateral circumfex Iemoral vessels was clearly
visualized and optimal ALT skin paddle designs were obtained
without the use oI hand-held Doppler. This imaging system
has the potential to revolutionize the intraoperative design oI
perIorator faps.
129
THE FREE DESCENDING BRANCH
MUSCLE SPARING LATISSIMUS DORSI
FLAP: VASCULAR ANATOMY, CLINICAL
RESULTS AND COMPARISON WITH THE
TRANSVERSE BRANCH
Original Presenter: Michel Saint-Cyr, MD
New Presenter: Shannon Colohan, MD
Authors: Saint-Cyr M, Graham D, Wong C,
DonIrancesco A, Colohan S,
Rohrich R
UT Southwestern Medical Center
Introduction: The latissimus dorsi fap holds an important
role in reconstructive surgery. Despite its widespread use as
a Iree fap, donor site morbidity can still be problematic. A
muscle sparing version oI the latissimus dorsi Iree fap can
help alleviate donor site morbidity while still providing an
excellent tool Ior reconstruction.
Purpose: To investigate the vascular anatomy and clinical
results oI the Iree muscle sparing latissimus dorsi fap based
on the descending branch oI the thoraco-dorsal artery. We
also report the vascular anatomy oI the transverse branch
muscle sparing latissimus dorsi fap and compare this to the
descending branch version oI the LD fap.
Methods and Materials: A total oI ten latissimus dorsi faps
were harvested Irom Iresh cadavers provided by the Willed
Body Program at The University oI Texas Southwestern
medical Center at Dallas. We investigated the vascular
perIusion oI the latissimus dorsi muscle and overlying skin
based solely on either the descending branch or transverse
branch oI the thoracodorsal artery. All faps were subjected to
three and Iour dimensional CT angiography to assess vascular
perIusion aIter injection with lead oxide and omnipaque
dye. For the clinical portion oI the study Iour patients who
underwent reconstruction oI the head and neck (1), lower
extremity (2) and upper extremity (1) were retrospectively
reviewed.
Results: The descending branch muscle sparing LD fap
resulted in the largest vascular perIusion Ior both the muscle
and skin when compared to the transverse branch. A total
oI 70 oI the LD muscle was perIused by the descending
branch alone compared to 50 Ior the transverse branch. The
descending branch oI the TDA was the dominant blood supply
to the LD fap and provided the longest pedicle length when
compared to the transverse branch (range 10-15 cm versus
5-10 cm respectively). Clinically, all faps survived and no
donor site morbidity was observed in any oI the patients.
Conclusion: The descending branch muscle sparing LD
fap can provide very reliable coverage as a Iree fap while
minimizing donor site morbidity.
130
THE ROLE OF IL-10 AND C3 TOXIN IN
NERVE REGENERATION IN AN END-TO-
SIDE NERVE REPAIR MODEL
Presenter: Maria Sakalidou, MD
Authors: Sakalidou M, Stark GB, Aktories K,
Penna V
University Clinic Freiburg Germany
Question: The role oI IL-10, an anti-infammatory cytokine
and C3 Iusiontoxin, a Rho-GTPase inhibitor, was investigated
in an end-to-side peroneal nerve lesion model oI the rat.
Methods: Thirty rats were used and divided into 3 groups:
(1) Control group, end-to-side nerve repair oI the peroneal
nerve onto the tibial nerve; (2) intraIasciculary injection
oI 0.125 g/100 l IL-10; or (3) intraIasciculary injection
oI 1 g/100 l C3 Iusiontoxin into the repair site. AIter
8 weeks, the outcome was assessed. Motor Iunction oI
the nerves was evaluated using the walking track test and
calculating the Peroneal Functional Index (P.F.I.). For
the electrophysiological evaluation, the nerve conduction
velocities (NCVs) were analyzed and histomorphological
evaluation consisted oI measurement oI the collagen levels
using picrosirius red staining and evaluation oI myelination
using methylene blue staining, total number oI axons and total
nerve area.
Results: 8 weeks post-operative there were no statistical
signifcant diIIerences in the P.F.I. and NCVs measurements.
Histologic studies revealed a thicker myelin sheath and a
lower G-ratio in the IL-10 group, indicating better myelination
with diIIerences being respectively statistically signifcant
among all groups (p0,001). In the C3 Toxin group, a
signifcant higher number oI axons compared to the other
two groups was Iound. Morphologic analysis demonstrated
signifcant lower collagen levels in the IL-10 group (p0,001),
suggesting lower scar Iormation.
Conclusion: These results suggest that a low dose oI
0.125 g/100 l IL-10 has a Iavorable eIIect in the nerve
regeneration process in an end-to-side neurorrhaphy model
and reduces scar Iormation. This fnding could help to
enhance clinical nerve surgery.
74
131
EFFECT OF CARPAL TUNNEL SYNDROME
ON TRIAL-TO-TRIAL ADAPTATION
TO OBJECT CENTER OF MASS-
SENSORIMOTOR INTEGRATION FOR
MULTI-DIGIT GRASPING
Presenter: Kyle Sanniec, MHA, MBE
Authors: Sanniec K, Zhang W, Johnston JA, Ross M,
Coakley BJ, Gleason E, Santello M,
Smith AA
Mayo Clinic Arizona
Introduction: Somatosensory Ieedback Irom the fngertips
is integrated with voluntary control oI hand muscles in order
to successIully grip objects. This integration can be disrupted
in neurological conditions such as Carpal Tunnel Syndrome
(CTS) and can be appreciated clinically when patients with
CTS complain oI dropping objects. This common clinical
complaint, which has not been studied in a laboratory setting,
raises the question oI how the central nervous system (CNS)
integrates sensory inIormation Irom CTS-aIIected and
non-aIIected digits. This project`s primary objective was to
use CTS as a model to understand mechanisms underlying
sensorimotor integration responsible Ior whole-hand griping
oI objects with a changing center oI mass (CM).
Methods: Fourteen CTS patients (3 males, 11 Iemales) and
age- and gender-matched controls participated in the study.
Subjects were instructed to use all digits (CTS-aIIected
hand) to grasp, liIt, hold level and release a grip device Ior 7
consecutive liIts. Object CM was changed across blocks oI
trials by inserting a mass (200g) underneath the grip device,
either in the middle, the thumb side, or the fnger side.
Subjects were unaware oI the object CM on the frst trial, but
were aware it would remain the same within the trial block.
Force and torque exerted by each digit were measured.
Results: CTS patients and controls reduced the amount oI tilt
on the object aIter frst liIt (P0.05). CTS patients were able
to anticipate and produce a compensatory Iorce to account
Ior the changed CM prior to liIting the device, but not as
eIIectively as the control group.
Conclusion: The inability to successIully grip objects, a
Irequent maniIestation oI carpal tunnel syndrome, appears
to be related to an inability oI these patients to successIully
integrate somatosensory Ieedback with voluntary control oI
the hand muscles.
132
MOLECULAR CHARACTERISTICS AND
TRANSFECTION OF HUMAN ADIPOSE
TISSUE-DERIVED STEM CELLS FOR
PERIPHERAL NERVE REGENERATION IN
VITRO
Presenter: Thomas Scholz, MD
Authors: Scholz T, Donovan PJ, Evans GR
University of California Irvine
Background: Human adipose tissue-derived stem cells
(ADSCs) have evidenced long-term expansion in vitro and
diIIerentiation into multiple mesodermal cell types making
them Iavorable Ior tissue engineered constructs. Previously
we were able to isolate, expand, and diIIerentiate ADSCs
into neuronal lineage cells thus improving peripheral
nerve regeneration in vitro and in vivo. To Iurther analyze
their Iunctional potential we hypothesize that ADSCs can
be transIected with neurotrophic Iactors in vitro to serve
as a growth Iactor delivery system Ior peripheral nerve
regeneration.
Methods: ADSCs were identifed Ior CD34, CD31, and
CD56 using fowcytometry. Then, the cell line was transIected
with Brain Derived Neurotrophic Factor (BDNF) Iused with
Cherry Fluorescent Protein and Green Fluorescent Protein
using a microporation technique. The successIul transIection
was confrmed by PCR and supernatant was collected daily
over seven days. BDNF ELISA was perIormed to quantiIy the
amount oI BDNF protein secreted by our cell line.
Results: Our cell population was negative Ior CD31 and
CD56 and positive Ior CD34 in 32.8. The microporation
technique Ior the transIection oI our cells achieved rates oI
40-50 and demonstrated a stable expression oI BDNF on
PCR when compared to negative controls. A stable secretion
oI 40 to 60 pg/ml over seven days was achieved by our
transIection protocol while the supernatant oI control groups
showed almost no detectable BDNF protein on ELISA.
Discussion: Our data suggests that ADSCs can be
successIully and stably transIected using neurotrophic Iactors.
This transIection results in a constant secretion oI protein
by the ADSCs and, thereIore, could be used within tissue
engineered nerve constructs Ior peripheral nerve regeneration.
133
ROBOTIC LATISSIMUS DORSI MUSCLE
HARVEST: A CADAVER STUDY
Presenter: Jesse C. Selber, MD, MPH
Authors: Selber JC
Background: The latissimus dorsi muscle is a workhorse oI
reconstructive surgery. Traditional harvest technique requires
a 15-25 cm incision at the donor site. Endoscopic harvest
is limited by technical challenges. Robotic harvest oI the
latissimus dorsi may allow Ior a simpler, minimally invasive
harvest technique.
Methods: Ten robotic latissimus dorsi harvests were
perIormed in 8 cadavers. Surgical approach involved an initial
axillary incision to identiIy, dissect and protect the pedicle.
This incision was then closed. Next, three robotic ports were
placed along the anterior border oI the muscle. The DaVinci
surgical robot was then docked, and insuIfation used to create
an optical window. Dissection was then carried out with a
grasper and monopolar scissors. First the undersurIace oI the
muscle was elevated, Iollowed by the subcutaneous plane.
Finally, then inIero-medial attachments were divided Ior
complete harvest.
Results: All ten latissimus dorsi muscles were successIully
harvested in their entirety. Average axillary incision length
was 5 cm. Three ports measuring 12 mm, 5 mm and 5 mm
were used in each case. The average time Irom incision to
robot docking was 23 minutes. Average time to harvest the
muscle was 68 minutes. Ports 1, 2 and 3 were placed an
average distance oI 16, 24.5 and 32.5 cm Irom the axillary
Iold, and 4.5, 6.5 and 5.5 cm Irom the anterior border oI the
muscle, respectively.
Conclusions: Robotic harvest oI the latissimus dorsi muscle
is Ieasible and reproducible. It oIIers technical advantages
over endoscopic harvest, and cosmetic advantages over the
open technique. Robotic latissimus harvest holds clinical
promise.
134
TREATMENT OF PSEUDOMONAS
AERUGINOSA BIOFILM-INFECTED
WOUNDS WITH CLINICAL WOUND CARE
STRATEGIES: A QUANTITATIVE STUDY
USING AN IN VIVO RABBIT EAR MODEL
Presenter: Akhil K. Seth, MD
Authors: Seth AK, Gurjala AN, Geringer MR,
Hong SK, Galiano RD, Leung KP,
Mustoe TA
Northwestern University Feinberg School of Medicine
Background: Bacterial bioflm, notably Pseudomonas
aeruginosa (PA), is now recognized as a major detriment to
chronic wound healing. The eIfcacy oI traditional wound care
methods against bioflm has never been studied. We evaluate
the eIIect oI these clinical strategies on bioflm-inIected
wounds in a quantitative, reproducible in vivo model.
Methods: Six mm dermal punch wounds in New Zealand
rabbit ears were inoculated with PA (10
6
colony-Iorming units
(cIu)) or leIt as uninIected controls 3 days post-wounding.
Planktonic bacteria were killed by topical antibiotic to Iorm
an in vivo bioflm by day 6. PA wounds acted as untreated
controls or underwent 1 oI 5 treatments (n18-24/group):
every other day (QOD) sharp debridement (1), QOD lavage
(2), QOD silvadene (3), QOD lavage and silvadene (4), initial
debridement with daily lavage and silvadene (5). Wounds
were harvested on day 12. Histological wound healing
parameters (epithelial gap (EG) (mm), granulation gap (GG)
(mm), total granulation area (TGA) (mm
2
) and viable bacterial
count (cIu/ml) were measured. Bioflm structure was studied
with scanning electron microscopy (SEM).
Results: UninIected controls healed better than PA bioflm
wounds (EG:0.29 v 4.29, GG:0.38 v 5.05, TGA:332.5 v 49.3;
p0.01). Groups 1-3 were similar to untreated PA in EG,
GG, TGA, and bacterial count. SEM aIter treatment showed
temporary disruption oI bioflm structure, reIorming in 24
hours. Groups 4 and 5 had improved healing (EG:3.46 and
2.89, GG:3.95 and 3.35, TGA:109.0 and 155.9, respectively;
p0.05) and decreased bacterial count (1.81 x 10
5
and 5.84
x 10
3
, respectively) compared to untreated PA (2.29x10
7
)
(p0.05).
Conclusions: Pseudomonal bioflm markedly impairs wound
healing, shown quantitatively with a reproducible in vivo
model. Despite common practice, wound care strategies
cannot restore bioflm wounds to a healing phenotype when
used alone or inIrequently. The durability oI bioflm extends
the chronicity oI non-healing wounds, thus requiring strict,
aggressive, multimodal therapy aimed at reducing bacterial
burden. Our novel, rigorous study validates critical principles
applicable to all clinical wound care.
76
135
BODY CONTOURING IN THE POST-
BARIATRIC SURGERY PATIENT
Presenter: Deana S. Shenaq, BA
Authors: Shenaq DS, Agarwal S, Teven C,
Roughton M, Prachand V, Zachary L
The University of Chicago Hospitals
Background: The obesity epidemic has directly led to an
increase in the number of bariatric procedures performed in
the United States. After bariatric surgery, massive weight
loss patients are often left with excess tissue and skin, which
can present a psychological barrier to further weight loss
maintenance and lifestyle change. We aimed to assess the
effectiveness of body contouring procedures on weight loss
maintenance at our institution.
Methods: A retrospective analysis of 30 adult patients (18+
yrs old) who underwent bariatric surgery and subsequent
body contouring procedures between January 1, 1990 and
October 1, 2009 was performed. Patients body mass indices
(BMIs) were calculated prior to bariatric and body contouring
surgeries and at the time of last follow up. BMIs were
corrected for the weight of tissue excised (grams) at the time
of contouring surgery.
Results: Average BMI immediately prior to gastric
bypass and contouring procedure was 56.4 and 37.1 kg/
m
2
respectively. Time to contour procedure averaged 42
months. On average patients showed a 5.0% increase in BMI
following contour procedure at mean follow up of 56 months.
Fourteen individuals had a BMI change of less than 10%
(range -1% to +8.8%, n=14) with one patient demonstrating a
+40% change.
Conclusion: The literature reports that up to 20% of bariatric
surgery patients cannot sustain their weight loss after 2-3yrs.
Preliminary results at our institution demonstrate that only one
individual undergoing subsequent body contouring had a BMI
increase of greater than 10% after an 8-year follow up. Our
data suggests that post-bariatric body contouring optimizes
bariatric surgery results and can aid with sustainable weight
loss. Therefore, contouring procedures may be viewed as
necessary to the total care of the bariatric patient.
136
LOCAL ADMINISTRATION OF CONTROL-
RELEASED BASIC FIBROBLAST GROWTH
FACTOR IMPROVES FLAP ISCHEMIC
REPERFUSION INJURY IN A MURINE
MODEL
Presenter: Azusa Shimizu, MD
Authors: Shimizu A, Wang Y, Orbay H,
Hyakusoku H, Miyamoto M, Tabata Y,
Mizuno H
Juntendo University School of Medicine
Introduction: Ischemia reperfusion injury decreases the
success rates in microsurgery after prolonged periods of
ischemia. Basic fbroblast growth factors (bFGF) play a
crucial role in wound healing process by promoting fbroblast
proliferation and neovascularization. Gelatin, a denatured
extract of collagen, has a capability of sustaining growth
factors, which are gradually released from gelatin. The
purpose of this study is to determine if bFGF-impregnated
acid gelatin hydrogel microsphere (AGHM) can improve
ischemic reperfusion injury in a skin fap model.
