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Shah J, Zhao R, Yi J, Otterburn D, Patel A, Szpalski C, Tanna N, Taub PJ, Weichman KE, Ricci JA. Frontline Reporting from the Epicenter of a Global Pandemic: A Survey of the Impact of COVID-19 on Plastic Surgery Training in New York and New Jersey. Plast Reconstr Surg 2022; 149:130e-138e. [PMID: 34936636 PMCID: PMC8691163 DOI: 10.1097/prs.0000000000008649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/19/2021] [Indexed: 12/05/2022]
Abstract
BACKGROUND Since the first documented case of coronavirus disease of 2019 (COVID-19), the greater New York City area quickly became the epicenter of the global pandemic, with over 500,000 cases and 50,000 deaths. This unprecedented crisis affected all aspects of health care, including plastic surgery residency training. The purpose of this study was to understand the specific impact of the COVID-19 pandemic on plastic surgery residencies. METHODS A survey of all plastic surgery residency training programs in the greater New York City area was conducted. The impact to training during the peak months of infection (March and April of 2020) was evaluated using resident education as measured by case numbers, need for redeployment, and staff wellness as primary outcome variables. RESULTS A total of 11 programs were identified in the region, and seven programs completed the survey, with a response rate 63.6 percent. When comparing productivity in March and April of 2019 to March and April of 2020, a total decrease in surgical volume of 64.8 percent (range, 19.7 to 84.8 percent) and an average of 940 (range, 50 to 1287) cancelled clinic visits per month were observed. These decreases directly correlated with the local county's COVID-19 incidence rates (p = 0.70). A total of 83 percent of programs required redeployment to areas of need, and correlation between local incidence of COVID-19 and the percentage of residents redeployed to non-plastic surgical clinical environments by a given program (ρ = 0.97) was observed. CONCLUSION As the first COVID-19 wave passes the greater New York area and spreads to the rest of the country, the authors hope their experience will shed light on the effects of the ongoing COVID-19 pandemic, and inform other programs on what to expect and how they can try and prepare for future public health crises.
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Affiliation(s)
- Jinesh Shah
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ruya Zhao
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph Yi
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - David Otterburn
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ashit Patel
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Caroline Szpalski
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Neil Tanna
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Peter J. Taub
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Katie E. Weichman
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph A. Ricci
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
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Shah J, Zhao R, Yi J, Otterburn D, Patel A, Szpalski C, Tanna N, Taub PJ, Weichman KE, Ricci JA. Novel Quantification of Real-Time Lymphatic Clearance: Immediate Lymphatic Reconstruction in a Large-Animal Model. Plast Reconstr Surg 2022; 149:130-141. [PMID: 34936612 PMCID: PMC8691163 DOI: 10.1097/prs.0000000000008631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 05/19/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND The real-time quantification of lymphatic flow remains elusive. Efforts to provide a metric of direct lymphatic function are not clinically translatable and lack reproducibility. Early reports demonstrate the promise of immediate lymphatic reconstruction (immediate lymphovenous bypass after lymphadenectomy) to reduce the risk of lymphedema development. However, there remains a heightened need to appraise this technique in a clinically translatable large-animal model. The aim of the authors' experiment was to evaluate the role of molecular imaging in the quantification of real-time lymphatic flow after lymphadenectomy, and lymphadenectomy with lymphovenous bypass using novel fluorophores in a swine model. METHODS A lymphadenectomy or lymphadenectomy with subsequent lymphovenous bypass was performed in 10 female swine. After subdermal fluorophore injection, near-infrared molecular imaging of blood samples was used to evaluate change in lymphatic flow after lymphadenectomy versus after lymphadenectomy with lymphovenous bypass. Continuous imaging evaluating fluorescence of the superficial epigastric vein in the torso and adjacent skin was performed throughout all experiments. Findings between modalities were correlated. RESULTS The near-infrared dye signal in central and peripheral blood samples was often difficult to separate from background and proved challenging for reliable quantification. Venous and skin near-infrared imaging demonstrated a lymphatic clearance rate decrease of 70 percent after lymphadenectomy versus a decrease by only 30 percent after lymphadenectomy with immediate lymphovenous bypass. CONCLUSIONS In this article, the authors describe a noninvasive, swine, large-animal model to quantify lymphatic clearance using skin imaging. The authors' findings were consistent with results yielded from real-time imaging of the vein. The authors believe this model may have important implications for eventual direct translation to the clinical setting.
