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Ilias G Petrou,1 Kheeldass Jugun,2 Eva Meia Rüegg,1 Thomas Zilli,3 Ali Modarressi,1 Brigitte Pittet-Cuénod11Division of Plastic, Reconstructive and Aesthetic Surgery, Geneva University Hospitals, University of Geneva Faculty of Medicine, Geneva, Switzerland; 2Private Practice, Wellkin Hospital, Moka, Mauritius; 3Division of Radiation Oncology, Geneva University Hospitals, University of Geneva Faculty of Medicine, Geneva, SwitzerlandBackground: Keloids are debilitating fibrous skin proliferations with a high recurrence rate after surgical treatment. Postoperative radiotherapy (PORT) is a well-tolerated adjuvant treatment to reduce the risk of recurrence, but the optimal regimen for this combined treatment remains unknown. The aim of this study is to evaluate the efficacy of combining surgical excision and immediate PORT.Methods: We retrospectively reviewed the records of patients with keloid lesions treated with adjuvant PORT in the period 2005–2014 at Geneva University Hospitals. Main outcomes were the rates of complications and recurrence in patients with a minimal follow-up of 1 year, including the Patient and Observer Scar Assessment Scale satisfaction scores.Results: 10 patients with 16 keloids were eligible (mean follow-up, 37 months). Only one recurrence was reported (6%). In 12.5% of cases, mild erythema appeared in the early postoperative period. No major complications were observed. The overall patient and observer satisfaction rate was excellent.Conclusion: Surgical excision combined with immediate PORT is an effective and easy treatment with good esthetic results and an acceptable recurrence rate. It should be considered for patients with persistent keloid formation after failure of other treatments and those at high risk of relapse.Keywords: keloid, scars, radiotherapy, intralesional excision, scar correction, recurrence

Background:The prevalence of breast lesions (benign, precancerous and cancer lesions) in reduction mammaplasty (RM) specimens has rarely been reported in Europe and never in the Swiss population.Methods:Personal and histopathological data from 534 female patients who underwent RM were reviewed.Results:Benign and/or malignant lesions were detected in 76.2% of all patients. Benign breast lesions associated with an increased risk of developing breast cancer represented 2.8% of all lesions. Breast cancer in situ was identified in 5 (0.9%) patients. Patient age and previous history of breast cancer were risk factors for incidental breast cancer.Conclusion:The rate of incidental carcinoma in situ was higher for patients with breast cancer history. Probably due to preoperative breast cancer investigation, no occult invasive breast cancer was found in reduction mammary specimens. Therefore before RM, breast cancer evaluation should be considered for all patients, especially for those with breast cancer risk factors (e.g., patient age, personal history of breast cancer). [ABSTRACT FROM AUTHOR]

Abstract Background Fournier’s gangrene is a bacterial infection characterized by necrotizing fasciitis, skin and soft tissue involvement, and eventually myositis of the perineal region. Aggressive debridement of devitalized tissue and overlying skin is of paramount importance, but often leaves large defects to be reconstructed. The present case reports successful extensive perineal defects coverage following Fournier’s gangrene and management of subsequent penile lymphoedema impairing sexual function in a young patient. Case presentation Following perianal abscess drainage, a healthy young man presented with scrotal pain. Fournier’s gangrene was diagnosed and treated with multiple surgical debridements. Tissue excision extended through the entire perineal area, base of the penile shaft, lower abdominal region, the inner thighs, and gluteal region, corresponding to 12% of the total body surface area. After serial debridements and negative pressure dressings, the defect was covered by two stages of skin grafting. Graft take was 90%. Healing was achieved without hypertrophic or retractile scar. However, chronic penile lymphedema remained and was first treated with compressive garments for 2 years. Upon failure of this conservative approach, we performed a circumcision, but only a “penile lift” allowed a satisfactory esthetical and functional result. Conclusion Fournier’s gangrene can be complicated by a chronic lymphedema of the penis. Conservative treatment is likely to fail in severe cases and can be treated surgically by “penile lift”.

