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Background: Skin- (SSM) and nipple-sparing (NSM) mastectomies are frequently performed surgeries with a considerable risk for post-operative hematoma or seroma. Tranexamic acid (TXA) is a potent antifibrinolytic drug commonly used in many surgical fields but rather novel in plastic and, specifically, breast surgery. This study investigates the influence of TXA in patients undergoing SSM or NSM with expander-based reconstruction (EbR) on post-operative outcomes. Methodology: A retrospective study was conducted on 132 patients undergoing uni- or bilateral SSM or NSM with EbR between May 2015 and March 2022. Patients receiving systemic TXA treatment for 48 h following a standardized protocol were compared to those who received no treatment. Multivariable linear regression was performed to identify influencing factors and quantify their effect on drainage volume, duration of drain placement, length of hospital stay, post-operative bleeding, and seroma formation. Results: The 132 patients underwent a total of 155 mastectomies (72 in the TXA group, 83 in the control group). TXA significantly reduced drainage volume (−22.3 mL, p = 0.011). Duration of drain placement and length of hospital stay were significantly shorter in the TXA group (p < 0.001 and p = 0.001). No significant side effects were reported. Conclusion: TXA is a safe drug if administered respecting the well-defined contraindications. Systemic TXA administration significantly reduces drainage volume in patients undergoing SSM or NSM and should encourage surgeons to reconsider using drains in post-operative protocols. Duration of drain placement and length of hospital stay were significantly reduced in the TXA group but other factors like resection weight might have a more substantial impact. [ABSTRACT FROM AUTHOR]

Background: Continuous research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) has introduced a focus on surface texturizations and a shift towards smooth breast devices, yet outcomes comparing the complication profiles of differently textured tissue expanders (TEs) remain conflicting. The study aim was to compare the complication profile of a new nanotextured and MRI-compatible TE to micro- and macrotextured TEs and to identify possible predictors for complications. Methods: A retrospective analysis of women undergoing expander-based breast reconstruction after mastectomy between January 2016 and March 2022 was conducted. The primary endpoint was the development of capsular contracture. Possible predictors were analyzed in a mixed-effects model using the least absolute shrinkage and selection operator (LASSO). Moreover, a comparison of complications and an evaluation of predictors were carried out. Results: A total of 147 breasts, encompassing 82 nanotextured, 43 microtextured and 22 macrotextured TEs, were analyzed. Breasts with nanotextured TEs were less likely to develop capsular contracture overall (OR, 0.12; 95%CI 0.05–0.28, p < 0.001). Post-mastectomy radiotherapy (PMRT) was identified as a predictor for capsular contracture (OR, 4.67; 95%CI 1.86–11.71, p < 0.001). Breasts with nanotextured TEs showed a higher rate of seroma, but lower rates of malposition and pain. Predictors for developing postoperative complications included higher mastectomy weight (p = 0.008). Conclusions: Breasts with nanotextured TEs exhibited the lowest rate of capsular contracture compared to micro- and macrotextured TEs. Together with its MRI-compatibility and improved oncologic follow-up, the nanotextured TE seems to be a favorable device for expander-based breast reconstruction. [ABSTRACT FROM AUTHOR]

Dermal substitutes require sufficient tissue integration and vascularization to be successfully covered with split-thickness skin grafts. To rapidly achieve this, we provide the proof of principle for a novel vascularization strategy with high translational potential. Nanofat was generated from subcutaneous adipose tissue of green fluorescence protein (GFP)+ C57BL/6J donor mice and seeded onto small samples (4 mm in diameter) of the clinically approved dermal substitute Integra®. These samples and non-seeded controls were then implanted into full-thickness skin defects in the dorsal skinfold chamber of C57BL/6J wild-type mice and analyzed by intravital fluorescence microscopy, histology and immunohistochemistry over a 14-day period. Nanofat-seeded dermal substitutes exhibited an accelerated vascularization, as indicated by a significantly higher functional microvessel density on days 10 and 14 when compared to controls. This was primarily caused by the reassembly of GFP+ microvascular fragments inside the nanofat into microvascular networks. The improved vascularization promoted integration of the implants into the surrounding host tissue, which finally exhibited an increased formation of a collagen-rich granulation tissue. There were no marked differences in the inflammatory host tissue reaction to nanofat-seeded and control implants. These findings demonstrate that nanofat significantly improves the in vivo performance of dermal substitutes without affecting their biocompatibility. [ABSTRACT FROM AUTHOR]

