Scientific Abstract Presentations: Research & Technology 6 Saturday, October 28 Sat, Oct 28 2:00-3:30 p.m. CDT

Purpose: Indocyanine green (ICG) lymphography has emerged as a promising tool for surgical planning and staging of lymphedema. However, current approaches are qualitative in nature and limit our ability to longitudinally measure changes following surgical intervention. In addition, although it is clear that ICG lymphography abnormalities are present in lymphedematous limbs, the specificity of ICG abnormalities for disease diagnosis is not known. The purpose of this study was to develop a novel method for quantitative analysis of the dermal backflow rate and analyze the accuracy, sensitivity and specificity of ICG in detecting lymphedema in breast cancer patients undergoing axillary lymph node dissection (ALND).

Methods: This was a prospective study conducted at a tertiary cancer center between 2019 and 2022. ICG lymphography was performed in patients 1 year after ALND, regardless of whether they developed lymphedema or not. Images were recorded 30 mins after dye injection, for both the lymphedema and the unaffected arm. Dermal Backflow rate was quantified using Image J. Both 2D and fluorescence images were thresholded and used to create a binary mask of each aspect of the arm. The ratio between the area occupied by dye and the total area of the patient's arm was calculated to provide the dermal backflow rate for each aspect of the arm. The mean value between the dorsal and volar aspects was calculated, with the unaffected arm acting as a control. Lymphatic Clearance Capacity was evaluated 10 days after dye injection, quantifying the percentage of dye left in each arm using the same methods utilized for dermal backflow analysis. Dermal backflow rate and clearance capacity were compared to relative volume change (RVC) to generate receiver operator characteristic (ROC) curves and the accuracy, sensitivity and specificity of both methods to diagnose lymphedema were analyzed.

Results: 82 patients aged 47.6±11.2 with a mean follow-up time of 12.2±2.1 months were included. 27 patients (32.5%) developed lymphedema, defined as an RVC of 10%. The optimal cutoff for dermal back flow rate and clearance capacity were 2.5% (AUC=0.635) and 10% (AUC=0.614), respectively. Dermal backflow rate had an accuracy of 63.6%, sensitivity of 70.6%, and specificity of 61.2%. Clearance capacity had an accuracy of 71.4%, sensitivity of 60.0% and specificity of 74.4%. LDEX scores had an accuracy of 61.3%, sensitivity of 55.0% and specificity of 63.3%.

Conclusions: Dermal backflow rate and clearance capacity demonstrated the highest sensitivity for the diagnosis of early-stage lymphedema. Screening for lymphedema and accurate quantitative assessment of dermal backflow patterns on ICG represents a major shift in current clinical practice paradigms, putting an emphasis on early detection of lymphedema rather than palliative treatments and symptomatic relief. These findings set the stage for the development of a practical, universal, ICG-based quantification system for the staging of lymphedema, a significant advancement in the field of plastic surgery.

Introduction: Laser-tissue welding is an important technique for achieving tight wound closure by simultaneously coagulating and cauterizing the tissue. It has several advantages over traditional suture-based wound closure methods, including fast wound closure and no foreign body reaction risk. Additionally, its ease of use makes it a potential option for wound closure in disaster scenarios or conflict areas, where trained personnel may not be available to perform complex surgical procedures. The unique properties of laser-based closure systems make them a promising frontier in wound care. However, the main challenge is to develop a laser-based method that can achieve potent wound closure without causing significant thermal injury. In this study, we aimed to investigate the use of different laser wavelengths to achieve better closure with minimal injury. Methods: Three vertical one cm full-thickness skin incisions were created along the paravertebral tract on both sides of the dorsolateral skin. Contralateral wounds were matched and closed with either a 980 nm or a 1064 nm laser-welding technique, using 1 watt for 10 seconds and 5 joules per wound. On postoperative day 4 or 7, skin samples were collected and stained with hematoxylin and eosin to measure superficial and deep wound closure, thermal damage area, coagulation area, and granulation area. Results: On days 4 and 7, the 980 nm tissue samples showed significantly less thermal damage than the 1064 nm samples. Histological evaluation showed that the shorter wavelength pulsation achieved greater closure on the superficial wound edge, resulting in tighter wound closure. The deep dermal wound edges were comparable between the two laser cohorts. However, the wounds treated with the 980 nm laser showed a significant reduction over time, bringing the profundal part closer together. There was no statistical difference between the two groups in terms of coagulation area. Conclusions: Our study demonstrated that the use of pulsed 980 nm laser welding resulted in a reduction in wound size and less formation of granulation tissue. Additionally, there were significantly fewer thermal side effects observed compared to the use of 1064 nm laser welding. These findings suggest that pulsed 980 nm laser welding may be a more effective and safer technique for wound closure. To our knowledge, there is no technique that can achieve good closure without excessive thermal side effects, and our method is novel in terms of achieving this. However, more research is necessary to fully understand the potential long- term effects of pulsed laser mode on various types of wounds and animal models. If future studies confirm the efficacy and safety of this technique, it could become a valuable method for surgical skin closure in both clinical and emergency settings.

