Vol. 116, No. 3 Supplement to Plastic and Reconstructive Surgery ®/ PAPERS

46: PSEF 2005 Scientific Essay Contest – Annual Bernard G. Sarnat, MD Junior Award, Basic
Science: Selective Percutaneous Desiccation of the Perforators with Radiofrequency for
Strategic Transfer of Angiosomes in a Sequential Four-Territory Cutaneous Island F
Yener Demirtas, MD; Suhan Ayhan, MD; Kemal Findikcioglu, MD; Reha Yavuzer, MD; Kenan Atabay, MD

The research in prevention of partial flap necrosis has recently concentrated on extending the safe length of a flap
by ligating vessels of known territories rather than dividing vessels randomly by elevating the flap. In order to
advance this approach one step further, we decided to investigate if selective desiccation of these pedicles with
percutaneous radiofrequency (RF) after identification with the Doppler probe would offer a simple but effective
surgical means for strategic transfer of angiosomes.
The study was conducted as three ensuing experiments and involved a total number of 44 rabbits.We first
developed a cutaneous island flap model spanning four adjacent vascular territories in a succeeding manner, each of
which has a well-defined single vascular source.Then, by using this flap model, we tested the possibility of
desiccating those vessels supply the angiosomes to be captured percutaneously with radiofrequency. Finally, we
compared the effectiveness of selective interference of these pedicles to minimize the number of target vessels for
successful transfer of angiosomes.
Percutaneous desiccation of the perforators with RF was found to be a reliable method comparable to ligation of
the vessels under direct vision. Both techniques augmented the flap viability to approximately 95% from 63% of the
flap without delay, confirming the utility of the new flap model. Furthermore, selective desiccation of the
perforator(s) was as efficient as destruction of all vascular sources other than the pedicle.
An alternative flap model is introduced for future investigation of vascular de; lay process to augment flap survival.
Using this flap, it was revealed that percutaneous desiccation of the perforators with RF would be an alternative
means for transfer of angiosomes and that selective desiccation of these perforators(s) as a minimally invasive, easy to
perform method would further promote strategic transfer of angiosomes.

47: PSE 2005 Scientific Essay Contest – Annual Bernard G. Sarnat, MD Senior Award, Basic
Science: The Lymphatic Territorires of the Upper Limb – Anatomical Study and Clincal
Implications
Hiroo Suami, MD; Ian Taylor; Pan Wei-Ren

The lymphatic system is a defense network of the body, closely related to the venous system.Although clinically
important as the main route of the immune system, the lymphatic vessels provide also the major route of cancer
metastasis and, unfortunately, our knowledge of the lymphatic system is very limited. Current understanding of the
pattern of lymph channels is largely dependant on the anatomical studies of Sappey (1) in the 19th century when
mercury was injected into human cadavers and the lymphatics were dissected.These studies have not been repeated
because of the use of mercury is now prohibited because of its toxicity.
The aim of this study was to find a new reliable method of delineating lymph channels in human cadavers and to
reappraise their gross anatomy and lymph node connections using a radiological technique. It took more than three
years to develop this new method. It commenced as a pilot study using animal cadavers and then it was applied to
various human body parts.The definitive technique utilized hydrogen peroxide to identify lymphatic vessels and to
inflate them.The individual channels were injected with a radio-opaque lead oxide mixture and recorded on x-ray
film. Each channel was meticulously dissected under the surgical microscope and its course examined in relation to
the regional lymph modes.This method was then applied to a 14 human cadaver upper limbs obtained from ten
different cadavers.
We found that the superficial lymphatic vessels course within the subcutaneous fat in close proximity to the main
subcutaneous veins. Communication between the superficial and the deep lymphatic system was not identified in
these studies. Most of lymph vessels were seen to flow into one main (sentry) lymph node in the axillary region,
however, some of the lymph vessels ran along the posterior forearm, bypassing the “sentry” node to reach other
smaller nodes.
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48: PSEF 2005 Scientific Essay Contest Junior Award – Clinical Research, Integra
Foundation: DVT Prophylaxis Practice and Treatment Strategies Among Plastic
Surgeons: Survey Results
George Broughton, MD, PhD; Jose L. Rios, MD; Rod J. Rohrich, MD; Spencer A. Brown, PhD

BACKGROUND: Deep vein thrombosis (DVT) is a known serious complication of surgical procedures and a
significant cause of morbidity and mortality. Plastic surgeon’s management of the risk of DVT and current
information regarding DVT incidence rates are limited.A survey was designed and mailed to plastic surgeons to
collect data on the patterns of practice with regard to DVT in patients undergoing plastic surgery procedures.
METHODS: A comprehensive self-administered, anonymous survey was mailed to 1557 members of the
American Society of Plastic Surgeons in March 2003.
RESULTS: A total of 334 completed responses were available for analysis.A subset of surgeons do not use any
DVI prophylaxis: 16.4% who perform fact lifts; 21.3% who perform liposuction; and 8.7% who do a combined
abdominoplasty-liposuction procedure. Only 48.7 % of surgeons performing face lifts, 43.7% of surgeons doing
liposuction, and 60.8% doing a combined procedure use DVT prophylaxis all the time.
CONCLUSIONS: These results demonstrate a need for educational efforts and guidelines to direct clinical
practice in line with evidence-based data concerning plastic surgery procedures and DVT. Plastic surgeons should
be aware of the potential and real risks of DVT and procedures for prevention and treatment to reduce morbidity
and mortality associated with DVT in all plastic surgery patients.

