Plastic and reconstructive surgery. Global open, Apr 1, 2020
Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly define... more Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly defined syndrome. Patients attribute a spectrum of symptoms to breast implants. Previously published series have observed a subjective improvement in breathing following breast implant removal and total capsulectomy. We hypothesized that patients presenting with BII would have significant improvement in pulmonary function tests after removal of their breast implants and capsules (explantation).
Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of rec... more Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of recent data on the biology of infection. This article examines specific problems in lower-extremity trauma that allow the wound to become susceptible to wound infection. It also illustrates the various principles of wound management in lower-extremity trauma that serve to prevent infection. Two case examples are used to illustrate principles of management. Other wound problems in lower-extremity trauma are also discussed, such as rabies, necrotizing soft-tissue infection, tetanus, and diabetic foot infections.
Plastic and reconstructive surgery. Global open, Jun 1, 2021
Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined s... more Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined syndrome. Prior published studies have identified difficulty breathing as a symptom, but definitive improvement in breathing following breast implant removal remains understudied. We hypothesized that patients presenting with breathing symptoms attributed to breast implants would have objective improvement in pulmonary function tests after complete implant/capsule explantation. Methods: A retrospective study of all patients who underwent investigation for symptomatic breast implants by a single surgeon over 2 years was conducted. Paired T-tests were used to compare PFTs before and after surgery. Multivariate analyses and linear regression models were used to examine the impact of patient- and implant-related factors, including size and texture on PFT changes. Results: Sixty-nine patients met inclusion criteria. Forced vital capacity (mean pre: 3.67 ± 0.61 L versus post: 3.82 ± 0.55 L), forced expiratory volume (2.78 ± 0.44 L versus 2.89 ± 0.39 L), and peak expiratory flow rate (5.91 ± 1.43 L versus 6.56 ± 0.96 L) were significantly improved postoperatively (P = 0.004, 0.01, 0.0001, respectively). Textured implants were associated with a greater improvement in PFTs after their removal (P = 0.009). Implant size and capsular contracture, even when controlled relative to body mass index, were not independent predictors of improvement. Conclusions: This study demonstrates that patients presenting with symptomatic breast implants with pulmonary complaints had significant improvement in pulmonary function after complete implant/capsule explantation. Forced vital capacity, forced expiratory volume, and peak expiratory flow rate consistent with a restrictive pattern of ventilation reliably improved in this symptomatic cohort. Textured implants were a significant predictive variable for improvement in pulmonary function.
Background: Reducing postoperative pain following abdominoplasty is essential for shortening the ... more Background: Reducing postoperative pain following abdominoplasty is essential for shortening the length of recovery time, reducing the use of narcotics, promoting quicker return to normal activities, and maximizing overall patient satisfaction. The extended use of narcotics and pain pumps is often unacceptable because of nausea, restriction of normal activities, and inconvenience. When the recovery process is not too lengthy and debilitating for the patients, they are more likely to refer the procedure to others and to return for additional elective procedures. Methods: The charts of 209 patients undergoing abdominoplasty over a 10-year period were reviewed. The control group (n ϭ 20) received no blocks, whereas the treatment group (n ϭ 77) received a combination of nerve blocks, using bupivacaine, tetracaine, and Depo-Medrol. Recovery room data and patient questionnaires were used to evaluate clinical efficacy. Patient procedures were classified into four severity classes for analysis. Results: The treatment group had significantly less pain across all severity classes and required significantly less narcotics and less time in the recovery room. Pain scores continued to be significantly lower at home. Patients had significantly less nausea, took less pain medication, and resumed normal activities significantly sooner than the control group. Conclusions: This is the first study showing successful long-term relief of pain associated with abdominoplasty using a combination of intercostal, ilioinguinal, iliohypogastric, and pararectus blocks. This pain-block procedure significantly reduces the recovery time and allows the patient to return to normal activities and work much sooner.
