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Lichen sclerosus et atrophicus is an inflammatory, scarring dermatosis of the female anogenital area and may lead to pain and sexual dysfunction. In select cases which are refractory to conservative therapy, surgery may provide significant symptom improvement. The objective of this study was to expand the range of surgical treatment options for these patients by presenting the operative outcomes of a specialised reconstructive method using the anterior obturator artery perforator (aOAP) flap. A retrospective cohort study was conducted on sexual outcomes following the excision of affected vulvovestibular tissue by skinning vulvectomy and subsequent single-stage reconstruction using the aOAP flap. Additional procedures, such as the Omega-Domed (OD) flap, scar surgery and clitoral re-exposure, were performed when indicated. Between 2014 and 2022, a total of 61 patients were surgically treated and retrospectively included in this study. Vulvectomy and subsequent reconstruction with bilateral aOAP flaps were performed in 53 (87%) cases. There was a significant reduction in the prevalence of dyspareunia and inability to have sexual intercourse at the 1-year follow-up compared to baseline (p < 0.001). There were several minor, reversible complications that required secondary intervention. The outcomes of this study indicate a substantial improvement in sexual function, evidenced by a significant reduction in dyspareunia and an increased ability to engage in sexual intercourse. Altered tissue quality in patients with lichen sclerosus et atrophicus and long-term cortisone application may predispose this patient population to a higher risk of minor post-operative complications. DRKS00033261 [ABSTRACT FROM AUTHOR]

Background: International migration from high-prevalence regions has increasingly confronted nonendemic countries with female genital mutilation/cutting (FGM/C), and Western-based health care providers have seen a greater demand for surgical reconstruction of female anatomic units. The authors introduce novel surgical techniques developed by the first author for clitoral and vulvovestibular reconstruction and examine operative outcomes., Methods: The authors performed a retrospective cohort study of operative outcomes of the omega domed flap, neurotizing and molding of the clitoral stump (NMCS procedure), and anterior obturator artery perforator flap for preputial, clitoral, and vulvovestibular reconstruction, respectively. Between 2014 and 2021, the authors treated patients with all types of FGM/C, and analyzed various data, including demographics, clitoral sensation, and symptoms such as dysmenorrhea, dysuria, dyspareunia, and anorgasmia. The authors aimed to examine the efficacy and safety of these techniques in improving clitoral sensation and reducing symptoms., Results: A total of 119 women (mean age, 31.0 ± 10.4 years) were included. The authors performed the omega domed flap (85%), the NMCS procedure (82%), or the anterior obturator artery perforator flap (36%), and had a 1-year follow-up period, which was attended by 94.1% of patients. Patients reported significant postoperative reduction of dysmenorrhea, dysuria, and dyspareunia, as well as significant improvement of clitoral sensation and ability to achieve orgasm ( P < 0.001). There was 1 major complication (loss of flap) reported. Secondary ambulatory interventions were performed in 10 patients (8.4%)., Conclusion: By allowing for safe and effective anatomic reconstruction of the female genitalia, the described surgical techniques represent a new stage of treatment possibilities for women with FGM/C., Clinical Question/level of Evidence: Therapeutic, IV., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Introduction: Numerous techniques have been proposed for the plastic surgical treatment of hypertrophic breasts. Challenges of the procedure include the preservation of vascular supply and sensitivity of the nipple areola complex (NAC), breast feeding, and an esthetically pleasing result., Objectives: In the present preliminary report, we introduce a new technique called the three-block L-wing reduction mammaplasty that addresses the aforementioned difficulties., Materials and Methods: The three-block L-wing reduction mammaplasty with a thick hemispheric superiorly based NAC pedicle and a medial as well as lateral pillar was performed in a total of 60 patients., Results: Our technique increases both, vascular safety and the sensory supply to the NAC, as it conceptually decreases the need for dissection of breast tissue and skin. The incidence of fat necrosis and wound healing disorders may be reduced with this technique. Because the ducts of the breast-gland underneath the NAC are not dissected, this technique also promises a higher probability of regular breast-feeding. Finally, our technique permits a cosmetically pleasing round-shaped mound of the breast., Conclusion: The three-block modification simplifies the procedure of the superior pedicle L-wing mammaplasty markedly. It may increase the esthetic as well as the functional outcome and decrease postoperative complications., Competing Interests: Declaration of Competing Interest All authors declare that they have no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Female genital mutilation/cutting (FGM/C) is a worldwide problem affecting millions of women and is especially common in Africa and Arabia. Women suffer from serious physical and psychological problems. Anatomic reconstruction, therefore, is an important and life-changing option for many affected women., Objectives: This work gives a short overview of specialized techniques invented by the author for functional and aesthetic vulvar reconstruction following FGM/C. This work does not intend to provide anatomic or surgical details., Materials and Methods: The anterior obturator artery perforator flap (aOAP flap), the omega domed flap (OD flap), and a microsurgical procedure called neurotizing and molding of the clitoral stump (NMCS procedure) are described., Results: The aOAP-flap for vulvar reconstruction, the OD-flap for clitoral prepuce reconstruction, and the NMCS-procedure for reconstruction of the clitoral tip provided natural, reliable, and long-lasting results, all of which normalize the anatomy of the mutilated outer female genitalia., Conclusions: The reconstructive options presented contribute to re-establish normal anatomy and, thus, support women's health and relieve the burden forced upon them by FGM/C.

