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Circumferential deep burns carry a high risk for a burn induced compartment syndrome. It was recently shown that an enzymatic bromelain-based debridement with Nexobrid® is a safe and efficient procedure to release pressure in deep circumferential extremity burns reducing the need for surgical escharotomy. We therefore herein aimed to analyze the conceptual relation between Nexobrid® and surgical escharotomy.We conducted a retrospective study on all patients with circumferential deep partial-thickness or full-thickness burns requiring immediate escharotomy that was either performed by surgical incision or Nexobrid®. Medical records of 792 patients that were treated at the burn center of the University Hospital Zurich between 2016 and 2021 were analyzed.Overall, 62 patients with circumferential deep partial-thickness or full-thickness burns who received preventive decompression either by Nexobrid® (N = 29) or surgical escharotomy (N = 33), were included. Whilst distribution of age, sex, BMI and type of injury showed no difference between the groups, the ABSI score, TBSA, percentage of third degree burns and mortality were significantly higher in patients who received a surgical escharotomy.While the use of Nexobrid® to prevent burn induced compartment syndrome has steadily increased, surgical escharotomies were predominantly performed in severely burned patients with a high degree of full-thickness burns. Thus, higher mortality in this patient group needs to be considered with caution and is mainly attributed to the higher TBSA. Although evidence is lacking for the use of Nexobrid® for larger body areas exceeding 15%, escharotomy is also the more reliable and faster approach in such critically burned patients.

An aesthetically and functionally pleasing phalloplasty is most commonly performed by a free radial forearm flap. However, the problem with donor site morbidity on the forearm remains unsolved. The aim of this study was to evaluate if the use of a dermal template such as MatriDerm® on the donor site significantly decreases the incidence of complications based on the Clavien–Dindo classification, such as wound healing disorders and reoperation rate, and if it could shortens the duration of hospital stay. A case series analysis was conducted at our institution. A total of 21 patients divided into two groups undergoing the phallic construction after the Gottlieb and Levine design in a single center underwent the donor site defect coverage either by MatriDerm® and split-thickness skin graft from the thigh or by full-thickness skin graft from the groin area. The use of MatriDerm® and split-thickness skin graft showed to have a statistically significant impact on the rate of complications (p = 0.008). Complications that were treated conservatively as well as that require surgical revision were significantly lower in the MatriDerm® group than in the full-thickness skin graft group (p = 0.002). Complications occurred not only at the forearm but also at the groin, where the full-thickness skin graft was harvested. The large dimension of the free radial forearm flap used for phalloplasty resulted in a significant donor site morbidity, leading to wound healing disorders, reoperations, and extended length of hospital stay. Therefore, we consider the use of dermal templates such as MatriDerm® as worth the additional effort and costs in this patient collective.

Introduction: Patient-reported outcomes (PROMs) are increasingly relevant to assess surgical quality and guide decisions in breast reconstruction (BR). Satisfaction with outcomes may change as time progresses. We assessed satisfaction in patients who underwent free-flap BR in the last 12 years. Methods: All patients who underwent free-flap BR from 2006 to 2018 were invited to complete the validated BREAST-Q for reconstruction. The BREAST-Q comprises 6 domains covering various aspects of satisfaction. Unadjusted linear regression assessed the relationship between different domains of the BREAST-Q and time since BR. Two-sample t tests assessed differences in satisfaction between patients who underwent BR ≥5 years versus Results: Forty-three women with primary or secondary free-flap BR between 2006 and 2018 were included in the study. Most patients (n = 33, 76.7%) underwent DIEP flap BR. Overall satisfaction with breasts and with outcomes improved as time since BR increased (p = 0.031 and p = 0.017, respectively). Overall satisfaction with outcomes scored higher in patients with BR ≥5 years prior (≥5 years vs. p = 0.005). Satisfaction with breasts and psychosocial well-being also scored higher in these patients. There was no difference in results between primary and secondary BR. Patients who underwent additional surgery (refinements) reported higher satisfaction with outcomes and abdominal well-being. Conclusions: PROMs concerning satisfaction with breast and with outcomes following BR improve as time since treatment progresses. This study demonstrates that time since diagnosis may be an important factor in satisfaction. It underlines the importance of long-term PROMs related to BR, to help provide patients and health care professionals in decision-making and in managing expectations related to BR.

Radical tumor ablation or severe trauma can result in challenging tissue defects. The split anterolateral thigh free flap has been promoted as an ideal option for complex defects. We aimed to evaluate whether this flap could be performed without major morbidity. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted to assess this hypothesis. An illustrative case about pharyngeal reconstruction is discussed, and the role of free split anterolateral thigh free flaps in modern reconstructive surgery is evaluated. The systematic search of literature yielded 221 studies with 7 articles about free anterolateral thigh flaps fully split in two separate flaps based on one pedicle. Favorable outcomes in a total of 31 patients were described. Tissue defects were mainly located at extremities, chest wall, lip, and cheek. A low complication incidence was reported in all studies, in terms of flap loss, donor site morbidity, and general wound healing problems. The flap was utilized for pharyngeal reconstruction and simultaneous neck resurfacing, which allowed a more convenient way of flap monitoring in the present case. Being technically a rather demanding flap variant, splitting the anterolateral thigh free flap has still become an accepted technique among microsurgeons. Currently, literature suggests that it can be performed without major complications for reconstructing extremities and the head and neck area. Rearrangement of the flap units in pharyngeal reconstruction increases the flap’s versatility as it allows neck resurfacing and external monitoring of buried inaccessible flaps.

Zusammenfassung. Methoden zur ästhetischen Brustvergrösserung ohne Silikonimplantate werden immer beliebter. Eine zumindest optische Brustaugmentation kann durch verschiedenen Mastopexieverfahren patientenspezifisch erreicht werden. Die Eigenfetttransplantation hat sich über die letzten Jahre in der rekonstruktiven und ästhetischen Brustchirurgie zu einem sicheren Standardverfahren in der Wiederherstellung eines natürlichen Erscheinungsbildes, zum Volumenaufbau und zur Angleichung von Asymmetrien und Konturunregelmässigkeiten, z.B. durch Narben im Brustbereich, bei bestimmten Patientinnen entwickelt. Die ästhetische Brustaugmentation mittels Eigenfett ist bei sehr kleinen Brüsten und Wunsch nach grösserem Volumen nur über eine Phase der Gewebeexpansion sinnvoll, um die Annahmerate des injizierten Fettgewebes zu erhöhen. Aufgrund der aktuellen Datenlage zur Sicherheit stellen Hyaluronsäureinjektionen keine valide Alternative zur ästhetischen Brustaugmentation dar und sind daher nicht zu empfehlen.