Background:. Acellular dermal matrices (ADMs) entered the market in the early 2000s and their use has increased thereafter. Several retrospective cohort studies and single surgeon series reported benefits with the use of ADMs. However, robust evidence supporting these advantages is lacking. There is the need to define the role for ADMs in implant-based breast reconstruction (IBBR) after mastectomy. Methods:. A panel of world-renowned breast specialists was convened to evaluate evidence, express personal viewpoints, and establish recommendation for the use of ADMs for subpectoral one-/two-stage IBBR (compared with no ADM use) for adult women undergoing mastectomy for breast cancer treatment or risk reduction using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results:. Based on the voting outcome, the following recommendation emerged as a consensus statement: the panel members suggest subpectoral one- or two-stage IBBR either with ADMs or without ADMs for adult women undergoing mastectomy for breast cancer treatment or risk reduction (with very low certainty of evidence). Conclusions:. The systematic review has revealed a very low certainty of evidence for most of the important outcomes in ADM-assisted IBBR and the absence of standard tools for evaluating clinical outcomes. Forty-five percent of panel members expressed a conditional recommendation either in favor of or against the use of ADMs in subpectoral one- or two-stages IBBR for adult women undergoing mastectomy for breast cancer treatment or risk reduction. Future subgroup analyses could help identify relevant clinical and pathological factors to select patients for whom one technique could be preferable to another.

Background: Surgical dissection and partial detachment of the temporalis muscle during neurosurgical procedures might result in a temporal depression known as "temporal hollowing". Reconstructive procedures to correct this condition include the implantation of synthetic materials (e.g., hydroxyapatite, methacrylate or polyethylene), injection of autologous fat or fillers as well as the use of flaps (e.g., temporo-parietal local flap and latissimus dorsi free flap). However, none of these techniques proved to be an ideal option due to a high complication rate or need for invasive and complex surgery. Adipo-dermal grafts are autologous; the resorption rate seems to be limited and the complexity of the procedure is minor. Moreover, autologous fat grafting can be performed to enhance the final outcome by correcting residual contour deformities. Methods: In this series of five patients, an institutional experience is presented using multi-layered adipo-dermal grafts harvested from the supra-pubic area for the restoration of volume and contour in post-surgical temporal hollowing. During the last follow-up, patients were asked to express their satisfaction, which was assessed by a survey. Results: this approach demonstrates a marked improvement in temporal hollowing associated with a low complication rate and good patient satisfaction. Conclusions: the aim of this consecutive case series is to emphasize the effectiveness of this surgical technique as one of the options to address temporal hollowing. [ABSTRACT FROM AUTHOR]

Background: Nowadays, multimodal cancer therapy results in very high survival rates of early-stage breast cancer and microsurgical flap-based breast reconstruction has become safe and reliable, with gradually increasing demand because of its durable and aesthetically pleasing results. This study aimed to explore the impact of different flap shaping and inset techniques on patient-reported outcome measures (PROMs) with regard to the aesthetic result in abdominal flap-based breast reconstruction. Methods: A systematic review was performed screening Pubmed, Cochrane Library and Web of Science for original articles reporting flap inset strategies, concomitantly providing PROMs on the aesthetic result. Results: Of 319 studies identified, six met the inclusion criteria. The studies described different flap rotation options according to the patient's morphology, different inset planes, and avoidance of the monitoring skin paddle, and suggested that a higher flap-to-mastectomy mass ratio was associated with better aesthetic results. In two comparative studies, according to the PROMs (BREAST-Q, Likert scale) and independent observer judgement, both higher patient satisfaction and superior aesthetic results were observed with the newly described techniques. Conclusions: Emphasis on the aesthetic outcome in terms of breast shape and symmetry, providing an individualized approach of flap inset, considering the contralateral breast's shape and volume, results in higher satisfaction scores. [ABSTRACT FROM AUTHOR]

Periodic fasting (PF) as a form of dietary restriction has been shown to induce tissue-protective effects against ischemic injury in several different tissues. Accordingly, in this study we analyzed whether a short-term 24 h fast is suitable to prevent necrosis of musculocutaneous flap tissue undergoing acute persistent ischemia. C57BL/6N mice were randomly divided into a PF group (n = 8) and a control group that was given unrestricted access to standard chow (n = 8). The PF animals underwent a 24 h fast immediately before flap elevation and had unrestricted access to food for the rest of the 10 day observation period. Musculocutaneous flaps with a random pattern design were dissected on the animals' backs and mounted into dorsal skinfold chambers. On days 1, 3, 5, 7 and 10 after surgery, nutritive tissue perfusion, angiogenesis and flap necrosis were evaluated using intravital fluorescence microscopy. Thereafter, the flap tissue was excised and fixed for histological and immunohistochemical analyses. The flaps of PF-treated animals exhibited a higher functional capillary density and more newly formed microvessels, resulting in a significantly increased flap survival rate. Moreover, they contained a lower number of myeloperoxidase (MPO)-positive neutrophilic granulocytes and cleaved caspase-3-positive apoptotic cells in the transition zone between vital and necrotic flap tissue. These findings indicate that short-term PF improves tissue survival in ischemically challenged musculocutaneous flaps by maintaining nutritive blood perfusion and dampening ischemia-induced inflammation. [ABSTRACT FROM AUTHOR]