Autologous nerve transplantation (ANT) is the clinical gold standard for the reconstruction of peripheral nerve defects. A large number of bioengineered nerve guides have been tested under laboratory conditions as an alternative to the ANT. The step from experimental studies to the implementation of the device in the clinical setting is often substantial and the outcome is unpredictable. This is mainly linked to the heterogeneity of clinical peripheral nerve injuries, which is very different from standardized animal studies. In search of a reproducible human model for the implantation of bioengineered nerve guides, we propose the reconstruction of sural nerve defects after routine nerve biopsy as a first or baseline study. Our concept uses the medial sural nerve of patients undergoing diagnostic nerve biopsy (≥ 2 cm). The biopsy-induced nerve gap was immediately reconstructed by implantation of the novel microstructured nerve guide, Neuromaix, as part of an ongoing first-in-human study. Here we present (i) a detailed list of inclusion and exclusion criteria, (ii) a detailed description of the surgical procedure, and (iii) a follow-up concept with multimodal sensory evaluation techniques. The proximal medial sural nerve biopsy model can serve as a preliminary nature of the injuries or baseline nerve lesion model. In a subsequent step, newly developed nerve guides could be tested in more unpredictable and challenging clinical peripheral nerve lesions (e.g., following trauma) which have reduced comparability due to the different nature of the injuries (e.g., site of injury and length of nerve gap).

Fibromata pendulantia often appear as small filiform skin tags with a narrow pedicle in the neck, axilla and groin areas. Hitherto, extensive fibromata pendulantia were resected either surgically (curette, scissors, scalpel) or by laser. The present case study of an adipose patient with disseminated fibromata pendulantia in the axillary region in the setting of pseudoacanthosis nigricans introduces the Versajet hydrosurgery technique as an alternative method. It is able to remove tissue and rinse the wound simultaneously by means of a high-pressure water jet.

Evaluation of functional and structural recovery after peripheral nerve injury is crucial to determine the therapeutic effect of a nerve repair strategy. In the present study, we examined the relationship between the structural evaluation of regeneration by means of retrograde tracing and the functional analysis of toe spreading. Two standardized rat sciatic nerve injury models were used to address this relationship. As such, animals received either a 2 cm sciatic nerve defect (neurotmesis) followed by autologous nerve transplantation (ANT animals) or a crush injury with spontaneous recovery (axonotmesis; CI animals). Functional recovery of toe spreading was observed over an observation period of 84 days. In contrast to CI animals, ANT animals did not reach pre-surgical levels of toe spreading. After the observation period, the lipophilic dye DiI was applied to label sensory and motor neurons in dorsal root ganglia (DRG; sensory neurons) and spinal cord (motor neurons), respectively. No statistical difference in motor or sensory neuron counts could be detected between ANT and CI animals.In the present study we could indicate that there was no direct relationship between functional recovery (toe spreading) measured by SSI and the number of labelled (motor and sensory) neurons evaluated by retrograde tracing. The present findings demonstrate that a multimodal approach with a variety of independent evaluation tools is essential to understand and estimate the therapeutic benefit of a nerve repair strategy.