Background Lipedema is a common adipose tissue disorder affecting women, characterized by a symmetric subcutaneous adipose tissue deposition, particularly of the lower extremities. Lipedema is usually underdiagnosed, thus remaining an undertreated disease. Importantly, no histopathologic or molecular hallmarks exist to clearly diagnose the disease, which is often misinterpreted as obesity or lymphedema. Materials and methods The aim of the present study is to characterize in detail morphologic and molecular alterations in the adipose tissue composition of lipedema patients compared with healthy controls. Detailed histopathologic and molecular characterization was performed using lipid and cytokine quantification as well as gene expression arrays. The analysis was conducted on anatomically matched skin and fat tissue biopsies as well as fasting serum probes obtained from 10 lipedema and 11 gender and body mass index–matched control patients. Results Histologic evaluation of the adipose tissue showed increased intercellular fibrosis and adipocyte hypertrophy. Serum analysis showed an aberrant lipid metabolism without changes in the circulating adipokines. In an adipogenesis gene array, a distinct gene expression profile associated with macrophages was observed. Histologic assessment of the immune cell infiltrate confirmed the increased presence of macrophages, without changes in the T-cell compartment. Conclusions Lipedema presents a distinguishable disease with typical tissue architecture and aberrant lipid metabolism, different to obesity or lymphedema. The differentially expressed genes and immune cell infiltration profile in lipedema patients further support these findings.

BACKGROUND Chylous leak is an uncommon complication after head and neck surgery and typically results from a lesion of the thoracic duct (TD). Beside conservative treatment, different minimally invasive and surgical procedures exist, of which almost all lead to a total closure of the TD. METHODS We report on a rare case of microsurgical lymphovenous anastomosis to treat a TD lesion. An additional systematic review on surgical procedures to treat TD lesions with special attention to lymphovenous anastomoses was performed according to the PRISMA guidelines. RESULTS A 52-year-old patient with a chylous fistula after modified radical neck dissection was successfully treated by a lymphovenous anastomosis of the TD and external jugular vein with additional coverage by sternocleidomastoid muscle flap. The patient showed a complete resolution of chylous leak with an uneventful postoperative course.The systematic search of literature yielded 684 articles with 4 case reports on lymphovenous anastomosis in chylous leak with a high success rate. Other surgical techniques include transcervical, thoracoscopic, or video-assisted thoracoscopic TD ligation, either alone or combined with a local muscle flap. CONCLUSIONS Lymphovenous anastomosis of the TD is a feasible and safe technique allowing for treatment of cervical TD lesions, especially if minimally invasive procedures fail. Compared with other techniques, lymphatic circulation can successfully be maintained.

Introduction: Progressive hemifacial atrophy (PHA) and linear scleroderma (LS) are both rare conditions and defined by atrophy and/or sclerosis of the skin and subcutaneous tissue. The ideal timing of reconstructive intervention in these patients is controversial. We compared the outcome and satisfaction of autologous lipofilling performed during active and stable phases of the diseases in adults. Methods: A retrospective chart review was conducted with all patients diagnosed with PHA or LS between 2007 and 2019 in our department. We analysed demographic data, clinical features, and surgical procedures. The changes in symmetry, volume and skin texture were rated by surgeons at 1 week, 3 months and 6 months compared to the preoperative presentation. We compared the outcomes of patients treated during the active and the stable phase of the disease. Additionally, patients were asked to fill out a quality-of-life questionnaire. Results: We found a total of 11 patients diagnosed with PHA and LS, 8 of whom had undergone autologous fat injections to correct facial asymmetry. Of those, 4 patients were treated in their active and 4 in their stable phase. We found similar treatment outcomes in both groups. The social component had the greatest negative effect on patient's quality of life. Conclusion: In this small cohort, autologous fat grafting during the active phase did not appear to be inferior to fat grafting during the stable phase. It could be a safe technique for correction of PHA and LS during the active phase of disease.

Objective Lymphedema is a chronic, progressive and burdensome disease that is known to have a substantial impact on quality of life (QOL). Hence, the assessment of QOL is an important aspect of any study which seeks to evaluate outcomes after lymph reconstructive surgery. We therefore aimed to analyze currently available patient-reported outcome measurements (PROMS) for patients with lower limb lymphedema (LLL) with regard to their psychometric properties. Furthermore, we intended to evaluate the change in QOL in patient undergoing lymphovenous anastomosis (LVA) or vascularized lymph node transfer (VLNT). Methods A literature research of four databases on studies that included PROMS for LLL was conducted. All selected studies were assessed for validity according Consensus-based Standards for the selection of Health Measurement Instruments. Studies that used the Lymph Quality of Life Measure for Limb Lymphedema (LYMQOL) after LVA and/or VLNT were included for quantitative analysis. Results In total, 988 studies were screened, of which 30 studies were included in this review. We identified six validated PROMS to assess LLL. Of those, the LYMQOL was the most commonly used questionnaire. Based on the LYMQOL, a significant improvement of QOL in LLL was noted in all studies after reconstructive lymph surgery (LVA/VLNT) regardless of lymphedema etiology, stage, or time since diagnosis. On the basis of the Consensus-based Standards for the selection of Health Measurement Instruments criteria, the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema seems to be superior in terms of its psychometric properties. Conclusions A significant improvement in the QOL in patients with LLL after reconstructive lymph surgery can be observed. Future studies on reconstructive lymph surgery need to include both objective and congruent volume measurements, as well as data on QOL based a well-validated PROM such as the Lymphoedema Functioning, Disability and Health Questionnaire for Lower Limb Lymphoedema.