49: PSEF 2005 Scientific Essay Contest Senior Award – Clinical Research, Integra
Foundation: Selective Ipsilateral and Selective Contralateral C7 in OBPP
Julia K. Terzis, MD, PhD; Epaminondas Kostopoulos, MD

INTRODUCTION: Avulsion brachial plexus injuries in OBPP patients are considered as difficult to treat and are
always a challenge for every reconstructive surgeon.The use of ipsilateral or contralateral C7 root represents a
valuable source of motor donors in such difficult conditions. In our center the C7 root is used in a more selective
manner, which means that more of C7 root elements are spared.The aim of this study is to present the results of its
use as ipsilateral or contralateral motor donor.
MATERIALS AND METHODS: 38 children were treated in our center, with the selective technique of
ipsilateral and contralateral C7 root. In 16 of them the ipsilateral C7 (IC7) was used, while in the remaining 22 the
contralateral C7 (cC7).We studied each group separately. For the clinical evaluation, the British Medical Research
Council Grading System expanded with intermediate grades (i.e. M1-, M1, M1t, M2, etc.) was used. Concerning
the shoulder function the modified Mallet scale was used with a grading from 1 to 4. For the hand function
evaluation we used the modified Gilbert-Raimondi scale.We divided the patient population in four groups
according to their denervation time (A, B, C, and D) in order to examine its impact in the outcome of our
reconstructions.
RESULTS: The overall functional restoration showed a clear improvement at a statistical significant level (p<0.05)
for all targets above and below the elbow in both populations.The results were good and excellent in both groups
for functional restoration above the elbow, fair and excellent in IC7 patients, and finally fair and good in CC7
patients for the reconstructions below the elbow.The only difference was found (p<0.05) for hands’ extension
function restoration.
No patient complained for any sensory or motor disturbance following the severance of the C7 root six months
following the surgery.
CONCLUSION: The C7 root remains a valuable solution for OBPP avulsion injuries and with its selective use
gains a very important place in the armamentarium of every reconstructive surgeon.

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50: PSEF 2005 Scientific Essay Contest D. Ralph Millard, MD Investigator Award, First Place:
siRNA Mediated Noggin Suppression Enhances Osteoblast Differentiation and Mineral
Deposition
Derrick Wan, MD; Jason H. Pomerantz; Randall P. Nacamuli; Michael T. Longaker, MD

The BMP antagonist Noggin is differentially expressed in the developing murine cranial vault, with elevated
expression found in the mesenchyme and dura mater of sutures destined to remain patent.While it is presumed that
decreased Noggin leads to an increase in osteogenesis – and eventual fusion of the posterior-frontal suture – the
effect of altered Noggin expression on osteoblast development and subsequent suture fate remains unknown.We
show that Noggin may play a crucial role in the regulation of differentiation and thus potentially dictate the rate of
osteogenesis.A restriction enzyme-generated system was employed to create 5 individual noggin directed siRNA’s,
2 of which possessed sufficient capacity to abrogate the detection of protein. Suppression of noggin resulted in
enhanced mineralization and bone nodule deposition as assessed by Alizarin red and von Kossa staining following
21 days of differentiation. Quantitative Real-Time RT-PCR analysis of gene expression at this same time point
revealed elevated transcript levels for both runx2/cbfal and osteopontin when compared to undifferentiated cells.
This upregulation was noted to be smaller, however, relative to normal differentiated controls suggesting a more
terminally differentiated osteoblast phenotype in the absence of noggin. In accordance with this, expression of a
late marker for osteoblast differentiation, osteocalcin, demonstrated the greatest rise when noggin protein was
abrogate. Our results imply that Noggin may serve to naturally regulate osteoblast differentiation, with elimination
of this protein leaving BMP activity unopposed to drive osteogenesis. Such an absence may presumable contribute
to pathologic suture fusion and suggest a future avenue for therapy to potentially modify postnatal skeletal
development.

51: Presented in Title Only: 2004 PSEF Research Fellowship – Fresh Start: Improved TissueEngineering Through Predictive Mechanistic Models
Mytien Goldberg, MD; Warren L. Garner, MD

52: PSEF 2004 Research Fellowship – Lyndon Peer: Sutural Distraction Osteogenesis for the
Treatment of Cleft Palate Disease
Miroslav S. Gilardino, MD; Mark C. Martin, MD; Hanni Sino, MD; Janet E. Henderson, MD;
H. Bruce Williams, MD

53: PSEF 2004 Research Fellowship – Mercedes Benz, USA: Steps to Engineering Flexible
Ear-Shaped Cartilage
Niamh-Anna O’Sullivan, MD; Mark A. Randolph, MD; Michael J. Yaremchuk, MD