Background: The superior pedicle, frequently used with vertical mammaplasty, bears some risk for vascular complications of the nipple areola complex (NAC) particularly in large breasts. The suprasternal notch to nipple distance (SSN:N), geometrically associated with the longitudinal axis of the breast and length of the superior pedicle, might be an indicative parameter to assess these complications. Importance of the SSN:N for vascular complication of the NAC was focussed upon in this study., Material and Methods: Arterial and venous complications of 104 patients following the superior pedicle vertical mammaplasty were retrospectively evaluated both sided (n=208 breasts), according to the preoperatively measured SSN:N. Binary logistic regression (p≤0.05) was used for statistical evaluation., Results: Probability of vascular compromise of the NAC is influenced by the SSN:N within the context of the superior pedicle vertical mammaplasty. An SSN:N>30 cm (n=112 breasts) is subject to venous (p=0.002) as well as arterial (p=0.232) complications of the NAC, both of which may result in partial necrosis of the tissue (p=0.029)., Conclusion: The SSN:N measurement can be helpful to identify patients at risk for vascular complications of the superiorly stalked NAC. Modifications of the superior pedicle or other pedicles potentially providing enhanced vascular impact might be considered with an SSN:N beyond 30 cm to reduce vasculature-related complications of the NAC., (Copyright © 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Assessment of the therapeutic potential of interventions to bridge-repair peripheral nerve defects heavily relies on the demonstration of improved functional outcome. In the present study we used CatWalk gait analysis (locomotor-test) and Static Sciatic Index (SSI) (static-toe-spread-test) to assess the behavioural benefits of autologous nerve transplantation (ANT) repair of 2-cm rat sciatic nerve defects (neurotmesis-lesion). A reproducible and standardised rat sciatic nerve crush lesion model (axonotmesis-lesion) was used to assess the extent of recovery supported by maximal axon regeneration (measured by SSI and CatWalk). Animals were behaviourally followed for a period of 10 weeks. SSI analysis showed that ANT induced a significant improvement in motor deficit from about -95 to -65, however, CatWalk analysis did not show any major indication of locomotor recovery. This discrepancy might suggest that improvements in static motor functions (such as toe spreading) could reflect an early indicator for the recovery of function. We also noted differences in axon regeneration including increased axon density, smaller axon diameters and thinner myelin sheaths in the distal region of the ANT in comparison to the equivalent region of crushed and normal nerves. This difference in axon regeneration may be related to the clearly improved toe spreading function. We conclude that SSI and CatWalk present different advantages and disadvantages for the assessment of motor recovery after bridge-repair of peripheral nerve defects., (Copyright © 2010 Elsevier B.V. All rights reserved.)