ZusammenfassungIm Frühstadium von Nervenläsionen stellt die klinische Differenzierung zwischen Neurapraxie, Axonotmesis und Neurotmesis oftmals eine große Herausforderung dar. Vor allem im Frühstadium von Nervenläsionen ist eine korrekte Klassifizierung des Schädigungstyps jedoch von essenzieller Bedeutung, da hiermit das therapeutische Konzept, insbesondere das operative Vorgehen und damit die Prognose, maßgebend bestimmt werden. Neben einer ausführlichen klinischen Statuierung und Anamneseerhebung bedarf es zur Präzisierung der Diagnose den Einsatz ergänzender elektrophysiologischer (funktioneller) und/oder bildgebender Untersuchungen. Eine elektrophysiologische Diagnostik kann hierbei Auskunft über Lokalisation, Schweregrad, Verlauf, Schädigungstyp und einer beginnenden oder stattgehabten Reinnervation geben. Präoperativ sollten hinsichtlich der funktionellen Diagnostik eine Neurografie, Nadel-Elektromyografie (EMG) und ggf. evozierte Potentiale (EP) und bildgebend eine Nervensonografie oder Magnetresonanztomografie (MRT) durchgeführt werden. Ergänzend kann eine EMG auch intraoperativ erfolgen.

Surgery trainees use videos as a means to learn about surgical procedures. YouTube is the biggest online video platform and used for educational content as well but the medical information provided does not undergo peer review or other forms of scientific screening and can thus be of poorer quality. We performed a systematic review that examined the quality of educational videos about surgery and plastic surgery in particular on YouTube. The focus was towards studies on the benefit of YouTube videos for surgical trainees. A literature review was performed to determine the educational quality of plastic surgery videos found on YouTube. Articles reviewing the educational quality of videos about surgical procedures, their accuracy, and their utility for surgical trainees were included. An additional review was performed evaluating the literature about the quality of educational plastic surgery videos. Eleven articles were selected reviewing the educational quality of videos about surgical procedures. Six studies were fully assessed and evaluated concerning the quality of educational plastic surgery videos. There currently seems to be a lack of comprehensive educational surgery and in particular plastic surgery-related information on YouTube. The popularity of YouTube among surgical trainees is high. The quality of available educational surgical video content varies widely. It is in the interest of plastic surgery teaching institutions to provide trainees with high-quality educational video material.

Over the last years, the layout of surgical training has significantly changed. Surgical residents rely on YouTube videos to prepare for upcoming cases. Eyelid surgery including blepharoplasty ranks among the 5 most often performed cosmetic surgeries. It will be one of those surgeries regularly researched by plastic surgery residents. Therefore, the aim of this study was to evaluate the educational value of the most viewed upper lid blepharoplasty videos on the most popular video broadcasting website, YouTube. A video scoring system consisting of 8 items was developed in accordance with the technical details described in the literature. Video scores were categorized into 3 groups, namely as 'poor', 'moderate; or 'good' in terms of their contribution to surgical education. The first 300 videos were evaluated for the search results for 'blepharoplasty'. After exclusion and summarization of video fragments, a total number of 36 videos were included in the study. Multivariable logistic regression models found no correlation between likes, views, comments and the attributed educational score. The quality of available educational surgical video content varies widely, and surgical trainees need to be critically aware of this as view counts as well as the number of likes and comments will not necessarily relate to videos' educational quality. There is a need for high-quality educational videos.

Background:. Numerous approaches have been employed to treat chronic lymphocele and cutaneous lymphatic fistulas (LFs) with little success. Given a high incidence and substantial consequences for patients, there is an ongoing demand for effective therapeutic and preventive strategies. The aim of this study was to evaluate the results after microscopic lymphatic ligation (MLL) and lymphovenous anastomosis (LVA) as a therapeutic and preventive approach in this context. Methods:. Demographic data, surgical characteristics, complications, and the overall outcome of all patients undergoing surgery for postoperative LF from 2014 to 2019 were collected retrospectively. Patients were categorized in accordance with predefined inclusion/exclusion criteria and with their treatment. Statistical analysis was conducted using descriptive, summary statistics to identify a central tendency. Results:. Thirty-four patients underwent indocyanine-green-lymphangiography guided revision surgery for LF. Two patients were lost to follow-up at 6 months. LF was successfully treated in all patients (n = 32) with a multimodal approach. Only MLL was performed in 22 patients and MLL/LVA in 10 patients. LF resolved in 78% of all patients with MLL only or MLL/LVA. In the remaining 22%, LF resolved after additional sclerotherapy within 3 months. Conclusions:. Treatment of LF should follow a standardized staged surgical approach to optimize outcome. LF was treated successfully in all our patients. We therefore propose a multimodal interdisciplinary approach to this common clinical problem that includes adjunctive sclerotherapy.

OBJECTIVE: This study aimed to determine the benefits of sclerotherapy with OK-432 for the treatment of postoperative chronic lymphocele. BACKGROUND: Postoperative chronic lymphocele formation is common and accounts for a high postoperative morbidity. Nonsurgical strategies comprise repetitive percutaneous fluid aspiration or percutaneous sclerotherapy. OK-432 has been used to treat congenital lymphatic malformations with several reports of promising results. We hypothesized that it is more beneficial than repetitive percutaneous fluid aspiration for the treatment of symptomatic lymphocele. METHODS: Two cohorts of melanoma patients who developed recurrent lymphocele after lymph node dissection from January 2013 to August 2017 were compared. The first cohort was treated with repetitive percutaneous fluid aspiration (n = 20). The second cohort received OK-432 sclerotherapy (n = 20). Primary end points were overall treatment duration, number of treatment sessions, and the clinical success in both cohorts. Secondary end points were surgical site infection rate, need for additional antibiotic treatment, wound healing disorders, and the need for revision surgery. RESULTS: Mean overall duration of treatment with sclerotherapy was significantly shorter than with repetitive aspiration (9.4 ± 7.2 vs 47.5 ± 31.9 days, P < 0.01). Mean number of sclerotherapy treatment sessions were 2.5 ± 1.2. Clinical success with OK-432 was 19 of 20, and that with repeated aspiration was 7 of 20 (χ = 15.82, P < 0.001). No surgical site infection occurred in the sclerotherapy cohort, which was significantly lower than those treated with repetitive aspiration (P < 0.03). Surgical revision was mandatory in 12 of 20 patients who were treated with repetitive aspiration, and only 1 of 20 patients in the sclerotherapy cohort. CONCLUSION: Sclerotherapy with OK-432 for the treatment of postoperative lymphocele is highly beneficial with a significant reduction of morbidity and the overall treatment time compared with repetitive aspiration.

