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Face reconstruction could soon use ‘shape-shifting’ material

Injuries, birth defects (such as cleft palates) or surgery to remove a tumor can create gaps in bone that are too large to heal naturally. And when they occur in the head, face or jaw, these bone defects can dramatically alter a person’s appearance. Researchers reported that they have developed a “self-fitting” material that expands with warm salt water to precisely fill bone defects, and also acts as a scaffold for new bone growth.

Shape-Shifting Material
A new material that changes shape upon heating could help heal bone lesions caused by injuries, tumor removal or birth defects, such as cleft palates. (The white bar is 1 cm, or less than half an inch long.)
Credit: Melissa Grunlan, Ph.D.

The team described their approach at the 248th National Meeting & Exposition of the American Chemical Society (ACS).

Currently, the most common method for filling bone defects in the head, face or jaw (known as the cranio-maxillofacial area) is autografting. That is a process in which surgeons harvest bone from elsewhere in the body, such as the hip bone, and then try to shape it to fit the bone defect.

“The problem is that the autograft is a rigid material that is very difficult to shape into these irregular defects,” says Melissa Grunlan, Ph.D., leader of the study. Also, harvesting bone for the autograft can itself create complications at the place where the bone was taken.

Another approach is to use bone putty or cement to plug gaps. However, these materials aren’t ideal. They become very brittle when they harden, and they lack pores, or small holes, that would allow new bone cells to move in and rebuild the damaged tissue.

To develop a better material, Grunlan and her colleagues at Texas A&M University made a shape-memory polymer (SMP) that molds itself precisely to the shape of the bone defect without being brittle. It also supports the growth of new bone tissue.

SMPs are materials whose geometry changes in response to heat. The team made a porous SMP foam by linking together molecules of poly(e-caprolactone), an elastic, biodegradable substance that is already used in some medical implants. The resulting material resembled a stiff sponge, with many interconnected pores to allow bone cells to migrate in and grow.

Upon heating to 140 degrees Fahrenheit, the SMP becomes very soft and malleable. So, during surgery to repair a bone defect, a surgeon could warm the SMP to that temperature and fill in the defect with the softened material. Then, as the SMP is cooled to body temperature (98.6 degrees Fahrenheit), it would resume its former stiff texture and “lock” into place.

The researchers also coated the SMPs with polydopamine, a sticky substance that helps lock the polymer into place by inducing formation of a mineral that is found in bone. It may also help osteoblasts, the cells that produce bone, to adhere and spread throughout the polymer. The SMP is biodegradable, so that eventually the scaffold will disappear, leaving only new bone tissue behind.

To test whether the SMP scaffold could support bone cell growth, the researchers seeded the polymer with human osteoblasts. After three days, the polydopamine-coated SMPs had grown about five times more osteoblasts than those without a coating. Furthermore, the osteoblasts produced more of the two proteins, runX2 and osteopontin, that are critical for new bone formation.

Grunlan says that the next step will be to test the SMP’s ability to heal cranio-maxillofacial bone defects in animals. “The work we’ve done in vitro is very encouraging,” she says. “Now we’d like to move this into preclinical and, hopefully, clinical studies.”

Title

“Self-fitting” shape memory polymer (SMP) scaffold with potential to treat cranio-maxillofacial (CMF) bone defects

Abstract Improvements in scaffold design are needed to realize the potential of tissue engineering to heal critical-sized cranio-maxillofacial (CMF) bone defects. In particular, scaffolds that can precisely match the irregular boundaries of bone defects as well as exhibit an interconnected pore morphology and bioactivity would enhance tissue regeneration. In this work, a shape memory polymer (SMP) scaffold was developed exhibiting an open porous structure and the capacity to conformally “self-fit” into irregular defects. The SMP scaffold was prepared via photocrosslinking of poly(e-caprolactone) (PCL) diacrylate using a solvent casting/particulate leaching (SCPL) method which included a fused salt template. A bioactive polydopamine coating was applied to the pore walls. Following exposure to warm saline at T > Ttrans (Ttrans = Tm of PCL), the scaffold became malleable and could be pressed into an irregular model defect. Subsequent cooling caused the scaffold to lock in its temporary shape within the defect. Polydopamine-coated scaffolds exhibited superior bioactivity (i.e. formation of hydroxyapatite in vitro), osteoblast adhesion, proliferation, osteogenic gene expression and ECM deposition.