Objective: Vulvar reconstruction following oncologic resection is challenging. Some flaps used for reconstruction can show adverse characteristics such as excessive tissue bulk or increased distance to the defect. Region of the sulcus genitofemoralis is of thin and pliable tissue proximate to the vulva. Vasculature and suitability of that region used for vulvar reconstruction were focused in this work., Methods: Vascular architecture of the region comprising the sulcus genitofemoralis was examined bilaterally on 10 female corpses (n = 20 specimens). In addition, tissue characteristics and suitability of that region to form a fasciocutaneous flap for vulvar reconstruction were anatomically examined and clinically proven., Results: Vasculature of the sulcus genitofemoralis is reflected by either a musculocutaneous perforator (80%, 16/20) piercing the gracilis muscle or a septocutaneous perforator (20%, 4/20) passing the posterior border of the gracilis muscle 1.3 ± 0.3 [cm] laterally to the inferior pubic ramus. Both types of perforators derive from the anterior branch of the obturator artery and accompanying vein. This perforator, the anterior obturator artery perforator (aOAP), supplies a skin territory of about 7 × 15 [cm] centered on the sulcus genitofemoralis. The aOAP flap proved its suitability and versatility for vulvar reconstruction., Conclusions: The sulcus genitofemoralis is of a constant vascular anatomy reflected by the aOAP vessel. Especially the tunneled aOAP island flap offers outstanding characteristics beneficial for reconstruction of a more anatomically normal vulva. Scars are limited within anatomic borders of the urogenital region improving self-image. The aOAP flap clearly enlarges the surgical options available to restore the form and function of the vulva., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Purpose: Separation of midline abdominal wall components or other procedures involving the papilla umbilicalis within the context of abdominal wall reconstruction can significantly affect vasculature of the umbilicus. Adjusting dissection to the vascular anatomy of that region may evade such complications. For this purpose, an anatomic microdissection study was performed, focusing on the vascular architecture of the papilla umbilicalis in the midst of the stratigraphical anatomy of the midline abdominal wall., Methods: Ramifications of the epigastric vessels were filled with dye on 27 abdominal walls originating from 15 female and 12 male corpses. Vascular architecture of the midline abdominal wall was examined by X-ray imaging and microdissection focusing region of the papilla umbilicalis., Results: Vasculature of the papilla umbilicalis is provided by both myocutaneous and septocutaneous perforator vessels originating from the medial branch of the arteria epigastrica inferior and accompanying veins. On their way to the inferiolateral basis of the papilla umbilicalis, these perforators prove an intimate and regular association with the rectus abdominis muscle, and different components of the rectus sheath., Conclusions: Vasculature of the papilla umbilicalis is susceptible to damage resulting from separation of midline abdominal wall components or periumbilical dissections. To secure vasculature of the papilla umbilicalis, the integrity of the loose areolar fascia covering the posterior surface of the rectus abdominis muscle must be kept from being harmed by dissection. In addition, the musculo-fibrous-aponeurotic anatomy on either the left or the right side of the papilla umbilicalis must be left in structural continuity.

Little is known about species differences in the peripheral nerve system and quantitative evaluation of main tissue components has rarely been done. Nevertheless, animal models are used for example in pain research without exact knowledge of degree of fibrosis in pathological states which would determine possible treatment options. It would therefore be of crucial interest to describe the degree of fibrosis and the remaining functional nerve tissue as exact as possible. In the present study we evaluated collagen (stroma) and nerve fiber (parenchyma) composition of peripheral nerves in three species (human, rat, pig) and used digital colour-separation and analysis for collagen type differentiation and quantification of immuno-positive-stained area. We found similar ratios of collagen types I and III in epineurium and similar immuno-positive area for staining of neurofilament and S-100beta. In contrast, we measured significantly different ratios of collagen type I to type III in the endoneurium. This combined analysis of the main tissue components of peripheral nerves could be an easy-to-use tool in evaluating changes during damage caused by scaring, systemic disease or compression syndromes. The calculated collagen type I/III ratio may serve as an objective diagnostic value for the description or as prognostic marker for therapeutic approaches in peripheral nerve pathology. However, in particular studies of collagen accumulation in nerves, species dependant differences have to be considered., (Copyright 2010 Elsevier B.V. All rights reserved.)

The standard split-thickness superior pedicle vertical mammaplasty technique sometimes suffers from tension on the nipple-areola complex (NAC). We suggest a bisected full-thickness superiorly based flap that offers two vectors for transposition within the context of superior pedicle vertical mammaplasty. The procedure increases both upper-pole fullness and projection of the breast while decreasing tension on the NAC. The surgical procedure presented contributes to a natural appearance of the breast. It should provide a useful and simple surgical option, increasing the versatility of the superior pedicle vertical mammaplasty technique.