Zygomaticomaxillary complex (ZMC) and orbital blow out fractures are commonly encountered midfacial fractures that may result in aesthetic and functional impairment. This retrospective study reports on the surgical treatment and associated postoperative complications in our patient collective. We evaluated 100 patients who underwent open reduction and internal fixation of midfacial fractures between 2010 and 2015. Preoperative clinical features, surgical technique and postoperative complications were analyzed. Surgery was performed with a mean latency of 7 days after trauma. We used titanium mesh and polydioxanone sheets to reconstruct the orbital floor. Most ZMC fractures were stabilized with two point fixation with titanium plates. Preoperative symptoms were present in 70 patients (70%). Infraorbital hypesthesia occurred in 49 patients, diplopia in 41 patients and ocular motility impairment in 24 patients. Postoperative symptoms persisted during a mean follow-up time of 4.5 months in 47 patients (47%) showing infraorbital hypesthesia in 24%, diplopia in 17%, ectropion in 7% and ocular motility impairment in 4%. Complications requiring revision were retrobulbar hematoma 3% (

Since the first description many variations of the dorsal metacarpal reverse island flap have been published but there is still uncertainty about which vascular component should be included for an optimal result. Therefore, it was the aim of this study to analyze vascular reliability and ischemic complications of dorsal metacarpal artery perforator (DMAP) flaps and dorsal finger perforator (DFP) flaps in our patient collective. We performed 40 of these flaps from the dorsum of hand and fingers for finger injuries. The choice of donor site was made according to the defect's location. Patients were analyzed with respect to flap necrosis, ischemic complications and achievement of overall reconstruction goals. In addition, we divided our patients in two groups, one group where we raised the flap from the dorsum of the proximal phalanx and a second one where the flaps were raised from the intermetacarpal space to identify complication rates based on the pedicles location. Of the 40 flaps, 36 survived completely. 4 partial necroses were observed in flaps transferred to more distal defects and in one flap that was used in a wrap-around technique for both dorsal and palmar proximal phalanx. These perforator flaps are a reliable method to cover finger defects and the dorsal metacarpal artery is not necessary for their survival, since the blood supply comes from perforating branches of the palmar vascular system. There is a clear trend for a higher complication rate in flaps raised from the dorsum of the fingers compared to the intermetacarpal space.

Zusammenfassung Hintergrund Soziale Medien (Social Media) spielen sowohl in der Freizeit als auch im medizinischen Berufsleben zunehmend eine wichtige Rolle. Gesellschaften wie die Föderation der Europäischen Gesellschaften für Handchirurgie (FESSH) tragen der Bedeutung von Social Media Rechnung, indem sie Social-Media-Gremien eingerichtet haben. Über die Nutzung von sozialen Medien in der und für die Handchirurgie gibt es bis dato keine Publikationen. Ziel Das Ziel dieser Studie war es, die derzeitige Nutzung sozialer Medien in der und für die Handchirurgie am Beispiel von Instagram zu analysieren. Material und Methoden Jeweils die ersten 100 Top-Beiträge (Posts), die im Juli 2019 auf Instagram mit den Hashtags #handsurgery, #handsurgeon und #fessh veröffentlicht wurden, wurden in Hinblick auf Autor, Thema und Art des Beitrags sowie die Reaktion auf den Beitrag ausgewertet. Ergebnisse 101 der 300 Beiträge stammten von Handchirurgen. Die meisten Beiträge (172 = 57,3 %) waren Eigenwerbung; 41 (13,7 %) dienten der Vermittlung medizinischen Wissens. 199 (66,3 %) Beiträge beinhaltete nur ein Foto, 63 (21,0 %) Beiträge zwei oder mehr Fotos, 38 (12,7 %) ein Video. Video-Beiträge und Beiträge von Handtherapeuten erhielten die meisten Likes und Kommentare. Schlussfolgerung Soziale Medien werden für die Handchirurgie zur Eigenwerbung, aber auch zur Wissensvermittlung genutzt. Video-Beiträge werden von der Social-Media-Gemeinde besser bewertet als Foto-Posts.

The deep inferior epigastric artery perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. We therefore aimed to identify crucial factors that might increase the risk for abdominal bulging and an impaired aesthetic appearance. We conducted a multicenter study evaluating all patients receiving autologous breast reconstruction using a DIEP flap between 2013 and 2017. Medical records were analyzed with special attention to flap technique, number of perforators, localization of perforator, and donor site complications. In addition, the aesthetic appearance of the abdominal donor site was evaluated by blinded clinicians at one-year follow-up. A total of 242 patients underwent DIEP flap breast reconstruction. Abdominal bulging occurred in 7%. Further subgroup analysis revealed a significant correlation between abdominal bulging and two or more perforators (P = .003), the use of lateral row perforators (P = .009), and a higher BMI (P = .002). Obesity (P = .003) and higher patient's age (P = .003) could be identified as risk factors for an undesirable appearance of the donor site. We recommend the use of a medial-row single perforator whenever possible in order to optimize donor site morbidity and decrease the risk of abdominal bulging. Proper patient selection and careful donor site closure following a standardized approach should be performed to limit the risk of aesthetically undesirable results.

Numerous causalities, including attempts at penile augmentation with silicone or paraffin, can lead to extensive circular penile shaft defects. Reconstruction is challenging and skin grafting is a suboptimal option despite its widespread use. We present a surgical technique for penile shaft reconstruction with a bipedicled anterior scrotal flap.A retrospective data analysis was performed of patients treated for symptomatic penile siliconomas who underwent subsequent penile reconstruction with a bipedicled anterior scrotal flap between 2010 and 2015. The surgical technique is described and depicted in detail.A total of 43 men were treated with radical circular excision of penile siliconomas and extensive shaft defects were reconstructed with a bipedicled anterior scrotal flap. Mean ± SD age was 36.95 ± 11.27 years, mean followup duration was 10.69 ± 9.54 months and mean operative time was 2.53 ± 0.46 hours. The operation proved uneventful in all cases. Only minor complications were observed, such as partial necrosis in 9% of patients, hematoma of the donor site in 12% and partial wound disruption in 19%. The mean patient satisfaction score was 4.37 on a scale of 1 to 5. All patients reported postoperative erection ability and the ability to achieve sexual intercourse.We present a surgical technique to reconstruct extensive penile shaft defects with an axial scrotal flap, which provides well vascularized coverage with comparable donor skin quality and thickness. The results are associated with minor donor site morbidity, good functional and aesthetic outcomes, and high patient satisfaction.