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Study finds more women receiving breast reconstruction after mastectomy

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Study finds more women receiving breast reconstruction after mastectomy

A new study finds that the majority of women who undergo mastectomy for breast cancer go on to get breast reconstruction, a practice that has increased dramatically over time.

Researchers found that 46 percent of patients received reconstruction in 1998 but that figure rose to 63 percent by 2007.

“Breast reconstruction has a big impact on quality of life for breast cancer survivors. As we are seeing more women survive breast cancer, we need to focus on long term survivorship issues and ensuring that women have access to this important part of treatment,” says study first author Reshma Jagsi, M.D., D.Phil., associate professor of radiation oncology at the University of Michigan Comprehensive Cancer Center.

The researchers, from academic medical centers and private practice, looked at insurance claims data from a large nationwide employment-based database of medical claims. They identified a total of 20,506 women who had been treated with mastectomy for breast cancer between 1998 and 2007. Results appear in the Journal of Clinical Oncology.

While overall rates of reconstruction increased, women who received radiation therapy were less likely to get reconstruction. This is especially concerning because radiation therapy is increasingly being used after mastectomy as a way to further reduce the risk of the cancer returning in women with more aggressive or advanced disease.

The researchers note that reconstruction is more challenging after radiation, which limits the reconstruction options available for these patients. And often the results are not as good.

“As a growing number of women are eligible for radiation after mastectomy, we have to be aware that this alters those patients’ reconstruction options and outcomes. Patients’ and physicians’ concerns about how best to integrate reconstruction and radiation may be influencing patient decisions. We need to determine the best approach to reconstruction for women who receive radiation,” Jagsi says.

“In appropriately selected patients, radiation saves lives and is generally well tolerated. However, radiation does cause a certain degree of damage to normal tissue which complicates and often delays breast reconstruction. Team-based collaborative care between breast surgeons, plastic surgeons and radiation oncologists is critical to help patients experience good outcomes,” says senior author Benjamin Smith, M.D., associate professor of radiation oncology at The University of Texas MD Anderson Cancer Center.

The study also revealed dramatic variation in reconstruction based on geographic region, from a low of 18 percent in North Dakota, to a high of 80 percent in Washington, D.C. This was largely associated with the number of plastic surgeons working in each state.

“Any time we see geographic variations in practice patterns, we worry that care is not being appropriately individualized and that patients are not being offered all their options. It’s important to make sure women have all the information they need about breast reconstruction and are aware that it is an option,” Jagsi says.

Other findings reported show that the rate of bilateral mastectomy increased six-fold between 1998 and 2007, and that three-quarters of women receiving bilateral mastectomy also have breast reconstruction.

The researchers also note that more women are receiving implants rather than recreating breasts using tissue from other parts of their body, called autologous reconstruction. Autologous techniques tend to deliver better cosmetic results and higher satisfaction, but it’s a time-consuming, demanding operation that requires a longer hospital stay and recovery time. The researchers raise concern that current medical reimbursement discourages surgeons from offering autologous reconstruction.

“Overall, our finding of substantial increases in breast reconstruction over time is good news for women with breast cancer and reflects positively on cancer care in the United States. However, we need to keep working to ensure that all women have access to quality breast cancer care,” Smith says.

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Breast cancer statistics: 235,030 Americans will be diagnosed with breast cancer this year and 40,430 will die from the disease, according to the American Cancer Society

Additional authors: Adeyiza O. Momoh, University of Michigan; Jing Jiang, Sharon H. Giordano, Thomas A. Buchholz, MD Anderson; Steven J. Kronowitz, Baylor College of Medicine; Amy Alderman, The Swan Center for Plastic Surgery

Funding: American Cancer Society grant MRSG-09-145-01-CPHPS; Cancer Prevention and Research Institute of Texas grant RP101207; Tracy Starr Breast Cancer Award

Disclosure: None

Trends and Variation in Use of Breast Reconstruction in Patients With Breast Cancer Undergoing Mastectomy in the United States: Journal of Clinical Oncology, doi: 10.1200/JCO.2013.52.2284, published online Feb. 18, 2014

University of Michigan Health System

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28 Feb. 2014.