Materials and Methods: Two paired rectangular island skin
faps (1x5 cm each) nourished by deep circumfex iliac vessels
were elevated on the dorsum of Fisher 344 rats (n=40). Flap
ischemia was induced by clamping the pedicle for 6 hours.
Before declamping the pedicle followed by insetting the faps,
each fap received the following injection; (Group I) AGHM
with PBS, (Group II) 20?g bFGF-AGHM, (Group III) 50?g
bFGF-AGHM, (Group IV) 150?g bFGF-AGHM, respectively
(n=10 each). After 7 days, each fap was evaluated by (1)
fap survival area, (2) fap temperature measurement by
thermography, (3) hematoxylin and eosin staining, (4)
immunohistochemistry for vascular endothelial growth factors
(VEGF), transforming growth factor-? (TGF-?), fbroblast
growth factors (FGF), (5) microangiography and (6) scanning
electron microscopy (SEM). All the quantifed data were
analyzed for statistical signifcance using a one-way analysis
of variance. A p value of less than 0.05 was considered
signifcant.
Results: Mean fap survival area was 52.27%, 64.00%,
64.30% and 78.47% in groups I to IV, respectively. There
was a signifcant difference between group IV and others
(p<0.05). Average number of vessels in H&E sections and
microangiography was signifcantly higher in group IV
(p<0.05). The expressions of VEGF, TGF-?, and bFGF were
signifcantly higher in group IV in comparison with the other
groups (p<0.01).
Conclusions: These fndings suggest that the appropriate dose
of bFGF-AGHM improve the fap ischemic reperfusion injury.
137
Abstract Withdrawn
138
215 MANDIBLE FRACTURES IN
120 CHILDREN: DEMOGRAPHICS,
TREATMENT, OUTCOMES, AND GROWTH
Presenter: Darren M. Smith, MD
Authors: Smith DM, Bykowski MR, Rottgers SA,
Vecchione L, Cray JJ, Naran S,
Kinsella CR, Losee JE
University of Pittsburgh Medical Center
Purpose: The management oI pediatric mandible Iractures
requires preservation oI this structure`s dynamic Iunction as
well as its growth potential. We hypothesize that conservative
management is preIerable in these injuries wherever Ieasible.
We present early growth data and a database dedicated to
monitoring mandibular growth, development, and Iunction on
a prospective basis.
Methods: Presentation, treatment, and outcomes were
assessed in patients presenting over ten years. Adverse
outcomes were categorized as: Type 1: secondary to Iracture
alone, Type 2: secondary to treatment alone, and Type
3: secondary to combined Iactors including growth and
development aIter Iracture. Cephalometric analysis was
conducted in patients with available cephalograms Irom at
least 1 year aIter injury.
Results: 215 mandible Iractures in 120 patients were
included. 67.5 oI patients were male, average age 9.9 years
(0.8-18.7 years). Average Iollow-up was 19 months (0.2
months-9 years). Condylar neck (26.5) and head (26.1)
Iractures were most common. OI 54 patients with greater
than 1 year Iollow-up, 57.4 had no adverse outcomes.
Type 1 adverse outcomes accounted Ior 29.6 oI all adverse
outcomes, Type 2 Ior 14.8, and Type 3 Ior 55.6. An
adverse outcome was signifcantly more likely to occur in
operatively managed patients (69.5) than in conservatively
managed patients (22.6) (Chi-square, p 0.001). No
appreciable growth disturbances (T-test, p ~ 0.05) were
discernable on cephalometric analysis (N 42, average injury
to cephalogram time 39 months, range 1 to 9 years).
Conclusions: A conservative approach has yielded largely
uncompromised mandibular Iunction. Growth is thus Iar
unimpeded. While longer Iollow-up is necessary beIore
defnitive conclusions can be made, it seems that conservative
management is advisable whenever possible. The least
invasive approach is to be Iavored iI surgery is required.
Surgeons treating these injuries must be committed to a
long-term treatment plan incorporating annual qualitative,
quantitative and cephalometric evaluations.
78
139
REPAIR OF ALVEOLAR CLEFT DEFECT
WITH PRE-CONDITIONED MULTIPOTENT
CELLS
Presenter: Sarah Sorice, BS
Authors: Sorice S, Fan K, Ehsani N, Tabit C,
Gabbay J, Zuk P, Bradley J
Background: Tradition repair oI alveolar cleIt deIects
requires an autologous bone graIting with the known
morbidity at the iliac crest donor site. To look at
alternative methods, we studied multipotent cells and their
preconditioning with a linear stress model, implanted in rat
alveolar cleIt deIects.
Methods: Human adipose derived stromal cells (ASCs)
and MC3T3 (preosteoblasts) were polymerized in a three-
dimensional collagen gel attached to polyethylene bars within
our microdistraction model. Linear stress was applied using
distraction (0.5m/day) over a 14 day period. Optimization
oI the time and conditions oI the model had previously been
perIormed. Cells were harvested and pellets were used to
seed resorbable collagen sponge matrices. A Critical-sized
unilateral alveolar deIects were created in athymic rats (n24)
and treated with 1) preconditioned ASCs; 2) ASCs (non-
stressed control) 3) preconditioned MC3T3s; 4) MC3T3s
(non-stressed control) and 5) collagen sponge only 6) deIect,
no collagen. AP and lateral radiographs at 2, 4, 8, 12 weeks
compared midIace growth (ANS-OC) and mineralization.
MicroCT at 12 weeks assessed percent regrowth and density
(Iactorial ANOVA).
Results: Pre-conditioned cells demonstrated increased
osteogenic gene expression aIter 14 days oI linear stress
compared to controls (PC-MC3T3sCBFA-1 20 Iold,
Alk Phos 12 Iold; PC-ASCsCBFA-1 4 Iold, Alk Phos
2 Iold). AIter rat alveolar deIect correction, there was
growth restriction in all groups compared to unoperated
control animals, but restriction was similar in each oI the
operated groups (mean oI 12-15 ANS-Occiput, decreased
midIace growth). Rat alveolar deIects with pre-conditioned
MC3T3s healed 72-83 Iaster and with 20-29 more bone
mineralization than MC3T3s, ASCs or collagen alone. Bone
density in the groups were: 1) PC-MC3T3s92, 2) MC3T3s
76, 3) PC-ASCs48, 4) ASCs38, 5) collagen
only33 and 6) deIect17.
Conclusions: Improved alveolar deIect healing
(mineralization and bone density) occurred when
preconditioning multipotent cells with linear stress.
140
UTILIZATION OF EXPLANTABLE
MICROVASCULAR NETWORKS FROM
ADIPOSE TISSUE FOR ORGAN-LEVEL
TISSUE ENGINEERING
Presenter: Michael Sorkin, MD
Authors: Sorkin M, Wong VW, Kosaraju R,
Glotzbach JP, Rustad KC, Chen JS, Suga H,
Stanford University
Introduction: The Iabrication oI organ-level constructs
currently relies on de novo neovascularization to supply
exceedingly complex cell/scaIIold units. However, pre-
patterned Iunctional vascular beds exist throughout the body
and are both explantable and readily re-integrated with the
systemic circulation. Thus, we hypothesize that isolation oI
these vascular networks could provide a pre-vascularized
scaIIold Ior progenitor cell seeding and organ-level tissue
engineering.
Methods: Superfcial inIerior epigastric (SIE) faps were
harvested Irom Sprague-Dawley rats and maintained on
a perIusion bioreactor. EMBs were decellularized with
combinations oI enzymatic/solvent treatments. Vascular
patency was assessed with histological staining and SEM
analysis oI acrylic-based vascular casts. EIfciency oI
decellularization and preservation oI extracellular matrix
were examined with histologic analysis. Decellularized
EMBs were seeded with human adipose-derived stem cells
(hASCs) in vitro and longterm viability was Iollowed using
bioluminescent imaging. A novel oxygen-delivery protein was
tested to augment fap oxygenation.
Results: SIE/EMB tissue faps were eIIectively decellularized
with combinations oI peracetic acid and alcohol-based
perIusates. Collagenase, sodium dodecyl sulIate, and triton-
X-based treatments signifcantly disrupted vascular and
matrix architecture. Vascular patency varied with the type
oI decellularization treatment and was optimal Iollowing
peracetic acid treatment. Microcirculatory networks were
maintained ex vivo on the bioreactor Ior over 24 hours.
hASCs seeded onto decellularized EMBs demonstrated
excellent viability, and perIusion oI oxygen-delivery proteins
signifcantly improved EMB oxygenation up to normoxic
levels.
Conclusion: Autologous vascular beds can be eIIectively
isolated, decellularized, and seeded with hASCs. Strategies
to augment ex vivo fap survival through oxygen-delivery
proteins appear promising. Together, these preliminary studies
suggest that progenitor cell-seeded vascularized scaIIolds are
a promising approach to organ-level tissue engineering.
141
DEMONSTRATION OF THE LYMPHATIC
SYSTEM IN ANIMAL MODELS
Presenter: Hiroo Suami, MD, PhD
Authors: Suami H, Chang DW
The University of Texas MD Anderson Cancer Center
Purpose: Despite a critical need Ior better understanding
oI lymphedema and evaluating eIfcacy oI various surgical
treatments Ior lymphedema, there is no standard animal
model Ior investigating the lymphatic system. The aim oI this
study is to delineate the lymphatic system in diIIerent animal
models and to identiIy a suitable animal model Ior studying
the lymphatic system.
Methods: Rats, rabbits, and mongrel dogs were used. AIter
animals were euthanized, intralymphatic microinjection
technique was applied Ior delineating the lymphatic system:
3 hydrogen peroxide with or without dye was injected
into the dermis and the subcutaneous tissue in the peripheral
area. The lymphatic vessels were infated by fne oxygen
bubbles and identifed under a microscope. Each lymphatic
vessel were cannulated with an attenuated glass tube or 30G
needle and flled with a radio-opaque lead oxide mixture. The
specimens were radiographed and the course oI the lymphatic
vessels was recorded on the flms. The results were compared
with our studies oI human lymphatic system.
Results: Using the microinjection technique, the lymphatic
system could be demonstrated in all species. However, the
defnitive deep lymphatic system, which course below the
deep Iascia, was only identifed in the dogs. The range oI
diameter oI lymphatic vessel in rat, rabbit and dog was
0.1-0.2 mm, 0.3-0.5 mm, 0.3-1.5 mm, respectively. The
dog`s lymphatic system was most similar to that oI human`s
with similar lymphatic vessel size, and is most suitable Ior
manipulation and Ior anatomic studies. The major diIIerence
between human and dog lymphatic system in the upper
extremity was a location oI the dominant lymph node; which
is the axillary lymph node in human and the superfcial
cervical node in dog.
Conclusions: We investigated the lymphatic system in
3 animal models. The dog model is the most suitable Ior
studying the lymphatic system because oI its similarities to
human lymphatics in size, the number oI lymphatic vessels,
and the ease Ior manipulating the vessels.
142
ADIPOSE-DERIVED STEM CELLS
DEMONSTRATE INCREASED SURVIVAL
AND PROMOTE LOCAL VASCULOGENESIS
VIA A PARACRINE MECHANISM
IN ISCHEMIC ADIPOSE TISSUE:
EXPERIMENTS WITH MOLECULAR
IMAGING
Presenter: Hirotaka Suga, MD
Authors: Suga H, Glotzbach JP, Sorkin M,
Stanford University
Introduction: Adipose-derived stem cells (ASCs) have
shown potential Ior cell-based therapy in the feld oI plastic
surgery. However, the Iate oI ASCs aIter transplantation and
the mechanisms oI their eIIects still remain unclear.
Methods: We isolated ASCs Irom transgenic mice that
express both luciIerase and green fuorescent protein (GFP)
and injected the cells into inguinal Iat pads oI wild-type mice.
We used an established Iat pad ischemia model and tested Iour
experimental groups: ischemic Iat pads with/without ASCs
and control Iat pads with/without ASCs.
Results: Transplanted ASCs were tracked with in vivo
bioluminescence imaging oI luciIerase activity. The
luminescence gradually decreased over 14 days, suggesting
cell death aIter transplantation, which was confrmed with
TUNEL and PI staining. Interestingly, more ASCs were
retained in the ischemic Iat pads on day 7 compared to
control (non-ischemic) Iat pads. Surviving ASCs on day 14
were detected as GFP cells using immunohistochemistry,
and they were mostly located in the interstitial space
between adipocytes. A small minority oI the surviving cells
stained positive Ior perilipin (adipogenic marker) or CD31
(endothelial marker), suggesting that minimal diIIerentiation
oI transplanted ASCs into specifc lineages had occurred.
On day 14, the vascular density was higher in the ASC
transplantation groups compared to those without ASCs.
In addition, western blotting showed higher expression oI
hepatocyte growth Iactor (HGF) and vascular endothelial
growth Iactor (VEGF) in the groups with ASCs, suggesting
a paracrine mechanism Ior ASC-enhanced vasculogenesis.
Finally, ASC transplantation decreased atrophy oI adipose
tissue in ischemic Iat pads.
Conclusions: In vivo molecular imaging can be used to track
ASC survival aIter transplantation. Transplanted ASCs are
preIerentially retained in ischemic adipose tissue, although
most oI the cells undergo cell death aIter transplantation.
They exert vasculogenic eIIects in ischemic tissue mainly by
secreting growth Iactors such as HGF and VEGF.
80
143
FAT GRAFTING ACCELERATES
NEOVASCULARIZATION AND DECREASES
FIBROSIS FOLLOWING THERMAL INJURY
Presenter: Steven M. Sultan, BA
Authors: Sultan SM, Butala P, Barr JS, Davidson EH,
Weinstein AL, Knobel D, Saadeh PB,
Warren SM, Coleman SR, Hazen A
New York University
Background: Fat graIting has been shown clinically to
improve the quality oI burn scars. To date, no study has
explored the mechanism oI this eIIect.
Methods: Wild type FVB mice (n20) were anesthetized,
shaved and depilitated. Brass rods were heated to 100C in a
hot water bath beIore being applied to the dorsum oI the mice
Ior 10 seconds, yielding a Iull-thickness injury. Following
a 2-week recovery period, the mice underwent Doppler
scanning beIore being Iat/sham graIted with 1.5 cc`s oI human
Iat/saline. HalI were sacrifced Iour weeks Iollowing graIting,
and halI were sacrifced eight weeks Iollowing graIting. Both
groups repeat Doppler scanning immediately prior to sacrifce.
Burn scar samples were taken Iollowing sacrifce at both time
points Ior protein quantifcation, PCR Arrays, CD31 staining
and Picrosirius red staining.
Results: Doppler scanning demonstrated signifcantly greater
fux in Iat-graIted animals than saline graIted animals at Iour
weeks (Iat305+15.77 mV, saline242+15.83 mV; p0.026).
ELISA analysis in Iat graIted animals demonstrated signifcant
upregulations oI vasculogenic proteins at Iour weeks (VEGF:
Iat74.3+4.39 ng/ml, saline34.3+5.23 ng/ml; p0.004)
(SDF-1: Iat51.8+1.23 ng/ml, saline graIted10.2+3.22 ng/
ml; p0.001) and signifcant decreases in fbrotic markers at
eight weeks (TGF-: saline9.30+0.93, Iat4.63+0.38 ng/
ml; p0.002)(MMP9: saline13.05+1.21, Iat6.83+1.39 ng/
ml; p0.010). Results oI PCR arrays Ior vasculogenic and
fbrotic markers were in agreement the ELISA fndings. CD31
staining demonstrated signifcantly upregulated vascularity at
Iour weeks in Iat graIted animals (Iat30.8+3.39 vessels/hpI,
saline20.0+0.91 vessels/hpI; p0.029). Sirius red staining
demonstrated signifcantly reduced scar index in Iat graIted
animals at eight weeks (Iat0.69+0.10, saline2.03+0.53;
p0.04).