Purpose: Over 1.5 million patients annually in the USA have an adverse reaction to medical adhesive dressings including allergic contact dermatitis (ACD), skin blistering, skin tears, poor scar formation or surgical site infections.1 These complications, known as medical adhesive related skin injuries (MARSI), are one of the most overlooked complications in surgery.2 We hypothesize that a natural hypoallergenic silk dressing will decrease the incidence of MARSI in comparison to a synthetic alternative.

Methods: This prospective, randomized, single-blinded trial studied 25 patients who were dressed with Dermabond® Prineo® on one side of their body and on the contralateral side with the silk wound dressing after undergoing abdominoplasty or reduction mammoplasty procedures. Data was collected over 5 postoperative visits using photographs and an investigator administered questionnaire to track rash, itch, discomfort, erythema, SSIs, need for pharmaceutical intervention, mechanical injury, and bathing routines.

Data: 64% (16/25) of patients characterized the severity of discomfort as a score of 4 out of 10 or greater on the Dermabond® Prineo® control side and only 4% (1/25) for the silk dressing side (p<0.001). 52% (13/25) had a visible rash of 4 or higher on the Dermabond® Prineo® side of their incision and 0% (0/25) had a rash on the silk side (p<0.001). 52% (13/25) required pharmaceutical intervention (steroids or antibiotics) to treat MARSI to Dermabond® Prineo® and 0% (0/25) required pharmaceutical intervention on the silk dressing side (p<0.001).

Summary of Results: The study has revealed an alarming range of MARSI associated complications to the Dermabond® Prineo® skin closure system with ACD being the most significant; causing erythema, pruritus and discomfort. We believe that ACD to Dermabond® Prineo® can be the result of a skin reaction to the Dermabond® 2-octyl cyanoacrylate adhesive or the Prineo® synthetic polyester mesh. Hypersensitivity reactions may either be localized to the site of application or may spread causing a skin reaction beyond the site of application . ACD to Dermabond® Prineo® can result in both acute and chronic complications. Acute ACD is characterized by erythematous rash or vesicles. Chronic ACD leads to erythematous and pruritic lesions that may result in lichenification, scaling and fissuring.

Conclusions: We demonstrate the safe and effective use of a hypoallergenic silk wound dressing that is superior to the Dermabond® Prineo® skin closure system. The advantages of a hypoallergenic silk mesh laminated with a pressure sensitive acrylic adhesive includes the ease of application and removal, resistance to detachment during normal postoperative bathing routines, the ability to be applied over irregular surfaces and the low incidence of ACD or adverse mechanical injury. We postulate that the widespread adoption of a hypoallergenic silk wound dressing has the potential to decrease the financial burden MARSI causes the healthcare system while improving the overall patient postoperative experience.

1. Fumarola S, Allaway R, Callaghan R, et al. Overlooked and underestimated: medical adhesive-related skin injuries. Journal of Wound Care. 2020;29(Sup3c):S1-S24. doi:10.12968/jowc.2020.29.Sup3c.S1

2. McNichol L, Lund C, Rosen T, Gray M. Medical adhesives and patient safety: state of the science: consensus statements for the assessment, prevention, and treatment of adhesive related skin injuries. J Wound Ostomy Continence Nurs. Jul-Aug 2013;40(4):365-80; quiz E1-2. doi:10.1097/WON.0b013e3182995516

Introduction: The secretory properties of white adipocytes are thought to contribute to the association between hair folliculogenesis and a hair growth. [1,2] We preset the results of our 10-years experience in application of Adipose Derived Stem Cells (ADSCs) in treatment of Androgenetic Alopecia (AGA). Also, we analysed the quantitative and qualitative secretome profiling of ADSCs from different zones of hair growth in patients with AGA.

Method: We included all patients treated with ADRCs from January 2012 till January 2022 in our clinic. Additionally, we present 6 male patients, candidates for follicular unit extraction hair transplantation, all in early stage of AGA. 1mm punch samples of adipose tissue located beneath hair follicles of 3 scalp areas (alopecia, border-line and normal hair growth) and 1 periumbilical sample from each patient were enzymatically digested, centrifuged, washed, and cell pellets were ceded and maintained in culture medium until reached monolayer. {Figure 1] Conditioned media samples were thawed and analyzed with 41plex kit. Results were registered by Luminex platform and calculated with xPonent software.

