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Gigantomastia is a debilitating condition characterised by an excessive breast tissue growth impacting patients' quality of life. Surgically treatment options include the limited-length pedicle (LP) technique with free nipple grafting (FNG) and the elongated pedicle (EP) technique, which maintains continuity of the nipple-areola complex (NAC). Initially, despite the less satisfactory aesthetic outcome, FNG was preferred to treat hypertrophic breasts requiring resections over 1000 g of parenchymal and adipose tissue, due to concerns about NAC perfusion. Recently, many studies have questioned this indication. The aim of this study was therefore to evaluate the safety of the NAC-carrying EP technique in patients with gigantomastia eventually challenging the need for FNG. A literature search using PubMed and Cochrane databases was performed, including studies describing the outcome of EP technique for resection exceeding 1000 g of breast tissue. Thereby, a meta-analysis was conducted to evaluate the rate of NAC necrosis, whereas a descriptive statistic was applied to assess all other surgery-associated complications. Twenty-five studies, encompassing 1355 patients (2656 breasts), were included. EP demonstrated an extremely low rate of NAC necrosis. Moreover, the analysis demonstrated a low rate of ischaemia-independent complications and a very high probability of maintaining NAC-sensation equal to the preoperative state. Current evidence indicates that the EP technique should be the preferred surgical method to treat gigantomastia with or without massive ptosis whenever indicated. It has proven to be safe. Furthermore, it yields superior aesthetic and functional outcomes, including breast feeding and preservation of NAC-sensation compared to the LP technique. [ABSTRACT FROM AUTHOR]

Pyoderma gangrenosum (PG) is a rare inflammatory neutrophilic dermatosis that can develop at a surgical site. Diagnosis can be challenging at its presentation causing delays in appropriate treatment. The aim of this study is to review the current literature as well as to describe the clinical presentation, diagnostic pathway, and treatment of PG after reduction mammaplasty in order to define a standardized multidisciplinary diagnostic and therapeutic approach. In the future, this may ease early identification and prompt treatment, and eventually minimize severe morbidity and long-term sequelae. The entire PubMed/Medline database was screened following the PRISMA guidelines to identify studies describing PG that have occurred after reduction mammoplasty. Twenty-eight articles including 31 patients reported a PG after breast reduction surgery between January 1988 and March 2022. Twenty-one (68%) patients presented with skin ulcerations, 14 (45%) with erythema, and 5 (16%) with vesicles. Out of the 30 cases that underwent bilateral surgery, 18 (60%) developed PG bilaterally. In 12 out of 31 patients, nipple–areolar complex (NAC) involvement was evaluated, though in 10 patients (83%) the NAC was spared. Of the 20 patients (65%) who underwent skin biopsies for histopathological examination, 18 (90%) showed neutrophilic infiltration of the dermal layers. All 31 patients (100%) showed rapid clinical improvement after the introduction of immunosuppressive therapy. PG can result in devastating skin alterations also after reduction mammoplasty, if misdiagnosed. However, it presents with constant yet unspecific local and general signs and symptoms that can be recognized to early initiate an appropriate pharmacological treatment. [ABSTRACT FROM AUTHOR]

Background Surgical site complications (SSCs) pose a major post-operative challenge. Single-use negative pressure wound therapy (sNPWT) systems have been shown to be effective for reducing SSCs. An upgraded sN-PWT system (PICOTM 7) with improved functional performance and ease-of-use was assessed in a prospective, single-arm study. The study aimed to assess if the system was a safe and effective therapy for delivering consistent negative pressure. Methods Between November 2018 and May 2019, eligible patients across 11 sites with a closed abdominal or knee arthroplasty incision, skin graft or flap, were enrolled. Postoperatively, patients received sNPWT for up to 7 days with follow-up until 30 days. Endpoints included the ability to maintain a consistent negative pressure for the intended duration, complication rates, clinician and patient usability and satisfaction and serious adverse events. Results The device was capable of delivering consistent negative pressure across all assessed surgical wounds and was statistically equivalent to the reference negative pressure (-80.2 mmHg) (n=46; p=0.002). Low complication rates were observed within 30 days post-surgery. High levels of clinician usability (>90%) and patient satisfaction (95%) were reported. No serious device-related adverse events were reported. Conclusions The study demonstrated the functional performance, favourable safety profile and clinician- and patient-reported satisfaction of this upgraded PICO 7 sN-PWT device across multiple closed surgical wound types. Implications Application of an sNPWT system can lead to improved wound healing outcomes within closed surgical wounds while also demonstrating high levels of clinician and patient satisfaction. [ABSTRACT FROM AUTHOR]