INTRODUCTION: Congenital microtia not only leaves deep psychological scars on affected children, and
remains one of the most challenging pediatric reconstructive problems. It requires precise technique and artistic
creativity, and the surgery is unforgiving.Total reconstruction of the external ear currently requires a
subcutaneously placed ear-shaped framework of either alloplastic material of autologous costal cartilage to recreate
the complex three-dimensional shape of the auricle.Tissue engineering of cartilaginous ear-shaped frameworks has
also been attempted; however, the resultant cartilage is small, brittle and inflexible.
In an effort to tissue engineer flexible ear shaped cartilage, we have decided to focus on a number of steps to bring
us closer to the clinical reality. Based on our labs extensive experience in tissue engineering of cartilage, I will
present a number of the steps we have researched as part of the fellowship.We have focused on the tissue
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engineering of cartilage using human auricular and nasal chondrocytes, the lamination of tissue engineered
cartilage with pseudoperichondria, the immunogenicity of isolated chondrocytes for tissue engineering and the
integration of engineered cartilage with the native environment.All of the studies are ongoing and here I present a
summary of the findings to date.
Flexible Tissue-Engineered Cartilage Framework using Small Intestinal Submucosa and Different
Chondrocyte Sources: Our previously published work has shown that it is possible to engineer flexible neocartilage through the use of support materials simulating perichondrium (Xu et al, 2001). Recently, we combined
fresh swine chondrocytes ear chondrocytes with xenogenic lyophilised perichondrium (XLP) to engineer flexible
cartilage in the shape of an adult human ear (Xu, 2005) In an effort to bring these techniques closer to a clinical
scenario, we hypothesized that both auricular and costal chondrocytes, when expanded in culture and combined
with small intestinal submucosa as a pseudoperichondrium could be utilized to produce flexible, ear-shaped,
cartilaginous framework. In this study we focused on engineering neocartilage from a variety of cell sources and
laminating it with the commercially available small intestinal submucosa (Cook Inc, Bloomington, IN) as an
alternative pseudoperichondium. Our aim was to assess the integration and adhesion of tissue engineered cartilage
to SIS, and evaluate its ability to confer flexibility to engineered cartilage.
Methods: Chondrocytes were isolated from swine by enzymatic digestion. Cells were then mixed in fibrinogen at
a density of 80 x 106 cells/ml. 0.15ml of cells and fibrinogen was mixed with the same volume of thrombin and
placed between two layers of small intestinal submucosa in bone wax wells.The control constructs consisted of
acellular fibrin glue between two layers of SIS,The trilayer experimental constructs were implanted into dorsal
subcutaneous pouches of nude mice for 6 and 12 weeks. Four constructs in each group were evaluated
histologically and six constructs were subject to mechanical testing.
Results: Histology revealed that new cartilaginous matrix had formed between the SIS in all experimental
constructs.The neocartilage adhered to and penetrated into the structure of the SIS at the interface.The
experimental samples did not fracture when forcefully bent in any direction, and all recovered following testing.
Conclusions: Chondrocytes and fibrin glue form neocartilage that adheres to and integrates with SIS. Small
intestinal submucosa was found to confer flexibility to tissue engineered cartilage, and could be used as a
pseudoperichondrium for this purpose.
Expression of Major Histocompatibility Antigens on Isolated Human Chondrocytes for Tissue
Engineering: One option for obtaining large numbers of cells for engineering cartilage is to use allogenic sources.
A central issue involving allotransplantation of chondrocytes is their potential to elicit an immune response after the
removal of their immunoprotective matrix (e.g., isolation for tissue engineering), which may expose major
histocompatibility antigens on the cell surface. It is crucial to determine the antigenicity of chondrocytes in order
to assess the utility of allogenic chondrocytes for tissue engineering.This study examined MHC expression in
human articular chondrocytes from both osteoarthritic (OA) and healthy hip and knee joints. In addition the
antigenicity of isolated auricular, nasal and costal chondrocytes was ascertained, as these cells are being used
increasingly to tissue engineer cartilage.
Methods: Chondrocytes were isolated by enzymatic digestion from fresh human osteoarthritic hip and knee joint
articular cartilage, and healthy articular, auricular, nasal and costal cartilage. Peripheral blood lymphocytes were
isolated from human blood to serve as the positive control cell type. Human dermal fibroblasts served as the
negative class II cell control.All cells were prepared by cytospin onto plus glass slides. Indirect immunoperoxidase
assay was performed with mouse monoclonal antibodies against HLA class-1, HLA class 2-DR. Negative controls
specimens were incubated without the primary antibody. Following staining, the slides were subjected to doubleblind evaluation by 3 independent observers.
Results: All blood cells expressed both class I and class II MHC antigens as expected.All fresh hip and knee OA
chondrocytes were found to express class I MHC antigens.The OA chondrocytes were also shown to express class
II-DR antigens, but the presence of class II antigen expression was less prevalent. Isolated human articular (nonOA), auricular, nasal and costal cells were found to consistently express class I and class II MHC antigens. Frozen
sections taken from the same cartilage samples however, failed to express either type I or type II MHC antigens.
Conclusion: In conclusion, human OA articular chondrocytes were shown to express class I and class II MHC
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antigens, which is contrary to previously published findings.Additionally, all other tested sources of human cartilage
were found to positively express both antigens.Although allogenic cells may be a suitable alternative for tissue
engineering approaches to cartilage repair and regeneration, these findings could present an obstacle for their use if
the MHC antigens are exposed.The next step would be to assess and quantify the immunogenicity of tissue
engineered cartilage, both in vitro and in vivo.
Mechanics of Tissue Engineered Cartilage to Bone: Integration of engineered cartilage with its host
environment is critical for a successful repair.The objective of this study was to investigate the morphological and
biomechanical bonding capacity of engineered cartilage with native bone substrate.
Methods: Articular chondrocytes were enzymatically isolated from pig joints. Six mm bone discs were obtained by
a brass punch from their scapulae. Both vital and freeze-thawed devitalized bone discs were used. Chondrocytes
were suspended in fibrin glue gel and placed between the cortical sides of 2 bone discs. Control constructs were
made using cortical bone with acellular fibrin glue.The constructs were subcutaneously implanted into the backs of
nude mice for 6 and 12 weeks. Few specimens were processed for histology, and the remaining were
biomechanically tested.The constructs were glued to plexiglass rods and mounted in the actuator of the Dynastat.
Tensile displacements were applied to failure and Ultimate tensile strength, failure strain, failure energy, and tensile
modulus were calculated from the resultant loads. Post-testing histology was also performed.
Results: All samples with cells suspended in fibrin glue appeared to be integrated, while only few samples of the
controls were found integrated.
Histology showed new cartilage matrix formed between the discs when chondrocytes were incorporated in the
fibrin glue.All specimens fractured through the interface of the new cartilage tissue and bone.
Integration strength was highest in 12 weeks samples using vital bone.There was no increase in integration strength
with time for samples made from non vital bone. Similar trends were observed in failure energy and tensile
modulus, with 12 weeks samples from vital bone larger than all other groups.There was no difference in failure
strain between groups.
Conclusion: This data demonstrates that engineered cartilage has the capacity to integrate and form mechanically
functional bonds with native bone in-vivo. Further studies will focus on understanding the mechanism that control
process of integrative bone and cartilage repair.
SUMMARY: It is possible to engineer flexible ear-shaped cartilage.We have successfully engineered cartilage from
human nasal and auricular chondrocytes, using our previously published protocols with fibrin glue polymer.We
have ascertained that tissue engineered cartilage, adheres to and forms mechanically functional bonds with native
bone and native cartilage (Silverman et al, 1999).Antigenicity studies of isolated chondrocytes have yielded
interesting results. Further studies are currently in progress to determine the extent and effect of the MHC
expression of chondrocytes in relation to the clinical application of tissue engineering in plastic and reconstructive
surgery. Further study of these steps, hopes to bring this model closer to its clinical reality.