Conclusions: Fat graIting accelerates neovascularization at
the burn site and, in turn, decreases fbrosis in the burn scar.
144
CIAP1 ATTENUATES BLOOD SHEAR
STRESS INDUCED APOPTOSIS OF
HBMSCS FOR TISSUE ENGINEERED
BLOOD VESSELS VIA INHIBITION OF
MITOCHONDRIAL APOPTOSIS PATHWAY
Presenter: Yang Sun, MD, PhD
Authors: Sun Y, Yi W, Xia W, Lau W, Wei X, Ma X,
Guo S
Xijing Hospital 4th Military Medical University
Background: Due to the dearth oI clinically Ieasible vascular
graIts, particularly small-bore variety, tissue engineered blood
vessels (TEBVs) have garnered extensive attention. Human
bone mesenchymal stem cells (hBMSCs), though a promising
source oI TEBV seed cells, are limited in their applicability,
as vascular scaIIolding detachment occurs with blood shear
stress, atop cellular apoptosis. However, the underlying
mechanism oI hBMSCs apoptosis under shear stress remains
unknown.
Methods: hBMSCs were subjected to 3, 10, and 30 dyne/
cm
2
shear stress Ior diIIerent time periods up to 24 h.
Amplifcation oI apoptosis was observed with increased
and prolonged shear stress, as measured via fow cytometry
(p0.05), LDH release (p0.01), caspase-3 activity (p0.001).
Microarray screening revealed the marked upregulation oI
BOK and APAF1, key proteins oI the mitochondrial apoptotic
pathway, during shear stress (3 dyne/cm2), but when hBMSC
apoptosis (via caspase-3 activity assessment) was not
signifcantly increased.
Results: Dissection oI the molecular mechanisms underlying
the discrepancy revealed the elevation oI cIAP1, a caspase-9
inhibitor. Interestingly, when hBMSCs were subjected to
higher shear stresses, cIAP1 levels were reduced. Utilizing
exogenously administered human recombinant cIAP1 to the
hBMSCs under various shear stress magnitudes and periods
up to 24 h, both caspase-3 activity (3 dynes: 1.796 versus
control 3.428 nmol/mg/h, p0.05; 10 dynes: 2.899 versus
control 4.732 nmol/mg/h, p0.05; 30 dynes: 3.655 versus
control 6.655 nmol/mg/h, p0.001, all 24 h exposure) and
LDH release (3 dynes: 6.708 versus control 12.141; 10
dynes: 10.074 versus control 15.308; 30 dynes: 12.358
versus control 18.277 total LDH release, all 24 h exposure,
all p0.01) declined, and cell proliIeration increased (p0.01).
However, the protective eIIect oI cIAP1 was completely
abolished by administration oI exogenous human recombinant
competitive cIAP1 inhibitor (DIABLO), as measured by
caspase-3 activity, LDH release, and cellular proliIeration.
Conclusions: cIAP1 attenuates shear stress-induced hBMSCs
apoptosis via the BOK-APAF1-caspase-3 apoptotic pathway.
145
GELDANAMYCIN IMPROVES
FUNCTIONAL RECOVERY AFTER
PERIPHERAL NERVE CRUSH IN RATS
Presenter: Hank H. Sun
Authors: Sun HH, Hunter DA, Johnson PJ,
Mackinnon SE
Washington University School of Medicine
Introduction: Functional recovery aIter peripheral nerve
injury depends upon the rate and vigor oI target reinnervation.
FK-506, an immunosuppressant, has demonstrated the ability
to accelerate nerve regeneration and improve Iunctional
recovery. The complex oI FK-506 bound to heat shock protein
90 (Hsp90) disrupts the steroid receptor complex, which then
leads to the activation oI neurotrophic signals downstream.
FK-506, however, can also cause severe complications
associated with systemic immunosuppression, rendering its
use undesirable in certain clinical scenarios. Geldanamycin, in
contrast, is a non-immunosuppressive ligand oI Hsp90. It has
been shown to promote neurite outgrowth in vitro and may
enhance nerve regeneration in vivo. In this study, we use a rat
nerve crush model to examine whether the administration oI
geldanamycin improves Iunctional and histologic outcomes to
the same degree as FK-506.
Experimental Design: Twenty-eight (N28) Lewis rats
were randomized into three groups. Group I (n10) received
geldanamycin (0.2 mg/kg/day). Group II (n10) received FK-
506 (2 mg/kg/day). Group III (n8) received an equivalent
amount oI the vehicle, DMSO (1 ml/kg/day), and served as
a negative control. All the animals underwent a right-sided
tibial nerve crush injury 5 mm distal to the sciatic triIurcation.
Dosing was perIormed daily via subcutaneous injection
beginning three days prior to the crush. Print length Iactor
Irom walking track and muscle Iorce output were analyzed Ior
Iunctional recovery oI the tibial nerve. Wet muscle mass and
nerve histomorphometry were also assessed Ior target muscle
preservation and axonal regeneration.
Results: Animals dosed with geldanamycin or FK-506
showed earlier return oI motor Iunction (walking track),
higher Iorce production (muscle Iorce output), and better
target muscle preservation (wet muscle mass) compared with
control animals.
Conclusion: Geldanamycin, like FK-506, improves Iunctional
recovery aIter peripheral nerve injury.
146
IMPAIRED HEALING IN PROGERIC MICE:
THE ROLE OF P53 AND ITS EFFECTS ON
REACTIVE OXYGEN SPECIES STATE
Presenter: Caroline Szpalski, MD
Authors: Szpalski C, Wetterau M, Butala P, Cohen O,
Hwang L, Patel M, Leyleiv J, Ceradini D,
Saadeh PB, Warren SM
NYU Langone Medical Center
Purpose: When characterizing the Hutchinson-GilIord
Progeria Syndrome Zmpste24 knockout murine as a mouse
model oI senescent healing, we demonstrated marked
elevation in reactive oxygen species (ROS), p53 and PUMA
genes levels in injured skin. Since, in other murine models,
p53 can elaborate genes that decrease or increase ROS
generation, depending on stress state, we hypothesized that
delayed healing noted in injured progeric mice was due to a
positive Ieedback cycle oI impaired healing resulting Irom
increased ROS generation itselI defning an increased stress
state. To study this hypothsis, we targeted PUMA, a p53
mediated gene responsible, in part, Ior the elaboration oI
ROS.
Methods: Paired 6 mm wounds were created on 8-week
old male Zmpste24-/- mice (previously established model).
PUMA siRNA complexed in agarose gel matrix was applied
topically to the wounds (day 1, 7, 14). Nonsense siRNA
served as control. Wound closure time was photometrically
assessed (days 0, 7, 10, 14) until healed. Wounds were
harvested Ior immunohistochemistry (IHC), quantitative
RT-PCR, and ELISA (days 10, 14). Paired t-test determined
signifcance (p0.05).
Results: Local PUMA silencing consistently improved
wound healing (18 /- 1.5 vs 41/-2.5 days). IHC revealed
decreased oxidative DNA damage (8-OH-2`-deoxyguanosine),
consistent with decreased ROS. RT-PCR oI the wound beds
demonstrated near complete knock down oI PUMA and,
importantly, its upstream regulator, p53, consistent with
the interruption oI a Ieedback loop. Bax, a pro-apoptotic
gene, under p53 (not PUMA) control Iurther supported this
observation. Additionally, 40 Iold increase in VEGF levels
was noted in the treatment group. Protein analysis showed
signifcant increase in angiogenic Iactors, namely SDF (1.44
vs 5.33 ng/mL) and VEGF (102.60 vs 2207.38 ng/mL) in the
treated group. Later time point showed similar results.
Conclusions: Delayed healing noted in progeric mice is
improved by PUMA silencing which alters genes and gene
products both downstream and upstream Irom its known
actions thereby implicating an injurious positive Ieedback
cycle involvng p53 and ROS.
82
147
BENEFICIAL ROMBERG
RECONSTRUCTION DESPITE POORER FAT
GRAFT TAKE AND MULTIPLE SOFT AND
HARD TISSUE PROCEDURES
Presenter: Christina J. Tabit, BA
Authors: Tabit CJ, Slack G, Andrews B,
Kawamoto H, Bradley J
Introduction: For the treatment oI Romberg disease or
progressive hemiIacial atrophy, we studied fve controversial
issues: 1) Optimal timing; 2) Volume retention oI autologous
Iat graIts within diseased regions; 3) Skin changes aIter Iat
graIting; 4) Need Ior skeletal reconstruction; and 5) Need Ior
soIt tissue (medial canthus/lacrimal duct) reconstruction.
Methods: Patients with Romberg syndrome (~5 year I/up)
were divided into two groups: 1) Less than 14 years oI age; 2)
14 years or older (n29). Gender, age, severity oI deIormity,
number oI procedures, operative times, augmentation Iat
volumes were recorded. A digital 3D photogrammetry
system were used to determine fnal Iat take and symmetry
(aIIected vs. unaIIected side). Romberg Iat graIting volumes
were compared to non-aIIected cosmetic Iat graIted patients.
Physician and patient satisIaction surveys (4 points scale)
were elicited including skin color/texture, and overall
outcome. Pre/postoperative 3D CT scans were also reviewed.
Results: Younger patients required more procedures (4.3 vs
2.8) but had higher patient/Iamily satisIaction scores (3.7
vs 3.0). With Romberg patients mean Fat GraIting volume
injected per case was 48 cc with total Iat injections oI 188 ccs
and a fnal measured volume oI 101 ccs. Romberg patients
had less Iat graIt take that non-aIIected graIted patients: Final
take 41 vs 81. Symmetry score improved Irom 60
preoperatively to 93 aIter last procedure. Physician and
patient skin color/texture showed 3 Iold improvement aIter
multiple Iat graIting procedures.
Conclusions: Romberg patients required multiple corrective
surgeries but showed improvements even when beginning
beIore pueberty. Fat graIt take was poorer in diseased regions;
soIt and hard tissue reconstruction was more involved but all
were benefcial.
148
EFFICACY OF G-CSF MOBILIZED
AUTOLOGOUS PERIPHERAL BLOOD
EPC TRANSPLANT FOR NON HEALING
DIABETIC FOOT PATIENTS
Presenter: Rica Tanaka, MD, PhD
Authors: Tanaka R, Imagawa K, Fukui T,
Miyasaka M, Asahara T
Tokai University School of Medicine
Background: One oI the causes oI non healing diabetic
wound is poor vasculogeneis and recently, we and others
have demonstrated that endothelial progenitor cells (EPCs)
contribute substantially to successIul wound healing and
vasculogenesis. Based on these preclinical studies, we have
started a prospective phase I/II clinical trial oI autologous
G-CSF (granulocyte colony-stimulating Iactor) mobilized
EPC (CD34 cells) on diabetic patients with chronic wounds.
We have enrolled fve patients and here we report the saIety
and eIfcacy oI our study.
Methods: Type 1 and 2 diabetic patients with chronic (~3
months) Ioot ulcers were treated with 5 days oI G-CSF
(10 microgram/kg). Mobilized peripheral blood CD34
cells (i.e. EPCs) were harvested by apheresis and 2x10
7
cells were injected within 20 cm
2
oI the chronic wound and
wound healing was monitored photometrically. ABI (Ankle
Brachial Index), SPP (Skin perIusion pressure), Angiography,
Thermography was perIormed to assess vascular perIusion.
Results: Total oI fve diabetic patients with chronic (average
oI 7 months) Ioot ulcers were treated. Average age was 57.8
years old. All wounds healed with complete wound closure
at average oI 18 weeks. ABI showed no signifcant diIIerence
pre and post therapy (0.91+0.1 vs 0.92+0.2 ns), however SPP
showed signifcant increase in all patients aIter EPC therapy
(14.8+5 vs 53.6+16 p0.01) indicating increased vascular
perIusion due to EPC transplantation.
Conclusion: Transplantation oI G-CSF mobilized EPCs oIIers
an eIIective and saIe method oI increased wound healing
and therapeutic vasculogenesis in patients with non healing
diabetic Ioot.
149
AMIFOSTINE MITIGATES THE
UNTOWARD EFFECTS OF RADIATION
ON THE MINERALIZATION CAPACITY
OF IRRADIATED BONE IN THE MURINE
MANDIBLE
Presenter: Catherine N. Tchanque-Fossuo, MS, MD
Authors: Tchanque-Fossuo CN, Donneys A,
Deshpande SS, Farberg AS, Nelson NS,
Boguslawski MJ, Buchman SR
Background: Radiation (XRT) is an essential adjuvant
therapeutic modality in head and neck cancer (HNC)
treatment and is associated with signifcant morbidity to the
underlying bone. The objective oI this study was to assess
the radioprotective eIIect oI AmiIostine (AMF) therapy on
the mineralization oI the murine mandible aIter receiving a
human equivalent dose oI radiation (HEDR) utilizing micro-
computed tomography (CT). Our hypothesis is that AMF
will Iunction to protect the irradiated mandible Irom the
pathologic degradation oI the mineralization process and the
loss oI viable new bone Iormation.
Methods: Male Sprague Dawley rats were randomized
into 3 groups. Group 1, XRT (n5) and Group 2, AMF/
XRT (n8) underwent a 5-day Iractionated HEDR over the
leIt hemimandibles. Group 2 received AMF prior to XRT.
Animals were compared to a standard control (Group 3) that
did not receive XRT, or AMF. AIter XRT completion, animals
recovered Ior 56 days and hemimandibles were harvested
Ior CT radiomorphometric analysis. ANOVA was used and
statistical signifcance considered at p0.05.
Results: Clinically, we observed less alopecia, mucositis,
and weight loss in the AMF pre-treated group. Grossly,
XRT caused visible thinning, and loss oI cortical density
compared to both control and AMF/XRT. Radiomorphometric
parameters were derived Irom a comparative histogram.
Statistically signifcant diIIerences were observed in the
mean total mineralization volume (76 vs. 90 oI control;
p0.005) and the 5th percentile oI mineralization (28
vs. 54 oI control; p0.002) when comparing irradiated
mandibles to the AMF pre-treated specimens.
Conclusion: Our results demonstrate the ability oI AMF
to prophylactically preserve the mineralization capacity oI
bone as substantiated by our clinical, gross, and quantifable
fndings. These diIIerences refect a protection Irom loss oI
mineral volume, and the preservation oI new bone Iormation.
These fndings support the potential addition oI AMF to
all Radiation therapy protocols that involve exposure to
underlying bone regardless oI pathology.
150
SCALP MELANOMAS AND IN-TRANSIT
METASTASES: A RETROSPECTIVE CASE-
CONTROLLED STUDY
Presenter: Edward Teng, MD
Authors: Teng E, Nishikawa S, Sawh R, Tom L,
Colebunders B, Salameh B, Narayan D
Yale University
Introduction: Scalp melanomas appear to have a worse
prognosis compared to cutaneous melanomas that occur
elsewhere based on epidemiological data. The exact role
oI anatomic location in determining the prognosis remains
unclear. In-transit metastases (ITM) are local cutaneous
recurrences between the primary lesion and regional nodal
basin. These are considered intralymphatic extensions oI the
primary lesion and have serious prognostic indications Ior
survival. In light oI recent studies showing an extensive and
unexpected lymphatic drainage pattern oI the head and neck
region, our goal is to determine whether scalp melanomas
have a higher rate oI ITM compared to cutaneous melanomas
in other parts oI the body.
Methods: A retrospective case controlled study was
perIormed using the patient populations oI two surgeons
at our institution. All scalp melanoma cases collected and
compared to a control population oI all lower extremity
melanoma cases. A total oI 71 scalp melanomas and 112 lower
extremity melanomas cases were identifed. The demographic
data, staging inIormation, operative reports, pathology reports,
and instances oI ITM were recorded and compared.