The burn comb model is a well-established model for studying secondary burn progression. It creates four rectangular burn surfaces intercalated by three unburned zones prone to secondary burn progression. While burn progression is a tri-dimensional phenomenon, of which the vertical extension from the superficial to deeper tissue layer is clinically most relevant, the models initial focus was mainly on the horizontal surface extension within interspaces. The aim of this study is to evaluate the correlation between horizontal surface and vertical depth burn progression.24 large (400-450 g) Wistar male rats underwent standardized burn injuries using a burn comb. Laser Doppler flowmetry to assess perfusion, planimetric evaluation of burn progression within interspaces and histological analyses assessing burn depth were performed before burn induction (baseline; BL) and after 1 h, as well as after 1, 4, and 7 days. Histological burn depth was graded from superficial (1) to the subcutaneous layer (5). Furthermore, final scarring time and contracture rate were also assessed.The burn comb resulted in consistent and uniform superficial burns (mean ± SEM burn depth score: 2 ± 0; hour 1) separated by intact but critically perfused interspaces (63 ± 1% of BL; p 0.05 vs. BL). Tissue damage significantly progressed to the deep dermis within the first day (burn depth score 4.3 ± 0.2; p 0.05 vs. hour 1), while significant interspace necrosis at the surface did not develop within this time period (4 ± 3% of interspace necrosis; p n.s vs. hour 1). However, interspace necrosis was observed at day 4 (83 ± 3%; p 0.05 vs. hour 1) and further progressed until day 7 (94 ± 2%; p 0.05 vs. hour 1).This study shows the limits of the burn comb model originally described with a discrepancy between horizontal surface and vertical depth progression of the burn injury. We herein propose a necessary refinement of this model to adequately evaluate vertical depth progression using a histological score. This revisited approach focusing on assessment of depth progression of the burn will allow a better evaluation of experimental burn treatments in future.

Background: The aim of a mastopexy is to raise the breast projection, tighten the skin envelope, and place the nipples in an optimal position in projection to the inframammary fold. This procedure is often combined with prosthetic implants or an autoimplant. Given the current increasing demand for the use of autologous tissue, we evaluated mastopexies combined with either an autoimplant or prosthetic implant in terms of patient satisfaction and long-term results. Methods: We evaluated 34 patients who underwent a mastopexy with simultaneous breast prosthesis or an autoimplant. During follow-ups we obtained standardized breast measurements, BREAST-Q score, and pre- and postoperative photographs to perform photometric measurements. Results: BREAST-Q score of patients that underwent autoimplant-mastopexies revealed a higher patient satisfaction with significant differences in satisfaction with breast appearance (69±18 vs. 55±16, P=0.03) and outcome (71±18 vs. 48±26, P=0.009). Regarding breast shape, photometric evaluations presented a significantly different breast shape with higher upper pole fullness in augmentation-mastopexy patients. No statistical significance between long-term results and complication rates could be observed in either patient groups. Conclusions: The BREAST-Q score implies a higher overall long-term satisfaction in patients that received autoimplant-mastopexy with similar long-term results compared with augmentation-mastopexy. Nevertheless, individual decision-making is necessary and should be based on the degree of ptosis, existing breast volume, previous operations, and patients’ preferences regarding postoperative breast shape and projection.

Background: The deep inferior epigastric perforator flap (DIEP) has gained widespread popularity in autologous breast reconstruction due to its natural aesthetic results and muscle-sparing design. However, donor site results regarding aesthetic outcome are often less favorable. Despite several studies on surgical technique and improvements of flap harvest, only a small number of studies addressing donor site aesthetic exist. Methods: A systematic review was performed on donor site aesthetic after DIEP flap harvest according to the PRISMA guidelines. Secondary interests were abdominal wall morbidity and complication rates in general. The following electronic databases were included to identify relevant studies: Medline, Embase, PubMed, Cochrane, and Web of Science. Results: The search yielded 95 articles for full-text analysis, with only four key studies found on donor site aesthetic specifically. Regarding complication rates, the overall rate of abdominal hernia ranges from 0 to 7.1%. Abdominal bulging occurs in 2.3% to 33%. Besides abdominal wall integrity, wound dehiscence (12–39%), seroma (1–48%), hematoma (1–15%), infections (1–12%), fat necrosis (0–11%) and umbilical necrosis (2–3%) significantly impair donor site aesthetic. Conclusions: This systematic review reveals that the topic of donor site aesthetic and potential improvement of results has largely been neglected in the past decade. This study provides a thorough evaluation of potential problems that plastic surgeons may encounter and includes recommendations to improve results.

Objective The aim of our systematic meta-analysis was to find out if lipofilling to the breast alters follow-up imaging procedures and leads to an increased number of biopsies because of suspicious findings. Methods We conducted a systematic meta-analysis of the literature including all prospective and retrospective studies focusing on imaging outcomes in patients with a history of breast cancer who have received one or more lipofilling procedures after oncologic surgery to the breast. Results Twelve studies met the inclusion criteria, comprising 1711 patients and at least 2261 lipofilling procedures. 564 patients (33%) were followed up only with ultrasound, 735 patients (43%) only received mammography, 273 (16%) had a combination of ultrasound, mammography and MRI, and 37 patients (2.1%) were followed up via ultrasound and mammography. A collective of 102 patients making up a matched-cohort study received ultrasound, mammography, MRI, and PET/CT, while only 51 of them made up the investigation group who had autologous fat grafting (3%). Biopsy rates were 1%-24% with a medium of 6.5% over all groups. Medium follow-up was 18.8 months (range 6-50 months). The rate of local oncologic events among the patients with lipofilling procedures detected during the study periods was 0.7%. Conclusion Lipofilling to the breast after oncologic operations appears to be a safe procedure with overall low biopsy and local recurrence rate. Suspicious imaging occurs in most cases out of physiologic remodeling and inflammation processes at the operation site and needs to be distinguished from malignant focusses. The amount of required biopsies stands in relation to the used imaging method and the time to follow-up.