Results: From January 2012 till January 2022 we had 94 patients treated with ADRCs, 75 male and 19 female, all with confirmed diagnosis of Androgenetic Alopecia. The average improvement in hair growth was 17.5% of terminal hair increase. All patients were in early stages of hair loss. From punch biopsies taken from different hair growth regions we analyzed the levels of 35 signaling proteins. The levels of Inteleukin-6, Vascular Endothelial Growth Factor, Endothelial Growth Factor and Eotaxin were significantly higher in the alopecia zone in comparison to the periumbilical and occipital. The similar trend was found for Monocyte Chemotactic Protein-3, Interferon gamma-inducible Protein-10 and Macrophage Inflammatory Protein-1 alpha. On the other side, Monocyte Chemoattractant Protein-1 level was the lowest in alopecia comparing to other zones. Other examined proteins did not shown changes.

Conclusion: Dermal white adipose tissue, especially those surrounding hair follicles should be considered a target for any potential therapy that aims to modulate the hair growth, weather to promote or to remove unwanted hair. The cell therapies for hair loss have not fulfilled the expectations so far. The observed differences in these signaling molecules expression could contribute for both, achieving therapeutic goals for hair loss conditions and shading more lights on the AGA etiology but also highlight the need to investigate ADSCs secretory proteome in all other conditions linked to hair loss.

References: 1. Schmidt B, Horsley V. Unravelling hair follicle-adipocyte communication. Exp Dermatol. 2012;21(11):827-30. doi: 10.1111/exd.12001. 2. Kruglikov IL, Zhang Z, Scherer PE. The Role of Immature and Mature Adipocytes in Hair Cycling. Trends Endocrinol Metab. 2019;30(2):93-105. doi: 10.1016/j.tem.2018.11.004. Epub 2018 Dec 14. Tracks:

Background: Laser imaging detection and ranging (LiDAR) is a three-dimensional (3D) technology that measures the round trip of an infrared laser beam to accurately detect the presence and features of objects. Notably, iPhone with built-in LiDAR sensors have existed since 2020. Our team developed a software application for 3D breast scanning and geometric analysis. Therefore, this study assessed the precision of our application on this platform by comparing tapeline measurements.

Methods: The software application Innoscan (Innoyard, Ltd., Seoul, Korea) based on iOS devices with built-in LiDAR sensors having two functional components: 3D scanning and 3D analysis. While using 3D scanning subsystem, each participant was instructed to maintain a comfortable sitting position while holding both hands overhead and relaxing the whole body. Anatomical landmarks were selected through touching on the device's screen. The photographer moved 360° around the participant at a distance of 50 cm from the object to capture the entire trunk. Spatial and RGB color point cloud features of the object were obtained through LiDAR sensor. The application automatically reconstructed a RGB 3D model with denoising artifact and detecting body segments. Using 3D analysis subsystem, the user selected two landmarks, and the application measured the distance between them. A curved line was used for the mid-clavicle-to-nipple, sternal notch-to-nipple and nipple-to-IMF distances. A straight line was used between nipples. 2D circumferential measurements were taken on vertical plane of nipple and IMF level. A total of 46 participants were scanned with iPhone application, and tapeline measurement were taken. Breast geometry, including mid-clavicle-to-nipple distance, sternal notch-to-nipple distance, nipple-to-inframammary fold (IMF) distance, distance between nipples and body circumference on nipple and IMF level were measured using both methods. The relative technical error of measurement (rTEM) value was used to calculate the error ratios between the measurements acquired by the software application and those of the tapeline.

Results: Good rTEM values ranging from 2.99 to 5.19% were found in the mid clavicle-to-nipple distance, sternal notch-to-nipple distance, distance between nipples, nipple level circumference and IMF level circumference. However, there was a poor rTEM value over 10% in the nipple-to-IMF distance.

Conclusion: The proposed software application installed on iPhone with a built-in LiDAR sensor provides convenient 3D scanning capabilities to clinicians and patients worldwide. This development provides good accuracy, uses smart mobile devices that people already own, and is more affordable than contemporary 3D scanning systems.