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Tissue Fusion to commercialize laser surgical device developed at University of Colorado

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Tissue Fusion to commercialize laser surgical device developed at University of Colorado

Tissue Fusion and the University of Colorado recently completed a license agreement that will allow the company to continue developing a new surgical device that utilizes lasers, rather than staples and sutures, to close wounds during nasal surgery.

The two most common nasal surgeries are septoplasty (repair of deviated or deformed septum, thousands performed each year) and rhinoplasty (“nose job,” over 150,000 performed each year). Currently, wounds are closed during these surgeries using staples, sutures or intranasal packing, all of which can be dangerous (needles can break, and bleeding can occur) as well as uncomfortable for the patient. After the procedure, techniques like stapling or suturing can cause infection, scarring or other side effects.

Lasers have been used for decades in place of scalpels to cut tissues in procedures like LASIK eye surgery. Lasers also have the ability to ‘weld’ tissue together, but have not been widely used in this capacity due to the complexity of the laser (different parameters for different tissues) and the exceptional surgical skill required to use them.

A team led by mechanical and aerospace engineer Michael Larson, also the El Pomar Endowed Chair of Engineering and Innovation at the University of Colorado Colorado Springs, has developed a laser-based device for closing wounds during nasal surgery that circumvents these technical hurdles. The device generates heat and pressure to fuse tissue membranes together, but is designed specifically for use in septoplasty and rhinoplasty, using pre-set parameters to make the device easy to use by a surgeon or a trained medical technician. In addition to making the surgical procedure faster and simpler, the fusion device also has the potential to shorten healing time and reduce side effects like swelling, scarring, and infection.

Tissue Fusion is currently gathering data on the efficacy and safety of the device in controlled trials. The company will use the results in seeking approval from the FDA for clinical use in procedures related to the ear, nose and throat. Ultimately, the company hopes to introduce additional surgery-specific devices; further research by Larson’s team shows that the technology holds promise for “spot welding” layers of tissue in a range of surgeries, including microsurgical applications. “We’re pleased to be working in partnership with the University of Colorado to commercialize a new medical technology that is already adding jobs to the Colorado economy,” said Larson, who also serves as the company’s CEO.

“The technology licensed to Tissue Fusion has been a great example of Colorado’s innovation infrastructure, since it represents years of development efforts at MIND Studios in Colorado Springs, as well as a state grant to bring it closer to commercial readiness,” said Molly Markley of CU’s Technology Transfer Office. “We are looking forward to following the company’s progress as it moves towards FDA approval.” Tissue Fusion received a State of Colorado Early-Stage Company grant in 2013 under its Bioscience Discovery and Evaluation Grant program.

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University of Colorado. “Tissue Fusion to commercialize laser surgical device developed at University of Colorado.” Medical News Today. MediLexicon, Intl., 21 Feb. 2014. Web.
28 Feb. 2014.

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University of Colorado. (2014, February 21). “Tissue Fusion to commercialize laser surgical device developed at University of Colorado.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/272962.

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Body contouring after bariatric surgery helps obese patients keep the weight off

Patients who have plastic surgery to reshape their bodies after bariatric procedures are able to maintain “significantly greater” weight loss than those who do not have surgery, according to a new study by Henry Ford Hospital researchers.

“As plastic and reconstructive surgeons, we are encouraged by the idea that improved body image can translate into better long-term maintenance of a healthier weight, and possibly a better quality of life for our patients,” says Donna Tepper, M.D., a Henry Ford plastic surgeon and senior author of the study.

Study results will be presented Oct. 11 at the annual conference of the American Society of Plastic Surgeons in Chicago.

Used to help obese patients lose weight, bariatric surgery includes several types of procedures that limit the amount of food the stomach can hold, including removal of a portion of the stomach or constricting it with a gastric band. Such weight loss can be significant, and result in a lower risk of diabetes and heart disease.