Differentiation of fibroblasts to myofibroblasts is governed by the transforming growth factor beta (TGF-β) through a mechanism involving redox signaling and generation of reactive oxygen species (ROS). Myofibroblasts synthesize proteins of the extracellular matrix (ECM) and display a contractile phenotype. Myofibroblasts are predominant contributors of wound healing and several pathological states, including fibrotic diseases and cancer. Inhibition of the ROS-generating enzyme NADPH oxidase 4 (NOX4) has been proposed to mitigate fibroblast to myofibroblast differentiation and to offer a therapeutic option for the treatment of fibrotic diseases. In this study, we addressed the role of NOX4 in physiological wound healing and in TGF-β-induced myofibroblast differentiation. We explored the phenotypic changes induced by TGF-β in primary skin fibroblasts isolated from Nox4-deficient mice by immunofluorescence, Western blotting and RNA sequencing. Mice deficient for Cyba, the gene coding for p22 phox , a key subunit of NOX4 were used for confirmatory experiments as well as human primary skin fibroblasts. In vivo, the wound healing was similar in wild-type and Nox4-deficient mice. In vitro, despite a strong upregulation following TGF-β treatment, Nox4 did not influence skin myofibroblast differentiation although a putative NOX4 inhibitor GKT137831 and a flavoprotein inhibitor diphenylene iodonium mitigated this mechanism. Transcriptomic analysis revealed upregulation of the mitochondrial protein Ucp2 and the stress-response protein Hddc3 in Nox4-deficient fibroblasts, which had however no impact on fibroblast bioenergetics. Altogether, we provide extensive evidence that NOX4 is dispensable for wound healing and skin fibroblast to myofibroblast differentiation, and suggest that another H 2 O 2 -generating flavoprotein drives this mechanism., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Reconstruction of large chest wall defects is challenging. Here we discuss the process of decision-making in planning chest wall reconstruction, considering the requirements of tumor removal, stabilization of the chest wall, and soft tissue coverage, illustrated by a case of a hemi-chest wall defect in a child. Ewing sarcoma measuring 10 × 9 × 13 cm was resected in a 9-year-old boy, followed by stabilization using a Gore-Tex patch. Due to extension of the oncologic resection far into the superomedial quadrant of the chest, tension-free coverage with a classical latissimus-dorsi flap could not be achieved. Integrating the serratus-anterior muscle into the flap creating a chimeric latissimus-dorsi/serratus-anterior flap allowed for excellent soft tissue coverage of the foreign body. As the skin could be preserved, careful incision planning was necessary to allow for best possible exposure during oncologic resection and flap harvest, while ensuring skin vascularization impaired by underlying tumor resection. Two vertical skin incisions were chosen, one presternal and a second in the mid-axillary fold delineating a large bipedicled skin flap. Postoperative recovery was excellent. Solid skin vascularization and adequate soft tissue coverage of the alloplastic material allowed for the patient to receive two cycles of postoperative radiotherapy without developing wound dehiscence. Careful interdisciplinary planning of skin incisions allowed for good exposure for tumor resection and flap harvest while preserving skin vascularization. Choosing a chimeric latissimus-dorsi/serratus-anterior flap provided larger coverage than a classical latissimus-dorsi flap with minimal additional donor site morbidity. Taken together, we here present a pragmatic solution to a complex problem., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: An increasing number of breast cancer patients undergo immediate or secondary breast reconstruction, but the ideal method in terms of patient satisfaction remains ambiguous. We compared the 3 most common breast reconstruction techniques to determine patient satisfaction and objective outcomes., Methods: Retrospective study of 184 patients with breast cancer who underwent a reconstructive procedure between 1993 and 2011 at our institution. Procedures evaluated were implant-based reconstruction (IBR) alone, latissimus dorsi (LD) flap reconstruction with/without implant, and deep inferior epigastric perforator (DIEP) free flap reconstruction. A retrospective patient satisfaction questionnaire was sent to all women. Twenty patients from each subgroup were matched to conduct a standardized objective assessment of the sensitivity of their reconstructed breast. A blinded photographic evaluation was also performed by 3 independent observers to assess the esthetic aspect and symmetry., Results: DIEP obtained significantly higher average scores regarding the esthetic outcome, immediate reconstruction impact, and overall score in the questionnaire evaluation. The IBR had the best results in the somatosensory evaluation, with DIEP scoring better than LD. DIEP received higher scores on average than LD for the criteria of size and symmetry in the esthetic evaluation. No statistically significant differences were observed between IBR and DIEP., Conclusions: Good results were reported overall for all breast reconstruction procedures, with more reserved scores for LD. The DIEP reconstruction appeared to be the most satisfactory and best experienced reconstruction method for patients, despite the complexity of the intervention. Clinicians should be encouraged to consider DIEP as the principal choice for breast reconstruction., Competing Interests: Declaration Of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