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Affiliation(s)
- Jinesh Shah
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ruya Zhao
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph Yi
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - David Otterburn
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Ashit Patel
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Caroline Szpalski
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Neil Tanna
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Peter J. Taub
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Katie E. Weichman
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
| | - Joseph A. Ricci
- From the Division of Plastic and Reconstructive Surgery, Montefiore Medical Center; Division of Plastic and Reconstructive Surgery, Weill Cornell Medical Center; Division of Plastic and Reconstructive Surgery, Albany Medical Center; Division of Plastic Surgery, St. Joseph’s Health; Division of Plastic and Reconstructive Surgery, Northwell Health; and Division of Plastic and Reconstructive Surgery, Mount Sinai Hospital
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Broer PN, Thiha A, Ehrl D, Sinno S, Juran S, Szpalski C, Ng R, Ninkovic M, Prantl L, Heidekrueger PI. The ideal ear position in Caucasian females. J Craniomaxillofac Surg 2018; 46:485-491. [DOI: 10.1016/j.jcms.2017.12.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 11/29/2017] [Accepted: 12/18/2017] [Indexed: 10/18/2022] Open
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Heidekrueger PI, Szpalski C, Weichman K, Juran S, Ng R, Claussen C, Ninkovic M, Broer PN. Lip Attractiveness: A Cross-Cultural Analysis. Aesthet Surg J 2017; 37:828-836. [PMID: 27677824 DOI: 10.1093/asj/sjw168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Perception of beauty is influenced by the individual's geographic, ethnic, cultural, and demographic background. However, objective measurements remain the foundation for aesthetic evaluations. In the quest for to better define "ideal" lip characteristics, this study assumes interdependence between variables such as country of residence, sex, age, occupation, and aesthetic perception. Objectives This study will increase surgeons' awareness with respect to different lip size preferences. The provided information might enhance and clarify communication among plastic surgeons and aid to put often quoted "ideal proportions" in context. Methods An online survey was designed. Modifiable ranges of lip fullness were achieved via digital alteration, enabling participants to interactively change the shape of a single model's lips. The questionnaire was sent to more than 9000 plastic surgeons and laypeople worldwide. Demographic data were collected and analysis of variance was used to elucidate lip shape preferences. Results A total of 1011 responses (14% response rate) from 35 different countries were gathered. Significant differences regarding lip fullness were identified. Surgeons who practice in Asia or non-Caucasian surgeons prefer larger lips, while those in Europe and Caucasians prefer smaller lips. Lastly, laypersons living in Asia prefer the smallest lips. Conclusions Country of residence, ethnic background, and profession significantly impact individual lip shape preferences. These findings have implications for patients and surgeons, because differences in aesthetics' preferences can lead to dissatisfaction of patients and surgeons alike. In our increasingly global environment, cultural differences and international variability must be considered when defining new aesthetic techniques, treating patients, and reporting outcomes.