Plastic and reconstructive surgery. Global open, Nov 1, 2021
Sir: W thank Dr. E. Swanson for his comments regarding our recent publication.1 The purpose of st... more Sir: W thank Dr. E. Swanson for his comments regarding our recent publication.1 The purpose of studying respiratory function in this group of breast implant illness patients was due to the clinical observation that they could breathe better and more deeply with less effort after implant removal and capsulectomy. We developed a quantitative symptomatic data tool to study the outcomes of explantation with capsulectomy.1 These studies were our attempt to provide evidencebased information about this specific group of patients.2,3 The improvement in pulmonary function experienced by these patients may have many complex etiologies. One of these may be the weight on the chest. The effect of breast hypertrophy on pulmonary function has been studied in multiple studies.4–8 The relief of weight can have a beneficial effect on pulmonary function. Another etiology for improvement may be the relief of scarring on chest wall in improving chest wall mechanics in breathing. It is important to note that for these patients, the decision to explant is challenging. Not only do they feel that they have to undo an augmentation surgery that they once desired, but they also have to face potential deformity resulting from years of implantation. Their decision is purely based upon the possibility that their health could be improved. The diagnosis of breast implant illness is also not an easy one. These 11 symptoms can mimic Lyme disease, hypothyroidism, menopause, autoimmune disease, or multiple sclerosis. The diagnosis of breast implant illness is based upon a diagnosis of exclusion and improvement of symptoms following implant removal and capsulectomy. This study is not a randomized controlled study comparing implant removal with capsulectomy versus implant removal without capsulectomy. This type of study is ideal, but clinically challenging to execute practically. Total capsulectomy can be associated with increased complications. We did not report any complications from the 750-patient or 72-patient cohort related to pneumothorax complication. There is a clearly defined plane between the capsule and the external intercostal muscle. When you separate the capsule from the external intercostal muscle and you preserve this muscle, pneumothorax can be avoided. Bleeding complications have occurred, but in less than 1% of the group. The selection criteria for the respiratory study3 are welldefined in our methods section. Only those patients who were able to return for a repeat spirometry after explantation were included. We have excluded patients with pre-existing airway and parenchymal disease such as asthma and COPD. That leaves 69 patients for statistical analysis. The exclusion rate is 4%. We did not use a t-test for independent samples of means because the variables that we were testing, before and after capsulectomy, came from the same patient. Therefore, the paired t-test was more appropriately utilized. The online t-test or independent samples t-test is a less powerful and ideal t-test for this study because the same individuals are being measured before and after explant. The paired t-test was used to account for within patient variations. TheP values in the paired t-test for FVC (P = 0.008), FEV1 (P = 0.009), and PEFR (P = 0.001) have all met the rigorous level of less than 0.01. In the multivariate and univariate analysis, both FEV1 P values of 0.009 for univariate analysis and 0.018 P value for multivariate analysis for the textured versus smooth implants are considered significant. We look forward to future study of this under characterized patient population to better answer the thoughtful critiques and questions described by Dr. Swanson and many other accomplished surgeons caring for patients with symptomatic breast implants.
Silicone breast implants (SBI) induce formation of a periprosthetic, often inflammatory, fibrovas... more Silicone breast implants (SBI) induce formation of a periprosthetic, often inflammatory, fibrovascular neo-tissue called a capsule. Histopathology of explanted capsules varies from densely fibrotic, acellular specimens to those showing intense inflammation with activated macrophages, multinucleated giant cells, and lymphocytic infiltrates. It has been proposed that capsuleinfiltrating lymphocytes comprise a secondary, bystander component of an otherwise benign foreign body response in women with SBIs. In symptomatic women with SBIs, however, the relationship of capsular inflammation to inflammation in other remote tissues remains unclear. In the present study, we utilized a combination of TCR-chain CDR3 spectratyping and DNA sequence analysis to assess the clonal heterogeneity of T cells infiltrating SBI capsules and remote, inflammatory tissues. TCR CDR3 fragment analysis of 22 distinct beta variable (BV) gene families revealed heterogeneous patterns of T cell infiltration in patients' capsules. In some cases, however, TCR BV transcripts exhibiting restricted clonality with shared CDR3 lengths were detected in left and right SBI capsules and other inflammatory tissues. DNA sequence analysis of shared, size-restricted CDR3 fragments confirmed that certain TCR BV transcripts isolated from left and right SBI capsules and multiple, extracapsular tissues had identical amino acid sequences within the CDR3 antigen binding domain. These data suggest that shared, antigen-driven T cell responses may contribute to chronic inflammation in SBI capsules as well as systemic sites of tissue injury.