Following peripheral nerve injury repair, improved behavioural outcome may be the most important evidence of functionality of axon regeneration after any repair strategy. A range of behavioural testing paradigms have been developed for peripheral nerve injury research. Complete injury of the adult rat sciatic nerve is frequently used in combination with walking track analysis. Despite its wide-spread use, these walking track analyses are unsuitable for the simultaneous assessment of both dynamic and static gait parameters. Conversely, a novel automated gait analysis system, i.e. CatWalk can simultaneously measure dynamic as well as static gait parameters and, importantly, it's easy to control for the speed of locomotion which can strongly affect gait parameters. In a previous study, CatWalk was already successfully used to examine deficits in both dynamic and static gait parameters using the sciatic nerve lesion model with a 1cm gap characterized by absence of recovery [Deumens R, Jaken RJ, Marcus MA, Joosten EA. The CatWalk gait analysis in assessment of both dynamic and static gait changes after adult rat sciatic nerve resection. J Neurosci Methods 2007;164:120-30]. Using the sciatic nerve crush injury model (validated with the static sciatic index) and a follow-up period of 12 weeks, we now show that CatWalk can also measure behavioural recovery. In particular dynamic gait parameters, coordination measures, and the intensity of paw prints are of interest in detecting recovery as far as these parameters completely return to pre-operative values after crush injury. We conclude that CatWalk can be used as a complementary approach to other behavioural testing paradigms to assess clinically relevant behavioural benefits, with a main advantage that CatWalk demonstrates both static and dynamic gait parameters at the same time.

Complete nerve transection (neurotmesis) of the rat sciatic nerve is a well-established animal model. The most frequently used behavioural for evaluation of neurotmesis-induced deficits is the walking track analysis with calculation of the sciatic functional index (SFI). More recently, the static sciatic index (SSI) has been developed, which shows a good correlation with the SFI. However, despite all advantages (high accessibility, easy handling, high accuracy, cost-effectiveness), the SSI is still not widely used. We, therefore, developed a novel programme ("Visual-SSI"), which will be made freely available for the assessment of the SSI. As gold-standard for the treatment of neurotmesis-induced nerve gaps, autologous nerve transplantation studies in the rat sciatic nerve model (n=16 [6 weeks], n=8 [12 weeks]) were carried out to test the effectiveness and feasibility of the Visual-SSI software. We observed a significant recovery starting from the pre-operative condition over the 3rd, 6th, 9th weeks until the 12th week after surgery (p<0.05). Theoretically, the SSI can be calculated from both rearing and normal standing position of the rats and we investigated whether the SSI is affected differentially by these positions. We observed no significant differences between animals in a rearing and normal standing stance (p>0.05). The present method combines efficiency (simplicity of use, rapid and economical setup) with accurate and precise quantification of the functional regeneration in the sciatic nerve lesion model of the rat.

Background and Objective: Concerning current clinical practice, laser-assisted lipoplasty is still secondary to other procedures. In order to evaluate effects of thermal interaction with fatty-tissue, a near infrared diode laser was examined under reproducible conditions., Methods: Based on optical spectroscopy of fatty-tissue, a high-powered diode laser (lambda = 940 nm) was used to irradiate n = 59 fat samples of fresh corpses in non-contact mode. Thermal effects were histologically evaluated by computer based metric measurements. Calculated values included ablation rate (AR) and the ratio of cavity diameter to diameter of collateral damage (CCD(ratio)). Pearson's correlation and analysis of covariance (ANCOVA) were used for statistical evaluation. P values of less than 0.05 were considered to indicate statistical significance., Results: Regarding the conditions examined, irradiances from 250 to 400 W/cm(2) revealed both increased ablation capacities and decreased collateral damages. An average irradiance of 370+/-0 W/cm(2) shows an average CCD(ratio) of 2:1 and an average AR of 9.98+/-7.65 mm(3)/second., Conclusion: Near infrared high-powered diode laser energy proved to be eligible for tissue protective ablation of fat in vitro. Further studies are necessary to improve efficiency and safety of this procedure.