Results: OI the 71 scalp-melanoma charts reviewed, 62 cases
involved invasive melanoma, and 11 (17) were positive
Ior ITM. OI the 112 lower extremity, 84 involved invasive
melanoma, and 4 (5) were positive Ior ITM. A chi-square
test was perIormed which showed a signifcant diIIerence in
the rate oI ITM (p0.05).
Conclusions: Our results suggest that there is a higher rate
oI ITM in scalp melanomas. DiIIerences in rates oI ITM
persist when the test population is divided into subgroups
and compared to equivalently clinically-staged, lower-
extremity melanomas. The rates oI ITM reported in our study
are consistent with reported rates oI ITM Irom 2.3 to 13
in the literature Ior all types oI melanomas. The limitations
oI our study arise Irom diIIerences in our populations with
the melanoma group composed oI more men (76 vs 33)
and mean age (66 vs 54). Our preliminary fndings suggest
a higher rate oI ITM among scalp melanomas compared to
other sites.
84
151
THE USE OF A NOVEL BIOCOMPATIBLE
SCAFFOLD TO PRODUCE BONE IN 3-D
CELL CULTURE
Presenter: Chad M. Teven, BS
Authors: Teven CM, Collier JH, Natale RB, He TC,
Reid RR
University of Chicago Pritzker School of Medicine
Background: A limitation oI cranial deIect repair is the fnite
supply oI bone available. As such, other methods to produce
bony healing must be explored. Modular, selI-assembly
peptides are able to undergo simultaneous tuning oI several
oI their physicochemical properties, allowing Ior their use in
3D culture. We have shown robust bone Iormation using ad-
BMP-inIected and biophysically-stimulated osteoprogenitor
cells. The next step is to fnd an ideal vehicle Ior osteogenic
diIIerentiation in 3D, thereby creating the microarchitecture
oI native bone. We aim to do this using a novel selI-assembly
peptide.
Methods: The selI-assembly peptide Q11 (Ac-
QQKFQFQFEQQ-Am) was synthesized per our protocol.
Ad-GFP-inIected MEFs, primary murine calvarial cells,
and C3H10T1/2 cells were added to varying peptide
concentrations (1-10mM) to determine ideal cell number
and peptide concentration Ior in vitro and in vivo use. Such
parameters were inIerred Irom scaIIold handling and cell
viability, which was based on GFP expression. Stimulated,
embedded cells are being tested Ior early and late markers
oI osteogenic diIIerentiation, and are compared to ad-GFP
controls. Peptide concentrations oI 3-5mM are ideal Ior
scaIIold handling. Concentrations less than 3mM are too fuid,
leading to carrier dispersion. Concentrations above 5mM are
too rigid Ior in vivo use.
Results: Each cell type embedded within Q11 expressed
GFP Ior at least 7 days in vitro (C3H10T1/2 cells Ior 21
days) regardless oI cell number (.5x106-2x106). Cells are
retained in the 'Z axis based on photomicrographs showing
GFP expression in diIIerent Iocal planes in the 'Z direction
as well as conIocal microscopy. In vitro cell diIIerentiation
assays, and in vivo bone Iormation studies are in progress.
Conclusions: The selI-assembly Q11 peptide maintains
viable osteoprogenitor cells Ior several days in a 3-D matrix.
Preliminary results demonstrate that these cells are stimulable
towards diIIerentiation in this biomaterial. This novel selI-
assembly peptide provides a 3-D construct in which precursor
cells produce bone and may serve as a dependable and saIe
scaIIold in the context oI cranial deIects.
152
A MODEL FOR SHORT-TERM MEDICAL
MISSION EVALUATION: THE IMPACT OF A
HAND SURGERY MISSION TO HONDURAS
Presenter: Laura K. Tom, BS
Authors: Tom LK, Ragins K, Colebunders B,
Thomson JG
Yale School of Medicine
Background: Short-term medical missions to serve patients
in developing countries have become increasingly popular
among doctors Irom the United States. It is estimated that
over 6,000 such trips are coming Irom the United States alone
to developing nations each year. Despite the large number oI
these trips, little research has been published quantitatively
evaluating the impact oI such trips on patients. It would be
necessary to conduct quantitative outcome studies oI such
trips to develop evidence-based comparative best practices.
This study evaluates the impact oI a short-term hand surgery
mission to San Pedro Sula, Honduras on patient upper
extremity morbidity and health-related quality oI liIe.
Methods: A short-term surgical mission identifed Honduran
patients with indications Ior surgery oI their upper extremities
and conducted surgeries during a weeklong trip in January
2010. Researchers administered research-validated Quick
DASH and SF-12v2 surveys preoperatively and 6 months
post-operatively to 70 patients to evaluate changes in patient
upper extremity morbidity and overall health-related quality
oI liIe.
Results: Patients showed statistically signifcant
improvements in the physical component summary, physical
Iunctioning, and mental health sections oI their SF-12v2
scores as well as their Quick DASH scores at 6 months post-
operatively.
Conclusions: Honduran patients with upper extremity
problems that received surgical repairs as part oI this
short-term surgical mission had decreased upper extremity
morbidity and improved health-related quality oI liIe 6
months post-operatively. Furthermore, this study shows that
Iollow-up studies oI patients oI short-term medical missions
in developing countries are becoming increasingly Ieasible
with the spread oI mobile phones, allowing Ior post-mission
Iollow-up months later with even the most diIfcult to access
oI patients. This study provides a model Ior other short-term
medical missions to quantitatively measure their impact, so
that in the Iuture comparative analysis and determination
oI best practices in short-term medical missions might be
possible.
153
TOLERANCE OF CLASS I-MISMATCHED
COMPOSITE TISSUE ALLOGRAFTS
IN SWINE TOLERANT OF RENAL
ALLOGRAFTS
Presenter: Radbeh Torabi, BS
Authors: Torabi R, Scalea JR, Leto Barone AA,
Gillon BC, Cormack TA, Randolph MA,
Sachs DH, Yamada K, Cetrulo CL
Harvard Medical School Massachusetts General Hospital
Introduction: The success oI hand and Iace transplantation
using standard systemic immunosuppression regimens has
demonstrated that composite tissue allotransplantation (CTA)
is a viable option Ior the reconstruction oI amputations and
severe cranioIacial deIects. Tolerance-induction protocols
Ior CTA would represent a critical advance and allow more
widespread application oI reconstructive allotransplantation.
The aim oI this study was to determine whether a CTA would
be accepted without immunosuppression in swine already
tolerant to a major histocompatibility complex (MHC) class-I
mismatched renal allograIt.
Methods: MGH miniature swine, with well-characterized
MHC, can be used to simulate transplantation across various
genetic barriers. Tolerance oI an MHC class-I mismatched
kidney transplantation was induced using a previously
established protocol. Tolerance was confrmed by in vitro
assays and serial biopsies. Once tolerant oI transplanted
kidneys Ior more than 100 days, the animals underwent
kidney-MHC-matched gracilis myocutaneous CTA
transplanted to the groin and anastamosed to the recipient`s
Iemoral artery and vein. GraIts were examined daily and
biopsies oI skin and muscle were taken at days 60, 100 and at
times oI suspected rejection.
Results: One animal Iully accepted the CTA, exhibiting no
signs oI rejection oI muscle or skin clinically or histologically
as oI day 100. The second animal accepted the graIt until
day 70 at which point the graIt demonstrated epidermolysis
Iollowed by recipient reepithelialization oI the CTA dermis.
The third animal similarly accepted the fap but lost the
epidermis beginning on day 40 and has also healed by
recipient reepithelialization. Biopsies confrmed epidermolysis
and viability oI both the dermal and muscle layers in both
animals. All three animals remained tolerant oI donor by in
vitro assays.
Conclusions: Class-I disparate CTAs are accepted by animals
oI donor matched renal allograIts, emphasizing the Ieasibility
oI tolerance strategies Ior patients in need oI CTAs. These
data are encouraging Ior the development oI approaches Ior
tolerance oI CTAs.
154
TGF-BETA-MEDIATED FGF9-PITX2
SIGNALING REGULATES CELL
PROLIFERATION DURING PALATE
FORMATION
Presenter: Lily Tung, BS
Authors: Tung L, Iwata J, Ramenzoni L,
Chaudhry O, Chai Y, Urata M
Keck School of Medicine University of Southern California
Background: CleIt palate is a malIormation oI secondary
palate development and represents a common congenital birth
deIect, aIIecting approximately 1/700 live births worldwide.
TransIorming growth Iactor beta (TgI-beta signaling plays
critical Iunctions in regulating cranioIacial development, and
loss oI TGF-beta receptor type II in cranial neural crest cells
(CNCC) leads to cranioIacial malIormations including cleIt
palate in mice (TgIbr2f/f;Wnt1-Cre mice). Here we identifed
candidate target genes oI TgI-beta signaling.
Methods: These target genes were selected based on a
comparison oI results Irom a microarray analysis oI E14.5
palates Irom TgIbr2f/f;Wnt1-Cre mice and previously
identifed knockout mice phenotypes that included cleIt
palate.
Results: We Iound that fbroblast growth Iactor 9 (FgI9)
and transcription Iactor pituitary homeobox 2 (Pitx2) are
signifcantly down-regulated in the palate oI TgIbr2f/f;Wnt1-
Cre mice and that FgI9 and Pitx2 mutations result in cleIt
palate in both mice and humans. Gene expression oI Pitx2 was
down-regulated by siRNA knockdown oI FgI9, and reduced
FgI9 in TgIbr2f/f;Wnt1-Cre mice resulted in decreased
expression oI both cyclin D1 and D3, Iollowed by a deIect in
cell proliIeration in CNCC-derived palatal mesenchyme.
Conclusions: Our study indicates that TgI-beta-mediated
FgI9-Pitx2 signaling regulates cell proliIeration in CNCC
during palate Iormation.
86
155
LONG TERM STABILITY OF
REGENERATIVE PERIPHERAL NERVE
INTERFACES (RPNI)
Presenter: Melanie G. Urbanchek, PhD
Authors: Urbanchek MG, Baghmanli Z, Wei B,
Egeland BM, Cederna PS
Purpose: We propose to interIace amputee peripheral nerves
to engineered systems Ior neuro-prosthetic limbs. Many
component combinations Ior regenerative peripheral nerve
interIaces (RPNIs) have been tested; however, long term
stability oI neurotized muscle RPNIs has not been established.
Two RPNI designs were compared with unoperated controls
Ior tissue integrity and Iunction aIter neurotization and in situ
stabilization lasting at least 12 months.
Methods: RPNI (1.5 x 0.5 cm) were implanted in a rat
lower hind limb amputation model. RPNI were constructed
by implanting; 1) cultured myoblasts (MyoCells) n6, or 2)
Ireely transIerred muscle (MusTran) n9 within a shell oI
acellular submucosa. Each RPNI was neurotized with the
transected proximal stump oI the peroneal nerve. No attempt
was made to revascularize the tissues. 12 months Iollowing
implantation, the RPNI`s were Iunctionally assessed using
electrophysiologic studies (EMG, NCV). The RPNI`s were
then harvested and underwent histomorphometric analysis.
Results: At harvest all RPNIs were covered by a thin capsule
oI scar tissue less than 1mm in thickness. All RPNIs were
well vascularized and without evidence oI inIection. RPNI
MusTran muscle fbers regenerated to 47 oI control fber
cross sectional area (CSA); while MyoCell RPNI fbers
matured to only 3. Peroneal nerve electrodiagnostics
showed MusTran RPNI perIormance was similar to Control
nerve Ior tests oI compound muscle action potential (CMAP)
latency, area, duration and velocity. MyoCells RPNI recovered
weaker Iunctions Ior CMAP amplitude and latency than
MusTran RPNIs. Neuromuscular junction (NMJ) staining on
MusTran RPNI muscle fbers indicated extensive muscle fber
reinnervation while MyoCells RPNI showed Iew NMJ.
Conclusion: Freely transIerred muscle becomes reinnervated
when neurotized by transected peroneal nerve. Vital muscle
and nerve tissues were sustained Ior up to 12 months in both
the MusTrans and MyoCell RPNI.
156
IN POST-MASTECTOMY BREAST
RECONSTRUCTION: A SYSTEMATIC
REVIEW AND METAANALYSIS
Presenter: Raghunandan Venkat, MD, MPH
Authors: Venkat R, Ohkuma R, Hui-Chou HG,
Manahan MA, Magarakis M, Rosson GD
Johns Hopkins Medical Institutions
Background: Acellular Dermal Matrix (ADM) is a popular
adjunct to tissue expander (TE) or implant based breast
reconstruction aIter mastectomy. We sought to systematically
review postoperative outcomes and risk oI adverse events
with the use oI ADM Ior breast reconstruction.
Methods: We identifed relevant English-language studies
by a search oI MEDLINE and EMBASE to July 2010 and
reviewed the reIerence lists oI relevant articles. Studies that
reported the number oI postoperative inIections, hematomas,
seromas, skin fap necrosis, premature re-excision or removal
oI TE/implant were included. Reports with Iewer than 10
patients or those describing purely cosmetic procedures were
excluded. Two authors independently reviewed and extracted
data Irom the articles. Individual reports were assessed Ior
quality by senior authors based on established guidelines Ior
systematic review oI observational studies. A random-eIIects
model was used to combine studies that compared outcomes
with and without the use oI ADM.
Results: 18 studies were included which evaluated the
association oI ADM with the rate oI postoperative inIection
(n17), seroma (n14), hematoma (n8), premature removal
oI expander/implant (n9), skin fap necrosis (n8) and
esthetic outcomes (n5). 6 studies were included in a
metaanalysis. Use oI ADM was associated with a signifcant
increase in the risk oI seroma (Mantel-Haenszel Odds Ratio
|OR| 3.68, p0.0001), any inIection (OR2.34, p0.0003)
and inIection requiring IV antibiotics or removal oI TE/
implant (OR3.11, p0.02). There was a trend towards an
increased risk oI premature re-excision or removal oI TE/
implant (OR2.43, p0.07) with the use oI ADM. Overall,
studies reported excellent esthetic outcomes with ADM.
Conclusion: ADM is a useIul adjunct to TE/Implant based
breast reconstruction given its utility in providing additional
coverage and support Ior the inIerior pole with excellent
esthetic outcomes. However, it is associated with higher
rates oI postoperative inIection and seroma. CareIul patient
selection and postoperative management are essential in
improving overall reconstructive outcome.
157
NEUROMODULATION IN FUNCTIONAL
RECONSTRUCTION THROUGH
PERIPHERAL NERVE TRANSPLANTATION
INTO CENTRAL NERVE SYSTEM IN
SPINAL CORD INJURY IN RATS APPLYING
CEREBROLYSIN
Presenter: Tobias von Wild, MD
Authors: von Wild T, Siemers F, Trillenberg P,
Heidbreder M, Zrner B, Brunelli G,
von Wild K, Catoi C, Muresanu D,
Mailnder P
UKSH Campus Lubeck
Introduction and Aims: Recovery oI Iunction Iollowing
spinal cord injury is generally limited by the lack oI
regenerative capacity in the central nervous system (CNS).
The aim oI the present proposal is to investigate motor re-
innervations and the infuence oI FPF 1070 (Cerebrolysin
EBEWE) in cell- protection, plasticity and regeneration aIter
transplantation oI a peripheral nerve into the lateral white
matter oI the spinal cord in rats.
Material and Methods: 30 rats were transplanted, 10 oI
which as a control group as each 10 double-blinded Ior
Cerebrolysin vs Placebo. AIter laminectomy and an incision
in the lateral Iuniculus oI the right T11-T12 spinal cord (SC)
a stump oI the sural nerve was inserted into the cord incision.
The motor nerve innervating the right internal obliquus
abdominis muscle was transected and the distal stump was
anastomosed to the graIted nerve. Three months aIter graIt
rats were monitored Ior compound muscle action potentials
(Nicolet USA). The co-adapted PN transplant was dissected
and retrogradly traced by Iast blue (EMSGrivory) Ior
another 10 days beIore animals were deeply anesthetized and
sacrifced.
