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Mechanisms of Action of External Volume Expansion Devices

Lancerotto, Luca M.D.; Chin, Michael S. M.D.; Freniere, Brian M.D.; Lujan-Hernandez, Jorge R. M.D.; Li, Qiong M.D.; Vasquez, Alessandro Valderrama M.S.; Bassetto, Franco M.D.; Del Vecchio, Daniel A. M.D.; Lalikos, Janice F. M.D.; Orgill, Dennis P. M.D., Ph.D.

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Plastic and Reconstructive Surgery: March 2014 - Volume 133 - Issue 3 - p 426e-428e
doi: 10.1097/01.prs.0000438468.21464.ea
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Sir:

We would like to thank Dr. Swanson for his review of our article.1 We would also like to thank Dr. Geoffrey Gurtner for his thoughtful video review of our article, which nicely summarizes what this article shows as well as its limitations (http://journals.lww.com/plasreconsurg/pages/videogallery.aspx?videoId=387&autoPlay=true).

Several years ago, when we began to see excellent results from fat grafting by Drs. Coleman and Rigotti and later when Drs. Khouri and Del Vecchio extended these results using external volume expansion, we wondered about the mechanism of action of this system. Many have focused on important details of the process, such as cannulas, the amount of suction used, and the degree of centrifugation required. Others have studied the effect of enriching grafts with adipose-derived stem cells. Our laboratory has looked extensively at the effect of mechanical forces on soft tissues.2–4 We wondered (Del Vecchio and Orgill) if we could use the science background of our laboratory combined with the emerging clinical data. We planned out a series of basic science and clinical projects to answer questions about external volume expansion. We applied for several grants, mostly getting negative responses, and self-funded the early experiments. A breakthrough came when Yvonne Heit, a plastic surgery resident from Heidelberg, successfully designed an external volume expansion system in a mouse model.5 We now have a series of both clinical6,7 and basic science articles1,5 that have been published or are in the process of being published. Along the way, we have met with many thoughtful surgeons and scientists around the world who share our passion for better understanding fat grafting and external volume expansion. Among those are Drs. Lalikos, Chin, and Freniere, of the University of Massachusetts, who have helped us understand the skin perfusion issues better. Prof. Franco Bassetto, from Padova, Italy, also interested in mechanobiology, has helped us with immunostaining and shares with us his plastic surgery residents and students (Lancerotto and Valderrama Vasquez). We were fortunate to have excellent collaboration from three well-known academic laboratories combined with a surgeon in private practice. We would like to make a few points.

First, this is an early mouse study, which gives us a substantial amount of information and has led us to perform additional studies that are underway. We also hope to obtain more human data for confirmation, but this is obviously more challenging.

Second, external volume expansion differs significantly from the classical wound healing experiments: there is no wound. Although there are some similarities with wound healing, we believe that our experimental model is sufficiently different from wound healing and that the classical wound healing sequence likely does not apply.

Third, external volume expansion differs also from traditional “bi-dimensional” tissue expansion, in that the forces applied to the skin on a microlevel are completely different. Therefore, many observations made with conventional tissue expansion are unlikely to translate into external volume expansion. One example would be the tremendous amount of edema generated in external volume expansion compared with conventional tissue expansion.

Dr. Swanson raises the issue of improving clinical data in plastic surgery. We agree that, as a field, we will need to do much better at reporting clinical data in the future.8 We also recognize the challenges of doing prospective randomized clinical trials in surgery which have been reviewed elsewhere.9,10 We disagree with the inference that somehow this study was influenced by industry. Our external volume expansion studies were spontaneous and self-funded, not connected with producers of clinical external volume expansion devices. However, industry is essential in moving an idea from the laboratory to a useful device in the clinic. Industry often provides critical basic science support to move ideas forward, and collaboration with surgeons is essential in optimizing these devices for our patients. We firmly believe that a better understanding of mechanisms to enhance fat grafting techniques has the potential to revolutionize plastic surgery. We are encouraged by the large number of investigators around the world who are doing both basic science and clinical studies to further advance this field. We look forward to being a constructive part of this evolution in care.

DISCLOSURE

Dr. Orgill has been an expert witness, consultant, and grant recipient of funding provided by Kinetic Concepts, Inc., the manufacturer of vacuum devices used in experimental studies to which this communication is related. The other authors have no financial interest to declare.

Luca Lancerotto, M.D.

Tissue Engineering and Wound Healing Laboratory

Division of Plastic Surgery

Brigham and Women’s Hospital and Harvard Medical School

Boston, Mass.

Institute of Plastic Reconstructive and Aesthetic Surgery

University of Padova

Padova, Italy

Michael S. Chin, M.D.

Brian Freniere, M.D.

Division of Plastic Surgery

University of Massachusetts Medical School

Worcester, Mass.

Jorge R. Lujan-Hernandez, M.D.

Qiong Li, M.D.

Alessandro Valderrama Vasquez, M.S.

Tissue Engineering and Wound Healing Laboratory

Division of Plastic Surgery

Brigham and Women’s Hospital and Harvard Medical School

Boston, Mass.

Franco Bassetto, M.D.

Institute of Plastic Reconstructive and Aesthetic Surgery

University of Padova

Padova, Italy

Daniel A. Del Vecchio, M.D.

Back Bay Plastic Surgery

Boston, Mass.

Janice F. Lalikos, M.D.

Division of Plastic Surgery

University of Massachusetts Medical School

Worcester, Mass.

Dennis P. Orgill, M.D., Ph.D.

Tissue Engineering and Wound Healing Laboratory

Division of Plastic Surgery

Brigham and Women’s Hospital and Harvard Medical School

Boston, Mass.

REFERENCES

1. Lancerotto L, Chin MS, Freniere B, et al. Mechanisms of action of external volume expansion devices. Plast Reconstr Surg. 2013;132:569–578
2. Pietramaggiori G, Liu P, Scherer SS, et al. Tensile forces stimulate vascular remodeling and epidermal cell proliferation in living skin. Ann Surg. 2007;246:896–902
3. Chin MS, Ogawa R, Lancerotto L, et al. In vivo acceleration of skin growth using a servo-controlled stretching device. Tissue Eng Part C Methods. 2010;16:397–405
4. Chin MS, Lancerotto L, Helm DL, et al. Analysis of neuropeptides in stretched skin. Plast Reconstr Surg. 2009;124:102–113
5. Heit YI, Lancerotto L, Mesteri I, et al. External volume expansion increases subcutaneous thickness, cell proliferation, and vascular remodeling in a murine model. Plast Reconstr Surg. 2012;130:541–547
6. Del Vecchio D. Breast reconstruction for breast asymmetry using recipient site pre-expansion and autologous fat grafting: A case report. Ann Plast Surg. 2009;62:523–527
7. Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion and autologous fat transplantation: A clinical radiographic study. Plast Reconstr Surg. 2011;127:2441–2450
8. Agha RA, Camm CF, Edison E, Orgill DP. The methodological quality of randomized controlled trials in plastic surgery needs improvement: A systematic review. J Plast Reconstr Aesthet Surg. 2013;66:447–452
9. McCarthy CM. Randomized controlled trials. Plast Reconstr Surg. 2011;127:1707–1712
10. Pitak-Arnnop P, Hemprich A, Pausch NC. Evidence-based oral and maxillofacial surgery: Some pitfalls and limitations. J Oral Maxillofac Surg. 2011;69:252–257

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