References 1. Weissler JM, Stern CS, Schreiber JE, Amirlak B, Tepper OM. The Evolution of Photography and Three-Dimensional Imaging in Plastic Surgery. Plast Reconstr Surg. 2017;139:761-769. 2. Luetzenburg G, Kroon A, Bjork AA. Evaluation of the Apple iPhone 12 Pro LiDAR for an Application in Geosciences. Sci Rep. 2021;11:22221. 3. Petrides G, Clark JR, Low H, Lovell N, Eviston TJ. Three-dimensional scanners for soft-tissue facial assessment in clinical practice. J Plast Reconstr Aesthet Surg. 2021;74:605-614. 4. Rudy HL, Wake N, Yee J, Garfein ES, Tepper OM. Three-Dimensional Facial Scanning at the Fingertips of Patients and Surgeons: Accuracy and Precision Testing of iPhone X Three-Dimensional Scanner. Plast Reconstr Surg. 2020;146:1407-1417.

Purpose: In implant-based breast reconstruction, infection is mainly concerned at the early stage and capsular contracture at the late stage [1,2]. Antibiotics are used systemically to prevent early infection, but antibiotics do not reach as much as expected immediately after mastectomy due to poor blood flow of the mastectomy flap. It would be ideal if the drug could reach effectively to the capsule tissue, and an antibiotic would act immediately after surgery and an immunosuppressive drug that prevents fibrosis after wound healing with late onset of release. In this study, we introduced a 3D-printed drug-releasing patch that was applied to the human-mimic rat model. Methods: Nineteen Sprague-Dawley rats were divided into 3groups. 2x2x0.7cm3 smooth silicone implants were placed pre-muscular pocket. The 3D-printed drug-releasing patch was made by decellularized extracellular matrix (dECM) from porcine blood vessels and methacrylate hyaluronic acid(HAMA). In group 1 (n=10), only the implant was inserted, and in group 2 (n=14), 2x108 colony-forming unit of S.epidermidis was injected after implantation. Group 3 (n=10) injected bacteria after implantation and placed an antibiotics-only drug-releasing patch on the ventral side. Group 4 (n=9) injected bacteria after implantation and placed an antibiotics&triamcinolone sequential drug-releasing patch on the ventral side After 8 weeks, rats were sacrificed and histological and immunohistochemical analysis (α-SMA and TGF- β) was performed. Results: Drug release patch (Group 3 and Group 4) groups show thinner capsules, lower myofibroblast, and inflammation compared to Group 2. Double-layered patch (Group 4) showed better results than single layered patch (Group 3) and has comparable results with the control group (Group 1). Conclusion: The 3D-printed drug-releasing patch could reduce capsule formation and inflammation in the human-mimic rat model. An antibiotics&triamcinolone sequential drug-releasing patch has a better outcome than an antibiotics-only drug-releasing patch. This 3D-printed drug-releasing patch could be an ideal new technique that can be effective in preventing capsular contracture while reducing concerns about systemic side effects.

1. Kanapathy, M., Faderani, R., Arumugam, V., Haque, S., Mosahebi, A. Management of periprosthetic breast infection: a systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2021;74:2831-2845.
2. Woo, S. H., Kim, W. S., Bae, T. H., Kim, M. K., Park, S. W., Kim, H. K. Comparison of the Effects of Acellular Dermal Matrix and Montelukast on Radiation-Induced Peri-implant Capsular Formation in Rabbits. Ann Plast Surg 2020;85:299-305.

This study evaluated the safety and efficacy of the above product, (exosome) on radiated breast skin in post mastectomy and reconstructed breast cancer patients. The design involves an initial 5 mm biopsy of radiated breast skin, 5 ml of intradermal exosome treatment in the same 4x4 cm area and 9 months later, a second 5 mm biopsy of this radiated and exosome treated breast skin. Blinded dermatopathologic evaluation and comparative analysis of pre and post-treatment was done. The second arm of this study is to evaluate clinical changes in the stiffness or indurated nature of radiated breast skin using a SkinFibrometer (Delfin) The stiffness reading is a quantity which indicates palpable tissue induration in quantitative means both prior to treatment and at the 9-month period. The SkinFibrometer utilizes an indenter which is briefly pressed on the skin. The skin resists the change in shape when an external force is applied and thus the skin's response under short term load indicates its stiffness. The specimens were embedded whole in paraffin and three sections were taken and stained: one with hematoxylin and eosin (H & E), one with Miller's elastic van Gieson and one with picosirius red. Additional sections were taken as needed to serve as test and negative control sections for immunohistochemistry (IHC) labeling. Sections designated for immunohistochemically were labeled for Type 1 collagen and CD31, an anti-human antibody specific for human endothelial cells. Human placenta sections served as a positive control tissue for both CD31 and Type 1 collagen labeling. The details of the preparation and processing can be discussed in a more formal setting. A dermatopathologist with Histion Corp. provided a semiquantitative and qualitative analysis of the biopsies before and 9 months after treatment. The microscopic analysis was completed blind to treatment for all sections to evaluate fibrosis, necrosis, and a distinct dermal/epidermal junction, elastin, Type 1 collagen and inflammation using a predetermined semiquantitative scoring system. The qualitative analysis assessed the sections further microscopically. Photomicrographs were taken to illustrate the findings. A comparative analysis of each patient's two biopsies was also done. The planned number of patients in the study was 10. We have 6 completed study patients due to patients moving away, and refusals to undergo a second biopsy.