It has been recently brought to light that the Chinese, as early as 1025, A.D., had already devis... more It has been recently brought to light that the Chinese, as early as 1025, A.D., had already devised a preparation which would extract hormones from urine. This paper attempts to trace the development of Chinese medical thought, from 25 A.D., which had led to such a sophisticated preparation.
Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobili... more Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobilization--are investigated in the canine model. The elevation of paired musculocutaneous (MC) and random pattern (RP) flaps allowed comparison of healing flaps with significant differences in blood flow (lower in random pattern flaps) and resistance to infection (greater in musculocutaneous flaps). Blood flow changes as determined by radioactive xenon washout were compared in normal skin and distal flap skin both after elevation and following bacterial inoculation. Simultaneous use of In-111 labeled leukocytes allowed determination of leukocyte mobilization and subsequent localization in response to flap infection. Blood flow significantly improved in the musculocutaneous flap in response to infection. Although total leukocyte mobilization in the random pattern flap was greater, the leukocytes in the musculocutaneous flap were localized around the site of bacterial inoculation within the dermis. Differences in the dynamic blood flow and leukocyte mobilization may, in part, explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection.
The tissue response to silicone gel breast implants typically includes an inflammatory infiltrate... more The tissue response to silicone gel breast implants typically includes an inflammatory infiltrate that consists of macrophages, foreign body-type giant cells, and a variable number of lymphocytes and plasma cells. The phenotype of the lymphocytic component was investigated with three-color flow cytometry. Lymphocytes were obtained by collecting fluid from the space between the implant and the fibrous capsule or by washing cells from the fibrous capsule at the time of implant removal with total capsulectomy. Eighty-nine percent of the implant-associated lymphocytes were T cells. Twenty-five percent of the CD3+ T cells coexpressed HLA-DR compared with only 7.9% of matched peripheral blood lymphocytes. Sixty-eight percent of the implant-associated T cells coexpressed CD4 and CD29, while only 3% of the T cells coexpressed CD4 and CD45RO. The expression of HLA-DR and the predominance of CD29+ CD4+ T cells indicate that there is immune activation with the potential for stimulating antigen...
Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly define... more Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly defined syndrome. Patients attribute a spectrum of symptoms to breast implants. Previously published series have observed a subjective improvement in breathing following breast implant removal and total capsulectomy. We hypothesized that patients presenting with BII would have significant improvement in pulmonary function tests after removal of their breast implants and capsules (explantation).
Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined s... more Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined syndrome. Prior published studies have identified difficulty breathing as a symptom, but definitive improvement in breathing following breast implant removal remains understudied. We hypothesized that patients presenting with breathing symptoms attributed to breast implants would have objective improvement in pulmonary function tests after complete implant/capsule explantation. Methods: A retrospective study of all patients who underwent investigation for symptomatic breast implants by a single surgeon over 2 years was conducted. Paired T-tests were used to compare PFTs before and after surgery. Multivariate analyses and linear regression models were used to examine the impact of patient- and implant-related factors, including size and texture on PFT changes. Results: Sixty-nine patients met inclusion criteria. Forced vital capacity (mean pre: 3.67 ± 0.61 L versus post: 3.82 ± 0.55 L), forced expiratory volume (2.78 ± 0.44 L versus 2.89 ± 0.39 L), and peak expiratory flow rate (5.91 ± 1.43 L versus 6.56 ± 0.96 L) were significantly improved postoperatively (P = 0.004, 0.01, 0.0001, respectively). Textured implants were associated with a greater improvement in PFTs after their removal (P = 0.009). Implant size and capsular contracture, even when controlled relative to body mass index, were not independent predictors of improvement. Conclusions: This study demonstrates that patients presenting with symptomatic breast implants with pulmonary complaints had significant improvement in pulmonary function after complete implant/capsule explantation. Forced vital capacity, forced expiratory volume, and peak expiratory flow rate consistent with a restrictive pattern of ventilation reliably improved in this symptomatic cohort. Textured implants were a significant predictive variable for improvement in pulmonary function.