54: Plastic Surgery Research Council 2005 Clifford C. Snyder, MD Award: Myelination of
Regenerated Sciatic Nerve Fibers by Engrafted Schwann Cells Identified with Gfp and
Fluorescence In-situ Hybridization (Fish) for Y Chromosomes
Christine Radtke, MD; M. Sasaki, MD; P.M. Vogt, MD; D.S. Krause, MD; J.D. Kocsis, MD

INTRODUCTION: Schwann cells reorganize after nerve transection and provide a permissive environment for
nerve regeneration.The present study was performed to determine if transplanted Schwann cells identified by GFP
fluorescence and fluorescence in situ hybridization (FISH) for Ychromosome can integrate and participate in
axonal regeneration, remyelination and node of Ranvier formation.
METHODS: Schwann cells were prepared from dissociated sciatic nerves of GFP transgenic male rodents. Sciatic
nerves of female rats were exposed and crushed for 20 sec with fine forceps to transect all axons. Immediately after
nerve crush of a GFP-Schwann cell suspension was injected just distal to the crush site through a glass pipette
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attached to a Hamiliton syringe. 2-3 weeks later the nerves were removed and dissociated on glass slides.The
engrafted cells were identified by GFP fluorescence and FISH for Y chromosome. Immunostaining for Na+
channel (Nav 1.6) and paranode (Caspr) was used to define nodes of Ranvier on regenerated axons.
RESULTS: GFP+ cells distributed throughout the crush lesion and longitudinally distal to the nerve transection.
GFP was observed only in the cytoplasmic compartments of the Schwann cells which included the cell body and
the outer mesaxon.The nuclei of the GFP+ cells had Y chromosomes further indicating the donor origin of the
myelin-forming cells.The GFP cells aligned longitudinally and surrounded the regenerated axons. Nodes of
Ranvier between GFP+ cells were observed as breaks in green fluorescence and by intense sodium channel (Nav
1.6) staining on the regenerated axons.
CONCLUSION: The transplantation of identified Schwann cells into an acute axotomy model results in axonal
regeneration and remyelination by the transplanted cells.The donor myelin-forming cells could be identified by
GFP fluorescence and by FISH for Y chromosome.The transplanted cells were able to survive and form myelin
with mature nodes of Ranvier on the regenerated axons.These results indicate that engrafted Schwann cells into
injured peripheral nerve can integrate and participate in neural repair.

55: Plastic Surgery Research Council Peter J. Gingrass, MD Award: Migration of Murine
Mesenchymal Stem Cells to Tumors is Regulated by FGF2 and VEGF
Adam D. Perry, MD; K. Tucciarone, MD; E. Bieberich, MD; J. Yu, MD; E. F. Ritter, MD

INTRODUCTION: Mesenchymal stem cells (mMSCs) migrate to, and preferentially integrate into growing
tumors providing stroma, and potentially serving as delivery vehicles for apoptosis inducing molecules.The present
study was performed to investigate the role of FGF2 and VEGF in the migration of mMSCs toward melanoma, and
breast cancer.
METHODS: To evaluate the chemotactic effect of melanoma on mMSCs, 25 x 103 mMSCs were suspended in
low melting agar and cocultured adjacent to either acellular agar droplets (control) or agar droplets containing 25 x
103 B16 melanoma cells. Migration of mMSCs was quantitated after 24 hours. Serum free media (Group I), Sarkar
breast cancer conditioned media (Grp II), serum free media plus FGF2 (Grp III), serum free media + VEGF (Grp
IV) serum free media+FGF2+VEGF (Grp V), FGF2 depleted Sarkar conditioned media (Grp VI),VEGF depleted
Sarkar conditioned medium, (Grp VII), and VEGF and FGF2 depleted Sarkar conditioned medium, (Grp VIII) were
placed in target wells, and 25x103 mMSCs were placed in the upper wells of modified Boyden chambers.
Migration was quantitated after 24 hours of incubation. RT-PCR and Western blot analysis were performed on
appropriate specimens.
RESULTS: 73.7% +/- 14% of mMSCs cocultured with B16 migrated, as compared with 1.1% for the control.
Percent migration by transwell assay Grp I: 1.1%, +/- 0.50, Grp II: 23.9%, +/- 0.56, Grp III: 14.3%, +/- 13, GrpIV:
11.1%, +/- 11, Grp V: 11.9%, +/- 12, Grp VI: 13.3%, +/-7.3, GrpVII: 15.5 +/- 1.1, Grp VIII: 10.3 +/- 1.2 (N=6,
+/- SD). RT-PCR demonstrated VEGFR, FGFR1, and FGFR4 on mMSCs.Western blot analysis demonstrated
the presence of FGF2 and VEGF in the conditioned media. Identification of mMSC was performed using antiCD11b, and anti-Sca-1 monoclonal antibodies.
CONCLUSION: Tumor cells secrete FGF2, and VEGF. mMSCs express receptors for VEGF and FGF2.VEGF and
FGF2 enriched media induce migration.Antibody depletion of VEGF and FGF2 of tumor conditioned media
reduces its migratory effect.VEGF, and FGF2, play key roles in the migration of mMSCs to cancer cells.