Reusing tissue of amputated or unsalvageable limbs to reconstruct soft tissue defects is one aspect of the “spare parts concept.” Using a free fillet flap in such situations enables the successful formation of a proximal stump with the length needed to cover a large defect from forequarter amputation without risking additional donor-site morbidity. The use of free fillet flaps for reconstruction after forequarter and traumatic upper extremity amputations is illustrated here in a case report. A 41-year old patient required a forequarter amputation to resect a desmoid tumor, resulting in an extensive soft-tissue defect of the upper extremity. A free fillet flap of the amputated arm and an additional local epaulette flap were used to reconstruct the defect. At 9 months after the procedure, a satisfactory result with a very well healed flap was attained. Free fillet flaps can be used successfully for reconstruction of large upper extremity defects, without risking additional donor-site morbidity.

Sentinel lymph node dissection (SLND) and radical lymph node dissection (RLND) represent standard surgical procedures in skin cancer patients. Complications may arise, with seroma formation being the most prevalent. Although both conservative and surgical approaches have been undertaken in effort to reduce the occurrence of postoperative seroma, none have been able to show a beneficial effect. Therefore, the aim of our study was to examine the rate of complications in RLNDs and SLNDs in respect to the influence of different preventative techniques on potential seroma formation. We performed an evaluation of all SLNDs and RLNDs within a 2-year period at our hospital. The primary focus was seroma formation, with secondary points being infection, wound healing problems (WHP), and lymphedema, as well as the total length of hospital stay and revision surgery. Three hundred eighty-nine patients were recorded, of which 268 patients (69 %) underwent an SLND while 121 patients (31 %) underwent an RLND. Seroma in RLNDs occurred significantly more frequently with 46.3 % compared to SLNDs with only 11.6 %. Pressure and vacuum dressings were associated with a considerably higher chance of seroma formation, namely 3.5 and 2.1 times more than with a normal dressing. Other methods such as ligation, clipping, fibrin glue, or a sartorius flap showed no effects. RLNDs are associated with a higher rate of seroma regardless of surgical or postoperative approach, whereas SLNDs only induce a few side effects. Further infections, wound healing problems, and lymphedema were significantly associated with seroma formation. Level of Evidence: Level IV, risk / prognostic study

BACKGROUND The application of acellular matrices, biomaterials, and polymeric scaffolds in reconstructive surgery facilitates postsurgical tissue remodeling and is increasingly used clinically in order to improve tissue healing and implant coverage. This study presents an in vivo investigation of the integration of the knitted, silk-derived surgical scaffold, SERI(®) with regard to angiogenesis and wound healing. METHODS SERI(®) Surgical Scaffold was implanted into a full-thickness skin defect in male C57BL/6J mice (n = 45) via the dorsal skinfold chamber (DSC). Skin tissue samples were collected for histology on days 2, 5, 7, 10, 14, and 21 (n = 5 per time point) post implantation. Immunohistochemistry was performed for various angiogenic and inflammatory markers, as well as collagen deposition (CD31, VEGF, CD3, CD45, Desmin, and Sirius red). Vascular corrosion casting was used to assess the neovasculature within the silk and was visualized with scanning electron microscopy. RESULTS We observed both early and late stages of inflammation during the healing process characterized by the infiltration of regenerating tissue by different subsets of leukocytes. Histological analysis displayed capillary-containing granulation tissue with full scaffold integration. In addition, collagen deposition within the scaffold and full skin defect was significantly increased over time. Qualitative analysis of the regenerated vasculature through corrosion casting and scanning electron microscopy revealed a complex, angiogenic network of capillaries originating from the wound bed. CONCLUSIONS Based on these findings, SERI(®) displays the potential to be a promising resorbable bioengineered material for use in reconstructive surgery.

Background The vertical posteromedial thigh (vPMT) perforator flap is a new reliable flap with versatility. The purpose of this article was to report our experience with the use of free vPMT flap for reconstruction of the breast. Patients and Methods From May 2015 to December 2015, seven patients received immediate unilateral breast reconstruction with seven free vPMT flaps. The flaps were raised based on the first medial perforator of the profunda femoris artery (PFA). The internal mammary artery and vein were dissected as recipient vessels. Results The flap sizes varied from 25 × 9 cm to 30 × 10 cm. The average weight of the flap and mastectomy specimen was 431 g (range: 390 to 470 g) and 410 g (range: 360 to 450 g) respectively. The average pedicle length was 10.4 cm (range, 8.5 to 12.5 cm) and the average arterial diameter was 2.1 mm (range, 1.8 to 2.6 mm). All of the flaps survived completely after surgery. The donor sites were all primarily closed with minimal morbidities. Follow-up observations were conducted from 3 to 9 months. All of patients were satisfactory with the reconstruction. Conclusion The vertical vPMT is suitable for breast reconstruction in women with small to moderate breast size; the vertical pattern of the PMT avoids some of the problems related to other flaps with transverse patterns and represents an alternative design that can be successfully used for breast reconstruction. © 2016 Wiley Periodicals, Inc. Microsurgery, 2016.

After microvascular tissue transfer, free flaps require meticulous postoperative surveillance. The purpose of this study was to evaluate the effect and applicability of indocyanine green fluorescence angiography (ICG-FA) in bedside monitoring of free flaps postoperatively, especially considering its role in correctly identifying vascular thromboses. Between February 2012 and October 2015, 210 free flaps used for defect reconstruction were analyzed. The flaps were monitored bedside for flap perfusion compromise by clinical examination and by ICG-FA in a standardized procedure in the first 3 postoperative days. Data were evaluated retrospectively with respect to the etiology of the perfusion compromise with special focus on vascular thromboses and revision rates. In total, 23 vascular thromboses were identified. The combination of clinical examination and ICG-FA (85%) was most successful in determining the prevalence of vascular thromboses. In 41 cases, clinical and/or ICG-FA examinations indicated revision surgery. The flap salvage rate after revision was 77% (31 cases), which results in an overall flap survival rate of 96%. The revision rates were reduced over the study time from 22% in 2012 to 12% in 2015. ICG-FA as an adjunct to clinical examination of free flaps can help in correctly identifying vascular thromboses and can help decide if revision surgery is necessary in not obvious cases of perfusion compromise.