Key Results: Recordings oI electrophysiological activity
aIter three month confrmed muscle re-innervation in
rats. Outstanding histo- neuro- pathological and immuno-
histochemical results concerning origin and type oI outgrown
cells, position oI the implanted transplant in the CNS, size
and number oI muscle-cells, as type oI transmitter will be
presented.
Conclusion: First Iunctional results oI re-innervation could
show potential in direct transplantation oI PN into the
corticospinal tract with neuromuscular co-adaptation because
oI induced neuromodulation and central neuro-plasticity. This
means a remarkable increase in microsurgical reconstruction
aIter brachial plexus avulsion accompanied with SC damage
in humans. Regenerative potential and plasticity might be
positively be infuenced by neuro- modulating and neuro-
protecting substances like Cerebrolysin.
158
TREATMENT OF APERT SYNDROME: A
LONG-TERM FOLLOW-UP STUDY
Presenter: Derrick C. Wan, MD
Authors: Wan DC, Kawamoto H, Allam K, Bradley J
Background: Patients with Apert syndrome have severe
malIormations oI the skull, with brachyturricephaly and
occipital fattening, and the Iace, with midIace hypoplasia and
anterior open bite, requiring multiple complex reconstructive
procedures. In addition, an abnormally thick skin envelope
accentuates skeletal abnormalities, and developmental delay
may exist. We present a long-term Iollow-up study reporting
both surgical results and psychosocial status oI Apert patients.
Methods: A review oI patients diagnosed with Apert
syndrome by our multidisciplinary team treated Ior at least
15 years Iollowing IrontoIacial advancement with complete
radiographic and clinical evaluations (1975-2010). A complete
psychosocial and educational review was perIormed at
completion oI all reconstructive procedures. Highest level oI
education completed, relationship status, and work history
were queried.
Results: Thirty-one patients with Apert syndrome were
identifed, fIteen with long term Iollow-up and complete
records. Average patient age was 31.6 years. Primary
procedures perIormed included strip craniectomy and Ironto-
orbital advancement. All underwent surgical orthognathic
correction. There were documented Iunctional indications Ior
94 oI the procedures. Multiple auxiliary procedures were
also perIormed Ior better Iacial symmetry. Complications
included: CSF leak (2 patients); encephalocele (1 patient);
Contour irregularity (6 patients). Psychosocial evaluation
demonstrated good integration oI Apert patients into
mainstream liIe. Nine patients had enrolled in regular
education and 6 received special education. All but 1 patient
reported a normal social liIe with several Iriends. Three
patients were married, 3 were in a relationship, and the rest
were single.
Conclusions: This report presents one oI the longest available
Iollow-up studies oIsurgical correction oI patients with Apert
syndrome. While multiple reconstructiveprocedures were
necessary, they played an important role in improving the
Iunctional, morphologic and psychologic condition oI the
patient, helping them integrate into mainstream liIe.
88
159
A VALIDATED TOOL FOR ASSESSMENT OF
MICROSURGICAL SKILLS
Presenter: Kelli N. Webb, MD
Authors: Webb KN, Cooney DS, Cooney CM,
Bueno RA, Neumeister MW
Southern Illinois University
Background: Objective evaluation oI surgical education
and core competencies is rapidly gaining importance in
surgical training Ior numerous reasons: reduced resident work
hours, evolving ACGME requirements regarding skills lab
training, patient saIety, and competencies set Iorth by medical
specialties and educational programs. These points have
necessitated the development oI surgical education protocols
outside the operating room. Microsurgical education is
gaining importance in plastic surgery and currently there is no
validated, objective evaluation tool to assess the perIormance
oI microsurgical trainees. The purpose oI this study is to
refne, validate, and publish an assessment tool as a resource
Ior measuring microsurgical skill.
Methods: Since July 2009, 23 novice and expert
microsurgeons were flmed perIorming microsurgical 1mm rat
Iemoral artery anastomoses. Based on the surgical education
literature and Objective Structured Assessment oI Technical
Skills (OSAT), a pilot microsurgical assessment tool was
developed. This assessment tool was specifc to microsurgical
skills and included 3 sections: a perIormance checklist, a
Likert-type question set, and a modifed OSAT question set. A
web-based system was employed to Iacilitate the evaluation
oI participant video recordings by expert microsurgeons Irom
several diIIerent institutions. Data were statistically analyzed
Ior inter-rater variability, construct validity, and reliability.
Results: The microsurgical assessment tool has construct
validity and diIIerentiates between expert and novice
microsurgical skills. The inter-rater variability is low and
reliability is high leading to statistically signifcant diIIerences
in measured groups.
Conclusions: A validated microsurgical assessment tool is
necessary to produce meaningIul objective measurements
oI competency and provide participants with constructive
Ieedback. In Iuture studies, this tool will be used to measure
educational interventions in a controlled laboratory setting
and develop a microsurgical teaching protocol with the goal oI
improved resident operating room perIormance.
160
HISTOLOGIC AND TACTILE EVALUATION
OF CHRONIC NEUROMAS FROM A
PERIPHERAL NERVE INTERFACE
Presenter: Benjamin Wei, MD
Authors: Wei B, Urbanchek MG, Baghmanli Z,
Shim BS, Martin DC, Kuzon WM,
Cederna PS
Objective: Our goal is to develop a peripheral nerve interIace
(PNI) Ior neural control oI an artifcial limb. Our PNI uses the
highly conductive polymer, poly (3,4-ethylenedioxythiophene)
(PEDOT), to reduce impedance and limit bioIouling.
Neuromas oIten accompany nerve lesions; they are painIul
and can be a source oI signal interIerence. Our hypothesis
is that neuroma Iormation is unaIIected by the presence oI
PEDOT at 3 and 6 months.
Methods: In a rat model, the peroneal nerve was divided,
and the proximal stump was coapted to a scaIIolding oI
small intestinal submucosa (SIS). PEDOT was polymerized
on these scaIIolds Ior two oI the study groups. Dry PEDOT
was chemically polymerized resulting in a stiII compound.
Wet PEDOT was electrochemically polymerized resulting in
a soIter, more compliant compound. The study groups (n8
per group) were: Sham, Primary Repair, Divided Nerve, SIS
alone, SIS with Dry PEDOT, and SIS with Wet PEDOT.
Tactile sensation was evaluated with von Frey flament
stimulation at the operative site at 3 and 6 months. Nerve
cross sections were taken at 6 months. Morphometric analysis
was perIormed using an unbiased sampling technique to
quantiIy axon count and neural tissue.
Results: On histologic evaluation, both SIS with Dry PEDOT
and SIS with Wet PEDOT appear qualitatively healthier than
divided nerve, but not signifcantly diIIerent than SIS alone.
Initial quantitative data Irom overall neural tissue refects a
similar fnding. On von Frey evaluation, lower sensitivity
thresholds imply more pain due to neuroma Iormation.
Addition oI Dry PEDOT to the SIS scaIIold increased the
sensitivity oI the operative site compared with the SIS
scaIIold alone at 3 months. Neither Dry nor Wet PEDOT
groups were signifcantly diIIerent Irom the SIS group at 6
months.
Conclusions: At 6 months, both Iorms oI PEDOT showed
minimal diIIerences in histologic changes and tactile
sensitivity compared to SIS scaIIolding alone. These data
suggest that PEDOT has minimal eIIect on neuroma Iormation
in the chronic phase and is a promising material Ior use in a
peripheral nerve interIace.
161
LIPID NANOPARTICLE-BASED GENE
SILENCING: ONE-STAGE TOPICAL GENE
THERAPY
Presenter: Meredith T. Wetterau, MD
Authors: Wetterau MT, Wilson S, Szpalski C,
Cohen O, Patel M, Hwang L, Henderson R,
Warren SM, SoIou S, Saadeh PB
NYU Langone Medical Center
Background: Disorders oI the skin present ideal targets Ior
topical gene manipulation since the skin aIIords local therapy
with easy re-treatment, thereby potentially avoiding untoward
eIIects oI conventional or genetically-oriented systemic
pharmacotherapy. Silencing RNA (siRNA) is a very eIIective
in-vitro tool to achieve gene knockdown, however, delivery
oI siRNA into the skin is highly cumbersome largely due to
the impermeability oI the stratum corneum, which, in prior
work, required lengthy and extensive pretreatment. We aimed
to develop a new, one-stage topical siRNA delivery system to
simply and eIfciently suppress target genes in the skin.
Methods: siRNA to MAPK, a ubiquitous housekeeping gene
highly expressed in the skin, was complexed with preIormed
DOTAP-containing lipid nanoparticles (NP) under vigorous
vortexing at the mole ratio oI 1:10 (siRNA:DOTAP). The size
and zeta potential oI complexes were monitored over several
days. Complex suspensions were applied to the depilated
dorsa oI mice. Treated sections were harvested at 0, 6, 12,
24, 72, 96, 120 and 168 hrs aIter application and analyzed
(mRNA, protein, and immunohistochemistry (IHC). Paired
t-test determined signifcance (p0.05).
Results: 600-800nm siRNA-DOTAP particle sizes with a
positive zeta potential provided optimal delivery. RT-PCR
demonstrated 20 knockdown oI MAPK beginning at 6 hrs,
and maximal 70 knockdown at 24 hrs, with return oI protein
expression to baseline (Day 0) at 168 hrs. Targeted mRNA
suppression led to similar but expectedly delayed protein
suppression (p0.05). IHC demonstrated highly specifc
knockdown oI the target gene confned to the treatment area.
No oII-target gene silencing was noted (lungs, liver, spleen).
Conclusion: Cutaneous diseases represent a wide spectrum
oI genetic derangements, some oI which may be amenable
to gene silencing. The novel lipid nanoparticle-based siRNA
delivery method described above provides a one-stage, simple
and eIIective means to achieve temporary topical silencing oI
a target gene oI interest while obviating the attendant risks oI
systemic genetic manipulation.
162
CD109, AN ENDOGENOUS TGF-BETA
ANTAGONIST, ENHANCES WOUND
HEALING AND REDUCES SCARRING AND
FIBROSIS
Presenter: Sebastian Winocour, MD
Authors: Winocour S, Vorstenbosch J, Alajmi H,
Trzeciak A, Lessard L, Philip A
McGill University
Background: Our group has identifed a novel endogenous
TGF-beta antagonist, CD109, which inhibits extracellular
matrix production in vitro. To examine whether CD109
regulates TGF-beta action in vivo, we generated transgenic
mice overexpressing CD109 in the epidermis. In the current
study, we determined the eIIects oI CD109 overexpression in
cutaneous wound healing, scarring and fbrosis. Since fbrotic
skin disorders are oIten associated with hypoxia, we examined
whether CD109 is able to regulate healing and scarring under
hypoxia.
6SHFLF$LP To determine whether CD109 regulates skin
wound healing, scarring and fbrosis in vivo, using transgenic
mice overexpressing CD109 in the epidermis (TG mice).
Methods: Wound healing and scarring were examined using
incisional and excisional wounds in TG mice by evaluating
healing and scarring parameters on days 3, 7, and 14 post-
wounding. Skin fbrosis was evaluated by bleomycin-injection
into the skin oI TG mice and analyzing fbrotic responses on
days 21 and 28 post-frst injection. The role oI hypoxia on
healing and scarring was analyzed using excisional wounds
in bipedicle skin faps in TG mice and analyzing healing and
scarring parameters on days 7 and 14 post-wounding.
Results: In excisional wounds, CD109 TG mice demonstrate
improved collagen architecture, enhanced keratinocyte
proliIeration, accelerated granulation tissue resolution, and
reduced infammation, with an associated decrease in ECM
deposition. In the bleomycin-induced fbrosis model, TG
mice show improved collagen architecture, decreased dermal
thickening and ECM deposition with an associated decrease in
TGF-beta signaling. Finally, in the hypoxic excisional wound
model, TG wounds display decreased ECM deposition and
dermal thickness with no eIIect on collagen assembly.
Conclusions: CD109 overexpression reduces scarring and
fbrosis in vivo. Also, in hypoxia, an important component oI
fbrotic wounds, TG mice display reduced dermal thickness
and ECM content. Collectively, these results demonstrate
the potential therapeutic value oI CD109 Ior the treatment oI
scarring and fbrotic skin disorders.
90
163
FIBROBLAST-SPECIFIC FOCAL
ADHESION KINASE LINKS MECHANICAL
FORCE WITH SCAR FORMATION BY
REGULATING FIBROPROLIFERATIVE
AND INFLAMMATORY PATHWAYS POST-
INJURY
Presenter: Victor W. Wong, MD
Authors: Wong VW, Rustad KC, Akaishi S,
Januszyk M, Glotzbach JP, Sorkin M,
Stanford University
Background: Reconstructive surgeons have long recognized
the importance oI mechanical Iorces in wound repair.
Although clinical modalities that manipulate the mechanical
environment are commonplace in plastic surgery (negative
pressure wound therapy, distraction osteogenesis, tissue
expansion), the molecular mechanisms underlying these
therapies remain obscure.
Methods: We applied genomewide cDNA microarray
analysis to a mechanical load model oI hypertrophic scarring.
Candidate mechanotransduction pathways involving Iocal
adhesion kinase (FAK) were targeted using Cre/loxP
technology to generate fbroblast-specifc FAK knockout
(KO) mice. Deletion oI FAK was assessed using PCR,
immunoblotting and immunolocalization, and regulation oI
associated Iocal adhesion components pyk2, src, p130cas,
and ILK was examined. FAK siRNA was used to investigate
human fbroblast contraction in vitro. The hypertrophic scar
model was applied to FAK KO mice, and fbroproliIerative
(Ki67, alpha-SMA) and infammatory markers (MCP1,
macrophages) were studied.
Results: Transcriptome networks linking FAK with
chemokine signaling and matrix Iormation were signifcantly
upregulated with mechanical loading oI murine wounds.
Temporospatial control oI FAK expression was achieved using
tamoxiIen-inducible fbroblast-specifc FAK KO mice. FAK
abrogation resulted in decreased pyk2 activation in isolated
murine fbroblasts and impaired human fbroblast contraction
in 3D collagen lattices. FAK KO mice demonstrated
signifcantly decreased scar Iormation Ior up to 21 days. Post-
injury day ten scars were associated with reduced cellularity,
proliIeration, matrix density, myofbroblast activation,
macrophage recruitment and MCP-1/CCR2 signaling.
Conclusions: Fibroblast-specifc FAK plays a critical
role in wound mechanotransduction and tightly regulates
MCP-1 signaling, thus constituting a putative mechanistic
link between mechanical Iorce and fbrosis. These fndings
establish a molecular Iramework to investigate the mechanical
modulation oI wound repair and may yield novel targeted
therapies to prevent fbrosis and promote tissue regeneration.
164
NOTCH3 KNOCKDOWN AFFECTS
FUNCTIONAL BEHAVIOR OF INFANTILE
HEMANGIOMA STEM CELLS
Presenter: Alvin Wong, AB
Authors: Wong A, Adepoju O, Kitajewski A,
Kitajewski J, Wu J
Columbia University
Background: InIantile hemangiomas (IHs) are the most
common benign tumor oI inIancy, yet their pathogenesis
is still poorly understood. We have previously shown that
Notch3, a mural cell-associated Notch gene, is highly
expressed in hemangioma stem cells (HemSCs) compared
to hemangioma endothelial cells and that Notch target genes
Hes1, Hey1, Hey2, and HeyL are expressed with cell type
specifcity in hemangiomas. Since Notch signaling Iunctions
in cell Iate determination and vascular development, we
investigated whether Notch3 signaling is important in the
maintenance oI stem cell characteristics oI HemSCs.
Materials & Methods: Notch3 gene expression was reduced
in HemSCs using lentiviral expression oI Notch3 shRNA
(N3KO) lentivirus vector with a scrambled insert (Scr) serving
as control. Knockdown was confrmed with quantitative PCR
(RT-qPCR) and western blotting (WB). RT-qPCR was used
to measure expression levels oI Notch downstream signaling
genes Hes1, Hey1, Hey2, and HeyL. HSC proliIeration was
measured using a water-soluble tetrazolium colorimetric
assay. HSC migration was assessed using a scratch wound
assay and analyzed with TScratch soItware.
