Canadian Society of Plastic Surgeons
Sociéte Canadienne des Chirurgiens Plasticiens
51st Annual Meeting/51e réunion annuelle
Calgary, Alberta
Abstracts 1-10
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1
Severe streptococcal infections and the superantigen-induced immune response: A new paradigm in the approach to treatment
L’utilisation de la réponse immunitaire provoquée par super-antigène dans les infections sévères à streptococque : Un noveau modèle de traitement
BS Gan, D Anastakis, PC Neligan, DE Low
Toronto, Ontario
Recently a steady increase in the incidence of invasive streptococcal disease has been noted. Almost half of these patients present with skin and soft tissue infections, ranging from cellulitis to fulminant necrotizing fasciitis (NF). Life-threatening hypotension and multiple organ system failure (streptococcal toxic shock syndrome, STSS) remain a feared complication, carrying a mortality rate of up to 90% and occurring in more than 10% of invasive streptococcal infections. STSS is thought to be caused by exotoxin(s) acting as bacterial superantigens mediating T-cell receptor activation by interacting directly with the invariable region of the T-cell receptor and MHC Class II molecules on specialized B-cells and monocytes, thus leading to massive cytokine production and STSS. Previous data that have demonstrated that pooled normal polyspecific IgG (IVIG) contains neutralizing antibodies to several Gram-positive bacterial superantigens were the rationale for treatment with high dose IVIG in cases of STSS. 21 patients received high dose IVIG (2 g/kg) in addition to aggressive surgical debridement and appropriate antibiotic therapy, and this group was compared to a group of 32 matched case-controls. The 7-day survival rate was increased from 50% to 90% (P<0.01) and the 30-day survival from 34% to 67% (P<0.02). Multivariate analysis showed that only IVIG and decreased APACHE score were significantly associated with survival. Plasma samples collected from the patients treated with IVIG showed a significant increase in neutralizing capacity to superantigenic activity of the causative streptococcal culture supernatant. These data suggest that high dose IVIG may be an effective adjunct to surgery in the treatment of severe streptococcal soft tissue infections.
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Tissue engineering laboratory solutions for clinical problems: Optimizing the quantity, quality and form of elastic neo-cartilage Applications cliniques de l’ingénieurie tissulaire en laboratoire : Comment maximiser la quantité, la qualité et la forme du néo-cartilage élastique
T de Chalain MD FRCSC, JH Phillips MD FRCSC, A Hinek MD PhD
Toronto, Ontario
Introduction: Tissue engineering, a synthesis of materials science and cell biology, seeks to develop functional neo-organs and tissues. Examples in current clinical use include dermis, pancreas and bone. Conditions such as microtia make the synthesis of autologous neo-cartilage in precise, 3-D shapes, very appealing. Many plastic surgical applications can be imagined. Purpose: This study aimed to perfect techniques for optimizing human elastic cartilage harvest and propagation. Factors influencing the quality and quantity of the extracellular matrix (ECM), (which forms the bulk of the cartilage construct) were to be assessed, as were three techniques for 3-D shape synthesis. Methods: Human elastic chondrocytes were harvested from clinical cases of microtia reconstruction and ear tag excision. A porcine model and nude mice were used as in vivo testbeds. In vivo, cells were cultured in settlement and suspension and treated with factors thought to stimulate growth and ECM production. In vitro, cell behaviour when attached to a rigid 3-D framework such as poly-L-lactide, or immured in hydrogels such as agarose, alginate or Type 1 collagen were examined. Results: Human and porcine elastic chondrocytes can be isolated, purified and propagated in culture. Suspension culture and the addition of k elastin fragments stimulated growth and ECM production. Immurement of microaggregates of cells in a combination of collagen and calcium alginate, ptionally moulded to a specific shape, yielded promising cartilage synthesis, as did high-density cell seeding of a poly-L-lactide framework. A porcine scalp fascial flap (analogous to the TPF flap) has been developed and shown to be capable of carrying a cartilage construct. A combination of these techniques is currently being explored.
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Autotransplantation of epidermal cells in the pig via an aerosol vehicle L’autotransplantation de cellules épidermiques par un substrat aérosole chez le porc
FOG Fraulin, A Bahoric, AR Harrop, T Hiruki, HM Clarke
Toronto, Ontario
Can epithelial cells in the form of an aerosolized suspension remain viable and capable of cell proliferation?