 The goals of the study were to show safety and efficacy. These goals were achieved. There were no adverse events in any portion of the study other than patients not completing the study for personal reasons.

 The objective fibrometer data show an average of 19.4% improvement in treated radiated breast skin stiffness. The comparative semiqualititative analysis shows varying levels of dermatopathologic improvement in skin integrity as seen by improvements in the elastin scores and fibrosis scores, more uniform distribution of long elastic fibers, and reduction in necrosis. The description most commonly seen are "Some evidence "in improvement in skin integrity. The raw data can be included in the more formal paper to be written.
 These results indicate a high level of safety. The efficacy results should be interpreted with caution as sampling is a large variable in this study, the need to clearly determine efficacy would involve a larger study group.

Regards David A Jansen MD FACS

This study was a prospective evaluation of the safety and efficacy of using the stem cell derived extracellular isolate product (1 ml in all patients) in combination with micro fat to subtlety improve perioral facial volume. We looked at 10 patients who received 6 cc of micro fat injected in precise areas in the perioral region along with the 1 ml of stem cell derived extracellular vesicle isolate product. Initial 3-dimensional photographic data (Canfield, Vectra) was acquired prior to treatment and then nine months after. This study achieved the primary goal, proving the safety of the product. There were no adverse events in the ten patients treated. The efficacy will require a larger clinical trial There were some difficulties with data capture in the three-dimensional facial data allowing us only to use three patients. The difficulties involved facial expressions which changed from the baseline to final evaluation. Of the three patients with solid data, there was a perceptible change in both the retained volume (43.7%) and improvement in skin quality. This supports what is accepted in the plastic surgery community. Historically, micro fat volume retention is very low. Micro fat grafting is seen as more of a treatment for skin texture. The purpose of this study was to evaluate the safety and efficacy of this product in combination with micro fat grafting There was an opportunity to study the product's ability to increase vascularity of the graft and decrease the inflammatory response thus allowing for more retention of the micro fat.

The actionable volume change image analysis data is as follows: Subject JD 1.5 cc micro fat placed in each upper lip area Right Volume increase, 56.91mm3 37.9 % Left Volume increase,41.57mm3 27.7 % Subject LH 1.5 cc micro fat placed in each upper lip area Right Volume increase, 116.30 mm3 77.5% Left Volume increase, 36.85mm3 24.6% Subject MG 1.5 cc micro placed in each lower lip area Right Volume increase, 101.30 mm3 67.5% Left Volume increase, 35.57 mm3 23.7 % Average graft take. 43.7 %

It has been commonly accepted that minimal volume change will occur with micro fat injections and that the greatest benefit is textural improvements. This limited data set seems to indicate that the average, 43.7%, improvement in micro graft take can be expected, clearly more than what was previously thought. The high mobility of this area has been seen to cause grafts to be absorbed over time. Historically, this highly mobile, aesthetically important area has been over-treated with grafting in order to increase graft take. This can cause an extremely poor cosmetic appearance. We feel this study, although limited in actionable data points, proves the safety and efficacy of this treatment plan and supports the somewhat surprising retention of volume. These careful volume changes seem to improve the overall aesthetic appearance with the added benefit of positive textural changes. A subjective review of the remaining 7 patients shows excellent improvement in skin texture and overall skin quality. Six out of these seven patients expressed a positive and beneficial improvement and would do the procedure again The goal of this study was to access the safety of micro fat and the exosome treatment. This was proven with no adverse events. This limited data set does indicate further larger clinical studies in an attempt to improve and further quantify the volumetric changes. This can be achieved with a larger clinical trial in this very mobile and very aesthetically sensitive area. Regards David A. Jansen MD FACS