There is increasing interest in the use of adipose-derived mesenchymal stromal cells (ASCs) for wound repair. As the fate of administered cells is still poorly defined, we aimed to establish the location, survival, and effect of ASCs when administered either systemically or locally during wound repair under physiological conditions. To determine the behavior of ASCs, a rat model with wounds on the dorsal aspect of the hind paws was used and two treatment modes were assessed: ASCs administered systemically into the tail vein or locally around the wound. ASCs were transduced to express both firefly luciferase (Fluc) and green fluorescent protein to enable tracking by bioluminescence imaging and immunohistological analysis. Systemically administered ASCs were detected in the lungs 3 hours after injection with a decrease in luminescent signal at 48 hours and signal disappearance from 72 hours. No ASCs were detected in the wound. Locally administered ASCs remained strongly detectable for 7 days at the injection site and became distributed within the wound bed as early as 24 hours post injection with a significant increase observed at 72 hours. Systemically administered ASCs were filtered out in the lungs, whereas ASCs administered locally remained and survived not only at the injection site but were also detected within the wound bed. Both treatments led to enhanced wound closure. It appears that systemically administered ASCs have the potential to enhance wound repair distally from their site of entrapment in the lungs whereas locally administered ASCs enhanced wound repair as they became redistributed within the wound bed., (© 2019 The Authors. Stem Cells Translational Medicine published by Wiley Periodicals, Inc. on behalf of AlphaMed Press.)

Background : Noma can be a lethal disease and causes disfigurement in young children in low-resource countries, particularly in Africa. In these settings, 80% of the population mainly consult traditional healers for healthcare problems. Our study aimed to describe the sociodemographic characteristics of traditional healers and to assess their knowledge of noma. Methods : We conducted a survey among traditional healers in three Malian regions from May 2015 to January 2016 and collected data on sociodemographic characteristics, professional activity, knowledge, and experience of noma and collaboration with modern medicine. Results : Among 770 traditional healers invited to participate, 732 responded (95%) (mean age, 54.5 years). Most were illiterate (66.3%), which was associated with older age ( p < 0.001). Although they treated all types of disease, only 10.5% had some knowledge of noma, with regional differences ( p < 0.001). Conclusion : Noma is poorly known among traditional healers, especially in remote areas. Our findings suggest a lack of interest among young people for traditional medicine, implying an imminent decrease of healers, and thus the need for national health systems to strengthen and promote access to modern health care. Training programmes to improve the early diagnosis referral of noma patients should include all types of primary health workers.