Negative pressure wound therapy (NPWT) is a wound‐dressing system that applies sub‐atmospheric pressure on the surface of a wound to promote healing. An evolution of this technology, NPWT with solution instillation and dwell time (NPWTi‐d), is increasingly being used to maximise wound closure and reduce failure rates. However, there is still a lack of evidence concerning its use in orthoplastic surgery. Therefore, the aim of this study is to compare NPWTi‐d with NPWT and standard of care for wound management in orthoplastic surgery. A comprehensive literature search using PubMed, Web of Science, and Cochrane databases up to 15 March 2022 was performed, including studies describing the outcomes of NPWTi‐d for traumatic/orthopaedic injuries. A meta‐analysis on the number of surgical debridements, as well as the rate of complete wound closure and complications was carried out, although for other outcomes, a descriptive statistic was applied. Risk of bias and quality of evidence were assessed using the Downs& Black's Checklist for Measuring Quality. Thirteen studies with a total number of 871 patients were included, in which NPWTi‐d demonstrated significantly higher primary wound closure and lower complication rates (P <.05). No difference in the number of surgical procedures required for final wound healing was observed. Moreover, five out of six studies showed better results for NPWTi‐d when the change of the bioburden and bacterial count of the wound were analysed. A singular study investigating the length of the hospital stay of patients treated with NPWTi‐d showed a reduction in the latter. The present meta‐analysis proves that NPWTi‐d is superior to NPTW or conventional dressings in orthoplastic wound care management, in terms of complete wound closure rate and the reduced number of complications. Still, the limited quality of the studies analysed shows that future randomised studies are needed to confirm the benefits and to identify the most appropriate recommendations for using NPWTi‐d in orthoplastic surgery, as well as to investigate the cost‐effectiveness of this wound‐dressing system. [ABSTRACT FROM AUTHOR]

Fat grafting is a frequently applied procedure in plastic surgery for volume reconstruction. Moreover, the transplantation of white adipose tissue (WAT) and brown adipose tissue (BAT) increasingly gains interest in preclinical research for the treatment of obesity-related metabolic defects. Therefore, we herein directly compared the vascularization capacity and survival of WAT and BAT grafts. For this purpose, size-matched grafts isolated from the inguinal WAT pad and the interscapular BAT depot of C57BL/6N donor mice were syngeneically transplanted into the dorsal skinfold chamber of recipient animals. The vascularization and survival of the grafts were analyzed by means of intravital fluorescence microscopy, histology, and immunohistochemistry over an observation period of 14 days. WAT grafts showed an identical microvascular architecture and functional microvessel density as native WAT. In contrast, BAT grafts developed an erratic microvasculature with a significantly lower functional microvessel density when compared to native BAT. Accordingly, they also contained a markedly lower number of CD31-positive microvessels, which was associated with a massive loss of perilipin-positive adipocytes. These findings indicate that in contrast to WAT grafts, BAT grafts exhibit an impaired vascularization capacity and survival, which may be due to their higher metabolic demand. Hence, future studies should focus on the establishment of strategies to improve the engraftment of transplanted BAT. [ABSTRACT FROM AUTHOR]