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Affiliation(s)
- Paul I Heidekrueger
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany
| | - Caroline Szpalski
- Department of Plastic Surgery, The University of Texas MD Anderson Center, Houston, TX
| | | | - Sabrina Juran
- United Nations Population Fund, Technical Division, Population and Development Branch, New York, NY
| | - Reuben Ng
- Division of Psychology, Nanyang Technological University & Lee Kuan Yew School of Public Policy, National University of Singapore
| | - Carla Claussen
- Technical University Munich Medical School, Munich, Germany
| | - Milomir Ninkovic
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany
| | - P Niclas Broer
- Department of Plastic, Reconstructive, Hand, and Burn Surgery, StKM - Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany
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Heidekrueger PI, Juran S, Szpalski C, Larcher L, Ng R, Broer PN. The current preferred female lip ratio. J Craniomaxillofac Surg 2017; 45:655-660. [DOI: 10.1016/j.jcms.2017.01.038] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/24/2016] [Accepted: 01/31/2017] [Indexed: 10/20/2022] Open
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Heidekrueger PI, Tanna N, Weichman KE, Szpalski C, Tos P, Ninkovic M, Broer PN. Added Qualifications in Microsurgery: Consideration for Subspecialty Certification in Microvascular Surgery in Europe. J Reconstr Microsurg 2016; 32:476-83. [PMID: 26872022 DOI: 10.1055/s-0036-1571796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background While implementation of subspecializations may increase expertise in a certain area of treatment, there also exist downsides. Aim of this study was, across several disciplines, to find out if the technique of microsurgery warrants the introduction of a "Certificate of Added Qualifications (CAQ) in microsurgery." Methods An anonymous, web-based survey was administered to directors of microsurgical departments in Europe (n = 205). Respondents were asked, among other questions, whether they had completed a 12-month microvascular surgery fellowship and whether they believed a CAQ in microvascular surgery should be instituted. Results The response rate was 57%, and 33% of the respondents had completed a 12-month microvascular surgery fellowship.A total of 61% of all surgeons supported a CAQ in microsurgery. Answers ranged from 47% of support to 100% of support, depending on the countries surveyed. Discussion This is one of the few reports to evaluate the potential role of subspecialty certification of microvascular surgery across several European countries. The data demonstrate that the majority of directors of microsurgical departments support such a certificate. There was significantly greater support for a CAQ in microsurgery among those who have completed a formal microvascular surgery fellowship themselves. Conclusion This study supports the notion that further discussion and consideration of subspecialty certification in microvascular surgery appears necessary. There are multiple concerns surrounding this issue. Similar to the evolution of hand surgery certification, an exploratory committee of executive members of the respective medical boards and official societies may be warranted.
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Affiliation(s)
- Paul I Heidekrueger
- Department of Plastic and Reconstructive Surgery, Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany
| | - Neil Tanna
- Department of Plastic Surgery, North Shore LIJ Hospital, New York City, New York
| | - Katie E Weichman
- Department of Plastic Surgery, Montefiori Medical Center, Bronx, New York City, New York
| | - Caroline Szpalski
- Département de Chirurgie Plastique, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierluigi Tos
- Microsurgery Unit, Az. San. Città della Salute e della Scienza, Turin, Italy
| | - Milomir Ninkovic
- Department of Plastic and Reconstructive Surgery, Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany
| | - P Niclas Broer
- Department of Plastic and Reconstructive Surgery, Klinikum Bogenhausen, Academic Teaching Hospital, Technical University Munich, Munich, Germany
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Avraham T, Weichman KE, Wilson S, Weinstein A, Haddock NT, Szpalski C, Choi M, Karp NS. Postoperative Expansion is not a Primary Cause of Infection in Immediate Breast Reconstruction with Tissue Expanders. Breast J 2015; 21:501-7. [PMID: 26132336 DOI: 10.1111/tbj.12448] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Perioperative infection is the most common and dreaded complication associated with tissue expander (TE) breast reconstruction. Historically, the expansion period was thought to be the time of greatest hazard to the implant. However, recent institutional observations suggest infectious complications occur prior to expansion. This investigation, therefore, was conducted to determine the timing of infectious complications associated with two-stage TE breast reconstructions. Following IRB approval, a retrospective review of all consecutive two-stage immediate TE breast reconstructions at a single institution from November 2007 to November 2011 was conducted. Reconstructions were then divided into two cohorts: those suffering infectious complications and those that did not. Infectious complications including minor cellulitis, major cellulitis, abscess drainage, and explantation were identified. Various operative and patient variables were evaluated in comparison. Eight hundred ninety immediate two-stage TE breast reconstructions met inclusion criteria. Patients suffering infection were older (55.4 years versus 49.3 years; p < 0.001), and more likely to have therapeutic mastectomy (94% versus 61%; p < 0.0001), the use of acellular dermal matrix (ADM; 72.5% versus 54.9%; p = 0.001), and greater initial TE fill (448.6 mL versus 404.7 mL; p = 0.0078). The average time to developing of infectious symptoms was 29.6 days (range 9-142 days), with 94.6% (n = 87) of infections prior to the start of expansion. Perioperative infections in immediate two-stage TE to implant breast reconstructions are significant and occur mostly prior to the start of expansion. Thus, challenging the conventional wisdom that instrumentation during expander filling as the primary cause of implant infections. Possible etiologic factors include greater age, therapeutic mastectomy versus prophylactic mastectomy, larger initial TE fill, and the use of ADM.