Nowadays autologous fibroblast application for skin repair presents an important clinical interest. In most cases , in vitro skin cell culture is mandatory. However, cell expansion using xenogeneic or allogenic culture media presents some disadvantages, such as the risk of infection transmission or slow cell expansion. In this study, we investigated an autologous culture system to expand human skin fibroblast cells in vitro with the patient's own platelet-rich plasma (PRP). Human dermal fibroblasts were isolated from patients undergoing abdominoplasty, and blood was collected to prepare nonactivated PRP using the CuteCell™ PRP medical device. Cultures were followed up to 7 days using a medium supplemented with either fetal bovine serum (FBS) or PRP. Fibroblasts cultured in medium supplemented with PRP showed dose-dependently significantly higher proliferation rates (up to 7.7 times with 20% of PRP) and initiated a faster migration in the in vitro wound healing assay compared with FBS, while chromosomal stability was maintained. At high concentrations, PRP changed fibroblast morphology, inducing cytoskeleton rearrangement and an increase of alpha-smooth muscle actin and vimentin expression. Our findings show that autologous PRP is an efficient and cost-effective supplement for fibroblast culture, and should be considered as a safe alternative to xenogeneic/allogenic blood derivatives for in vitro cell expansion. Impact Statement Autologous dermal fibroblast graft is an important therapy in skin defect repair, but in vitro skin cell culture is mandatory in most cases. However, cell expansion using xenogeneic/allogenic culture media presents some disadvantages, such as the risk of infection transmission. We demonstrated that an autologous culture system with the patient's own platelet-rich plasma is an efficient, cost-effective, and safe supplement for fibroblast culture. As it respects the good manufacturing practices and regulatory agencies standards, it should be considered as a potent alternative and substitute to xenogeneic or allogenic blood derivatives for the validation of future clinical protocols using in vitro cell expansion.

Keloids are debilitating skin lesions that develop often as a result of minor skin lesions. Unlike hypertrophic scars, their main clinical feature is the tendency to extend beyond the initial limits of the wound. They can be responsible for pain and itching and may appear several months after the trauma. Their pathophysiology remains unknown but various mechanisms seem to be involved. Their management includes invasive and non-invasive approaches. At present, there is no satisfactory method or consensus on their management. Since the risk of recurrence after treatment is particularly high, a combination of different methods is proposed. In this article, we present the therapeutic strategy used in our institution concerning these problematic lesions., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Background: The submental flap is a pedicled island flap with excellent color match for facial reconstruction. The flap can be raised with muscle, submandibular gland, or bone and can be transposed to reach defects up to two-thirds of the face. The authors report the primary author's (D.M.) experience of 25 years using the submental flap from its original description to most recent technical evolutions in both Europe and Africa., Methods: This is a retrospective study including all patients with facial defects who underwent reconstruction using a submental flap between 1991 and 2016. This study included the use of all four variations of the submental flap: platysmal, digastric, extended, and superextended. The authors report technical adaptations and complications encountered., Results: The authors performed 311 facial reconstructions using submental flaps: 32 platysmal, 133 digastric, 91 extended, and 45 superextended variations. In conjunction with these reconstructions, the authors performed 10 osteocutaneous submental flaps and two free flaps. The authors report two cases of total flap necrosis (0.6 percent) and 28 minor complications, including 23 cases of distal skin necrosis (7 percent), one reversible mandibular facial nerve palsy (0.3 percent), and three hematomas (1 percent)., Conclusions: The submental flap has proven to be a reliable flap for head and neck reconstruction. The four technical modifications described use varying amounts of soft tissue to replace tissue lost and can include vascularized bone from the mandibular margin. This flap exemplifies Gillies' principle of "replacing like with like" and should be discussed as an alternative to free tissue transfer in facial reconstruction, especially in settings where resources are limited., Clinical Question/level of Evidence: Therapeutic, IV.