Autologous postmastectomy breast reconstruction is associated with favourable long-term clinical outcomes and superior patient-reported outcomes (PROMs) compared with implant-based reconstruction. However, adjuvant radiotherapy has traditionally been considered a relative contraindication to immediate flap-based reconstruction due to its unpredictable effects on the reconstructive outcome. While modern adjuvant postmastectomy radiotherapy (PMRT) has been able to significantly reduce acute and chronic radiation-induced complications, plastic surgeons still hesitate to offer immediate autologous reconstruction to patients expected to undergo adjuvant radiotherapy. More recently, evidence has emerged suggesting a paradigm shift in favour of immediate autologous reconstruction despite subsequent radiotherapy. At the 44 th Annual Meeting of the German-speaking Society for Reconstructive Microsurgery (GSRM) in Bern, Switzerland, a workshop discussed the literature on PMRT and autologous breast reconstruction, aiming to establish consensus among the participants. Several areas of agreement were identified, including the goals of postmastectomy reconstruction, specifically the creation of a soft and sensitive breast symmetrical in shape and size to the unaffected breast via the safest procedure possible. The importance of preserving the maximum amount of native breast skin envelope through skin- and nipple-sparing approaches was emphasised. Finally, a consensus was reached that PMRT should no longer be considered a contraindication to immediate autologous breast reconstruction., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Autologous fat grafting is a common procedure in plastic, reconstructive, and aesthetic surgery. However, it is frequently associated with an unpredictable resorption rate of the graft depending on the engraftment kinetics. This, in turn, is determined by the interaction of the grafted adipose tissue with the tissue at the recipient site. Accordingly, preconditioning strategies have been developed following the principle of exposing these tissues in the pretransplantation phase to stimuli inducing endogenous protective and regenerative cellular adaptations, such as the upregulation of stress-response genes or the release of cytokines and growth factors. As summarized in the present review, these stimuli include hypoxia, dietary restriction, local mechanical stress, heat, and exposure to fractional carbon dioxide laser. Preclinical studies show that they promote cell viability, adipogenesis, and angiogenesis, while reducing inflammation, fibrosis, and cyst formation, resulting in a higher survival rate and quality of fat grafts in different experimental settings. Hence, preconditioning represents a promising approach to improve the outcome of fat grafting in future clinical practice. For this purpose, it is necessary to establish standardized preconditioning protocols for specific clinical applications that are efficient, safe, and easy to implement into routine procedures.

Recently, several new technologies to support microsurgeons have received European market approval. This article summarizes and discusses the impressions of an expert panel to classify the potential of new technologies in terms of benefits for the surgeon, specific indications and economic aspects during the 42nd Annual Meeting of the German-speaking Working Group for Microsurgery of Peripheral Nerves and Vessels (DAM) in Graz, Austria. In general, the expert panel addressed the principles and prerequisite for the successful establishment of new technologies and, in particular, novel optical and robotic systems. For this purpose, the current scientific literature was reviewed and initial clinical experience in the context of case series and retrospective studies was presented by the members of the expert panel. In the ensuing discussion, it was pointed out that it will first be necessary to identify patient subgroups in which the use of the new technologies is most likely to achieve a clinical benefit. Since clinical approval has already been granted for some systems, an approach can be developed for immediate clinical application from the simplest possible use to ever finer applications, i. e. from microsurgery to supermicrosurgery. Initially, funding for cost-intensive systems would presumably not be possible through revenue from standard care, but only through grants or subsidized clinical trials. In a final survey, the majority of meeting participants see the need for a price reduction of both visualization and surgical robotics technologies to enable widespread clinical establishment. Likewise, a majority of participants would prefer a combination of an exoscope or robotic microscope and a surgical robot for clinical use. The present consensus work addresses the development of a strategy for the effective establishment of new technologies, which should further increase the surgical quality of selected interventions., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Implant based breast reconstruction (IBBR) keeps evolving and has been influenced heavily by the use of synthetic and biologic meshes in the last years. In both, subpectoral as well as prepectoral approaches the use of synthetic and biologic meshes has made it possible to place implants precisely according to the breast's footprint and strengthen soft-tissue coverage, particularly in the lower pole of the breast with lower complication rates and better cosmesis. Various mesh options that differ in material, processing, size and cost are currently in clinical use. This review aims to define the role of biologic and synthetic meshes in IBBR regarding the advantages and disadvantages of their use., Competing Interests: Die Autoren geben an, dass keine Interessenskonflikte bestehen, (Thieme. All rights reserved.)

Breast-conserving therapy (BCT), meaning tumorectomy in combination with systemic therapy and locoregional radiation therapy has become the preferred method to treat early-stage breast cancer. With excellent long-term recurrence-free and overall survival rates, breast surgeons today must deliver du- rable and aesthetically appealing results that guarantee a good quality of life to meet the high patient expectations. Oncoplas- tic breast surgery (OPBS) is an innovative approach to improve the overall results of BCT. Often carried out by a team of a plastic surgeon and an oncologic breast surgeon, OPBS can actively prevent breast deformities without compromising oncological safety. In the following, an overview of the principles and techniques of oncoplastic breast surgery will be given due to its ever-increasing significance and its advantages and dis- advantages will be discussed in the context of reconstructive breast surgery., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps., Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)