BACKGROUND: In the United States (US), about 1.25 million people are treated each year for burns, and 40,000 are hospitalized for the treatment of these injuries resulting in high medical costs, approximately $7.9 billion per year. Early assessment of burn depth considered a predictor of pathological scarring that occurs in 30%-91% of burn injuries, and prioritizing burns that require surgical intervention is a critical task. However, it continues to be an open clinical challenge. We sought to develop a high accuracy automated system, that relies on multimodal Harmonic B-mode ultrasound (HUSD B-mode) and Tissue Elastography imaging (TEI), to classify burn pathology using novel techniques based on machine learning and artificial intelligence (AI). METHODS: Burn wounds of different degrees (superficial, partial, and full thickness; n=2 each per pig; size 2"x2") were created on the dorsum of female domestic pigs (70-80lbs) (n=6 pigs) using a standardized burner. Burn wounds were treated with the same dressing. Progression of burn wounds was followed by non-invasive imaging using digital photographs, HUSD B-mode, and TEI videos at day 0 - postburn, and on days 3, 7, 14, 21, 28, 35 and 42 postburn. Burn depth was validated by histopathological analysis and results were compared with US-acquired data at different time points. State-of-the-art deep learning methods to analyze images and videos such as convolutional neural networks (CNNs) were employed. These features were used to train task-specific networks. In the case of depth classification, the classifier was further enhanced using traditional computer vision features. RESULTS: Burns of different degrees were successfully created on all the pigs. HUSD B- mode and TEI showed characteristic biomechanical and biological response patterns unique to the different degrees of burn which was validated by H&E staining. Histological pattern graded the burn injury from superficial involving only epidermal layer to the full thickness burn involving all skin and subcutaneous layers. Data labelling, segmentation and augmentation was done and fed into the AI system. Our system was able to classify burn wounds with a mean accuracy greater than 90%. In burn segmentation, our system achieved a mean global accuracy greater than 0.87. Further, we calculated a mean intersection over union (IoU) score of ~0.8. These scores represent a statistically significant improvement over our baseline segmentation model. Critically, this part of our system presented a clear and human-readable masks to understand the surface of burn wounds, allowing a high degree of explainability often required to interpret AI-produced results. CONCLUSIONS: This work presented elements of an autonomous AI system to analyze and predict burn depth via texture-based image processing algorithms using multiple common medical modalities.

Purpose: Breast implant safety is a prominent topic within reconstructive surgery. The recognition of the role played by the breast implant shell in the development of Breast Implant Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) has spurred further intense investigation into the interactions between the breast implant shell and the cells commonly found around them. Although most previous studies examined cells directly seeded onto the shells, herein we investigated the direct and indirect interactions between silicone implant shells (textured and smooth) and both primary benign and triple negative breast cancer (TNBC) cells.

Methods: MDA-MB-231 TNBC cells and HFF-1 human foreskin fibroblast cells were cultured in media containing 10% fetal bovine serum and 1% penicillin/streptomycin. Adenovirus transfected genetically-modified pro-angiogenic endothelial E4 cells and human umbilical vein endothelial cells (HUVECs) were cultured in media containing 10% endothelial cell supplement. Cells were plated at 1,000 cells/well in 96-well plates. Textured and smooth silicone implant shells of three major brands available in the U.S. were cut, cleaned, sterilized and then used to line the walls of wells within 96-well plates 24 hours after cells were plated. Wells with no implants served as a control. Plates were imaged over 10 days and cell morphology and numbers were quantified per image frame at 100x magnification with ImageJ.

Results: Across implant shells from all three major manufacturers, the indirect lining of implant shells appeared to decrease cell counts of each cell type (more so in wells containing textured implants than smooth) relative to no implant comparison wells. For TNBC cells, wells without implant shells showed significant increases in normalized cell count over 10 days (p<0.001) that were greater than that of smooth implant wells (p<0.05); TNBC cells in textured-lined wells of all three brands grew significantly slower than smooth-lined counterparts (p<0.05). HUVEC, E4 and fibroblasts showed similar behavior with cells cultured with smooth implants growing significantly less than wells without shells but significantly faster than wells with textured shells.

Conclusions: This study is the first to examine the effect of exposure to various silicone breast implant shells (sourced from multiple manufacturers) on TNBC and other interstitial breast cell types in indirect culture. Surprisingly, both smooth and textured implant shells reduce the rate of growth of both primary and malignant cells, with textured shells consistently having a more pronounced effect. The underlying mechanism of this effect, which is seen despite the overwhelming majority of cells not being in direct contact with the implant shell, is currently under investigation.

Background The monopolar radiofrequency (RF) generates heat, with the targeted ultrasound (TUS) delivering the heat to the dermal layer, ensuring deep and homogenous heating of the skin tissue. The heat induces regenerative response in the skin, namely increasing the fibroblast activity, leading to the increased production of various compounds of extracellular matrix, including the hyaluronic acid (HA). This work aims to review the current knowledge gained by animal research, investigating the effect of standalone RF treatment with the simultaneous application of RF+TUS on stimulation of the hyaluronic acid production.