Results: Expression oI Notch3 shRNA in HemSC cells
reduced Notch3 gene expression by 50 compared to control,
as demonstrated by RT-qPCR. WB confrmed the decrease
oI Notch3 receptor expression. RT-qPCR also demonstrated
a statistically signifcant relative decrease in transcript
expression oI several downstream Notch target genes,
Hes1, Hey1, Hey2, and HeyL compared to control. HSC
proliIeration was reduced by 83 aIter three days oI growth
(p0.02). HSC migration was impaired by 6.2 12 hours
Iollowing scratch wound oI a confuent plate (p0.0008).
Conclusions: Knockdown oI Notch3 expression in HemSCs
leads to downregulation oI Hes1, Hey1, Hey2, and HeyL
mRNA expression. Notch3 knockdown also leads to
decreased proliIerative and migratory ability oI HemSCs.
These data suggest that Notch3 is an important regulator oI
HemSC Iunctions in inIantile hemangioma.
165
INFECTIOUS COMPLICATIONS WITH
ACELLULAR DERMAL MATRICES AND
BREAST RECONSTRUCTION
Original Presenter: Lesley Wong, MD
New Presenter: Jason Buseman
Authors: Wong L, Buseman J, Kemper P,
Oldham J
University of Kentucky
Introduction: Acellular dermal matrices are inert materials
but carry risks oI infammatory reaction and seroma Iormation
which may be precursors to the development oI inIection.
We hypothesize that the presence oI acellular dermal matrix
increases the chance oI developing post breast reconstruction
inIection, and also looked at other potentially contributing
Iactors.
Methods: A retrospective chart review oI consecutive patients
undergoing breast reconstruction with tissue expanders or
implant over a 5 year period perIormed a single university
division. Patient characteristics, type oI mastectomy, length
oI drain placement, history oI chemotherapy or radiation,
presence oI inIection, wound healing problems were noted.
Patients with inIection were studied to determine type, timing
and treatment. Patients with erythema alone that resolved
without sequelae were examined separately. Statistical
analysis oI the data (chi square, multivariate analysis, odds
ratio) to determine risk Iactors Ior the development oI
inIection and the probability oI inIection was undertaken.
Results: 125 patients were identifed. 42 (51/125) had
acellular dermal matrix placed with expanders and implants.
11 (14/125) patients had documented inIection. A nearly
equal number (n13) had erythema oI the reconstructed breast
which was treated with oral antibiotics and resolved without
any Iurther sequelae. No other variables (age, BMI, smoking,
diabetes, chemotherapy, radiation, multiple procedures,
immediate reconstruction) were statistically signifcant Ior
development oI inIection. In the patients with inIection, no
single organism predominated and timing oI occurrence
varied.
Conclusions: ADM is associated with development inIection
in a multi-physician, single-institution group oI patients
undergoing expander/implant reconstruction. The 'red
breast syndrome aIIects a similar number oI patients. This
fnding can explain the variable incidence oI inIection in the
literature. Our fndings suggest that caution be applied when
deciding to use ADM, especially in patients at risk Ior delayed
healing during immediate reconstruction.
166
DEVELOPMENT OF A MICROSPHERE
DRUG DELIVERY SYSTEM TO PROMOTE
NERVE REGENERATION AFTER
PERIPHERAL NERVE INJURY
Presenter: Matthew D. Wood, PhD
Authors: Wood MD, Kim H, Bilbily A, Kemp S,
Weber C, Gordon T, Shoichet MS,
Borschel GH
The Hospital for Sick Children, University of Toronto
Purpose: Repaired nerve transections generally have
acceptable clinical outcomes unless the injury has persisted
untreated Ior months. In these cases, the motor neurons
have undergone chronic axotomy resulting in axons that
require increased growth Iactor support to encourage them
to regenerate. Glial-derived neurotrophic Iactor (GDNF) has
previously been shown to promote motor nerve regeneration
Iollowing chronic axotomy. The majority oI bioengineering
strategies to promote nerve regeneration have Iocused on
therapies to bridge large nerve deIects while Iewer therapies
have Iocused on direct nerve repair. ThereIore, the design
oI controlled drug delivery systems Ior nerves Iollowing
chronic axotomy repair may be benefcial in promoting axon
regeneration.
Methods: We constructed polylactide-glycolic acid (PLGA)
microspheres capable oI extended GDNF release. In vitro
protein release assays (ELISA) and cellular biological activity
assays were perIormed to optimize the microsphere size,
encapsulation eIfciency oI GDNF within the microspheres,
and the time course oI GDNF release. An in vivo drug
delivery system was developed by placing the microspheres
within a carrier fbrin gel to localize the delivery system to
a nerve injury coaptation. The drug delivery system was
evaluated over 2 months to determine the drug delivery
system location and degradation.
Results: Microspheres containing biologically active GDNF
were constructed that encapsulated and retained at least
65 oI the initial GDNF loaded into the microspheres and
capable oI extended and cumulative release over time. The
in vivo drug delivery system demonstrated that microspheres
placed within a fbrin gel stay localized to the nerve Iollowing
implantation and degraded over the course oI 2 months.
Conclusions: Microspheres can delivery biologically active
GDNF Ior an extended period and can be incorporated into a
drug delivery system Ior localized delivery to a nerve injury
site. Overall, the ability oI the delivery system to provide
GDNF to a nerve injury site may promote improved nerve
regeneration and Iunctional outcomes Iollowing chronic nerve
axotomy.
92
167
BIOREACTOR CONDITIONING IN HUMAN
FLEXOR TENDON TISSUE ENGINEERING:
THE ROLE OF 3D-CONSTRUCT
BIOREACTORS
Presenter: Colin Y. Woon, MD
Authors: Woon CY, Kraus A, Raghavan S,
Pridgen B, Pham H, Chang J
Stanford University Medical Center
Introduction: Human tendon tissue engineering attempts
to address the shortage oI autologous tendon material in
mutilating injuries oI the hand and Iorearm. It is important
to maximize the tissue engineered constructs (TEC`s)
biomechanical properties prior to reimplantation. In this study,
we sought to determine the bioreactor treatment parameters
that aIIect these properties.
Methods: Using small- and large-chamber 3d-construct
bioreactors (SCB and LCB respectively), we applied cyclic
axial load to TECs comprising human fexor and extensor
tendons. Small-sample pilot studies using the LCB were
perIormed on matched Iull-length fexor tendons to establish
prooI oI concept. Large-sample studies using the SCB were
perIormed on matched extensor tendon segments to determine
how reseeding, load duty cycle, load magnitude, conditioning
duration, and testing delay aIIected ultimate tensile stress
(UTS) and elastic modulus (EM).
Results: The results oI LCB experiments suggested that
both reseeding and cyclic-conditioning contributed to an
increase in UTS and EM. With the SCB, we verifed that
compared with reseeded controls under dynamic-loading at
1.25N per TEC Ior 5 days, (1) acellular TECs had lower UTS
(p0.03) and EM (p0.01), (2) unloaded TECs had lower
UTS (p0.01) and EM (p0.02), (3) static-loaded TECs had
lower UTS (p0.01) and EM (p0.01), (4) TECs conditioned
Ior 3 days had lower UTS (p0.03) and EM (p0.04), and (5)
TECs conditioned Ior 8 days had higher UTS (p0.04) and
EM (p0.01). However, TECs conditioned at higher loads
(2.5N per TEC) and lower loads (0.625N per TEC) possessed
similar UTS and EM as controls stimulated with 1.25N per
TEC. Following cycle completion, there is rapid attrition oI
UTS (p0.01) and EM (p0.24) over a 2-day period.
Conclusion: The material properties oI acellularized
human tendon can be enhanced by reseeding and dynamic-
conditioning. The problem oI attrition in biomechanical
properties with time Iollowing cycle completion must be
addressed beIore bioreactor preconditioning can be introduced
as a step in the processing oI tissue-engineered constructs Ior
clinical application.
168
EX VIVO TRANSFER OF ADENOVIRUS-
MEDIATED CTLA4IG GENE COMBINED
WITH A SHORT COURSE OF RAPAMYCIN
THERAPY PROLONGS FREE FLAP
ALLOGRAFT SURVIVAL
Presenter: Bo Xiao, MD
Authors: Xiao B, Xia W, Zhao KF, Yang Y, Fu S,
Li Y, Liu B, Guo SZ
XIjing Hospital The Fourth Military Medical University
Background: Adenovirus-mediated cytotoxic T-lymphocyte-
associated antigen-4 immunoglobulin (AdCTLA4Ig) gene
transIer has been reported to enhance both organ and
composite tissue graIts survival in rodent transplantation
models. We tested the eIfcacy oI local expression oI
CTLA4Ig gene on the survival oI rat Iree fap allograIts.
Methods: Brown Norway rat groin faps were transplanted
to Lewis rat recipients. The donor faps were perIused
ex vivo with AdCTLA4Ig via aIIerent artery beIore
transplantation. The distribution and duration oI CTLA4Ig
transgene expression in the faps were assessed by
immunohistochemical staining and semiquantitative reverse
transcriptase polymerase chain reaction (RT-PCR) aIter
transplantation. Mixed lymphocyte reaction was perIormed
to test the antigen specifc immune response. Flow cytometry
was used to detect the variations oI CD425Foxp3 T cells
in recipients spleens.
Results: Immunohistochemical staining and RT-PCR
demonstrated expression oI CTLA4Ig transgene in the
AdCTLA4Ig-perIused Iree fap allograIts. AdCTLA4Ig-
perIused Iree fap allograIts survived signifcantly longer
compared with survival oI AdEGFP-perIused Iree fap
allograIts. When combined with a short course oI rapamycin,
the survival time oI AdCTLA4Ig-perIused Iree fap allograIts
was remarkably prolonged. The MLR results indicate that
ex vivo transIer oI AdCTLA4Ig induces antigen specifc
unresponsiveness. AdCTLA4Ig perIusion didn`t change the
proportion oI CD425Foxp3 T cells in recipients spleens.
169
CD4+ T-CELLS ARE NECESSARY FOR
FIBROSIS AND LYMPHATIC DYSFUNCTION
IN CHRONIC LYMPHEDEMA
Presenter: Alan Yan, MD
Authors: Yan A, Zampell JC, Avraham T,
Malliaris SD, Aschen SZ, Mehrara BJ
Memorial Sloan Kettering Cancer Center
Introduction: Chronic lymphedema results in soIt tissue
fbrosis and lymphatic dysIunction. However, the cellular
mechanisms that regulate this response remain unknown.
T-cells play an important role in fbrosis in a number oI other
fbroproliIerative disorders. The purpose oI these experiments
was, thereIore, to determine the role oI various types oI
T-cells in the regulation oI fbrosis and lymphatic dysIunction
resulting Irom lymphatic fuid stasis.
Methods: Lymphedema was produced by circumIerential
skin excision and microsurgical ligation oI the deep lymphatic
system oI adult Iemale CD4 knockout (KO) and wild-type
mouse tails. They were Iollowed Ior 6 weeks and their
lymphatic Iunction was evaluated. Also, wild-type mice
underwent tail excision and were selectively depleted oI
CD4 or CD8 cells beginning 2 weeks aIter surgery using
monoclonal antibodies. Lymphatic Iunction was evaluated 4
weeks later.
Results: CD4 KO mice had signifcantly decreased tail
lymphedema (~50), dermal thickness (~2x decrease),
and fbrosis (2.5x decrease) as compared with wild-types
(p0.05 Ior all). These changes were associated with
marked improvement in lymphatic Iunction as assessed by
microlymphangiography and lymphoscintigraphy (~100x
increased uptake, p0.01). Western blot analysis demonstrated
markedly decreased expression oI the profbrotic T-helper 2
(TH2) cytokines IL4 and IL13, and also decreased expression
oI the TH1 cytokine IFN-?. Depletion oI CD4, but not CD8
T-cells, decreased tail lymphedema and improved lymphatic
Iunction, indicating that CD4 T-cells are necessary Ior
fbrosis and lymphatic dysIunction.
Conclusion: CD4 T-cells are necessary Ior the development
oI fbrosis and lymphatic dysIunction in the setting oI chronic
lymphatic fuid stasis. This eIIect is due to, at least in part,
decreased expression oI the profbrotic TH2 cytokines IL4
and IL13. These fndings are important since identifcation
oI the mechanisms regulating the pathologic responses
to lymphedema may help identiIy targeted treatment or
preventive measures Ior this debilitating and common
disorder.
170
NERVE REGENERATION IN RAT
ORTHOTOPIC LIMB ALLOGRAFTS:
EVALUATION OF ACUTE REJECTION
RESCUE
Presenter: Ying Yan, MD, PhD
Authors: Yan Y, MacEwan M, Johnson P, Hunter D,
Mackinnon S, Tung T
Washington University in St Louis
Introduction: In the present study a rat orthotopic limb
transplant model was utilized to evaluate the eIIects oI
episodes oI rejection on nerve regeneration and motor
recovery.
Methods: Variable regimens oI the immunosuppressant
FK506 were utilized to preclude or induce rejection Iollowing
composite tissue allotransplantation (CTA) oI rodent hind
limb. Continuous administration oI FK506, administration oI
FK506 Ior 8 weeks and removal, or selective administration
oI FK506/dexamethasone Iollowing noticeable rejection
was utilized to induce no rejection, late rejection, or early
rejection Iollowing limb allograIt procedures, respectively.
Twelve weeks post-operatively, motor recovery was assessed
via evoked muscle Iorce measurement in extensor digitorum
longus (EDL) muscle, while nerve regeneration was assessed
via histological and histomorphometric analysis oI explanted
sciatic nerve.
Results: Results demonstrated that specifc tetanic Iorce
production by the EDL recovered 79.77 in isograIt, 66.24
in allograIt, 66.67 in allograIt early rejection, and 59.12
in allograIt late rejection groups compared to unoperative
controls (27.33 N/cm2). Histomorphometric analysis revealed
a close correlation between motor recovery and the number
oI regenerating nerve fbers. Specifcally, animals within the
isograIt group yielded the greatest number oI regenerated
nerve fbers (12103), Iollowed by allograIt (8955), allograIt
early rejection (8886), and allograIt late rejection (10741).
Conclusion: These preliminary results suggest that net FK506
dosage, rather than the timing oI administration, aIIects
axonal regeneration and Iunctional recovery in the setting oI
limb transplantation. Additionally, it suggests that the degree
oI rejection experienced by the animals in this study may not
be suIfcient to signifcantly infuence axonal regeneration and
Iunctional recovery in vivo. In total, the present study begins
to characterize the eIIect oI immunosuppression regimen
and timing oI immunosuppression on nerve regeneration and
motor recovery post-operatively in CTA.
94
171
RESEARCH ON THE EFFECT OF LOCAL
ADOPTIVE TRANSFUSION OF IMMATURE
DENDRITIC CELLS ON THE REJECTION
MODEL OF COMPOSITE TISSUE
ALLOTRANSPLANTATION
Presenter: Yang Yang, MS
Authors: Yang Y, Guo SZ, Xia W, Yi CG, Zhuang R,
Li Y, Fu S
Xijing Hospital of Fourth Military Medical University of
Chinese
Background: Immunological status is still one oI the
key points discussed in the area oI composite tissue
allotransplantation (CTA) mainly due to the risks oI liIe-long
systemic immunosuppression. This study Iocus on immature
dendritic cells (imDCs) and CD4CD25Foxp3 regulatory
T cells (Treg) to fnd their immunoregulatory roles in CTA,
and meanwhile to fnd a mild immunoregulation way with
minimal drug side-eIIects.