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Affiliation(s)
- Tomer Avraham
- Institute of Reconstructive Plastic Surgery, New York University, New York, New York
| | - Katie E Weichman
- Institute of Reconstructive Plastic Surgery, New York University, New York, New York
| | - Stelios Wilson
- Institute of Reconstructive Plastic Surgery, New York University, New York, New York
| | - Andrew Weinstein
- Institute of Reconstructive Plastic Surgery, New York University, New York, New York
| | | | - Caroline Szpalski
- Department of Surgery, University Libre de Bruxelles, Brussels, Belgium
| | - Mihye Choi
- Institute of Reconstructive Plastic Surgery, New York University, New York, New York
| | - Nolan S Karp
- Institute of Reconstructive Plastic Surgery, New York University, New York, New York
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Layliev J, Sagebin F, Weinstein A, Marchac A, Szpalski C, Saadeh PB, Warren SM. Percutaneous gene therapy heals cranial defects. Gene Ther 2013; 20:922-9. [PMID: 23594990 DOI: 10.1038/gt.2013.15] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 02/03/2013] [Accepted: 02/18/2013] [Indexed: 11/09/2022]
Abstract
Nonhealing bone defects are difficult to treat. As the bone morphogenic protein and transforming growth factor beta pathways have been implicated in bone healing, we hypothesized that percutaneous Smad7 silencing would enhance signaling through both pathways and improve bone formation. Critical sized parietal trephine defects were created and animals received percutaneous injection of: agarose alone or agarose containing nonsense or Smad7 small interfering RNA (siRNA). At 12 weeks, SMADs1, 2, 3, 5, 7 and 8 levels were assessed. Smad1/5/8 osteogenic target, Dlx5, and SMAD2/3 angiogenic target, plasminogen activator inhibitor-1 (Pai1), transcription levels were measured. Noncanonical signaling through TGFβ activated kinase-1 (Tak1) and target, runt-related transcription factor 2 (Runx2) and collagen1α1 (Col1α1), transcription were also measured. Micro-computed tomography and Gomori trichome staining were used to assess healing. Percutaneous injection of Smad7 siRNA significantly knocked down Smad7 mRNA (86.3 ± 2.5%) and protein levels (46.3 ± 3.1%). The SMAD7 knockdown resulted in a significant increase in receptor-regulated SMADs (R-SMAD) (Smad 1/5/8 and Smad2/3) nuclear translocation. R-SMAD nuclear translocation increased Dlx5 and Pai1 transcription. Additionally, noncanonical signaling through Tak1 increased Runx2 and Col1α1 target transcription. Compared with animals treated with agarose alone (33.9 ± 2.8% healing) and nonsense siRNA (31.5 ± 11.8% healing), animals treated Smad7 siRNA had significantly great (91.2 ± 3.8%) healing. Percutaneous Smad7 silencing increases signal transduction through canonical and noncanonical pathways resulting in significant bone formation. Minimally invasive gene therapies may prove effective in the treatment of nonhealing bone defects.
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Affiliation(s)
- J Layliev
- The Department of Plastic Surgery, Institute of Reconstructive Plastic Surgery Laboratories, New York University Medical Center, New York, NY, USA
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Szpalski C, Sagebin F, Barbaro M, Warren SM. The influence of environmental factors on bone tissue engineering. J Biomed Mater Res B Appl Biomater 2012; 101:663-75. [PMID: 23165885 DOI: 10.1002/jbm.b.32849] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Revised: 09/28/2012] [Accepted: 10/05/2012] [Indexed: 12/14/2022]
Abstract
Bone repair and regeneration are dynamic processes that involve a complex interplay between the substrate, local and systemic cells, and the milieu. Although each constituent plays an integral role in faithfully recreating the skeleton, investigators have long focused their efforts on scaffold materials and design, cytokine and hormone administration, and cell-based therapies. Only recently have the intangible aspects of the milieu received their due attention. In this review, we highlight the important influence of environmental factors on bone tissue engineering.