Summary It has been shown that pre- and postconditioning of ischemically challenged tissue with erythropoietin (EPO) is able to reduce necrosis in a dose-dependent manner. The aim of this study was to determine the tissue-protective effects of different EPO dosages and administration regimes. Three groups of six C57Bl/6-mice each were analyzed: (1) pre- and postconditioning with initial high doses of EPO (starting at 2500 I.U./kg bw i.p.) followed by low doses of EPO (125 I.U./kg bw i.p.) (EPO-high-dose); (2) pre- and postconditioning with low doses of EPO (125 I.U./kg bw i.p.) (EPO-low-dose); and (3) untreated control group. Randomly perfused musculocutaneous flaps were mounted on dorsal skinfold chambers undergoing acute persistent ischemia and developing ∼50% necrosis without treatment. Intravital epifluorescence microscopy was performed at days 1, 3, 5, 7, and 10 after surgery, assessing flap necrosis, microcirculation, and angiogenesis. The hematocrit was measured at days 0, 3, 7, and 10. Only the EPO-low-dose regimen was associated with a significant reduction of necrosis when compared to untreated controls. EPO-low-dose showed a higher increase in both arteriolar diameter and velocity, thereby resulting in a significantly increased arteriolar blood flow and a hence higher functional capillary density (FCD) of the critically perfused zone. EPO-induced angiogenesis was significantly increased in EPO-low-dose at days 7 and 10. Only EPO-high-dose reached a significant hematocrit increase by day 10. Tissue pre- and postconditioning with low doses of EPO protects the critically perfused musculocutaneous tissue by maintaining capillary perfusion because of increased arteriolar blood flow mediated by nitric oxide (NO) expression. [ABSTRACT FROM AUTHOR]

Soft tissue tumors of the foot are rare, and the diagnosis is often difficult. Surgery is indicated if pain, discomfort, or functional impairment is present or to rule out malignancy. We present the case of a 14-year-old female with a painless swelling at the lateral aspect of her right foot. After radiologic imaging, including ultrasonography and magnetic resonance imaging (MRI), we performed a subtotal resection of the abductor digiti minimi muscle, preserving its motor nerve. Four months later, recurrence of the soft tissue mass was observed. MRI revealed hypertrophy of the small muscles of the foot, including the abductor digiti minimi, quadratus plantae, and flexor digiti minimi brevis. Functional impairment resulted in complete excision of the remnant abductor digiti minimi muscle and partial excision of the flexor digiti minimi brevis muscle another 7 months later. Twelve months after the secondary surgery, neither clinical nor radiologic signs of a second recurrence were found. At the last follow-up visit, the patient was satisfied with the contour of her foot and not hindered at all during sporting activities. Our findings demonstrate that subtotal resection of a bulky muscle, preserving its motor nerve, can result in reactive hypertrophy of the remnant muscle part. The patient must be informed that partial excision of an innervated muscle could result in reactive hypertrophy and must be contrasted with radical muscle excision that might be more likely to result in functional impairment. [ABSTRACT FROM AUTHOR]

Summary: Background: Fat grafting for primary breast augmentation is growing in popularity due to its autologous properties and its side benefit of removing unwanted fat from other areas, although volume gain is unpredictable and patient safety remains unclear. Objective: The aim of this study was to provide an evidence-based overview of autologous fat grafting to healthy breast tissue with focus on volume gain, safety and complications. Design: A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Data sources: The MEDLINE, Cochrane Library and EMBASE databases were searched for clinical studies on autologous fat grafting to healthy breast tissue within the last 30 years. Data extraction: Clinical articles were evaluated for indication, pre- and postoperative work-up, surgical technique, volume gain (efficacy), complications, radiographic changes and oncological safety. The level of evidence was assessed according to the Oxford Centre for Evidence-based Medicine 2011. Results: A total of 36 articles involving 1453 patients with a mean follow-up period of 16.3 months (1–156 months) were included. No randomised controlled studies were found. Six percent of the patients undergoing fat grafting to healthy breast tissue experienced major complications requiring a surgical intervention or hospitalisation. Two patients with breast cancer (0.1%) after fat grafting for cosmetic purposes were reported. Average breast volume gain ranged from 55% to 82% relative to the grafted fat volume. Conclusions: The prevalence of complications and re-operations in fat grafting to healthy breast tissue compared favourably to implant-based breast augmentation. Although no increased incidence of breast cancer was found, long-term breast cancer screening and the implementation of publicly accessible registries are critically important to proving the safety of fat grafting. [Copyright &y& Elsevier]