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56: Plastic Surgery Research Council Update 2005
Gregory R. D. Evans, MD

What a milestone.The Plastic Surgery Research Council is 50 years old. Hard to believe that our organization
would continue to be the dominant voice for Plastic Surgery Research 50 years following that initial meeting in
Baltimore.This year, the 50th annual meeting took place at the University of Toronto. Under the able direction of
Christopher Forest as your local program chair, the meeting was a spectacular success. Over 200 members and
guests attended the meeting with the opening ceremony being held at the Hockey Hall of Fame.The member’s
dinner was held at the Royal Canadian Yacht Club and the Gala dinner was held at the beautiful Marriott Harbor
Hotel where the Snyder, Gingrass, Crikelair, Hardesty and Shenaq awards were presented.The award winners are
listed below.
Clifford C. Snyder, MD - Past Chairman Award
Presented to the plastic surgery resident or fellow presenting the best paper at the annual meeting of the Plastic Surgery Research
Council.
Awarded to Christine Radtke, MD, Hannover Medical School
Myelination Of Regenerated Sciatic Nerve Fibers By Engrafted Schwann Cells Identified With Gfp And Fluorescence In Situ
Hybridization (Fish) For Y Chromosone
Authors: Radtke C, Sasaki M,Vogt PM, Krause DS, Kocsis JD
John F. Crikelair, MD - Research Award
Presented to the high school or college student presenting the best paper at the annual meeting of the Plastic Surgery Research
Council.
Awarded to Bryan Jacobs, University of Michigan
Immunomodulation With Anti-Cd401 Monoclonal Antibody (Mr1) Enhances Neuroregeneration In The Murine Nerve
Allograft Model
Authors: Jacobs B,Yu D, Bishop K, Chan SY, Urbanchek MG, Cederna PS
The Shenaq International Research Award
Presented to the best oral presentation at the annual meeting of the Plastic Surgery Research Council by a graduate of a foreign
medical school (outside the US or Canada) who is currently performing plastic surgery research.
Awarded to John Mesa, MD, Massachusetts General Hospital
Chondrogenesis Of Swine Mesenchymal Stem Cells In Different Hydrogels Scaffolds
Authors: Mesa JM, Burdick JA, Persing S, Ranka MP, Craff MN, Claude O, Kristi A,Yaremchuk MJ, Randolph MA
Peter J. Gingrass, MD - Memorial Award
Presented to the medical student or non-plastic surgical resident presenting the best paper at the annual meeting of the Plastic
Surgery Research Council.
Awarded to Adam D. Perry, MD, Medical College of Georgia
Migration Of Murine Mesenchymal Stem Cells To Tumors Is Regulated By Fgf2 And Vegf
Authors: Perry AD,Tucciarone K, Bieberich E,Yu J, Ritter EF
J. K. Hardesty, MD - Best Poster Award
Presented to the individual presenting the best poster at the annual meeting of the Plastic Surgery Research Council.This award
is sponsored by Robert A. Hardesty, MD in honor of his parents, Dr. and Mrs. J.K. Hardesty.
Awarded to Farrah M.Yau, BS, University of Alberta
Peripheral Blood Fibrocytes In Fibrosis And Scar Formation
Authors:Yau FM, Scott PG, Medina A, Banjar A, Dodd C, Shankowsky H, Ghahary A,Tredget EE
This year, 5 panels were included in the program along with concurrent sessions.This change in format appeared to
appeal well with the attendees.The final panel of the program included Barrett Noone, Scott Spears, Mary
McGrath and Robert Goldwyn on the Future of Plastic Surgery and Research.We were fortunate enough to
record the session and this will be submitted for publication in the Plastic Reconstructive Surgery Journal.This year
also saw a change in the amount of poster presentations and excluded the 3 minute presentations.This limited
number of posters in our beer and peanut poster session, allowed the presenters more time to discuss and interact
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with the attendees.The 62 members of the program committee reviewed 223 abstracts.We were able to include
107 presentations with 87 papers and 20 posters.A fair balance between the numbers of abstracts submitted for
each particular category to those that were accepted was performed.This allowed all categories to be represented
with an equal opportunity.
New officers of the PSRC were elected at the Business meeting in Toronto. Michael Longaker, from Stanford
University was chosen as Chair-Elect and the Scientific Program Chair for the meeting at The University of
California, Irvine.
The current membership of the PSRC includes 192 Active, 29 Associate, 314 Senior, 6 Senior Associate, and 58
Resident members.These figures include the 17 new members whom we welcomed this year.
Finally, I would like to invite all of you to Laguna Niguel next year where the 51st annual PSRC will take place.
This meeting will offer again the best scientific material that we have to offer along with an opportunity to relax in
a beautiful setting. Bring your family as we are building free time into the meeting to take on some of the sights
around Orange County including our beautiful beaches, Disneyland and an afternoon of Golf.We look forward to
seeing you in the OC.