The internal mammary vessels as recipient site for free flaps in breast reconstruction were inves... more The internal mammary vessels as recipient site for free flaps in breast reconstruction were investigated in this paper because of their ideal location for breast reconstruction. Comparisons were made with the thoracodorsal vessels in terms of external vessel diameter, vessel size discrepancy, flap loss and reexploration rates, and ease of flap placement. Eighty-one patients underwent 110 breast free-flap reconstructions (92 TRAM flaps and 18 superior gluteal flaps) between 1988 and 1994. Vessel size measurements were available on 75 flaps. The internal mammary artery diameter (2.36 +/- 0.50 mm, n = 51) was significantly larger than the thoracodorsal artery diameter (1.79 +/- 0.34 mm, n = 23; p < 0.001). There was no significant difference between the diameters of the internal mammary vein 2.6 +/- 0.58 mm, n = 52) and thoracodorsal vein (2.51 +/- 0.50 mm, n = 23; p = 0.93). The right internal mammary artery (2.52 +/- 0.51 mm) was significantly larger than the left internal mammary...
Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of rec... more Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of recent data on the biology of infection. This article examines specific problems in lower-extremity trauma that allow the wound to become susceptible to wound infection. It also illustrates the various principles of wound management in lower-extremity trauma that serve to prevent infection. Two case examples are used to illustrate principles of management. Other wound problems in lower-extremity trauma are also discussed, such as rabies, necrotizing soft-tissue infection, tetanus, and diabetic foot infections.
Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobili... more Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobilization--are investigated in the canine model. The elevation of paired musculocutaneous (MC) and random pattern (RP) flaps allowed comparison of healing flaps with significant differences in blood flow (lower in random pattern flaps) and resistance to infection (greater in musculocutaneous flaps). Blood flow changes as determined by radioactive xenon washout were compared in normal skin and distal flap skin both after elevation and following bacterial inoculation. Simultaneous use of In-111 labeled leukocytes allowed determination of leukocyte mobilization and subsequent localization in response to flap infection. Blood flow significantly improved in the musculocutaneous flap in response to infection. Although total leukocyte mobilization in the random pattern flap was greater, the leukocytes in the musculocutaneous flap were localized around the site of bacterial inoculation within the dermis. Differences in the dynamic blood flow and leukocyte mobilization may, in part, explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection.
Plastic and reconstructive surgery. Global open, Apr 1, 2020
Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly define... more Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly defined syndrome. Patients attribute a spectrum of symptoms to breast implants. Previously published series have observed a subjective improvement in breathing following breast implant removal and total capsulectomy. We hypothesized that patients presenting with BII would have significant improvement in pulmonary function tests after removal of their breast implants and capsules (explantation).
Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of rec... more Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of recent data on the biology of infection. This article examines specific problems in lower-extremity trauma that allow the wound to become susceptible to wound infection. It also illustrates the various principles of wound management in lower-extremity trauma that serve to prevent infection. Two case examples are used to illustrate principles of management. Other wound problems in lower-extremity trauma are also discussed, such as rabies, necrotizing soft-tissue infection, tetanus, and diabetic foot infections.
Plastic and reconstructive surgery. Global open, Jun 1, 2021
Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined s... more Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined syndrome. Prior published studies have identified difficulty breathing as a symptom, but definitive improvement in breathing following breast implant removal remains understudied. We hypothesized that patients presenting with breathing symptoms attributed to breast implants would have objective improvement in pulmonary function tests after complete implant/capsule explantation. Methods: A retrospective study of all patients who underwent investigation for symptomatic breast implants by a single surgeon over 2 years was conducted. Paired T-tests were used to compare PFTs before and after surgery. Multivariate analyses and linear regression models were used to examine the impact of patient- and implant-related factors, including size and texture on PFT changes. Results: Sixty-nine patients met inclusion criteria. Forced vital capacity (mean pre: 3.67 ± 0.61 L versus post: 3.82 ± 0.55 L), forced expiratory volume (2.78 ± 0.44 L versus 2.89 ± 0.39 L), and peak expiratory flow rate (5.91 ± 1.43 L versus 6.56 ± 0.96 L) were significantly improved postoperatively (P = 0.004, 0.01, 0.0001, respectively). Textured implants were associated with a greater improvement in PFTs after their removal (P = 0.009). Implant size and capsular contracture, even when controlled relative to body mass index, were not independent predictors of improvement. Conclusions: This study demonstrates that patients presenting with symptomatic breast implants with pulmonary complaints had significant improvement in pulmonary function after complete implant/capsule explantation. Forced vital capacity, forced expiratory volume, and peak expiratory flow rate consistent with a restrictive pattern of ventilation reliably improved in this symptomatic cohort. Textured implants were a significant predictive variable for improvement in pulmonary function.