“Bariatric surgery has a measurably significant positive impact on patient illness and death,” Dr. Tepper says. “However, even with the technical and safety advancements we’ve seen in these procedures, their long-term success may still be limited by recidivism.

“There is a high incidence of patients who regain weight after the surgery.”

The new study followed 94 patients who underwent bariatric surgery at Henry Ford from 2003 through 2013.

Of those, 47 subsequently had body recontouring procedures.

Some previously obese patients opt for plastic surgery – such as face or breast lift, so-called “tummy tuck” or lifts of sagging upper arms, thighs or buttocks – to remove inelastic excess skin and tissue after substantial weight loss and to reshape or recontour their bodies.

The Henry Ford researchers recorded each patient’s Body Mass Index, or BMI – a weight-to-height ratio used to determine degrees of obesity – both before their bariatric surgery and 2.5 years after the procedure.

“Of the patients who underwent contouring surgery, the average decrease in BMI was 18.24 at 2.5 years, compared to a statistically significant 12.45 at 2.5 years for those who did not have further surgery,” Dr. Tepper explains.

While these findings suggest that aesthetic procedures following bariatric surgeries may contribute to improving their long-term results, Dr. Tepper says future studies will look at changes in BMI after five years, as well as how different types of contouring procedures may maintain weight loss.

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Stem cells from fat tissue show promise in reconstructive surgeries for face and skull

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Stem cells from fat tissue show promise in reconstructive surgeries for face and skull

A new study released in Stem Cells Translational Medicine shows that many patients with defects to the skull, face or jaw bone might benefit from reconstructive surgery combining stem cells taken from adipose (fat) tissue seeded on resorbable scaffolds.

These defects can be due to congenital malformations, such as cleft lip and palate, or to traumatic injuries or surgery to remove a tumor. The use of a patient’s own bone is still considered the gold standard for reconstructing these defects, but this requires yet another surgery to harvest the bone for the reconstructive procedure. The Stem Cells Translational Medicine study tracked the case of 13 patients undergoing regenerative medicine procedures.

“To our knowledge, this study represents the first GMP-compliant application for autologous adipose-derived stem cells in the treatment of defects at various sites of the cranio-maxillofacial skeleton,” said the study’s lead investigator, George K. Sándor, M.D., DDS, Ph.D., of the University of Tampere (UT), Tampere, Finland. He and Susanna Miettinen, Ph.D., were lead investigators on the study conducted by scientists and clinicians who, in addition to UT, came from the University of Oulu (Oulu, Finland) and Central Hospital (Jyväskylä, Finland).

Isolated reports of hard tissue (bone) reconstruction in the skull, face or jaw (cranio-maxillofacial skeleton) exist, but multi-patient case series are lacking. This study aimed to review the experience of 13 people with hard tissue defects at four anatomically different sites: the frontal sinus (three cases), cranial bone (five cases), the jaw (three cases) and the nasal septum (two cases).

Stem cells were harvested from adipose tissue in each patient’s abdomen, treated in the lab and then seeded onto resorbable scaffold materials for implantation back into the patient. The scaffolds were constructed with either bioactive glass or ß-TCP (a bone graft substitute). In some cases a protein called rhBMP-2, which plays an important role in the development of bone and cartilage, was added, too.

The results were promising. All three of the frontal sinus cases and three of the five cranial defect cases were successfully treated. (The other two cranial cases in which non-rigid resorbable containment meshes were used sustained bone resorption to the point that they required a redo procedure.) One of the two septal perforations failed after a year due to an infection resulting from the patient’s own actions, but the other healed successfully.

The three patients with reconstructed jaw defects also had good results; in fact, two of them chose to have dental implants placed directly into the stem cell-seeded grafts after healing, allowing these patients to once again enjoy a normal diet.

While the resorption of some of the constructs in the cranial defects was more than expected, “Nevertheless,” Dr. Sándor said, “the majority of these challenging defects – 10 of 13 – were successfully treated with integration of the stem cell-seeded constructs to the surrounding skeleton at the defect sites.” Dr. Miettinen added that the next steps should involve more animal studies and tracking of long-term results in humans.