Background: The treatment of extensive skin defects and bradytrophic wounds remains a challenge in clinical practice. Despite emerging tissue engineering approaches, skin grafts and dermal substitutes are still the routine procedure for the majority of skin defects. Here, we review the role of vascularization and lymphangiogenesis for skin grafting and dermal substitutes from the clinician’s perspective. Summary: Graft revascularization is a dynamic combination of inosculation, angiogenesis, and vasculogenesis. The majority of a graft’s microvasculature regresses and is replaced by ingrowing microvessels from the wound bed, finally resulting in a chimeric microvascular network. After inosculation within 48–72 h, the graft is re-oxygenated. In contrast to skin grafts, the vascularization of dermal substitutes is slow and dependent on the ingrowth of vessel-forming angiogenic cells. Preclinical angiogenic strategies with adipose tissue-derived isolates are appealing for the treatment of difficult wounds and may markedly accelerate skin reconstruction in the future. However, their translation from bench to bedside is still restricted by major regulatory restrictions. Finally, the lymphatic system contributes to edema reduction and the removal of local wound debris. Therapeutic lymphangiogenesis is an emerging field of research in skin reconstruction. Key Messages: For the successful engraftment of skin grafts and dermal substitutes, the rapid formation of a microvascular network is of pivotal importance. Hence, to understand the biological processes behind revascularization of skin substitutes and to implement this knowledge into clinical practice is a prerequisite when treating skin defects. Furthermore, a functional lymphatic drainage crucially contributes to the engraftment of skin substitutes.

Background Chronic secondary lymphedema is a well-known complication in oncologic surgery. Autologous lymph node transplantation, lymphovenous anastomosis, and other lymphatic surgeries have been developed in the last decades with rising clinical application. Animal models to explore the pathophysiology of lymphedema and microsurgical interventions have reached great popularity, although the induction of stable lymphedema in animals is still challenging. The aim of this review was to systematically assess lymphedema animal models and their potential use to study surgical interventions. Materials and methods A systematic review according to the PRISMA guidelines was performed without time or language restriction. Studies describing new or partially new models were included in chronological order. Models for primary and secondary lymphedema were assessed, and their potential for surgical procedures was evaluated. Results The systematic search yielded 8590 discrete articles. Of 180 articles included on basis of title, 84 were excluded after abstract review. Ninety-six were included in the final analysis with 24 key articles. Conclusions No animal model is perfect, and many models show spontaneous lymphedema resolution. The rodent limb appears to be the most eligible animal model for experimental reconstruction of the lymphatic function as it is well accessible for vascularized tissue transfer. There is a need for standardized parameters in experimental lymphedema quantification. Also, more permanent models to study the effect of free vascularized lymph node transfer are needed.

Background Congenital hypoplasia of facial bones has traditionally been treated by orthognathic surgery. However, the inherent invasiveness of orthognathic surgery often leads to a high complication rate. Facial fat grafting could be a less invasive method to correct facial deformities. Objectives The aim of this study was to evaluate the results of microfat grafting for facial contouring. Methods This retrospective chart review evaluated 166 patients who were treated with microfat grafting for maxillary and/or mandibular hypoplasia. Pretreatment and posttreatment photographs were compared regarding improvement of facial contour, and complications were recorded. Results The follow-up period ranged from 4 months to 10 years (mean, 2 years 7 months). Thirty-eight percent of the patients had a refill procedure 6 or more months after the first procedure. A majority of the evaluated patients stated that they benefited from the microfat grafting, with ratings of excellent (50%), sufficient (48%), and poor (2%). Complications included visible fat lobules under the lower eyelid skin (7%), which was seen during the first 4 years and was resolved by changing the injection cannulae and technique, and fat resorption, which was seen in all patients, with a clinical range from ±15% in the immobile malar area and chin region to ±50% in the mobile lip area. Conclusions Facial microfat grafting is a valuable alternative to more complicated advancement osetotomies being performed in patients solely for aesthetic reasons. The low morbidity and rapid recovery make facial microfat grafting a welcome tool in the armamentarium of the modern facial aesthetic surgeon. Level of Evidence 4![Graphic][1] Therapeutic [10.1093/asj/sjv084][2] [1]: /embed/inline-graphic-1.gif [2]: /lookup/doi/10.1093/asj/sjv084

Background Fat grafting has been gaining attention in tissue augmentation over the past decade, not only for lipofilling, but also for its observed regenerative properties and overall skin texture improvement. Objectives The aim of this study was to analyze the effect of nanofat grafting on scars, wrinkles, and skin discolorations in our clinic. Methods Nanofat was prepared by a standard emulsification and filtration protocol. The resulting liquid was injected intradermally or directly into the scar tissue. Skin quality was evaluated based on a scoring system, and patient satisfaction was documented. Three physicians compared and analyzed standardized pre- and posttreatment photographs in respect to general improvement of skin aesthetics. Results Fifty-two patients were treated with nanofat from November 2013 to April 2016. The mean (± standard deviation) posttreatment follow up was 155 ± 49 days and average volume of harvested fat amounted to 165 cc. The primary harvesting areas were the abdomen and flanks, and the injected volume of nanofat ranged from 1 to 25 mL (mean, 4.6 mL). A total of 40 scars (76% of all patient defects) were effectively treated as well as 6 patients with wrinkles, and 6 patients with discoloration. Posttreatment clinical evaluations showed a marked improvement of scar quality and a high patient satisfaction. The results in our clinic showed that nanofat grafting softened the scars, made discolorations less pronounced, and wrinkles appeared less prominent. Conclusions Nanofat grafting has been shown to have beneficial effects in the treatment of scars, wrinkles, and skin discolorations. Level of Evidence 4