Background: Reducing postoperative pain following abdominoplasty is essential for shortening the ... more Background: Reducing postoperative pain following abdominoplasty is essential for shortening the length of recovery time, reducing the use of narcotics, promoting quicker return to normal activities, and maximizing overall patient satisfaction. The extended use of narcotics and pain pumps is often unacceptable because of nausea, restriction of normal activities, and inconvenience. When the recovery process is not too lengthy and debilitating for the patients, they are more likely to refer the procedure to others and to return for additional elective procedures. Methods: The charts of 209 patients undergoing abdominoplasty over a 10-year period were reviewed. The control group (n ϭ 20) received no blocks, whereas the treatment group (n ϭ 77) received a combination of nerve blocks, using bupivacaine, tetracaine, and Depo-Medrol. Recovery room data and patient questionnaires were used to evaluate clinical efficacy. Patient procedures were classified into four severity classes for analysis. Results: The treatment group had significantly less pain across all severity classes and required significantly less narcotics and less time in the recovery room. Pain scores continued to be significantly lower at home. Patients had significantly less nausea, took less pain medication, and resumed normal activities significantly sooner than the control group. Conclusions: This is the first study showing successful long-term relief of pain associated with abdominoplasty using a combination of intercostal, ilioinguinal, iliohypogastric, and pararectus blocks. This pain-block procedure significantly reduces the recovery time and allows the patient to return to normal activities and work much sooner.
Plastic and reconstructive surgery. Global open, Nov 1, 2021
Sir: W thank Dr. E. Swanson for his comments regarding our recent publication.1 The purpose of st... more Sir: W thank Dr. E. Swanson for his comments regarding our recent publication.1 The purpose of studying respiratory function in this group of breast implant illness patients was due to the clinical observation that they could breathe better and more deeply with less effort after implant removal and capsulectomy. We developed a quantitative symptomatic data tool to study the outcomes of explantation with capsulectomy.1 These studies were our attempt to provide evidencebased information about this specific group of patients.2,3 The improvement in pulmonary function experienced by these patients may have many complex etiologies. One of these may be the weight on the chest. The effect of breast hypertrophy on pulmonary function has been studied in multiple studies.4–8 The relief of weight can have a beneficial effect on pulmonary function. Another etiology for improvement may be the relief of scarring on chest wall in improving chest wall mechanics in breathing. It is important to note that for these patients, the decision to explant is challenging. Not only do they feel that they have to undo an augmentation surgery that they once desired, but they also have to face potential deformity resulting from years of implantation. Their decision is purely based upon the possibility that their health could be improved. The diagnosis of breast implant illness is also not an easy one. These 11 symptoms can mimic Lyme disease, hypothyroidism, menopause, autoimmune disease, or multiple sclerosis. The diagnosis of breast implant illness is based upon a diagnosis of exclusion and improvement of symptoms following implant removal and capsulectomy. This study is not a randomized controlled study comparing implant removal with capsulectomy versus implant removal without capsulectomy. This type of study is ideal, but clinically challenging to execute practically. Total capsulectomy can be associated with increased complications. We did not report any complications from the 750-patient or 72-patient cohort related to pneumothorax complication. There is a clearly defined plane between the capsule and the external intercostal muscle. When you separate the capsule from the external intercostal muscle and you preserve this muscle, pneumothorax can be avoided. Bleeding complications have occurred, but in less than 1% of the group. The selection criteria for the respiratory study3 are welldefined in our methods section. Only those patients who were able to return for a repeat spirometry after explantation were included. We have excluded patients with pre-existing airway and parenchymal disease such as asthma and COPD. That leaves 69 patients for statistical analysis. The exclusion rate is 4%. We did not use a t-test for independent samples of means because the variables that we were testing, before and after capsulectomy, came from the same patient. Therefore, the paired t-test was more appropriately utilized. The online t-test or independent samples t-test is a less powerful and ideal t-test for this study because the same individuals are being measured before and after explant. The paired t-test was used to account for within patient variations. TheP values in the paired t-test for FVC (P = 0.008), FEV1 (P = 0.009), and PEFR (P = 0.001) have all met the rigorous level of less than 0.01. In the multivariate and univariate analysis, both FEV1 P values of 0.009 for univariate analysis and 0.018 P value for multivariate analysis for the textured versus smooth implants are considered significant. We look forward to future study of this under characterized patient population to better answer the thoughtful critiques and questions described by Dr. Swanson and many other accomplished surgeons caring for patients with symptomatic breast implants.