Full thickness skin was harvested from the groins of 6-wk-old pigs. An epithelial suspension was created using dispase and trypsin and placed into culture medium. 24 hours later, 4 full thickness wounds (7x7 cm) were created on the flanks of the pig. The control wound was sprayed with a solution without cells. The 3 experimental wounds were sprayed with cell suspensions. The wounds were protected with a silicone sheet, a foam-plastic chamber and circumferential foam. Four weekly evaluations were undertaken.
Total wound area and open area were calculated using an NIH graphics program. At 10 wks of age, the process was repeated with 3 wounds on the back.
10 control and 25 experimental wounds were evaluated. Control wounds healed by contraction alone with epithelium at the edges only. Histology showed granulation tissue and surface fibrin. Experimental wounds developed central epithelial islands at 2 weeks which coalesced by 4 weeks. Histology at 1 week showed groups of epithelial cells embedded in the granulation tissue. These groups became immature epithelial layers on the surface by 2 wks and all layers of epithelium were present by 4 wks. Flank experimental wounds had less open area at 2, 3, and 4 wks than control wounds (2wks: 9.8%±6.1 vs 18.9%±6.7; 3wks: 2.3%±2.7 vs 7.9%±3.9; 4wks: 0.2%±0.4 vs 1.4%±1.1; t-test P<0.05). Epithelial cells were delivered by a new type of aerosolization apparatus and remained viable and proliferative in a pig model.
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Hypertrophic scar and normal fibroblasts produce TGF-b protein: Antagonism by interferons a/g
Les cicatrices hypertrophiques et le protéine TGF-b produite d’un fibroblaste normal: Antagonisme par les interférons a/g
EE Tredget, R Wang, Q Shen, D Wong, A Ghahary
Edmonton, Alberta
Introduction: Hypertrophic scarring (Hsc) following burn injury is a common, disfiguring and functionally limiting form of dermal fibrosis compromising recovery from thermal injury. Previously, elevated levels of TGF-b, a fibrotic cytokine, have been discovered in wounds and serum of severely injured patients which have been antagonized in part by treatment with systemic Interferon-a2b (IFN-a2b) both in vitro and in vivo. It is hypothesized that although platelets may be an initial source of TGF-b, wound fibroblasts may be capable after activation of autoamplification of the initial response to injury by producing TGF-b mRNA and protein which may be responsive to IFN therapy with type I or II IFN or both.
Methods: Using 3 pairs of site-matched normal and Hsc fibroblasts from the same individuals, near confluent fibroblasts were assayed for the production of TGF-b protein secretion using ELISA for TGF-b (1,2&3) after acid ethanol extraction of media samples from 24h culture media samples. Hsc and normal fibroblasts were treated with IFN-a2b (2x106 u for 96h) or IFN-g (1,000 u for 12h) or both. Quantitative PCR was performed using a novel newly synthesized internal standard for TGF-b and subsequently confirmed by Northern analysis.
Results: Hsc and normal fibroblasts not only possess the mRNA for TGF-b but they also secrete mature TGF-b protein. Treatment of Hsc and normal fibroblasts with IFN-a2b or -g antagonized TGF-b protein production and together additive effects occur. PCR demonstrates that down regulation of TGF-b mRNA accounts in part for the reduction in protein secretion (105.7±4.1 TGF-b mRNA copies/cell control vs 84.9±5.8, a and g IFN, P<0.05).
Conclusions: Elevations of systemic TGF-b may be due to wound fibroblast TGF-b synthesis after activation of fibroblasts within the injured tissue. Antagonism of fibroblast TGF-b protein secretion occurs with either IFN-a or -g, but combinations of both g and a IFN may be significantly better than either IFN. This regulation of TGF-b secretion occurs in part by down regulation of TGF-b mRNA levels.
Acknowledgement: Medical Research Council of Canada, Alberta Heritage Foundation for Medical Research, Firefighters’ Burn Treatment Society.