Materials and Methods The author's review identified two studies with a combined number of 24 large white pigs. The treatment protocol consisted of four 30-minute procedures spaced 2-3 days apart. Two treatment groups were established based on the modality, which they were receiving. Group A (n=15) was treated with simultaneous application of RF+TUS, with group B (n=12) serving as a control group receiving standalone RF treatment only. PCR, MALDI-TOF, and ELISA were used for the quantitative evaluation of the changes in HA production. The distribution of hyaluronic acid within the skin tissue was then visualized with confocal and light microscopy.

Results The PCR focused on assessing the production of HAS1 and HAS2, enzymes responsible for HA synthesis. PCR results of group A revealed a +98% and +32% increase in HAS1 and HAS2 production after the treatments, respectively. The MALDI-TOF revealed a +218% increase in measured hyaluronic acid 2 months after the treatments, with ELISA showing a +95.2% increase. The changes were also visible by both the confocal and light microscopy. The control group showed no significant (p-value > 0.05) results in either of the studies.

Conclusion Based on the animal data, there is strong evidence that the simultaneous application of RF+TUS shows superior results for inducing the production of hyaluronic acid in the skin than radiofrequency alone. Supposedly, concurrent application of targeted ultrasound significantly enhances the natural regenerative processes in skin tissue. However, although the porcine animal model shares a great degree of similarity with human tissue, performing similar studies on human subjects in future would be a welcomed addition to this research.

References 1. Sakai S, Hirano K, Toyoda H, Linhardt RJ, Toida T. Matrix assisted laser desorption ionization-time of flight mass spectrometry analysis of hyaluronan oligosaccharides. Anal Chim Acta. 2007 Jun 19;593(2):207-13. doi: 10.1016/j.aca.2007.05.005. Epub 2007 May 6. PMID: 17543609; PMCID: PMC4129653. 2. Kim J. Clinical Effects on Skin Texture and Hydration of the Face Using Microbotox and Microhyaluronicacid. Plast Reconstr Surg Glob Open. 2018 Nov 12;6(11):e1935. doi: 10.1097/GOX.0000000000001935. PMID: 30881778; PMCID: PMC6414123.

Background: Polyethylene glycol (PEG) is a synthetic, biodegradable and hyperosmotic material that has shown promise in the treatment of acute peripheral nerve injuries. Fibrin glue has been used as an alternative to epineural suture neurorrhaphy. Our purpose was to investigate the immediate intraoperative impact of fibrin glue upon a confirmed PEG fusion in a rat model. To our knowledge, there is no literature that reports changes to immediate nerve conduction following application of fibrin glue.

Methods: Following a re-acclimatization period, 13 male Lewis rats underwent bilateral sciatic nerve surgery. In one leg, PEG fusion was performed using epineural sutures. Intraoperative electrophysiologic testing was performed. After recording nerve conduction parameters and confirming fusion, fibrin glue was applied to PEG fusion and then the same electrophysiologic testing was repeated. In the contralateral leg, fibrin glue was applied circumferentially to the intact sciatic nerve and nerve testing was performed once again. Outcome measures included nerve conduction velocity, nerve conduction latency, nerve conduction amplitude and visible distal muscle twitch with direct current stimulation (0.5 milliamps) proximal to the repair site. Independent samples t-test was used to compare primary outcome measures. A Shapiro-Wilk test was used to ensure normal distribution of data. Statistical significance was set at p < 0.05.

Results: Twenty-six nerves were investigated with an average baseline amplitude of 677.7µv, an average baseline velocity of 34.09m/s and an average baseline latency of 0.41ms. The first cohort of 13 nerves, which received a suture repair, fused by PEG had confirmed peg fusion in all nerves. In all nerves a visible distal muscle twitch could be elucidated by a stimulation of the nerve proximal to the repair with a simulating potential of 0.5 milliamps. This group had an average conduction velocity of 39.6m/s and amplitude of 314.9µv. Fibrin glue was then applied to the recently fused nerve and average conduction velocity was 41.42m/s (p=0.34) and average amplitude conversely decreased to 151.2µv (p<0.04). Following fibrin glue application, a distal muscle twitch could not be produced with proximal nerve stimulation. In the second cohort of 13 nerves, following exposure, fibrin glue was applied circumferentially to the nerve without nerve transection. This resulted in a decrease in amplitude from 911.7µv to 339.3µv (p = 0.037) and a decrease in latency 0.41ms to 0.35ms (p=0.013) and an increase in conduction velocity from 34.6m/s to 41.2m/s (p=0.013). No distal muscle twitch could be produced in this group when stimulating the nerve proximal to the site of fibrin glue application.