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Tuesday, September 27, 2005
57: Interactive Video — Short Scar Breast Reduction
Elizabeth J. Hall-Findlay, MD, Banff, AB, CANADA – Presenter
Claude Lassus, MD, Nice, FRANCE – Moderator/Discussant

This video will highlight the important preoperative marking and intra-operative techniques for short scar breast
reduction. Key maneuvers to facilitate the learning curve will be emphasized.

NOTES:

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58: Panel Discussion — Technical Applications in Absorbable and Semi-Permanent Fillers
Brian M. Kinney, MD, Los Angeles, CA – Moderator
Cheryl Burgess, MD, Washington, DC
Steven R. Cohen, MD, San Diego, CA
Steven Fagien, MD, Boca Raton, FL
Val S. Lambros, MD, Newport Beach, CA
Gottfried H. Lemperle, MD, La Jolla, CA

To present the chemical differences, longevity of effects and applicability among the various injectables, botulinum
toxin type A, hyaluronic acid, collagen, polylactic acid, calcium hydroxyapatite and others.To provide information
on: choosing patients wisely to maximize patient safety and minimize risk; which injectable to use in what location;
effectively combining injections with each other and with surgical procedures; improving techniques and
optimizing results in injections and; distinguishing between on label and off label uses.

NOTES:

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59: PSEF Maliniac Lecture: Balanced Practice in Cosmetic and Reconstructive Surgery – 48
Years of Experience
Jose Guerrerosantos, MD, Guadalajara, Jalisco, MEXICO

Dr. Guerrerosantos will present clinical examples for 48 years’ experience in cosmetic and reconstructive surgery.

NOTES:

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60: Panel Discussion — Female Plastic Surgeons’ Perspectives in Breast Reconstruction
Roxanne J. Guy, MD, Melbourne, FL – Moderator
E. Dale Collins, MD, Labanon, NH
Mary K. Gingrass, MD, Nashville, TN
Barbara B. Hayden, MD, Santa Monica, CA
Marga Massey, MD, Salt Lake City, UT

To explore and discuss choices in breast reconstruction from the perspective of female plastic surgeons. Following
this panel, participants should obtain an alternate view toward breast reconstruction to enhance both their delivery
of patient care and subsequent patient satisfaction.

NOTES:

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61: A Comparison of 500 Pre-filled Textured Saline Breast Implants versus 500 Standard
Textured Saline Breast Implants: Is There a Difference in Deflation Rates?
Elliot M. Hirsch, BA; W. Grant Stevens, MD; David A. Stoker, MD; Robert Cohen, MD

To date, no large study of the deflation rates of PIP pre-filled textured saline breast implants has been published.
This study provides the first large series (1000 implant) comparison of the deflation rates of PIP pre-filled textured
saline breast implants versus a control group of Mentor Siltex textured saline implants.The goal of this study is to
provide information regarding the deflation rates of PIP pre-filled textured saline breast implants as compared to
standard Mentor Siltex textured saline implants.
METHODS: A consecutive series of 500 PIP pre-filled textured saline breast implants was compared to a
consecutive series of 500 Mentor Siltex breast implants. Each breast implant was evaluated for a four-year period,
and the annual deflation rate (number of deflations during a given year divided by the total number of implants
remaining after accounting for previous deflations) and cumulative deflation rate (cumulative total of deflations
through a given year divided by the total number of implants [500]) were recorded. Statistical significance was
calculated using a Fisher’s exact test at year one and a chi square analysis at the remaining years.
RESULTS: The cumulative deflation rate of the PIP implants are as follows: year one= 1.2%, year two= 5.6%, year
three= 11.4%, and year four= 15.4%.The cumulative deflation rate of the Mentor implants are as follows: year
one= 0.2%, year two= 0.6%, year three= 1.6%, and year four 4.4%.
At year one, the difference between the cumulative deflation rates is not statistically significant at the = 0.05
significance level (Fisher’s exact test, p >0.05); however, at year two (chi square 13.29, p<0.001), year three (chi
square 37.91, p<0.001), and year four (chi square 32.69, p<0.001) the higher deflation rate of the PIP implants
versus the Mentor implants is statistically significant.
DISCUSSION: Our data clearly indicates that there is a statistically significant difference between the overall
deflation rates of PIP pre-filled textured saline breast implants and Mentor Siltex breast implants at year two
(p< 0.001), year three (p< 0.001), and year four (p< 0.001).After four years, the 15.56% cumulative deflation rate
of PIP implants was over 3.5 times higher than the 4.31% deflation rate of the Mentor Siltex implants (Fig. 1).The
deflation rate of the Mentor implants in this study is consistent with that previously reported in the literature,2-6
whereas the deflation rate of the PIP implants in this study is not consistent with previous reports.7 There may be
several factors contributing to the higher deflation rate seen in PIP implants, including possible in vitro
unrecognized partial deflation1 before implantation and silicone shell curing techniques. Regardless, this statistically
significant deflation difference must be taken into account when balancing the risks and benefits of PIP breast
implants.

Figure 1. Comparison of the Cumulative Deflation
Rates of the Mentor Series and the PIP Series.