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Affiliation(s)
- Caroline Szpalski
- Department of Plastic Surgery, New York University Langone Medical Center, New York, New York, USA
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Appelboom G, Zoller SD, Piazza MA, Szpalski C, Bruce SS, McDowell MM, Vaughan KA, Zacharia BE, Hickman Z, D'Ambrosio A, Feldstein NA, Anderson RCE. Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery. Neurosurg Focus 2012; 31:E5. [PMID: 22044104 DOI: 10.3171/2011.8.focus11177] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population. In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma. The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.
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Affiliation(s)
- Geoffrey Appelboom
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Wagner IJ, Szpalski C, Allen RJ, Davidson EH, Canizares O, Saadeh PB, Warren SM. Obesity impairs wound closure through a vasculogenic mechanism. Wound Repair Regen 2012; 20:512-22. [PMID: 22672117 DOI: 10.1111/j.1524-475x.2012.00803.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2011] [Accepted: 02/27/2012] [Indexed: 12/27/2022]
Abstract
Since obesity impairs wound healing and bone marrow (BM)-derived vasculogenic progenitor cells (PCs) are important for tissue repair, we hypothesize that obesity-impaired wound healing is due, in part, to impaired PC mobilization, trafficking, and function. Peripheral blood was obtained from nondiabetic, obese (BMI > 30, n = 25), and nonobese (BMI < 30, n = 17) subjects. Peripheral blood human (h)PCs were isolated, quantified, and functionally assessed. To corroborate the human experiments, 6-mm stented wounds were created on nondiabetic obese mice (TALLYHO/JngJ, n = 15) and nonobese mice (SWR/J, n = 15). Peripheral blood mouse (m)PCs were quantified and wounds were analyzed. There was no difference in the number of baseline circulating hPCs in nondiabetic, obese (hPC-ob), and nonobese (hPC-nl) subjects, but hPC-ob had impaired adhesion (p < 0.05), migration (p < 0.01), and proliferation (p < 0.001). Nondiabetic obese mice had a significant decrease in the number of circulating PCs (mPC-ob) at 7 (p = 0.008) and 14 days (p = 0.003) after wounding. The impaired circulating mPC-ob response correlated with significantly impaired wound closure at days 14 (p < 0.001) and 21 (p < 0.001) as well as significantly fewer new blood vessels in the wounds (p < 0.001). Our results suggest that obesity impairs the BM-derived vasculogenic PC response to peripheral injury and this, in turn, impairs wound closure.
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Affiliation(s)
- I Janelle Wagner
- Department of Surgery, Temple School of Medicine, Temple University Hospital, Philadelphia, Pennsylvania, USA
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Szpalski C, Nguyen PD, Cretiu Vasiliu CE, Chesnoiu-Matei I, Ricci JL, Clark E, Smay JE, Warren SM. Bony engineering using time-release porous scaffolds to provide sustained growth factor delivery. J Craniofac Surg 2012; 23:638-44. [PMID: 22565873 DOI: 10.1097/scs.0b013e31824db8d4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Microporous scaffolds designed to improve bony repair have had limited success; therefore, we sought to evaluate whether time-released porous scaffolds with or without recombinant bone morphogenetic protein 2 (rhBMP-2) could enhance stem cell osteoinduction. Custom-made 15/85 hydroxyapatite/β-tricalcium phosphate scaffolds were left empty (E) or filled with rhBMP-2 (E+), calcium sulfate (CS), or CS and rhBMP-2 (CS+). All scaffolds were placed in media and weighed daily. Conditioned supernatant was analyzed for rhBMP-2 and then used to feed human adipose-derived mesenchymal stem cells (ASCs). Adipose-derived mesenchymal stem cell ALP activity, OSTERIX expression, and bone nodule formation were determined. E scaffolds retained 97% (SD, 2%) of the initial weight, whereas CS scaffolds had a near-linear 30% (SD, 3%) decrease over 60 days. E+ scaffolds released 155 (SD, 5) ng of rhBMP-2 (77%) by day 2. In contrast, CS+ scaffolds released only 30 (SD, 2) ng (10%) by day 2, and the remaining rhBMP-2 was released over 20 days. Conditioned media from E+ scaffolds stimulated the highest ALP activity and OSTERIX expression in ACSs on day 2. However, after day 6, media from CS+ scaffolds stimulated the highest ALP activity and OSTERIX expression in ASCs. Adipose-derived mesenchymal stem cells exposed to day 8 CS+-conditioned media produced significantly more bone nodules (10.1 [SD, 1.7] nodules per high-power field) than all other scaffolds. Interestingly, day 8 conditioned media from CS scaffolds simulated significantly more bone nodules than either E or E+ scaffold (P < 0.05 for both). Time-released hydroxyapatite/β-tricalcium phosphate porosity provides sustained growth factor release, enhances ASC osteoinduction, and may result in better in vivo bone formation.