Methods: Superfcial inIerior epigastric artery fap Irom
Brown-Norway (RT1n) was transplanted to Lewis (RT11)
rats (day 0). ImDCs were propagated Irom the recipient
(Lewis, RT11) or donor (Brown-Norway, RT1n) bone
marrow, stained with CFSE and then topically transIused into
allograIts through Iemoral artery pedicle on day 0. Group
1 (control group) did not receive any treatment. Groups 2
received rapamycin (Rapa) at a concentration oI 2mg kg-1
day-1 on days 0-7 postoperative. Groups 3 received donor
imDCs transIusion. Groups 4 received recipient imDCs
transIusion. Group 5 received combined treatment with
donor imDCs and Rapa (2mgkg-1day-1, days 0-7). Group
6 received combined treatment with recipient imDCs and
Rapa (2mgkg-1day-1, days 0-7). GraIt rejection was defned
as epidermolysis/desquamation/gangrene oI the donor skin.
Tissue samples were biopsied to analyze the histological
changes, and fow cytometry was perIormed to trace the
location oI imDCs labeling with CFSE and to quantiIy the
recipient Treg on end-point oI rejection.
Results: All animals in groups 4 and 6 showed evidence
oI longer survival time (p0.05). All animals in all groups
showed that transIused imDCs mainly migrated to bone
marrow early postoperative, and to liver later, but hardly
any to spleen. All animals in groups 4 and 6 showed lower
proportion oI Treg than normal, but higher than that oI groups
3 and 5 (p0.05).
Conclusion: The authors have Iound that recipient imDCs
transIusion combined with low dose rapamycin therapy
prolongs allograIt survival, and may be correlated with
the proportion oI Treg. It would be an evidence to support
application oI Treg adoptive transIusion therapy in Iuture
research.
172
RISK FACTORS FOR INCREASED
MORBIDITY POST TISSUE FLAP
RECONSTRUCTION OF COMPLICATED
STERNAL WOUNDS
Presenter: Hamid R. Zahiri, DO
Authors: Zahiri HR, Medina D, Kelishadi S,
Lumpkins K, Folstein M, Stromberg J,
Singh D
University of Maryland School of Medicine
Background: Complicated post-sternotomy wounds are
oIten eIIectively managed with fap closures. Our goal was
to identiIy risk Iactors that are signifcantly correlated with
increased risk oI morbidity post sternal wound repair with
tissue faps.
Methods: We perIormed a retrospective study oI patients who
underwent fap closure Ior complicated sternal wounds Irom
January 2002 to September oI 2010. Correlation between
post-operative complications and patient history including
age, gender, race, smoking, obesity, hypertension (HTN),
coronary artery disease (CAD), congestive heart Iailure
(CHF), myocardial inIarction (MI), renal insuIfciency (RI),
chronic obstructive pulmonary disease (COPD), steroid use,
immunosuppression, concurrent inIection and sepsis was
analyzed using odds ratio and confdence interval median-
unbiased estimation. Signifcance was determined by a p
value 0.05.
Results: Twenty-nine patients (21 males, 8 Iemales), with
average age oI 61.7 years, received 51 total faps Ior sternal
wound repair including 37 pectoralis advancements, 11
pectoralis split turnovers, and 3 omental faps. Nine patients
(31) required a re-operation aIter their initial sternal wound
fap repair due to complications including recurrent wound
inIection, dehiscence, mediastinitis, and hematoma Iormation.
Two additional patients (7) developed minor sternal wound
inIections treated with antibiotics. Our analysis Iound Obesity,
CHF, and CAD to be statistically signifcant risk Iactors Ior
complications post-sternal wound repair with p values oI 0.04,
0.04, and 0.02, respectively. On the contrary, age, gender,
race, history oI smoking, MI, HTN, RI, COPD, steroid use,
immunosuppression, concurrent inIections and sepsis were
not statistically signifcant risk Iactors Ior post-operative
complications in our patients (all p values ~ 0.05).
Conclusions: When Ieasible, preoperative optimization oI
weight, cardiac tissue perIusion, and ejection Iraction through
medical or surgical intervention may signifcantly reduce
morbidity post sternal wound repair with tissue faps.
173
HIF-1A MODULATES LYMPHATIC VESSEL
REGENERATION AND IS STABILIZED
DURING CHRONIC LYMPHEDEMA
Presenter: Jamie C. Zampell, MD
Authors: Zampell JC, Daluvoy S, Avraham T, Yan A,
Malliaris S, Aschen S, Mehrara BJ
Memorial Sloan Kettering Cancer Center
Introduction: Recent studies show that HIF-1a modulates
VEGF-C to promote lymphangiogenesis in hypoxic tumor
microenvironments; however, mechanisms promoting
lymphatic regeneration during wound healing are undefned.
Our goal was to determine the role oI HIF-1a in regulation oI
lymphatic regeneration and mechanisms leading to HIF-1a
stabilization during wound repair.
Methods: We used a mouse tail model oI lymphatic
regeneration in which lymphatics are excised microsurgically;
Iollowing surgery, HIF-1a activity was blocked by two
diIIerent small molecule inhibitors (YC-1, 2-ME) and
lymphatic regeneration evaluated. Finally, Iactors infuencing
HIF-1a stabilization were determined.
Results: Inhibition oI HIF-1a delayed lymphangiogenesis,
leading to increased edema (4-Iold, p0.01), dilated
lymphatics (4-Iold, p0.05), reduced lymphatic vessel density
(p0.05), impaired lymphatic fuid fow, and down-regulation
oI lymphatic diIIerentiation markers (LYVE-1). Impaired
lymphangiogenesis correlated with decreased VEGF-A and
VEGF-C expression (2-Iold, p0.05) as well as a Iewer
VEGF-C cells (2-Iold, p0.01) and LYVE-1/VEGF-C
cells (3-Iold; p0.01). HIF-1a expression correlated with
gradients oI tissue hypoxia in the early post-operative
period. However, at later time periods (~14 days), HIF-1a
was stabilized in non-hypoxic, lymphedematous tissue,
and expression localized to infammatory cell populations
including lymphocytes. Monoclonal antibody depletion
oI CD3 cells aIter wounding signifcantly reduced HIF-
1a expression (2-Iold), suggesting that T-cell mediated
infammation promotes HIF-1a stabilization.
Conclusions: These results show that HIF-1a modulates
lymphatic regeneration by regulating VEGF-A and VEGF-C.
HIF-1a stabilization during wound repair and in response to
lymphatic fuid stasis is dependent on both hypoxia and T-cell
infammation. These fndings provide insight into mechanisms
oI lymphangiogenesis and suggest that HIF-1a stabilization
is a coordinating Iactor in the regulation oI post-surgical
lymphatic regeneration.
174
INDUCTION OF STRUCTURALLY
ABNORMAL BONE AND INFLAMMATION
IN VIVO WITH HIGH DOSES OF BMP2
Presenter: Janette N. Zara, BSEE, MS, MD
Authors: Zara JN, Siu RK, Zhang X, Shen J, Ngo R,
Li WM, Chiang M, Chung J, Ting K, Soo C
Introduction: Bone morphogenetic protein 2 (BMP2) is the
major FDA approved osteoinductive Iactor in wide clinical
use, including in cranioIacial surgeries. Although BMP2
promotes robust bone Iormation, it also induces adverse
eIIects, including cyst-like bone Iormation and signifcant
soIt tissue swelling. In this study, we determine BMP2 dose
dependent eIIects by evaluating multiple BMP2 doses applied
in two animal models.
Methods: In a Iemoral segmental deIect (FSD) model, 18
male Lewis rats aged 12-14 weeks were divided into seven
experimental groups in which the Iollowing were implanted
into a 6 mm Iemoral segmental deIect: PLGA with (1) PBS
only (control), or PLGA with (2) 5 g/ml, (3) 10 g/ml, (4)
30 g/ml, (5) 150 g/ml, (6) 300 g/ml, and (7) 600 g/ml
oI BMP2. Radiographic imaging was perIormed at 2, 4, 6,
and 8 weeks. Animals were euthanized at 8 weeks. MicroCT
and histological analyses were perIormed. In an onlay model,
bilateral Iemurs oI 17 male Lewis rats aged 12-14 weeks were
overlaid with absorbable collagen sponges (ACS), cut into 1 x
2 cm strips. In each animal, one Iemur was overlaid with ACS
plus PBS (control); the contralateral Iemur was overlaid with
ACS plus 4mg/ml BMP2. Animals were sacrifced at 3, 7,
and 14 days. Immunohistochemistry was perIormed to detect
presence oI infammatory cells.
Results: Results oI our FSD model established a low BMP2
dose range unable to induce deIect Iusion (5, 10 g/ml),
a mid BMP2 dose able to Iuse the deIect without adverse
eIIects (30 g/ml), and a high BMP2 dose range able to Iuse
the deIect, but with Iormation oI cyst-like bony shells flled
with histology confrmed adipose tissue (150, 300, 600 g/
ml). In addition, 4 mg/ml BMP2 induced signifcant tissue
infammatory infltrates and exudates in the onlay model that
was accompanied by increased numbers oI osteoclast-like
cells at 3, 7, and 14 days compared to control.
Conclusion: We consistently reproduced known BMP2
side eIIects oI cyst-like bone Iormation and soIt tissue
swelling using high doses oI BMP2 and elucidated potential
mechanisms by which they occur.
96
175
ENHANCEMENT OF VASCULARIZATION
WITH VASCULAR RESIDENT
ENDOTHELIAL PROGENITOR CELLS IN
ISCHEMIA DERMAL SCAFFOLDS IN VIVO
Presenter: Ziyang Zhang, MD
Authors: Zhang Z, HopIner U, Ito WD, Harder Y,
Kremer M, Reckhenrich A, Lund N,
Lohmeyer J, Machens HG, Egana JT
Technical University of Munich
Backgrounds: Increasing evidences suggest that vascular
resident endothelial progenitor cells (VR-EPCs) are present
in vessel walls, playing an important role in postnatal
neovascularization. However, their structural and Iunctional
characteristics still remain unclear. In this work we isolated
and characterized VR-EPCs in vitro, evaluating their
regenerative potential in vivo.
Materials and Methods: VR-EPCs were isolated Irom
myocardial tissue in rats and characterized in vitro with regard
to morphology, cell surIace markers and angiogenic response.
ThereaIter, cells were seeded in a collagen scaIIold and their
regenerative potential was evaluated in vivo in a Iull thickness
skin deIect model.
Results: Isolated cells share several Ieatures with EPC
described Ior other tissues. Amongst others, VR-EPCs
expressed CD34 and CD133 and could developed capillary
like structures in vitro. AIter seeding VR-EPCs in a collagen
scaIIolds, cells were homogeneously distributed, Iorming
Iocal adhesions within the scaIIold which was confrmed by
conIocal microscope. Metabolic assays showed that the cells
could proliIerate in vitro Ior at least 2 weeks in the scaIIold
(p0.01). In vivo, we observed by transillumination/digital
segmentation (p0.001) and by histology assays (p0.05) that
the presence oI these cells enhanced dermal vascularization
compared to control scaIIolds. In order to explore the possible
mechanisms behind the improvement in tissue regeneration,
in vitro analysis was perIormed and showed that isolated
cells secreted several pro-angiogenic molecules including
VEGF and PDGF. Moreover, the migration capacity oI VR-
EPCs (p0.001) and the Iormation oI capillary like structures
(p0.01) were both improved under endothelial culture
conditions.
Conclusions: This work indicates that a highly clonogenic
VR-EPCs population that exhibits considerable regenerative
capacities can be established in vitro. Accordingly, these
cells could constitute a new therapeutic approach to induce
vascular regeneration in dermal scaIIolds.
176
BONE MARROW COMPONENT OF HIND-
LIMB ALLOGRAFT PROMOTES MARROW-
DERIVED HEMATOPOIETIC STEM CELL
ENGRAFTMENT, CHIMERISM AND
TOLERANCE
Presenter: Wensheng Zhang, MD, PhD
Authors: Zhang W, Wang Y, Liu Q, Solari M,
Murase N, Gorantla V, Lee WA, Zheng XX
Introduction: Current immunosuppressant regimens Ior
composite tissue allograIt (CTA) have allowed more than
95 1-year survival in the compliant hand transplant patients,
suggesting unique intrinsic mechanisms make CTA, as a
complex unit, more pro-tolerogenic than its most antigenic
component: skin. We hypothesize that the vascular bone
marrow in CTA provides stromal environment Ior sustained
donor derived hematopoietic stem cell (HSC) production and
provides an opportunity to achieve mixed chimerism (MC)
and CTA tolerance.
Methods: We utilized wild-type BN or gIp-transgenic SD
rats as bone marrow cells (BMC), vascularized skin/muscle
(VSM), vascularized skin/muscle/bone (VSMB) and hind-
imb allograIt donors and MHC mismatched LEW rats as
recipients, to determine the role oI donor bone component in
establishing MC and inducing tolerance in CTA recipients.
We also developed a strategy to induce CTA tolerance
consisting oI anti-lymphocyte serum (ALS) (day -4 and 1)
and CsA (day 0-7) Iollowed by RMP (day 8-21).
Results: 1) Persistent gIp multilineage MC were observed
in the peripheral blood oI gIp VSMB and gIp hind-limb
allograIt recipients (2.68-6.66) through out Iollow up 140
days. 2) In contrast, only 0.5 gIp cells were detected at
two-weeks post-transplant and disappeared thereaIter in
recipients receiving gIp VSM graIts. 3) The bone marrow
Irom the excised bone graIt 140 days post-transplantation
contained 39.5 gIp donor derived cells. 4) Donor gIp
cells, consist oI ~90 CD4CD8 cells, were evident in the
thymus oI VSMB recipients ~140-days post-transplantation.
5) In a BN to LEW CTA model the graIt survival time were
on an ascending order: VSM (30, 38, 39 days) VSMBMCI
(42, 61, 62, 87 days) VSMB (69, 74, 90, 104 days) hind-
limb (38, 39, ~150, ~150, ~150, ~150 days).
Conclusion: 1) vascular bone marrow oI CTA contributes
to the establishment oI MC in CTA recipients; 2) bone
component oI CTA provides stromal environment Ior
sustained donor derived HSC production; 3) donor HSC
migrate to thymus and undergo T cell diIIerentiation; 4)
vascular bone component promotes MC and CTA tolerance.
177
ALLOANTIGEN-PULSED HOST DENDRITIC
CELLS PROLONG ALLOGRAFT SURVIVAL
IN A RAT MODEL OF HETEROTOPIC
TRACHEAL ALLOTRANSPLANTATION
Presenter: Qixu Zhang, MD, PhD
Authors: Zhang Q, Zang M, Sacks JM, Robb GL,
Yu P
University of Texas MD Anderson Cancer Center
Background: Reconstruction oI large tracheal deIects
remains a signifcant clinical problem. The ideal method
oI reconstruction is to replace like with like, thus with
another trachea as composite tissue allotransplantation
(CTA). Recent studies have shown that bone marrow-based
cellular therapy successIully prolonged limb and Iacial CTA
survival. This project is to investigate the Ieasibility and
eIfcacy oI reduction oI immunorejection in tracheal allograIt
transplantation by cellular therapy with bone marrow-derived
dendritic cells.
Methods: Heterotopic tracheal allotransplantation Irom
Brown-Norway donors to Lewis recipient rats was
perIormed in 5 groups. Group 1isograIt; Group 2 allograIt
without treatment; Group 3 ALS (-4,1d, 0.5ml, ip)CsA
(0-7d,10mg/kg/day, ip); Group 4ALSCsAunpulsed
iDC (7,14d, 7x10
6
, iv); Group 5ALSCsAalloantigen
pulsed iDC (7,14d, 7x10
6
, iv). Donor splenocyte lysates
were used as the donor antigen in the DC pulsing. The
phenotype and homing oI iDC were analyzed by FACS and
immunohistochemistry staining. The graIts were harvested Ior
histological analysis at 4 weeks and 8 weeks respectively.
Results: The iDC purity was greater than 50 percent based
on staining Ior macrophages, T cells, B cells, or neutrophils
by FACS. Homing oI DC was confrmed by labeled iDC
localized to CD3 T cell areas oI spleen. The structure oI
trachea was intact with lumen rigidity and epithelial cover
in group 1, and total luminal occlusion with epithelial loss
in group 2 at 4 weeks. The group 3 and 4 showed partial
luminal occlusion with epithelial loss at 4 weeks and got
worsen at 8 weeks. The group 5 showed well luminal patency
with epithelial cover at 4 and 8 weeks. The immunological
rejection was dramatically reduced in group 5 confrmed by
CD4/CD8 T lymphocyte and CD68 positive macrophage
fltration.