“This case series, involving various sites of defect, illustrates the potential promise of engineering replacement bone in the lab to avoid harvesting bone from the patient,” commented Anthony Atala, M.D., editor of Stem Cells Translational Medicine and director of the Wake Forest Institute for Regenerative Medicine.

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Adipose stem cells used to reconstruct 13 cases with cranio-maxillofacial hard-tissue defects, Authors: George K. Sándor, Jura Numminen, Jan Wolff, Tuomo Thesleff, Aimo Miettinen, Veikko J. Tuovinen, Bettina Mannerström, Mimmi Patrikoski, Riitta Seppänen, Susanna Miettinen, Markus Rautiainen and Juha Öhman, Stem Cells Trans Med February (2014) doi: 10.5966/sctm.2013-0173

STEM CELLS Translational Medicine

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STEM CELLS Translational Medicine. “Stem cells from fat tissue show promise in reconstructive surgeries for face and skull.” Medical News Today. MediLexicon, Intl., 24 Feb. 2014. Web.
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STEM CELLS Translational Medicine. (2014, February 24). “Stem cells from fat tissue show promise in reconstructive surgeries for face and skull.” Medical News Today. Retrieved from
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Type of breast cancer surgery women undergo influenced by surgeons and health care settings

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Type of breast cancer surgery women undergo influenced by surgeons and health care settings

Breast cancer is one of the few major illnesses for which physicians may not recommend a specific treatment option. North American women are more likely to opt for precautionary breast surgery when physicians don’t specifically counsel against it, according to a new study.

The research, presented at the American Society of Breast Surgeons Annual Meeting in Las Vegas, also demonstrates how clarity during consultations and the capability of clinical facilities also play important roles influencing a woman’s breast cancer treatment choices.

There is more than one type of preventative breast surgery but this study looked only at cases where cancer has been diagnosed in only one breast. This form prophylactic breast surgery, called a contralateral prophylactic mastectomy, entails removing the healthy breast at the same time as the cancerous breast. The procedure can reduce the risk of breast cancer recurrence in women who have a strong family history of breast or ovarian cancers and in women who have a genetic mutation that makes breast cancer more likely.

“While effective for such groups,” explained Dr. Andrea Covelli, lead author and a University of Toronto general surgery resident whose research work was supervised by Dr. Nancy Baxter of St. Michael’s Hospital. “The number of prophylactic mastectomies across North America has risen among women without these underlying conditions – among women who have only an average risk of developing cancer in their non-cancerous breast.”

Previous national studies have shown that instances of prophylactic breast surgery among early-stage, average risk women have increased nearly twelvefold in the United States over the last decade. In Canada, rates increased by 140 per cent between 2008 and 2010.

Dr. Covelli interviewed 45 surgeons in North America to identify factors that determine the course of treatment.

In the United States, some states legislate that surgeons present all treatment options to patients. The research found that surgeons complied in the 20 states with such legislation but generally surgeons did not recommend one procedure over another. Instead, they encouraged patient choice. Canadian surgeons discussed similar surgical options with their patients. However, they more often specifically recommended breast-conserving surgery and counseled against prophylactic mastectomies.

“We learned that surgeon’s recommendations and detailed consultations influenced women’s decisions for breast cancer treatment,” said Dr. Covelli. “Consultations were especially important when it came to MRI findings. When MRI results were presented without detailed explanations, women were more likely to opt for prophylactic mastectomies.”

MRI exams have a high rate of false-positive results so patients who were given their exam results without detailed explanations were often concerned about new disease in addition to the recently diagnosed tumour.

Findings show that MRI exams were ordered less frequently in Canada than in the United States. It also showed that Canada’s surgeons often had more opportunity to discuss potential for inaccuracies with patients.

If women were being treated at health care facilities with access to immediate reconstruction, they were also more likely to choose prophylactic surgery.

“The availability of immediate breast reconstruction was another main factor in patients’ decisions,” said Dr. Covelli.