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Affiliation(s)
- Caroline Szpalski
- Department of Plastic Surgery, New York University Langone Medical Center, New York, NY, USA
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Szpalski C, Barbaro M, Sagebin F, Warren SM. Bone tissue engineering: current strategies and techniques--part II: Cell types. Tissue Eng Part B Rev 2012; 18:258-69. [PMID: 22224439 DOI: 10.1089/ten.teb.2011.0440] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Bone repair and regeneration is a dynamic process that involves a complex interplay between the (1) ground substance; (2) cells; and (3) milieu. Each constituent is integral to the final product, but it is often helpful to consider each component individually. While bone tissue engineering has capitalized on a number of breakthrough technologies, one of the most valued advancements is the incorporation of mesenchymal stem cells (SCs) into bone tissue engineering applications. With this new idea, however, came new found problems of guiding SC differentiation. Moreover, investigators are still working to understand which SCs source produces optimal bone formation in vitro and in vivo. Bone marrow-derived mesenchymal SCs and adipose-derived SCs have been researched most extensively, but other SC sources, including dental pulp, blood, umbilical cord blood, epithelial cells reprogrammed to become induced pluripotent SCs, among others, are being investigated. In Part II of this review series, we discuss the variety of cell types (e.g., osteocytes, osteoblasts, osteoclasts, chondrocytes, mesenchymal SCs, and vasculogenic cells) important in bone tissue engineering.
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Affiliation(s)
- Caroline Szpalski
- Department of Plastic Surgery, New York University Langone Medical Center, New York, New York 10016, USA
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Szpalski C, Wetterau M, Barr J, Warren SM. Bone tissue engineering: current strategies and techniques--part I: Scaffolds. Tissue Eng Part B Rev 2012; 18:246-57. [PMID: 22029448 DOI: 10.1089/ten.teb.2011.0427] [Citation(s) in RCA: 103] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Bone repair and regeneration is a dynamic process that involves a complex interplay between the (1) ground substance, (2) cells, and (3) milieu. While each constituent is integral to the final product, it is often helpful to consider each component individually. Therefore, we created a two-part review to examine scaffolds and cells' roles in bone tissue engineering. In Part I, we review the myriad of materials use for in vivo bone engineering. In Part II, we discuss the variety cell types (e.g., osteocytes, osteoblasts, osteoclasts, chondrocytes, mesenchymal stem cells, and vasculogenic cells) that are seeded upon or recruited to these scaffolds. In Part III, we discuss the optimization of the microenvironment. The biochemical processes and sequence of events that guide matrix production, cellular activation, and ossification are vital to developing successful bone tissue engineering strategies and are thus succinctly reviewed herein.
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Affiliation(s)
- Caroline Szpalski
- Department of Plastic Surgery, Institute of Reconstructive Plastic Surgery Laboratory, New York, New York, USA
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Abstract
Craniosynostosis is the premature fusion of one or more cranial sutures. When a cranial suture fuses prematurely, skull growth is altered and the head takes on a characteristic pathological shape determined by the suture(s) that fuses. Numerous treatment options have been proposed, but until recently there were no parameters or guidelines of care. Establishing such parameters was an important step forward in the treatment of patients with craniosynostosis, but results are still assessed using radiographic measurements, complication rates, and ad hoc reporting scales. Therefore, clinical outcome reporting in the treatment of craniosynostosis is inconsistent and lacks methodological rigor.