Background: Vascular-dependent necrosis of the nipple-areola complex following reduction mammaplasty is still present. Concerning anatomy, there is a lack of literature comparing the vasculature of different nipple-areola complex-bearing pedicles in detail. Including six arterial sources supplying the breast, this anatomical work intends to clarify arterial impact and vascular reliability of different nipple-areola complex-bearing pedicles., Methods: Microdissections of anterior chest walls following vessel filling with dye were performed to examine the architecture of the arteries supplying the breast and their contribution to the blood supply of the nipple-areola complex on seven female corpses (14 breasts)., Results: Four of six arterial sources supporting the breast were found to be mainly responsible for the blood supply of the nipple-areola complex. These are, in descending order of reproducibility, branches originating from the lateral thoracic artery, the internal mammary artery, the anterior branches of the intercostal arteries, and those deriving from the highest thoracic arteries. Despite vessel variability, both arrangements and subcutaneous courses of arteries advancing to the nipple-areola complex showed characteristic relationships., Conclusions: Vascular variability and overlap may account for the remarkable safety of diverse nipple-areola complex-bearing pedicles, even though pedicle thickness influences vascular reliability. Lateral and medial approaches, however, clearly show vascular advantages over that which can be observed in inferior and superior pedicles. The former may therefore be regarded as more reliable. Especially the full-thickness glandular dermal superolaterally based pedicle should regularly enclose dominant branches originating from the lateral thoracic artery and supplementary arteries deriving from minor important sources in this region.

Aim: This anatomic study is intended to point out the most regular and reproducible vessels supplying the nipple-areola complex (NAC) for use in vertical mammaplasty., Background: The superior pedicle technique routinely performed within the context of vertical mammaplasty procedures bears some risk for vascular dependent complications of the NAC especially in large breasts. Concerning vasculature, the supposedly most eligible pedicle to use should meet equally the best vascular requirements and technical demands necessary for maintaining both viability of the NAC and plasticity of the entire breast tissue., Methods: Based on an anatomic microdissection study of the thoracic vessel system of seven female corpses, a modification of the superior pedicle approach to carry the NAC was anatomically evaluated and tailored to vertical mammaplasty performed in the L-technique., Results: Out of six vascular sources responsible for the blood supply to the breast the branches originating from the lateral thoracic artery and concomitant veins appeared to reflect the major source of blood supply to the NAC due to their regularity and reproducibility. Especially the full-thickness glandular-dermal superolaterally-based pedicle should safely enclose these dominant branches, as well as supplementary vessels deriving from minor important sources in this region, while keeping plasticity of the vertically reduced breast., Conclusion: The superolaterally-based full-thickness glandular-dermal pedicle mobilized epipectorally to carry the NAC proves to be anatomically a safe and reliable procedure eligible as an integral part of vertical mammaplasty.

The comfort of heated car seats has gained popularity worldwide. We present a rare case of severe second- and third-degree burn in the lower back and sacral region of a 42-year-old post-traumatic paraplegic patient while using a heated car seat. The patient was admitted to our burn unit and required several reconstructive surgery procedures. Inadvertent thermal injury is a constant potential hazard for individuals with impaired sensibility such as paraplegics and other neurologically impaired patients. Early education of patients, manufacturers, and health care personnel is of eminent importance to prevent severe burn injuries in this risk population.

Aim: In order to prevent wound healing problems around the transposed umbilicus following abdominoplasty, we investigated the arterial vascularisation of the abdominal wall with special regard to the umbilicus. The aim was to optimise the planning of the umbilical stalk and flap design., Method: The inferior and superior epigastric arteries of 12 cadavers (mean age 83 years) were injected with barium-sulphate, lead-mennige and gelatine. The abdominal walls were resected en bloc and X-ray photographs were taken by conventional and mammographic technique., Results: The radiographic examination showed that the main trunks of the epigastric vessels follow an "hour-glass" or "rhomboid" pattern around the centromedial umbilicus. Each main trunk splits into two obligate branches one medial and one lateral. The anastomosis between the inferior and superior epigastric artery is located above the umbilicus. The umbilicus is nourished by separate axial vessels originating from the inferior epigastric artery. It was also shown that the inferior intercostal arteries anastomose with the branches of the inferior and superior epigastric artery., Conclusion: Dividing the abdominal wall into four quadrants around the central umbilicus, the lateral areas of the lower quadrants show the weakest vascularisation by the inferior epigastric artery. This fact may cause healing problems after surgery in this area. The axial vascularisation of the umbilicus makes any torsion or traction a potential hazard to the umbilical flap during abdominoplasty especially by re-siting the umbilicus. The anatomical study showed clearly the benefit of preparing a broad base fat layer with a generous diameter of incision line around the umbilicus.