Immediate reconstruction was associated with the choice of prophylactic mastectomy and is more widely available in the United States than in Canada. In both countries, many patients requested a prophylactic mastectomy after returning from a consult with a reconstructive surgeon.

“We need to look at what happens during that consult to better understand patient decision-making,” said Dr. Covelli. “Patients should ask for their doctor’s opinion if helpful to them. Most surgeons have years of experience treating breast cancer and can provide valuable counsel and advice.”

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Hospital, St. Michael’s. “Type of breast cancer surgery women undergo influenced by surgeons and health care settings.” Medical News Today. MediLexicon, Intl., 3 May. 2014. Web.
13 Jun. 2014.

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Hospital, S. (2014, May 3). “Type of breast cancer surgery women undergo influenced by surgeons and health care settings.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/276215.

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Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin

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Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin

Skin laxity and fat buildup under the chin is a common concern among facial aesthetic patients. Although surgery has long been the mainstay for reducing fat in this area, which is also known as the submental region, new research being presented at the Annual Meeting of the American Society for Aesthetic Plastic Surgery (ASAPS) being held April 24 – 29, 2014 in San Francisco, CA, shows the potential of a novel injectable drug for submental fat reduction. Steven H. Dayan, MD who practices in Chicago, IL, will present the latest data from clinical trials of a new, investigational injectable drug, ATX-101, during “ATX-101, A Submental Contouring Injectable Drug for the Reduction of Submental Fat” on Saturday, April 26th.

“An unfavorable profile can make people look older and heavier, negatively affect self-esteem, and cannot usually be significantly altered by diet or exercise,” said Dr. Dayan. “We are excited to present trial results on this potential first-in-class submental contouring injectable, which, if approved, could offer physicians and their patients a non-surgical option to eliminate fat under the chin, resulting in a thinner and more contoured profile and jawline.”

Dr. Dayan is presenting the first disclosure of a pooled analysis of two positive ATX-101 Phase III trials (REFINE-1 and REFINE-2) evaluating the reduction of submental fat. Results of the pooled analysis, conducted by KYTHERA Biopharmaceuticals, found that:

68.2 percent of ATX-101 (2 mg/cm2) subjects demonstrated a simultaneous improvement of at least one grade from baseline on clinician and patient reported rating scales vs. 20.5 percent in placebo (p<0.001). After two treatments, 52.2 percent of subjects achieved at least a one grade change from baseline in the clinician submental fat ratings, and 71.5 percent after four treatments. Response to ATX-101 was consistent across demographic and baseline subgroups with approximately 80 percent of subjects treated with ATX-101 demonstrating at least a one grade improvement in the clinician submental fat ratings regardless of age, gender, race, BMI, Fitzpatrick Skin Type and baseline severity. ?? Those treated with ATX-101 reported significant improvement in the visual and emotional impact of chin fat, including appearing thinner and more youthful, compared with those treated with placebo (p<0.001).

“Eliminating fat in the submental region not only plays a critical role in helping restore overall facial balance and harmony, but can also lead to vast improvements in self-perception as well as the first impression projected,” said Dr. Dayan. “We are looking forward to sharing our findings, which show how a noninvasive injection might offer patients the treatment option they’ve been desiring.” The pooled analysis also found that 80.9 percent of ATX-101 treatment-emergent adverse events were mild and 1.4 percent of ATX-101 subjects discontinued the studies due to adverse events. The most common adverse events observed in the clinical trials included temporary injection site events of pain, swelling, bruising and numbness. The incidence and severity of pain and swelling declined after the first treatment session.

ATX-101 is a proprietary formulation of a purified synthetic version of a naturally occurring molecule (deoxycholic acid) that aids in the breakdown of dietary fat. It is currently in late stage clinical trials for the reduction of submental fat, which commonly presents as a double chin. When injected into subcutaneous fat, ATX-101 contours the area under the chin by destroying fat cells while leaving surrounding tissue largely unaffected. It has been evaluated in double-blind, randomized, placebo- controlled clinical trials being conducted in the US and Canada with over 2,500 participants who have moderate-to-severe submental fat. Detailed data from a pooled analysis will be revealed during Saturday’s presentation.