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References
1. Stevens,WG, Hirsch, E.M., Stoker, D.A., Cohen, R. In vitro deflation of pre-filled saline breast implants. Submitted
for publication at Plastic and Reconstructive Surgery Journal.
2. Stevens,WG; Fellows, DR; Stoker, DA; Hirsch, EM.Acceleration of textured saline breast implant deflation rate:
Results and analysis of 645 implants. Aesthetic Surgery Journal. 2005. 25, 37-39
3. Mentor, H/S. Product insert sheet for Saline-filled and Spectrum™ mammary prosthesis. Mentor H/S, Inc. Santa
Barbara, California. May 2003.
4. Cunningham, B.L., Lokeh,A., Gutowski, K.A., Saline filled breast implant safety and efficacy:A multicenter
retrospective review. Plastic and Reconstructive Surgery. 105(6): 2143, 2000
5. Gutowski, K.A., Mensa, G.T., Cunningham, B.L. Saline-filled breast implants:A Plastic Surgery Educational
Foundation multi-center outcomes study. Plastic and Reconstructive Surgery. 100(4):1019, 1997
6. Rheingold, L.M.,Yoo, R.P., Courtiss, E.H. Experience with 326 inflatable breast implants. Plastic and Reconstructive
Surgery. 93(1):118, 1994
7. United States Food and Drug Administration. Medical devices advisory committee: General and plastic surgery
devices panel, minutes. Gaithersburg, Maryland, March 3, 2000.

62: Breast Cancer Recurrence Following Prosthetic, Post-mastectomy Reconstruction:
Incidence, Detection and Treatment
Colleen M. McCarthy, MD; Andrea L. Pusic, MD; Joseph J. Disa, MD; Peter G. Cordeiro, MD;
Jane V. Fey, RN, MPH; Claire Buchanan, MD; Lisa Sclafani, MD; Babak J. Mehrara, MD

INTRODUCTION: Locoregional (LR) recurrence of breast cancer following mastectomy has been associated
with a worse disease-specific survival.1 A paucity of data exists, however, regarding the impact of prosthetic
reconstruction on the incidence, detection and treatment of locoregional breast cancer recurrence.Thus, the
purpose of this study was to evaluate the influence of prosthetic reconstruction on the incidence, detection and
management of locoregional recurrence following mastectomy for invasive breast cancer.
METHODS: A matched, retrospective cohort study was performed involving women who underwent
mastectomy for invasive cancer of the breast from 1995 to 1999 at Memorial Sloan-Kettering Cancer Center.
Demographic, oncologic and reconstructive data was obtained from a prospectively-maintained clinical database.
Two patient cohorts were identified: i) patients who underwent mastectomy and immediate, tissue
expander/implant (TE/I) reconstruction; and ii) patients who underwent mastectomy without immediate or
delayed postmastectomy reconstruction. Only patients with at least two years of follow-up and/or patients who had
a breast cancer recurrence within two years of their primary breast cancer were included. Patients were excluded if
they had: pathology representing LCIS/DICS only, sarcoma/angiosarcoma or phyllodes; inflammatory breast
cancer; stage IV disease at presentation; synchronous bilateral breast cancer; and/or, a history of a prior breast
cancer. Patients who underwent autogenous, postmastectomy reconstruction were similarly excluded.
A total of 309 women who had mastectomy and immediate TE/I reconstruction were matched to 309 women who
had a mastectomy without immediate or delayed reconstruction. Patients were matched 1:1 on the basis of age (+/5 years) and breast cancer stage (I, II or III) 2.The primary endpoint was the development of a locoregional (LR)
recurrence. Incidence, time to and method of detection of a LR recurrence was evaluated in the matched,
reconstructed and non-reconstructed patient cohorts. LR recurrence was defined as a breast cancer returning to the
skin of the ipsilateral breast, regional lymph nodes (including axillary and supraclavicular) and/or chest wall.
STATISTICAL METHODS: Pairwise comparisons were performed using the McNemar’s 2 test for
categorical variables and the Wilcoxon matched-pairs signed-rank test for continuous variables. Unmatched,
continuous data was evaluated using the Mann-Whitney U-test. Statistical analysis was performed using STATA
software. Statistical significance was set at the p<0.05 level.
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RESULTS: In total, 618 patients who underwent mastectomy for invasive breast cancer from 1995 until 1999
were evaluated.Three hundred and nine women who had immediate TE/I reconstruction were matched to 309
women who did not undergo postmastectomy reconstruction. In the cohort of 309 patients who underwent
immediate tissue expander/implant reconstruction, a total of 339 permanent implants were placed. Median age for
the entire cohort (n=618) at the time of mastectomy was 48.8 years (range, 21.5- 73.8 yrs). Median follow-up was
5.7 years (range, 0.2 - 6.7 yrs). Clinicopathologic variables were compared between the reconstructed and nonreconstructed patient cohorts. (Table 1)
The incidence of LR recurrence was 6.8% (21/309) in patients who had immediate TE/I reconstruction and 8.1%
(25/309) in patients who did not have postmastectomy reconstruction (p=0.652).The incidence of any recurrence
(LR and/or distant recurrence) in the reconstructed cohort was 19.1% (59/309) compared to 23.9% (74/309) in
the non-reconstructed cohort (p=0.117). (Table 2) The median time to detection of a LR recurrence in
reconstructed patients and non-reconstructed patients was 2.3 years (range, 0.1-7.2 yrs) and 1.9 years (range 0.1 6.4 yrs), respectively (p=0.1418).
Within the reconstructed patient cohort, there were 21 LR recurrences: 12 patients had a LR recurrence confined
to the skin/subcutaneous tissue (9) or musculature of the chest wall (3); and, 9 patients had a regional lymph node
recurrence. Ninety-five percent (20/21) of LR recurrences in the reconstructed cohort were initially detected by
physical examination.All 20 patients who had a clinically detectable LR recurrence went on to have a CT scan of
the chest as part of a metastatic work-up.As evidenced by a review of the imaging studies, there were no lesions
obscured by the presence of a permanent implant, either clinically or radiographically. In one patient within the
reconstructed cohort (1/21), a LR recurrence was initially detected radiographically.This patient had a
computerized tomography of the chest for unrelated symptomatology and a mass in the pectoralis muscle anterior
to the prosthesis was detected.
Treatment of a LR recurrence in patients with a permanent prosthesis included: surgical excision (13),
chemotherapy (11), radiotherapy (5) and hormonal therapy (9). Permanent implants were removed in three patients
following: the development of a peri-prosthetic infection during radiotherapy for recurrence (1) and patient
request (2). Sixty-two percent of reconstructed patients (13/21) with a LR recurrence were alive at a median 4.2
years (0.5 - 5.6 yrs) following detection of their recurrence.Thirty-eight percent of reconstructed patients (8/21)
who presented with a LRR (+/- distant disease) following mastectomy and implant-based reconstruction died of
distant disease, a median 1.6 years (0.1 -3.3 yrs) following detection of their LR recurrence.
CONCLUSION: This series suggests that there is no difference in the incidence of locoregional breast cancer
recurrence in patients who undergo immediate, tissue expander/implant reconstruction compared to patients who
do not have postmastectomy reconstruction.Two-stage implant-based breast reconstruction does not appear to
hinder the detection of locoregional breast cancer recurrence. In the majority of patients with a permanent
prosthesis, management of the locoregional recurrence does not necessitate removal of the implant.