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An outcome analysis of 100 women following explantation of silicone-gel breast implants
Analyse des résultats chez 100 patientes ayant subi une explantation d’implants en gel de silicone
WJ Peters, DC Smith, S Lugowski, D Ibanez
Toronto, Ontario
This retrospective study analyzed the status of 100 women who had undergone explantation of 186 silicone-gel breast implants from 1991-1995. Patients were assessed clinically, by interviews, and using an extensive questionnaire (75% response). All patients had pre-operative assessment of their levels of autoantibodies, rheumatoid factor, and ESR. If elevated, these tests were repeated every 3 months after explantation. The main reasons for explantation were: suspected health problems (76%), suspected rupture (59%), firmness (36%), and breast pain (36%). Twelve patients had rheumatic disease: 10-fibromyalgia and 2-inflammatory arthritis. Six patients had autoimmune disease: 2-lupus, 2-rheumatoid arthritis, 1-multiple sclerosis, and 1-Raynaud’s disease. Others had various symptoms including: fatigue, phobia (fear of possible side effects of silicone), muscle and joint pain, GI problems, headaches, hair loss, sleep disturbances, and memory loss.
The mean duration of implantation was 12.2 years (range 2 -27). Thirty-six per cent of patients had undergone closed capsulotomy, 56%-open capsulotomy. Seventy per cent of patients had experienced some loss of nipple sensitivity after initial implantation. Loss of sensitivity was related to breast pain and to capsular contracture (P=0.001). Sixty-one per cent of the implants demonstrated a Baker III-IV contracture, 57% had failed, 27% demonstrated calcification, and 3.2% had extravasated into breast tissue. Colonization was present in 42% of the capsules. Using multivariate regression analysis, capsular contracture was not related to implant integrity (P=0.06) or to colonization (P=0.81). Capsular contracture was related to: insertion site (prepectoral vs submuscular) (P=0.0001), duration in situ (0.0001), calcification (P=0.0001), and the symptom - phobia (P=0.001). The proportion of patients with elevated autoantibodies was not statistically different between the explant patients and 100 age-matched control patients without exposure to breast implants (P<0.05).
The mean duration after explantation was 2.7 years (range 1-5 years). Most women had capsulectomy at the time of explantation. After explantation, 45% of the patients believed that their implants had caused permanent health problems. Of the 19 patients who had breast fed after receiving implants, only 1 felt that her implants had adversely affected her child. Fifty six per cent of women felt that they had not been given adequate informed
consent by their original surgeon. Only 43% of all patients had saline implants inserted following explantation. Without saline implants, only 51% of patients were pleased with their ultimate cosmetic result, 33% were disappointed, and 13% felt "mutilated". With saline implants, 78% were pleased. Nine patients had complications following explantation: 3-decreased breast sensitivity, 3- increased pain, 2 occult carcinoma, and 1-infection. After explantation, 38% of all patients described improved nipple sensation. After explantation, in patients without rheumatic or autoimmune disease, >80% demonstrated an improvement in their symptoms and psychological well-being. In contrast, patients with rheumatic or autoimmune disease did not have significant improvement in their symptoms or laboratory values.
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Breast reduction: A survey of present practice in Canada
La réduction mammaire : une revue de la pratique actuelle au Canada
J Mahoney MD, V Tighe MD, C Kerrigan MD
Toronto, Ontario
Clinical practice guidelines have been devised as a means to improve our quality of care and evaluate patient outcome. A clinical practice guideline for breast reduction (modified from the ASPRS) was circulated to members of the Canadian Society of Plastic Surgeon’s (CSPS) for their evaluation. Considerable concern was expressed as the proposed guidelines deviated from present individual practice patterns. A practice survey was therefore developed to evaluate present practice of patients undergoing bilateral breast reduction in Canada. Ethics approval was obtained.
Materials and Methods: Questionnaires were sent to all active members of the CSPS. If there was no response, a second questionnaire was sent a month later. All surveys were returned to the main office and entered into a spreadsheet program (Excel). The province of origin is being kept confidential. Data is in the process of being analyzed and evaluated. The results will be presented at the time of the meeting.
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Reduction mammaplasty: Impact on patient outcome
La mammoplastie de réduction : l’impact sur le devenir du patient
CL Kerrigan MD, J Sampalis PhD
Lebanon, New Hampshire and Montreal, Quebec
Purpose: 1) To describe the outcome associated with reduction mammaplasty in terms of physical parameters, quality of life and utilities; 2) to develop a self-administered questionnaire that assesses, in a reliable and valid manner, physical and psycho-social outcome following reduction mammaplasty and 3) to estimate the cost minimization associated with out-patient reduction mammaplasty.