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ATX-101, A Submental Contouring Injectable Drug for the Reduction of Submental Fat: A Pooled Analysis of Two Pivotal Phase 3 (REFINE-1 and REFINE-2) Multicenter, Double-Blind, Randomized, Placebo-Controlled Trials, Steven H. Dayan, MD, Derek H. Jones, MD, Jean Carruthers, MD, FRCS(c), Shannon Humphrey, MD, Fredric S. Brandt, MD, Patricia Walker, MD, PhD, Daniel Lee, MS, Paul F. Lizzul, MD, PhD, Frederick C. Beddingfield III, MD, PhD

The American Society for Aesthetic Plastic Surgery (ASAPS)

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The American Society for Aesthetic Plastic Surgery. “Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin.” Medical News Today. MediLexicon, Intl., 30 Apr. 2014. Web.
13 Jun. 2014.

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The American Society for Aesthetic Plastic Surgery. (2014, April 30). “Injectable drug offers promises as a nonsurgical alterntative to reducing fat under the chin.” Medical News Today. Retrieved from
http://www.medicalnewstoday.com/releases/276078.

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Skill development in robotic microsurgery assessed by new tool

A new standardized assessment provides a useful tool for tracking surgeons’ progress as they develop the skills needed to perform robot-assisted microsurgery, reports a study in the October issue of Plastic and Reconstructive Surgery®, the official medical journal of the American Society of Plastic Surgeons (ASPS).

“The Structured Assessment of Robotic Microsurgical Skills (SARMS) is the first validated instrument for assessing robotic microsurgical skills,” according to the report by ASPS Member Surgeon Dr Jesse C. Selber of the University of Texas MD Anderson Cancer Center, Houston. Initial assessments using the SARMS show that, after a steep initial learning curve, surgical trainees display steady improvement in their ability to perform robot-assisted microsurgery tasks.

SARMS Tracks Development of Robotic Microsurgery Skills

The researchers describe the development and testing of the SARMS as a standard technique for evaluating technical skills for robot-assisted microsurgery. The SARMS consisted of 11 items – six evaluating microsurgery skills and five evaluating robotic skills.

After the SARMS was validated, expert surgeons used it to grade videos of surgical trainees performing robot-assisted microvascular anastomoses – joining and suturing tiny artificial blood vessels, just three millimeters in diameter. Each of nine trainees was graded on five videos, made as they gained experience with the robotic surgical system. Changes in scores in each area were assessed, along with the time required to complete the procedure.

The SARMS scores documented general improvement in microsurgical skills with each practice session. On a five-point scale – from “novice” to “expert” – the trainees’ average ratings of overall skill and performance increased from around two to around four.

“The results showed an initial steep ascent in technical skill acquisition, followed by more gradual improvement,” Dr Selber and coauthors write. Across the five sessions, average operative time decreased gradually, from about 30 to 19 minutes.

Previous experience performing conventional microsurgery – under the operating microscope, but without robotic assistance – was the main factor affecting the trainees’ skill level. The SARMS items showed good to excellent consistency among the different expert raters.

Tool Will Aid Training in Robot-Assisted Plastic Surgery

Surgical robots have emerged as a potentially valuable tool in many surgical disciplines, including plastic and reconstructive surgery. By eliminating tremor of the surgeon’s hand and scaling hand motion, surgical robots are capable of “superhuman precision” – expanding the ability to perform delicate microvascular manipulations that would be all but impossible with the unaided human hand.

The SARMS score developed and evaluated in this study provides a new, standardized tool for evaluating trainees’ skill and performance as they gain experience with robotic microvascular surgery. The results suggest that surgical trainees can expect a tough going at first, but show gradual improvement in skills and shorter procedure times over as little as five practice sessions.

“Standardized evaluation and systematic learning of both robotic and conventional surgical techniques is necessary, and is the foundation of competency-based training, which itself is the future of surgical education,” Dr Selber and coauthors conclude. Dr Selber will give a special “Tech Talk” on the topic of Robotics at “Plastic Surgery – The Meeting,” the annual scientific meeting of the ASPS, to be held October 10-14, 2015 in Chicago, Ill.