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Table 1. Clinicopathologic Characteristics at Time of Mastectomy in the Total Population.
Prosthetic Reconstruction
n=309 patients

No Reconstruction
n= 309 patients

p-value

Median Age (yrs; range)

46.8 (25.6 - 73.3)

50.8 (21.5 - 73.8)

*

Stage
I
II
III

98
164
47

98
164
47

*
*
*

ER Status (n=532 patients)
Positive
Negative

189
77

164
102

0.022

PR Status (n=526 patients)
Positive
Negative

157
106

154
109

0.859

Lymphovascular Invasion (n=616 patients)
Positive
128
Negative
180

120
188

0.570

Adjuvant Radiation Received
(n=606 patients)
Yes
No

80
223

0.177

67
236

*Matched Variable
Table 2. Recurrence in the Total Population.

Median Age (yrs; range)

Prosthetic Reconstruction
n=309 patients

No Reconstruction
n= 309 patients

p-value

46.8 (25.6 - 73.3)

50.8 (21.5 - 73.8)

*

Locoregional Recurrence +/Metachronous Distant Metastases (%)

21 (6.8%)

25 (8.1%)

0.651

Any Recurrence (%)

59 (19.1%)

74 (23.9%)

0.141

10
5
6
38

4
11
10
49

0.180
0.210
0.455
0.215

Median Time to Detection of LRR (yrs)

2.3 (0.1-7.2)

1.9 (0.1-6.4)

0.733

Median Time to Detection of Any Recurrence (yrs)

2.3 (0.1-7.2)

1.9 (0.1-7.3)

0.117

Disease Status at First Recurrence
LRR Only
LRR + Distant Mets <3 mos
LRR + Distant Mets >3 mos
Distant only

References
1. Clemons M, Danson S, Hamilton T, and Goss P. Locoregionally recurrent breast cancer: incidence, risk factors and
survival. Cancer Treatment Reviews. 2001;27:67-82.
2. Greene FL, Page DL, Fleming ID, Fritz A, Blach DM, Haller DG, Morrow M.AJCC Cancer Staging Manual: 6th
Edition. Springer, 2002.

63: A Survey of Female Plastic Surgeons’ Attitudes Toward Breast Reconstruction Options
Susan Downey, MD; Cheryl Morales, BSN, RNFA

BACKGROUND: Breast cancer affects one in seven women every year.These patients go through a maze of
decisions to whether they will opt for breast conservation or will choose a mastectomy with reconstruction.
Patients rely on surgeons for guidance and often ask the surgeon which option they would choose if they were the
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patient. Studies have been done of patient satisfaction regarding their method of reconstruction but no studies have
been done as to physician preferences regarding type of reconstruction.This study was designed to explore the
opinions of female plastic surgeons regarding breast reconstruction.
METHOD: A questionnaire was developed for this study to inquire about female plastic surgeons preferences for
breast reconstruction if they were to be diagnosed with breast cancer.
RESULTS: At the 2003 ASPS meeting 54 female plastic surgeons attending the Women’s Plastic Surgeons
luncheon were polled by questionnaire as to the method of breast cancer treatment they would opt for if they were
diagnosed with breast cancer.The majority (49/54 or 91%) stated that they would opt for mastectomy rather than
undergo a lumpectomy and radiation. Only two (2/54 or 4%) would opt for mastectomy without reconstruction.
For their reconstruction choices 29 female plastic surgeons (29/54 or 54%) would choose tissue expansion with
implant and 15 (15/54 or 28%) would choose a tram flap. Only three (3/54 or 5%) would opt for a latissimus flap if
all methods of reconstruction were available to them. For the women choosing implant reconstruction 23 (23/29
or 79%) would choose a silicone implant, 7 (7/29 or 24%) would choose a saline implant while one respondent felt
either type of implant would be acceptable.The most frequently chosen reconstruction was tissue expansion
followed by a silicone implant (23/54 or 43%).
CONCLUSION: Female plastic surgeons offer a unique insight into surgical outcomes following breast
reconstruction.The Tram flap has been considered the Gold Standard for breast reconstruction, it is interesting the
female plastic surgeons with their knowledge and experience with the various reconstructive methods used for
breast reconstruction would choose tissue expander reconstruction.These reasons should be further explored.

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