Methods: A prospective cohort study was designed and included women undergoing bilateral breast reduction surgery at the Royal Victoria Hospital who consented to participation. Women were evaluated preoperatively for symptoms, physical parameters, quality of life (SF-36, Body-Self Relations Questionnaire (MBSRQ), breast specific quality of life), and general demographic characteristics that were identified as potential confounders. Postoperatively, women were monitored closely in the first 6 weeks for complications by telephone survey and then at 6 months postoperatively for physical parameters, quality of life and utility (gamble technique).
Results: A total of 74 women were entered in the study. Their average age was 32.3 and the mean grams of resected volume per breast was 630. There was statistically significant improvement of symptoms at 6 months as compared to the preoperative state (P=0.03). There was also statistically significant improvement in 5 subscales of the SF-36: bodily pain (P<0.0001), physical functioning (P<0.0001), role-physical (P=0.046), energy and fatigue (P=0.016) and mental health (P=0.07). Compared to women with 360 g of tissue resected/breast, women who had 250-360 g resected did not show as significant a change on these subscales but did show significant improvement in the psychosocial subscales (p>0.05). The MBSRQ subscale of appearance evaluation was significantly increased (2.69 vs. 3.12 P<0.05) whereas the appearance orientation subscale was unchanged. The breast specific quality of life questionnaire detected improvement in both patient satisfaction and patient psychological comfort. The modified gamble utility results demonstrated that 80 % of patients scored greater than 75.
Conclusions: This study has shown significant improvements in physical and psychological aspect of quality of life in women undergoing reduction ammaplasty. The amount of tissue removed appears to effect the change physical symptoms but not the change n psychosocial parameters. The use of utility assessments in this study was a new attempt in introducing these measures for the evaluation of patient outcomes in plastic surgery. These results are important for the assessment of the relative significance of these procedures in comparison to other treatments (e.g. hernia, cardiac surgery) and the estimation of quality adjusted life years. This information will be useful for health care policy and resource allocation decisions.
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Lower extremity salvage: Are the outcomes worth the means?
Le sauvetage d’un membre inférieur : Est-ce que résultats valent les moyens
employés?
AB Dagum, AK Best, JL Mahoney, E Schemitz
Toronto, Ontario
Advances in plastic surgery have allowed for impressive salvage of severe lower extremity trauma but not without complications when compared to immediate below knee amputation. Several amputation index scores (AIS) have been developed to help predict successful salvage as defined by a viable rather than a functional extremity. The purpose of this study was to evaluate the predictive value of the AIS scores as well as the true outcome of severe lower extremity salvage by outcome questionnaires. 45 severe open tibial fractures all of which required soft tissue coverage either by local or free flap or vascular repair by the plastic surgery service for leg salvage were reviewed. 40/45 pts were contacted with an avg. 5 yr. follow-up and completed validated generic and specific outcome questionnaires. 88% of patients had a successful salvage and 12% came to late 2° amp The AIS scores correctly predicted an amp. in 32% of pts. and did not correlate with the physical outcome scores. The AIS scores were not found to add any significant value of information to the surgeon’s decision making The avg. SF-36 outcome score was 37 which is significantly lower than that of serious medical illnesses implying that being injured impairs health more than being seriously ill. Patients undergoing 2° amp. had a worse outcome score than successful salvage P<.05. A positive trend in improved outcome scores in pts with isolated injuries vs other severe injuries, IIIB vs IIIC injuries, free flaps vs local flaps was noted. 60% (18/30) patients that were working, RTW at an avg of 17 months. No patients with an SF-36 score less than 28 RTW all pts with scores >28 RTW. 92% of patients preferred leg salvage to an amp. at any stage of their injury and none preferred a 1° amputation.
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Four layer dressing for treatment of chronic venous leg ulcers
Le traitement des ulcères variqueux avec un pansement à quatre épaisseurs
SC Brady
Richmond, British Columbia
A new four layer dressing (Profore®) has been used for healing chronic venous leg ulcers of 1 mo. to 3 years duration with excellent results in 4 to 6 weeks. Rationale, assessment application and case studies will be presented.
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Guidelines for the management of diabetic ulcers
Directives pour le traitement des ulcères diabétiques
K Dolynchuk
Winnipeg, Manitoba
The proposed guidelines are presented in an attempt to arrive at a working consensus for future development of national policy on the management of diabetic ulcers. The template used is based on that developed recently for pressure ulcer management. The algorithm presented will be used to standardize care and help develop future wound care policies. It is hoped that the paper will generate discussion and feedback for the presenter to use in preparing for ultimate publication by the society.