Conclusion: Our data suggests that fibrin glue application impacts immediate peripheral nerve function either with or without a PEG fusion. We suspect that the fibrin glue construct dissipates the nerve charge thereby attenuating or blocking the nerve from stimulating distal muscle through a significant reduction in signal amplitude. Although fibrin glue is rapidly dissolved in the human body, this finding can make the intraoperative confirmation of PEG fusion thru a distal muscle twitch problematic after fibrin glue application. Further survival and functional outcome studies are necessary to understand if this observed electrical blockade has any implications on the long-term functional effects on application of fibrin glue to PEG nerve fusions.

Purpose: In 2020, the ABPS announced an update in the personal leave policy for plastic surgery trainees extending personal leave to 12 weeks without delay in graduation. Simultaneously, the ACGME announced their update in lactation policy stating protected time and access to pumping facilities for medical trainees. Little is known about whether these policy changes impact the perspectives on family planning and lactation in plastic surgery trainees. Further, it is uncertain if trainees feel supported by their program to benefit from these policy changes while undergoing training. This study sought to understand plastic surgery trainees' current goals for family planning and lactation and decipher if policy change or perceived program support played any role in their decisions to pursue a family or lactation during their training.
Methods: An online 32-question survey was developed to evaluate plastic surgery trainees' perceptions of family planning, lactation, and perceived program support in the United States. The survey was approved by the ACAPS Research Committee which was sent out to a total of 216 plastic surgery program directors or coordinators. The survey included demographics, plastic surgery program characteristics, parental leave policies, lactational policies, and program support. Study data were collected and managed using REDCap electronic data capture tools.
Results: 130 plastic surgery trainees completed the survey. 66% of participants were female. 34% of respondents started their training after the changes in the ABPS and ACGME policies and 41% of those respondents stated their decision to apply to plastic surgery residency was influenced by perceived support for family planning and lactational goals of their trainees. Regarding family planning, 27/58 (47%) of females, stated they'd plan to have children during their training. For those who stated they'd wait until after training the most cited reasons were work hours (27%) and demand of training (23%). Regarding personal leave, only 50% of female trainees who experienced live birth took up to 12 weeks of maternity leave and 100% of those who took less than 12 weeks felt this was insufficient. Paternity leave ranged from one to six weeks and 85% of those who took two weeks or less found this insufficient. Regarding lactation, 14/16 (87%) of females, who experience pregnancy during training pumped at work and 5/6 (83%) who are currently breastfeeding reported there were lactation rooms and protected time. 3/6 (50%) reported feeling supported by their program to take time to pump. In contrast, 66% of all respondents perceived their program as supportive of those pumping.
Conclusions: As women are undoubtedly entering the field of plastic surgery in increasing numbers, policies and program support for family planning and lactation are changing. We found that policy changes and perceived support for family planning influenced a significant portion of those who applied to plastic surgery residency since implementation. Regarding family planning and lactation, the majority of trainees felt supported most or all of the time by their co-residents and program leadership. This suggests that the new policy has a beneficial impact on helping trainees with family planning

Background: Lymphedema and subsequent soft tissue infection is a growing threat to the quality of life of cancer survivors. Prevention of soft tissue infection in lymphedema patients is very important. Objective: To investigate the risk factors for soft tissue infection in female cancer survivors who had secondary peripheral lymphedema. Methods: A retrospective cohort study was conducted. Female patients with secondary lymphedema caused by breast, ovarian, endometrial, and cervical cancer were included. Clinical data related to the severity of edema, limb circumference at different sites, cancer treatment, comorbidities were included in the analysis as potential risk factors. The primary outcome was soft tissue infection. LASSO regression and multivariate logistic regression were used to screen the risk factors. Results: Seven out of 43 upper extremity lymphedema patients had soft tissue infection (16.28%), while 20 out of 81 lower extremity lymphedema patients had soft tissue infection (24.69%). The risk factors for lower extremity screened by multivariate analysis included: pain [OR=1.52085 (1.23571~1.87179), P=0.00023], limb circumference at 10 cm below the knee [OR=1.01559 (1.00521~1.02609) P=0.00479], Osteoporosis [OR= 2.50872 (1.53877~4.09009) P= 0.00055], Cancer Type [OR= 0.81159 (0.6935~0.94979) P=0.0121]. The internal validation of the multivariate regression results suggested a C-index = 0.917517, while the ROC curve suggested an area under the curve AUC = 0.918. Conclusions: Limb circumference, pain, osteoporosis and cancer type are risk factors for soft tissue infection in lower extremity lymphedema in female cancer survivors. Targeting the preventable factors, such as edema control by daily management, could be an effective way to reduce the risk of soft tissue infection.