Conclusions: Donor antigen pulsed host dendritic cell
combined with transient immunosuppression agents prolong
tracheal allograIt survival and has potential therapeutic
application Ior tolerance induction in both tracheal and lung
allotransplantation to inhibit luminal obliteration.
178
A COMPARISON OF POSTOPERATIVE
COMPLICATIONS BETWEEN
MASTECTOMY AND IMMEDIATE
BREAST RECONSTRUCTION: IMPACT ON
INITIATION OF CHEMOTHERAPY
Presenter: Toni Zhong, MD, FRCSC
Authors: Zhong T, HoIer SO, McCready D, Jacks L
University Health Network
Background: Since the role Ior postmastectomy
chemotherapy has been expanding, there is concern that the
routine use oI immediate breast reconstruction (IBR) may
delay the initiation oI adjuvant therapy.
Methods: A retrospective review was conducted oI all
consecutive patients who underwent mastectomy alone or
with IBR Irom May 2007 through June 2010 at University
Health Network, Toronto, Canada. The primary outcome
evaluated was postoperative complications and secondary
endpoint was delay in adjuvant chemotherapy defned as
greater than 12 weeks between mastectomy and start oI
chemotherapy.
Results: A total oI 432 patients were identifed, 174 had IBR
and 258 patients had mastectomy alone. The IBR group had
signifcantly greater proportion oI patients with previous
lumpectomy, breast irradiation, and more bilateral procedures
(P0.0001). Overall, the proportion oI patients who had a
postoperative complication was signifcantly greater in the
IBR group than mastectomy alone group. (26 vs. 17,
p0.02). Multivariate analysis revealed that aIter controlling
Ior the eIIect oI the other covariates, IBR was not a signifcant
predictor (p0.64) oI complications. Laterality was the only
independent predictor oI having increased complication (OR
Ior bilateral vs. unilateral 2.2, p0.04). In our cohort, 100
oI mastectomy alone patients were unilateral while 53 oI
IBR patients were bilateral cases. OI the 147 patients who
received adjuvant chemotherapy in this mastectomy cohort,
the median time Irom mastectomy to start oI chemotherapy
was 6.7 weeks in the mastectomy alone group compared to
8.4 weeks in the IBR group (p0.02). However, interestingly,
the 12 patients in the entire cohort who were Iound to
have had a delay in start oI chemotherapy were all in the
mastectomy alone group.
Conclusions: Higher postoperative complication rate
Iollowing IBR than mastectomy alone was most likely
explained by the signifcantly higher proportion oI bilateral
procedures in the IBR group than mastectomy group, rather
than by the IBR procedure itselI. The perIormance oI IBR did
not delay initiation oI chemotherapy.
98
179
BMP-2 MAY NOT INFLUENCE THE
OSTEOGENIC FATE OF HUMAN ADIPOSE-
DERIVED STEM CELLS
Presenter: Patricia Zuk, PhD
Authors: Zuk P, Chou YF, Mussano F, Benhaim P,
Wu B
Introduction: Recombinant human Bone Morphogenetic
Protein-2 (rhBMP2) has been shown to induce in vivo
bone Iormation in many model systems and has long been
approved by the FDA Ior selected human indications. While
recent studies have suggested that rhBMP2 can stimulate the
osteogenic capacity oI human Adipose-derived Stem Cells
(ASCs) in vivo and heal bony deIects, whether BMP2 truly
induces an osteogenic response in ASCs remains unknown
due to a lack oI well-controlled in vivo and in vitro studies.
Methods: The osteogenic response oI ASCs to rhBMP2
was assessed using an in vivo model oI bone Iormation (i.e.
Iemoral deIect system), together with an in vitro study on
ASC osteogenic capacity. In addition, rhBMP2-directed
signaling was also evaluated in vitro by examining signaling
through the BMPR-Smad pathway.
Results: Implantation oI rhBMP2 plus ASCs did not
signifcantly improve bone Iormation in a critical-sized
Iemoral deIect model system, as no signifcant diIIerence in
bone Iormation (as measured through micro-CT evaluation)
was Iound when experimental deIects implanted with
ASCrhBMP2 constructs were compared to control deIects
implanted with acellular constructs absorbed to rhBMP2
alone. In vitro, treatment oI osteo-induced ASCs with
rhBMP2 had no consistent and signifcant eIIect on matrix
mineralization or their expression oI several osteogenic
markers when compared to osteogenically-induced ASC
controls. Consistent and signifcant changes to Smad1/5/8
activation were also not observed upon rhBMP2 induction.
In addition, no observable translocation oI Smad1 and its co-
receptor Smad4 could be discerned in rhBMP-2 treated ASCs,
suggesting that the canonical rhBMP2 signaling pathway
may not be Iunctional. Interestingly, three downstream BMP2
pathway genes, dlx3, dlx5 and osterix were not expressed in
BMP2-induced ASCs, calling the utility oI rhBMP2 induction
in ASCs into question.
Conclusions: Taken together, the data Irom both the in
vitro and in vivo studies suggests that ASC osteogenic
diIIerentiation may not be infuenced by rhBMP2.
Consequently, combining rhBMP2 treatment with ASCs may
not be a viable strategy Ior bony healing.
180
EFFECT OF HYALURONAN ON FAT GRAFT
SURVIVAL
Presenter: Mohammed Alghoul, MD
Authors: Alghoul M, Mendiola A, Seth R, Rubin B,
Zins JE, Calabro A, Siemionow M,
Kusuma S
Cleveland Clinic
Purpose: Autologous Iat transplantation is a widely used
technique Ior soIt tissue augmentation. In spite oI meticulous
eIIorts, Iat graIt take can be unpredictable. Hyaluronan has
been shown to be a promising cell carrier in adipose tissue
engineering.
Methods: Fat was harvested Irom the groins oI 27 rats,
rinsed with lactated Ringer`s solution, leIt to drain on TelIa
and meticulously cut into very small injectable pieces. The
processed Iat was injected using 1 cc Luer-Lok syringes
beneath the rat`s dorsum Iorming two implants (0.8 cc
each). The frst implant contained Iat alone and the second
contained Iat and hyaluronan (HA 4 mg/ml concentration)
in 1:1 mix (Fat-HA). CT scan with volumetric analysis was
perIormed oI the implants in vivo at base line and at 4, 12 and
20 weeks. The Iat component volume oI the Fat-HA implant
was measured separately. Rats were sacrifced in three groups
at the same time intervals and histological studies were
perIormed with hematoxylin and eosin and CD 31 stains.
Results: One rat died Irom anesthesia. All graIts in all animal
groups were clinically viable. Radiographic Iat volume
change, measured as percentage change Irom baseline was
signifcantly diIIerent (smaller) Ior both Iat and Fat-HA
measures, at all time intervals. However, at 20 weeks, the
Iat component oI the Fat-HA implant had signifcantly less
volume loss than the Iat only implant (p0.008). Overall,
Iat necrosis was signifcantly less in the Fat-HA measures
as compared to the Iat alone measures (p0.001). This
diIIerence was most proIound at 4 weeks (p0.008). However,
diIIerences at 12 and at 20 weeks did not reach statistical
signifcance. At 12 weeks, the blood density measures Ior
the Fat-HA implants were signifcantly greater than Iat alone
(p0.016). However, this did not reach statistical signifcance
at 4 or at 20 weeks.
Conclusion: Hyaluronan was compatible with adipose
tissue and may act as a carrier to enhance cell viability, and
volume maintenance. This technology may provide technical
advancements in small volume Iat graIting oI contour deIects
in Iacial and breast reconstruction.
181
PATTERNS OF MANDIBULAR FRACTURES
BASED ON AGE AND MECHANISM OF
INJURY: OUR VIEW OF 13,148 CASES IN
THE US
Presenter: Julio A. Clavijo-Alvarez, MD, PhD
Authors: Clavijo-Alvarez JA, Zenati MS,
Peitzman AB, White MJ
Introduction: Although there have been various studies
reporting the Irequency oI mandibular Iractures, they Iail to
discriminate among age groups and mechanisms oI injury.
This defciency is due to the inadequate sample size that
would allow Ior a powered study.
Hypothesis: We hypothesized that diIIerent age groups
demonstrate distinct patterns oI mandibular Iracture.
Material and Methods: We analyzed the National Trauma
Data Bank (NTDB 2007 - National Sample Program NSP
database released in February 2009). Mandibular Iractures
were identifed using ICD9 codes 802.21 through 802.39.
Discrete variables were compared using chi-square test.
Continuous variables were compared using ANOVA Ior
multiple groups or unpaired t-test Ior 2 group comparisons.
Odds ratio was used to determine risk Iactors Ior Iracture
patterns. A p value 0.05 was considered signifcant.
Results: A total oI 13,148 patients with mandibular Iractures
were identifed. The patient population was subdivided into
13 age groups Iollowing the CDC age group classifcation.
The population had a bell-shaped distribution. The age groups
most Irequently presenting with mandibular Iractures ranged
Irom 18 to 44 years. There were 4 patterns oI Iractures at the
various anatomical areas oI the mandible as Iollows:
1. Patients between 15 and 54 were prone to have angle
Iractures and multiple areas oI Iracture
2. Pediatric patients and elderly patients were more likely to
Iracture the condyle and subcondylar regions
3. Increasing age was directly correlated with increased
coronoid process, ramus and alveolar Iractures.
4. Finally, there was a decreasing trend oI symphyseal
Iractures with aging.
Conclusion: DiIIerent age groups demonstrate distinct
patterns oI mandibular Iracture. Future studies will correlate
these patterns with the mechanism oI injury per age group.
182
CHEMICAL MYOTOMY WITH BOTULINUM
TOXIN FOR ABDOMINAL WALL
RECONSTRUCTION: A PORCINE PILOT
STUDY
Presenter: Karem C. Harth, MD, MHS
Authors: Harth KC, Rosem MJ, Blatnik J,
Schomisch S, Cash A, Soltanian H
University Hospitals Case Medical Center
Components separation in abdominal wall reconstruction
involves permanent surgical myotomy oI the external
abdominal oblique (EAO). This technique is reported to
close deIects 20cm wide. Botulinum toxin has been applied
in a variety oI settings. We report pilot results, evaluating
adequacy oI chemical myotomy with onabotulinumtoxinA
(oA) in abdominal wall advancement.
Methods: Randomized blinded pilot study. Ten 30Kg Iemale
swine received oA (150-200U) to a single randomly assigned
abdominal wall side under anesthesia. The contralateral
side received saline/placebo. oA vs saline was administered
into the EAO muscular substance. Animals survived (2-3
wks) and then underwent blinded in vivo abdominal wall
advancement measurements with a 2kg pulley system. Serial
standard measurements (cm) at the umbilicus were taken aIter
a midline laparotomy at the Iollowing levels on both sides:
1) skin intact (baseline), 2) skin and platysma fap created,
3) Iormal open components separation. oA vs. saline sides
were compared based on advancement Irom baseline at the
Iollowing levels: 2 vs. 2 respectively; 2 vs. 3 respectively.
Wilcoxon rank-sum test was perIormed and a p-value 0.05
considered signifcant.
Results: All animals survived. At level 2 vs. 2: oA (avg
2.5cm; SD 1.1) achieved similar advancement compared
to saline (avg 1.7cm; SD 1.1) (p0.27). This translated into
oA achieving an average oI 49 greater release compared
to saline. At level 2 vs. 3: oA (avg 2.5cm; SD 1.1) achieved
similar advancement compared to saline (avg 3.4; SD 1.0)
(p0.10). This translated into oA achieving 68 oI the Iormal
open component separation release.
Conclusions: Chemical myotomy oI the EAO with botulinum
toxin achieves 68 oI the abdominal wall advancement
accomplished by a Iormal open component separation. Use
oI botox may Iacilitate midline closure oI clinically important
ventral deIects at risk oI recurrence (5-10cm). Botox may
have a role in the preoperative setting as an adjunct to
preoperative pneumoperitoneum or laparoscopic components
separation with midline deIect closure. Further work is needed
and ongoing by our group.
100
183
ULTRASONOGRAPHIC ASSESSMENT OF
DIGITAL NERVE INJURIES
Presenter: Keshav T. Magge, MD
Authors: Magge KT, de la Lama MD, Kessler JK,
Umans HU, Liebling RL
Jacobi Medical Center Albert Einstein College of Medicine
Objectives/hypothesis: Distinguishing between mechanical
disruption and neuroapraxia shortly aIter digital nerve injury
can be diIfcult. Dysesthesia/anesthesia that Iails to resolve
oIten leads to exploration that yields intact structures.
Delaying exploration may prevent primary neurorraphy and
require conduit interposition. A non-invasive, eIfcient method
to reliably predict whether a small nerve is actually severed
could obviate the need Ior surgery and its associated risks
and cost. Such a modality would be especially useIul in the
pediatric age group. We hypothesize that the status oI small
nerves Iollowing injury can be reliably assessed employing
advanced ultrasound technique.
Design: Prospective Human Study
Methods: AIter obtaining inIormed consent, fve patients
(1 male, 4 Iemale, age 2-46 years old) with suspected small
nerve/digital nerve lacerations, underwent high Irequency
sonographic evaluation (all imaging was perIormed
using the Toshiba Aplio XG 14 MHz linear array hockey
stick transducer, 1 technologist, long axis images, with
corresponding digits oI the contralateral hand serving as
control) oI the aIIected digit. They then underwent operative
exploration within 1-6 days post sonography.
Results: OI the fve patients, ultrasound demonstrated two to
have intact radial and ulnar digital nerves, while three patients
had nerve transsection with retraction oI margins. All results
were concordant with surgical exploration.
Conclusions: The results oI this test group encourage us to
proceed with a larger, statistically signifcant study to show
that ultrasonography is a reliable tool in evaluating digital/
small nerve injury.
184
DOUBLE-OPPOSING BUCCAL
FLAP PROCEDURE FOR PALATAL
LENGTHENING
Presenter: Keith C. Neaman, MD
Authors: Neaman KC, Armstrong SD, Ebner B,
Bajnrauh R, Mann RJ
Grand Rapids Medical Education and Research Center/
Michigan State University
Purpose: Velopharyngeal dysIunction (VPD) has been treated
with either a pharyngeal fap or sphincteroplasty with varying
degrees oI success. Both oI these entities have their own
series oI problems, with sleep apnea and nasal mucus fow
disruptions at the IoreIront. The purpose oI this study is to
review the senior author`s experience perIorming the double-
opposing buccal fap Ior palatal lengthening.
Methods: All patients who were treated with double-opposing
buccal faps, between October 1994 and July 2007 were
reviewed. These patients presented with varying degrees oI
VPD showing some degree oI velar movement at the time oI
surgery. Pre and post-operative speech results were reviewed
Ior comparison.
Results: Twenty-seven patients underwent palatal lengthening
with an average length oI Iollow-up oI 58 months. Distal fap
necrosis occurred in two patients. The level oI intelligibility
(65.4 vs. 95.5) and resonance (moderately hypernasal vs.
normal resonance) signifcantly improved post-operatively.
Only one patient required the addition oI a pharyngeal fap Ior
persistent VPD and there were no post-operative issues with
sleep apnea.
Conclusions: The double-opposing buccal fap is an
eIIective technique Ior lengthening the palate and improving
speech, while decreasing the risks oI post-operative sleep
apnea. All patients experienced a dramatic improvement in
their resonance and intelligibility. This technique appears
most aIIective in patients with intact velar movement who
demonstrate a small to moderate posterior velar gap. The
double-opposing buccal fap is a useIul means oI treating
VPD, thus serving as an adjunct when improving pharyngeal
closure.

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Volume 127, Number 5 (Supplement) PSRC Abstract Supplement

9.2 Ior statistical signifcance Ior proportions oI

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