Summary: Background: Experimental data has shown an association with a reduction of flap necrosis after local heat-application to a supraphysiological level resulting from the up-regulation of heat shock proteins, such as HSP-32. The proteins maintained capillary perfusion and increased tissue tolerance to ischaemia. The purpose of this translational study was to evaluate the effect of local heat preconditioning before skin sparing mastectomy and immediate breast reconstruction. Methods: A prospective non-randomised trial was performed from July 2009–April 2010. 50 consecutive patients at risk of skin flap necrosis (BMI >30, sternal-to-nipple distance >26 cm or breast size >C-cup) were included. Twenty-five patients were asked to heat-precondition their breast 24-h prior to surgery using a hot water bottle with a water temperature of 43 °C (thermometers provided), in three 30-min cycles interrupted by spontaneous cooling to room temperature. Skin flap necrosis was defined by the need for surgical debridement. LDI images were taken pre- and post-mastectomy to demonstrate an increase in tissue vascularity. Results: 36% of women (n = 25) without local heat-treatment developed skin flap necrosis, 12% developed skin flap necrosis in the treatment group, resulting in a 24% difference (n = 25; p = 0.047 (95%CI 1%–47%)). LDI scanning of the heated breast demonstrated an increase in vascularity compared to the contralateral non-heated breast. Median length of inpatient stay for treatment group was 4 days (95%CI(4, 7)), controls 8 days (95%CI(8, 9) (p = <0.001)). Conclusions: The data suggests that in selected cases, local heat preconditioning is a simple and non-invasive method of reducing skin necrosis and length of hospital stay following skin sparing mastectomy. Clinical Trial Registration Number: ACTRN12612001197820. Level of evidence: II. [Copyright &y& Elsevier]

Summary: Breast hypertrophy, combined with massive ptosis with a suprasternal notch-to-nipple distance of more than 40cm, remains an endeavour. Different refinements of the initial technique with free nipple grafts have been described to circumvent the problems of nipple underprojection, areolar hypopigmentation and loss of sensibility secondary to nipple grafting, as well as lacking breast projection due to scarce glandular tissue. Techniques relying on nipple areola complex transposition, rather than grafting, have been described with inferior, superomedial and medial pedicles. The aim of this study is to present the results obtained in a series of 10 patients suffering from bilateral breast hypertrophy with massive ptosis, which was defined as a distance >40cm from the suprasternal notch-to the nipple. All breasts were managed with a superior pedicle and inverted T technique. The mean preoperative suprasternal notch-to-nipple distance was 44±2cm, and the resection weight ranged from 800 to 2490g per breast with an average of about 1450g in this patient population presenting with overweight or obesity. With a mean nipple areola complex (NAC) lift of 20±3cm, neither nipple nor areola necrosis was observed. One partial epidermolysis of the areola and two cases of delayed wound healing at the trifurcation point of the inverted T were conservatively managed. Only one re-operation was necessary for an important wound dehiscence of the lateral part of the horizontal scar. These results underscore the safety of the superior pedicle technique in cases of massive ptosis with transposition of the NAC of approximately 20cm, that is, a pedicle length of about 25cm. [ABSTRACT FROM AUTHOR]

Summary: Introduction: In plastic and reconstructive surgery, self-activating hydrogel expanders are used to augment soft-tissue space. The purpose of this study was to investigate the morphological response of underlying bone to the constant pressure exerted by a hydrogel expander. Methods: Eighteen Lewis rats were randomly divided into three groups. In group 1, a hydrogel expander was placed subperiosteally directly onto the calvaria of the rats. In group 2, the expander and the underlying bone were separated by a polydioxanone (PDS) foil. Group 3 animals served as controls. Before and 14 days after the insertion of the expanders, micro-computed tomography (CT) images were obtained and fused. We analysed hydroxyapatite density beneath and at the periphery of the expander and performed a histomorphometric bone analysis. Results: Whereas there were no significant differences (p <0.05) (groups 1 and 2) in bone density at the periphery of the expanders between the study groups, a significant decrease in hydroxyapatite density beneath the expanders was observed in those animals in which the devices were placed directly onto the calvaria (group 1). Whereas bone thickness was unaffected at the periphery of the expanders in all groups, it was significantly decreased beneath the expanders in all implanted animals. A morphological examination revealed resorption lacunae with a diameter of 218.4±56μm in those rats in which the expanders had been placed directly onto the calvaria. Conclusion: This study shows the direct influence of hydrogel expanders on underlying bone. Whereas bone resorption and connective tissue formation also occur underneath hydrogel expanders, these effects can be avoided if the expander and the underlying bone are separated by PDS foil. The key to success is to ensure the appropriate placement of expanders and thus to avoid bone resorption. [Copyright &y& Elsevier]