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Reorganization of blood vessels after face transplantation surgery

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Reorganization of blood vessels after face transplantation surgery

For the first time, researchers have found that the blood vessels in face transplant recipients reorganize themselves, leading to an understanding of the biologic changes that happen after full face transplantation. The results of this study were presented at the annual meeting of the Radiological Society of North America (RSNA).

Face transplantation is a recent development in reconstructive surgery for patients who have lost some or all of their face from injury or disease. The first full face transplantation in the United States was carried out at Brigham and Women’s Hospital in Boston in 2011. Hospital specialists subsequently performed full face transplantations on three additional patients.

As part of the procedure, surgeons connect the patient’s major arteries and veins to those from a donor face, or facial allograft, to ensure healthy circulation in the transplanted tissue. Because the technology is new, not much is known about the vascular changes that help blood penetrate, or perfuse, into the transplanted tissue. The development of new blood vessel networks in transplanted tissue is critical to the success of face transplant surgery.

“All three patients included in this study at Brigham and Women’s maintain excellent perfusion, or blood flow, the key element of viability of the facial tissues and the restoration of form and function to those individuals who otherwise had no face,” said study co-author Frank J. Rybicki, M.D., Ph.D., FAHA, FACR, director of the hospital’s Applied Imaging Science Laboratory. “We assumed that the arterial blood supply and venous blood return was simply from the connections of the arteries and the veins at the time of the surgery.”

To learn more, Dr. Rybicki and Kanako K. Kumamaru, M.D., Ph.D., research fellow at Brigham and Women’s Applied Imaging Science Laboratory, used 320-detector row dynamic computed tomography angiography (CTA) to study the facial allografts of the three patients one year after successful transplantation. The CTA technology offers imaging over 16 centimeters of coverage, enabling the researchers to view collateralization, a process in which the body stimulates existing blood vessels to elongate, widen and form new connections. Collateralization often results from anastomoses, or branches formed between adjacent blood vessels.

CT angiography after face transplantation
CT angiography after face transplantation. The donor’s external carotid artery (pink) was successfully anastomosed to the recipient’s vessel (rectangular area). Branches distal to the ligation (white line) receive blood flow from collateral vessels (arrows).
Credit: Radiological Society of North America

“The key finding of this study is that, after full face transplantation, there is a consistent, extensive vascular reorganization that works in concert with the larger vessels that are connected at the time of surgery,” Dr. Kumamaru said.

Results showed that the new blood vessel networks course posteriorly, or toward the ears and even farther behind the head, in addition to the large arteries and veins that course anteriorly in the face, or close to the jaw.

“We have found that since the vessels more commonly associated with the back of the head are critical to maintain the perfusion via vascular reorganization, it is essential to visualize these vessels and determine that they are normal pre-operatively,” Dr. Kumamaru said. “Patients under consideration for face transplantation have universally had some catastrophic defect or injury.”

The authors note that the findings could help improve surgical planning and assessment of potential complications in face transplant patients. For instance, previous literature recommends the joining of multiple arteries and veins to ensure adequate blood flow in the facial allograft. However, performing these multiple connections causes longer operation time compared with a single anastomosis.

“Our findings support the simplified anastomosis for full face transplant procedure that, in turn, can potentially shorten the operative time and reduce procedure-associated complications,” Dr. Rybicki said.

CT angiography CT angiography before (left image) and after (right image) face transplantation. The donor’s facial artery (yellow) was successfully anastomosed or reconnected to the recipient’s vessel.
Credit: Radiological Society of North America These tabs require JavaScript to be enabled.

Co-authors are Elizabeth George, M.B.B.S., Bohdan Pomahac, M.D., Michael L. Steigner, M.D., Geoffroy C. Sisk, M.D., Kurt Schultz, R.T., Dimitris Mitsouras, Ph.D., David S. Enterline, M.D., and Ericka M. Bueno, Ph.D.

Radiological Society of North America

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Radiological Society of North America. “Reorganization of blood vessels after face transplantation surgery.” Medical News Today. MediLexicon, Intl., 5 Dec. 2013. Web.
15 Feb. 2014.

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