Meralgia paraesthetica represents a neuropathy involving pain, burning, tingling, and numbness in the distribution of the lateral femoral cutaneous nerve (LFCN) of the thigh, which is commonly due to nerve entrapment under the inguinal ligament. We report an unusual case of compression of the LFCN at the anterior surface of the sartorius muscle in a professional female soccer player. Intraoperatively, the LCFN was found to pass without major compression under the inguinal ligament, but was strained over a fibrous thickening of the superficial thigh fascia and the anterior medial border of the sartorius muscle 8cm caudal of the inguinal ligament. Excision of the fibrous tissue completely resolved the symptoms. In professional athletes, the LFCN should be explored along its entire course on the anterior thigh during operative decompression to rule out a distal muscular compression site. Level of evidence: Level V, therapeutic study

Treatment of fracture dislocations of the PIP joint represents a hand surgical challenge. In hemi-hamate arthroplasty, the palmar joint surface is reconstructed using an osteochondral graft from the hamate and the immediate stability permits early movement.We performed hemi-hamate reconstructions in 10 patients (mean age 34.9 years), who sustained fractures of the base of the middle phalanx of ≥50% surface and dorsal PIP dislocations. Outcomes were assessed by clinical exam and X-ray. Evaluation criteria were range of motion of PIP and DIP joints, grip strength, joint alignment, complications and donor site morbidity. Mean follow-up was 8.6 months (range 3-14). Fractures mostly involved the 4th and 5th fingers, all patients were male. Indications were subluxation and comminuition in acute cases of6 weeks (5 patients) and chronic pain and morning stiffness in chronic cases (5 patients).Operative treatment was performed in average after 93 days (range 0-371 days) after injury. Average PIP motion was 71° (range 0-90); DIP motion was 54° (range 10-90) with a mean PIP flexion contracture of 6.5° (range 0-20). Grip strength averaged 95% of the opposite hand. 4 patients had revision surgery (2× arthrolysis PIP joint, 2× screw shortening, 1× neurolysis R. dorsalis N. ulnaris).Hemi-hamate autograft arthroplasty represents an effective procedure to address severe PIP joint fracture dislocations. It restores the comminuted articular surface in chronic injuries and in the acute injury it is a challenging but valuable alternative to extension block splinting. However, donor site morbidity and revision surgery have to be taken into account.

Background Despite advances in tissue engineering of human skin, the exact revascularization processes remain unclear. Therefore it was the aim of this study to investigate the vascular transformations during engraftment and to identify associated proteolytic factors. Methods The modified dorsal skinfold chamber with autologous skin grafting was prepared in C57BL/6J mice, and intravital microscopy was performed. The expression of proteases and vascular factors was quantified by immunohistochemistry. Results Reperfusion of the skin graft after 72 hours was followed by a temporary angiogenic response of the graft vessels. Wound bed bud formation appeared after 24 to 48 hours representing starting points for capillary sprouting. In the reperfused skin graft larger buds developed over several days without transformation into angiogenic sprouts; instead pruning took place. MT1-MMP was detected at sprout tips of in-growing vessels. MMP-2 expression was located at the wound bed/graft connection sites. Pericytes were found to withdraw from the angiogenic vessel in order to facilitate sprouting. Conclusions Skin graft vasculature responded with temporary angiogenesis to reperfusion, which was pruned after several days and exhibited a different morphology than regular sprouting angiogenesis present within the wound bed. Furthermore we identified MT1-MMP as sprout-tip located protease indicating its potential role as sprout growth facilitator as well as potentially in lysing the existing graft capillaries in order to connect to them. The differences between the wound bed and skin graft angiogenesis may represent a relevant insight into the processes of vascular pruning and may help in the engineering of skin substitutes.

Background In the early postoperative period after pancreas-kidney transplantation, pancreatic venous thrombosis is a major complication that leads to allograft dysfunction and graft loss. Beside ischemia and reperfusion injury, immunosuppressive drugs have been accused of supporting thrombogenicity. The aim of this study was to evaluate the effect of commonly applied immunosuppressants on microvascular thrombus formation in normal and postischemic tissue in vivo. Methods In the skin fold chambers of tacrolimus-, cyclosporine A-, antithymocyte globulin-, rapamycine-, or saline-treated mice, light/dye-induced microvascular thrombus formation was studied. Additional mice underwent ischemia and reperfusion of the skin fold chamber tissue and received tacrolimus, antithymocyte globulin, or saline before reperfusion. Additionally, the effect of prednisolone was tested in animals with ischemia and reperfusion. Concentrations of sP-selectin, soluble vascular cell adhesion molecule-1, and asymmetric dimethylarginine were assessed by enzyme-linked immunosorbent assay. Immunohistochemistry of the skin fold chamber tissue served for analysis of vascular endothelial nitric oxide synthase and inducible nitric oxide synthase expression. Results In normal tissue, tacrolimus, cyclosporine A, antithymocyte globulin, and rapamycine accelerated microvascular thrombus formation significantly when compared with saline. Whereas ischemia and reperfusion in saline-treated mice enhanced thrombus formation, thrombogenicity was not further increased by ischemia and reperfusion in tacrolimus - or antithymocyte globulin-treated animals. Application of prednisolone reversed the tacrolimus- and antithymocyte globulin-induced prothrombotic effect. Antithymocyte globulin increased sP-selectin and soluble vascular cell adhesion molecule-1, whereas tacrolimus induced asymmetric dimethylarginine production significantly. While tacrolimus and antithymocyte globulin additionally induced endothelial nitric oxide synthase and inducible nitric oxide synthase expression, cyclosporine A influenced only endothelial inducible nitric oxide synthase expression. Conclusion Immunosuppressants enhance thrombus formation in vivo. Although antithymocyte globulin activates the microvascular endothelium, we show for the first time that tacrolimus increases asymmetric dimethylarginine plasma levels. Thus, impaired nitric oxide availability might be the underlying mechanism for the tacrolimus-associated increased thrombogenicity. The efficacy of prednisolone to reverse the tacrolimus-associated and antithymocyte globulin-associated acceleration of thrombus formation underlines the application of this anti-inflammatory drug prior to reperfusion in immunosuppressive regimens.