Silicone breast implants (SBI) induce formation of a periprosthetic, often inflammatory, fibrovas... more Silicone breast implants (SBI) induce formation of a periprosthetic, often inflammatory, fibrovascular neo-tissue called a capsule. Histopathology of explanted capsules varies from densely fibrotic, acellular specimens to those showing intense inflammation with activated macrophages, multinucleated giant cells, and lymphocytic infiltrates. It has been proposed that capsuleinfiltrating lymphocytes comprise a secondary, bystander component of an otherwise benign foreign body response in women with SBIs. In symptomatic women with SBIs, however, the relationship of capsular inflammation to inflammation in other remote tissues remains unclear. In the present study, we utilized a combination of TCR-chain CDR3 spectratyping and DNA sequence analysis to assess the clonal heterogeneity of T cells infiltrating SBI capsules and remote, inflammatory tissues. TCR CDR3 fragment analysis of 22 distinct beta variable (BV) gene families revealed heterogeneous patterns of T cell infiltration in patients' capsules. In some cases, however, TCR BV transcripts exhibiting restricted clonality with shared CDR3 lengths were detected in left and right SBI capsules and other inflammatory tissues. DNA sequence analysis of shared, size-restricted CDR3 fragments confirmed that certain TCR BV transcripts isolated from left and right SBI capsules and multiple, extracapsular tissues had identical amino acid sequences within the CDR3 antigen binding domain. These data suggest that shared, antigen-driven T cell responses may contribute to chronic inflammation in SBI capsules as well as systemic sites of tissue injury.
It has been recently brought to light that the Chinese, as early as 1025, A.D., had already devis... more It has been recently brought to light that the Chinese, as early as 1025, A.D., had already devised a preparation which would extract hormones from urine. This paper attempts to trace the development of Chinese medical thought, from 25 A.D., which had led to such a sophisticated preparation.
Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobili... more Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobilization--are investigated in the canine model. The elevation of paired musculocutaneous (MC) and random pattern (RP) flaps allowed comparison of healing flaps with significant differences in blood flow (lower in random pattern flaps) and resistance to infection (greater in musculocutaneous flaps). Blood flow changes as determined by radioactive xenon washout were compared in normal skin and distal flap skin both after elevation and following bacterial inoculation. Simultaneous use of In-111 labeled leukocytes allowed determination of leukocyte mobilization and subsequent localization in response to flap infection. Blood flow significantly improved in the musculocutaneous flap in response to infection. Although total leukocyte mobilization in the random pattern flap was greater, the leukocytes in the musculocutaneous flap were localized around the site of bacterial inoculation within the dermis. Differences in the dynamic blood flow and leukocyte mobilization may, in part, explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection.
The tissue response to silicone gel breast implants typically includes an inflammatory infiltrate... more The tissue response to silicone gel breast implants typically includes an inflammatory infiltrate that consists of macrophages, foreign body-type giant cells, and a variable number of lymphocytes and plasma cells. The phenotype of the lymphocytic component was investigated with three-color flow cytometry. Lymphocytes were obtained by collecting fluid from the space between the implant and the fibrous capsule or by washing cells from the fibrous capsule at the time of implant removal with total capsulectomy. Eighty-nine percent of the implant-associated lymphocytes were T cells. Twenty-five percent of the CD3+ T cells coexpressed HLA-DR compared with only 7.9% of matched peripheral blood lymphocytes. Sixty-eight percent of the implant-associated T cells coexpressed CD4 and CD29, while only 3% of the T cells coexpressed CD4 and CD45RO. The expression of HLA-DR and the predominance of CD29+ CD4+ T cells indicate that there is immune activation with the potential for stimulating antigen...
Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly define... more Purpose: Breast Implant Illness (BII) after aesthetic breast augmentation remains a poorly defined syndrome. Patients attribute a spectrum of symptoms to breast implants. Previously published series have observed a subjective improvement in breathing following breast implant removal and total capsulectomy. We hypothesized that patients presenting with BII would have significant improvement in pulmonary function tests after removal of their breast implants and capsules (explantation).
Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined s... more Background: Breast Implant Illness after aesthetic breast augmentation remains a poorly-defined syndrome. Prior published studies have identified difficulty breathing as a symptom, but definitive improvement in breathing following breast implant removal remains understudied. We hypothesized that patients presenting with breathing symptoms attributed to breast implants would have objective improvement in pulmonary function tests after complete implant/capsule explantation. Methods: A retrospective study of all patients who underwent investigation for symptomatic breast implants by a single surgeon over 2 years was conducted. Paired T-tests were used to compare PFTs before and after surgery. Multivariate analyses and linear regression models were used to examine the impact of patient- and implant-related factors, including size and texture on PFT changes. Results: Sixty-nine patients met inclusion criteria. Forced vital capacity (mean pre: 3.67 ± 0.61 L versus post: 3.82 ± 0.55 L), forced expiratory volume (2.78 ± 0.44 L versus 2.89 ± 0.39 L), and peak expiratory flow rate (5.91 ± 1.43 L versus 6.56 ± 0.96 L) were significantly improved postoperatively (P = 0.004, 0.01, 0.0001, respectively). Textured implants were associated with a greater improvement in PFTs after their removal (P = 0.009). Implant size and capsular contracture, even when controlled relative to body mass index, were not independent predictors of improvement. Conclusions: This study demonstrates that patients presenting with symptomatic breast implants with pulmonary complaints had significant improvement in pulmonary function after complete implant/capsule explantation. Forced vital capacity, forced expiratory volume, and peak expiratory flow rate consistent with a restrictive pattern of ventilation reliably improved in this symptomatic cohort. Textured implants were a significant predictive variable for improvement in pulmonary function.
The internal mammary vessels as recipient site for free flaps in breast reconstruction were inves... more The internal mammary vessels as recipient site for free flaps in breast reconstruction were investigated in this paper because of their ideal location for breast reconstruction. Comparisons were made with the thoracodorsal vessels in terms of external vessel diameter, vessel size discrepancy, flap loss and reexploration rates, and ease of flap placement. Eighty-one patients underwent 110 breast free-flap reconstructions (92 TRAM flaps and 18 superior gluteal flaps) between 1988 and 1994. Vessel size measurements were available on 75 flaps. The internal mammary artery diameter (2.36 +/- 0.50 mm, n = 51) was significantly larger than the thoracodorsal artery diameter (1.79 +/- 0.34 mm, n = 23; p < 0.001). There was no significant difference between the diameters of the internal mammary vein 2.6 +/- 0.58 mm, n = 52) and thoracodorsal vein (2.51 +/- 0.50 mm, n = 23; p = 0.93). The right internal mammary artery (2.52 +/- 0.51 mm) was significantly larger than the left internal mammary...
Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of rec... more Soft-tissue infection after lower-extremity trauma has not been studied in detail in light of recent data on the biology of infection. This article examines specific problems in lower-extremity trauma that allow the wound to become susceptible to wound infection. It also illustrates the various principles of wound management in lower-extremity trauma that serve to prevent infection. Two case examples are used to illustrate principles of management. Other wound problems in lower-extremity trauma are also discussed, such as rabies, necrotizing soft-tissue infection, tetanus, and diabetic foot infections.
Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobili... more Two aspects of the inflammatory response to infection--blood flow alteration and leukocyte mobilization--are investigated in the canine model. The elevation of paired musculocutaneous (MC) and random pattern (RP) flaps allowed comparison of healing flaps with significant differences in blood flow (lower in random pattern flaps) and resistance to infection (greater in musculocutaneous flaps). Blood flow changes as determined by radioactive xenon washout were compared in normal skin and distal flap skin both after elevation and following bacterial inoculation. Simultaneous use of In-111 labeled leukocytes allowed determination of leukocyte mobilization and subsequent localization in response to flap infection. Blood flow significantly improved in the musculocutaneous flap in response to infection. Although total leukocyte mobilization in the random pattern flap was greater, the leukocytes in the musculocutaneous flap were localized around the site of bacterial inoculation within the dermis. Differences in the dynamic blood flow and leukocyte mobilization may, in part, explain the greater reliability of musculocutaneous flaps when transposed in the presence of infection.
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Papers by Lu-Jean Feng