Today, most reported evidence in the treatment of craniosynostosis is level 5 (expert opinion) or level 4 (case series) data. Challenges in obtaining higher quality level 1 or level 2 data include randomizing patients in a clinical trial as well as selecting the appropriate outcome measure for the trial. Therefore, determining core outcome sets that are important to both patients and health care professionals is an essential step in the evolution of caring for patients with craniosynostosis.
Traditional clinical outcomes will remain important, but patient-reported outcomes, such as satisfaction, body image, functional results, and aesthetic outcomes, must also be incorporated if the selected outcomes are to be valuable to patients and families making decisions about treatment. In this article, the authors review the most commonly used tools to assess craniosynostosis outcomes and propose a list of longitudinal parameters of care that should be considered in the evaluation, diagnosis, and treatment evaluation of a patient with craniosynostosis.
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Abstract
Bony defects in the craniomaxillofacial skeleton remain a major and challenging health concern. Surgeons have been trying for centuries to restore functionality and aesthetic appearance using autografts, allografts, and even xenografts without entirely satisfactory results. As a result, physicians, scientists, and engineers have been trying for the past few decades to develop new techniques to improve bone growth and bone healing. In this review, the authors summarize the advantages and limitations of current animal models; describe current materials used as scaffolds, cell-based, and protein-based therapies; and lastly highlight areas for future investigation. The purpose of this review is to highlight the major scaffold-, cell-, and protein-based preclinical tools that are currently being developed to repair cranial defects.
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Butala P, Sultan SM, Davidson EH, Crawford JL, Szpalski C, Knobel D, Marchac A, Saadeh PB, Warren SM, Coleman S, Hazen A. Progenitor Cell Mobilization Augments Fat Graft Survival. Plast Reconstr Surg 2010. [DOI: 10.1097/01.prs.0000388778.99220.39] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Butala P, Sultan SM, Davidson EH, Crawford JL, Szpalski C, Knobel D, Saadeh PB, Warren SM, Coleman S, Hazen A. Improved fat graft survival with mobilization of progenitor cells. J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.06.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Butala P, Szpalski C, Knobel D, Crawford JL, Marchac A, Davidson EH, Sultan SM, Wetterau M, Saadeh PB, Warren SM. Modeling senescent wound healing with the Zmpste24 transgenic mouse. J Am Coll Surg 2010. [DOI: 10.1016/j.jamcollsurg.2010.06.206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Van Keymeulen A, Mascre G, Youseff KK, Harel I, Michaux C, De Geest N, Szpalski C, Achouri Y, Bloch W, Hassan BA, Blanpain C. Epidermal progenitors give rise to Merkel cells during embryonic development and adult homeostasis. J Exp Med 2009. [DOI: 10.1084/jem20611oia26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Van Keymeulen A, Mascre G, Youseff KK, Harel I, Michaux C, De Geest N, Szpalski C, Achouri Y, Bloch W, Hassan BA, Blanpain C. Epidermal progenitors give rise to Merkel cells during embryonic development and adult homeostasis. ACTA ACUST UNITED AC 2009; 187:91-100. [PMID: 19786578 PMCID: PMC2762088 DOI: 10.1083/jcb.200907080] [Citation(s) in RCA: 187] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Lineage-tracing experiments show that the origin of specialized mechanosensory Merkel cells in the skin is epidermal progenitors, not the neural crest. Merkel cells (MCs) are located in the touch-sensitive area of the epidermis and mediate mechanotransduction in the skin. Whether MCs originate from embryonic epidermal or neural crest progenitors has been a matter of intense controversy since their discovery >130 yr ago. In addition, how MCs are maintained during adulthood is currently unknown. In this study, using lineage-tracing experiments, we show that MCs arise through the differentiation of epidermal progenitors during embryonic development. In adults, MCs undergo slow turnover and are replaced by cells originating from epidermal stem cells, not through the proliferation of differentiated MCs. Conditional deletion of the Atoh1/Math1 transcription factor in epidermal progenitors results in the absence of MCs in all body locations, including the whisker region. Our study demonstrates that MCs arise from the epidermis by an Atoh1-dependent mechanism and opens new avenues for study of MC functions in sensory perception, neuroendocrine signaling, and MC carcinoma.
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Affiliation(s)
- Alexandra Van Keymeulen
- Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire, Université Libre de Bruxelles, Brussels B-1070, Belgium
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