Background: Erythropoietin (Epo), the primary regulator of erythropoiesis, has recently been shown to exert antiinflammatory and antiapoptotic properties in neuronal and myocardial tissue. We herein studied whether Epo pretreatment can reduce cell death and ischemic necrosis in a chronic in vivo model. Methods: C57BL/6 mice were treated daily for 3 consecutive days with either 500 IU EPO/kg body weight (bw) (group Epo 500, n = 8) or 5000 IU EPO/kg bw (group Epo 5000, n = 8) administered intraperitoneally 24 hours before surgery. Thereafter, a random pattern myocutaneous flap subjected to acute persistent ischemia was elevated and fixed into a dorsal skinfold chamber. Flap elevation in animals receiving the water-soluble vitamin E analog Trolox (6-hydroxy-2, 5, 7, 8-tetramethylchroman-2-carboxylic acid) served as a nonspecific antiinflammatory agent control group (Tro); untreated control animals (Con) received saline only. Capillary perfusion, leukocyte-endothelial cell interaction, apoptotic cell death, and tissue necrosis were determined over a 10-day observation period using intravital multifluorescence microscopy. Results: Epo 5000 (44 ± 26 cm/cm2) but, more noticeably, Epo 500 (116 ± 32 cm/cm2) improved capillary perfusion compared with the two control groups, particularly the Con group (9 ± 7 cm/cm2; P < .05). The ischemia-associated leukocytic inflammation was found drastically attenuated in both Epo-pretreatment groups. Epo 500 further decreased apoptotic cell death and was effective in significantly reducing tissue necrosis (16% ± 4% vs Tro: 48% ± 7% and Con: 52% ± 4%; P < .001). No angiogenic blood vessel formation could be observed in either of the Epo groups. Of interest, Epo 5000—but not Epo 500—increased systemic hematocrit. Conclusion: Despite the lack of neovascularization, Epo pretreatment was capable of reducing ischemic tissue necrosis by protecting capillary perfusion, ie, nutrition of the tissue. Low-dose pretreatment was more effective, a result that was most likely due to the better perfusion conditions without an increase of the hematocrit values. Thus, low-dose Epo pretreatment might represent a promising strategy to protect critically perfused ischemic tissue. [Copyright &y& Elsevier]

Summary: Complications and failures after microvascular free tissue transfer for lower extremity reconstruction have a negative impact on postoperative course and final outcome. Therefore, a 10-year analysis on lower extremity reconstruction with free flaps was performed with a special emphasis on patient co-morbidities such as cardiovascular diseases, diabetes mellitus, body mass index and history of smoking, in order to identify potential risk factors. Complications such as haematoma, seroma, infection, wound dehiscence, as well as partial flap loss, postoperative thrombosis of the anastomosis and eventual total flap loss were gathered from the medical records. Limb salvage was 100%, however 40% suffered from complications ranging from minor wound dehiscence to total flap loss. None of the above-mentioned potential risk factors was associated with an increased rate of complications. However, in flaps that required revision for thrombosis, the age of the patients was significantly higher in the group of flaps that eventually failed when compared to flaps that were salvaged. In conclusion, lower extremity reconstruction with microvascular free tissue transfer is a safe and reliable procedure with a high success rate, however partial flap loss remains an important issue. Increased age was the only factor identified with an increased risk for subsequent flap loss in cases that were revised for thrombosis. [Copyright &y& Elsevier]

Objective: We developed a model for intravital microscopic analysis of the coronary microcirculation in transplanted murine hearts and assessed the influence of cold ischemia on postischemic microcirculatory dysfunctions. Methods: Murine hearts were exposed to 60 (n = 12) and 240 minutes (n = 8) of cold ischemia before syngeneic heterotopic transplantation. Intravital fluorescence microscopy allowed detailed analysis of the right ventricular coronary microcirculation, including feeding arterioles, nutritive capillaries, and postcapillary venules. With this technique, we further studied leukocyte–endothelial cell interactions, microvascular permeability, tissue oxygenation, and microlymphatics. Results: Cold ischemia of 240 minutes aggravated nutritive capillary perfusion failure, indicated by a significant reduction of functional capillary density and capillary flow velocity by 63% and 45% (P < .05 vs 60-minute cold ischemic isografts). The mitochondrial redox state, visualized by nicotinamide adenine dinucleotide hydrogen autofluorescence, was markedly deteriorated after 240-minute cold ischemia (P < .05), indicating a persistent mismatch between oxygen supply and demand resulting from pronounced capillary no-reflow. Prolonged ischemia further resulted in 6- and 11-fold higher numbers of rolling and firmly adherent leukocytes in postcapillary venules (P < .05), together with increased microvascular permeability. Conclusions: We introduce a novel approach to visualize in detail the murine coronary microcirculation in vivo by multifluorescence microscopy. Our data demonstrate that prolonged cold ischemia provokes posttransplant capillary no-reflow, leukocytic inflammation, and persistent tissue hypoxia. [Copyright &y& Elsevier]