Background: Median and paramedian craniofacial clefts are associated with hypertelorism, anterior encephalocele, positional abnormalities of the maxilla, and nasal deformity. Cleft lip and palate, eyelid coloboma, and widow's peak are frequently present., Methods: The authors collected data from 30 patients (mean age, 5.8 years; range, 4 months to 18 years) operated between 1986 and 2017 with median or paramedian craniofacial clefts of differing degrees of severity. Malformations of the different anatomic units and their surgical treatment were assessed, as well as complication rates., Results: All patients presented nasal malformations and either telecanthus (n = 16) or hypertelorism (n = 14). Most patients (n = 23) had anterior encephalocele. All patients underwent nasal corrections, and most of them had medial canthopexy (n = 24). Excision of encephalocele was associated with fronto-orbital remodeling. Medialization of the orbits was performed in 11 patients, mainly by box shift (n = 9). Patients from outside Switzerland (n = 23) were operated at an older age than those in the native patient group. Because of staged reconstruction, 13 patients had more than one operation. Surgical complications included three infections and one expander exposition. One patient had bone resorption of a frontal bone flap. Nasal correction needed more than one procedure in 5 patients, and medial canthopexy had to be repeated in 7 patients. Esthetic results were satisfactory, permitting social integration., Conclusion: Median and paramedian craniofacial clefts need adapted and carefully planned corrections respecting the growth of anatomic units. The quality of the medial canthal and nasal reconstruction is to a large extent responsible for the overall result., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: The adjunction of autologous platelet-rich plasma (PRP) is emerging as a promising approach to enhance the long-term survival of fat grafting, but there are still insufficient data on its efficacy. The aim of this in vivo study was to assess the effect of the addition of non-activated PRP on fat graft outcome., Methods: Human adipose tissue mixed with 20% of non-activated PRP was injected under the scalp skin of nude Balb/cAnNRj mice and compared to grafted fat mixed with 20% of saline. The fat graft volume was analyzed by a computed tomography scan until day 90 and immunohistochemistry was then performed to assess adipocyte viability and graft revascularization., Results: At day 90, the volume of fat graft was not enhanced by PRP compared to the saline control group. However, immunohistochemistry showed that PRP significantly increased the fat graft area occupied by intact adipocytes compared to the saline group (72.66% vs. 60.78%, respectively; p < 0.05). Vascularity was also significantly higher in the PRP group compared to the control group (6695 vs. 4244 CD31 + cells/µm 2 , respectively; p < 0.05)., Conclusion: The adjunction of non-activated-PRP to fat grafts significantly increased adipocyte viability and tissue vascularity. However, in contrast to other studies adding activated-PRP, non-activated-PRP did not increase residual fat graft volume until day 90. Further studies are therefore needed to understand whether PRP has a positive effect on fat graft volume. As 3D computed tomography scan is a reproducible and precise technique, it should be used to analyze fat graft volume changes over time., (Copyright © 2019. Published by Elsevier Ltd.)

Background: Eradication of chronic tibial osteomyelitis necessitates aggressive debridement is often followed by soft tissue reconstruction. Muscular flaps are said to be more effective than non-muscular flaps for infection treatment, while fasciocutaneous and perforator flaps are considered to be less invasive and offering a better aesthetic result., Methods: In this study, we reviewed 24 consecutive cases of chronic tibial osteomyelitis treated according to a specific protocol in a tertiary hospital. Soft tissue coverage was done with either muscular or non-muscular free flaps. Infection recurrence and complications were compared between different flap types. Additionally, we assessed the long-term functional and aesthetic results and patient's satisfaction., Results: Muscular flap was used in 13 patients (13 latissimus dorsi and 1 serratus anterior) and 11 patients underwent fasciocutaneous/perforator flaps [1 anterolateral thigh flap, 4 lateral arm flaps, 5 thoracodorsal artery perforator (TAP) flaps and 1 radial forearm flap]. Infection was resolved for 84.6% of patients in the muscular flaps group and 90.9% in the non-muscular flaps group. None of the patients with muscular flaps were satisfied with the aesthetic appearance of their reconstructed leg when compared to 83.3% of patients with non-muscular flaps. Also, a slight regain of touch sensitivity was acknowledged in the non-muscular flap group compared to the muscular., Conclusion: In this study of adult chronic tibial osteomyelitis cases, we demonstrated that fasciocutaneous and perforator free flaps offer a comparable efficacy to the muscle flaps for infection treatment, with a significantly higher patient satisfaction and aesthetic result.

Long-segment tracheal reconstruction remains a challenge. The ideal tracheal substitute should be an epithelialized tube to prevent stenosis and sufficiently rigid to maintain airflow patency. An autologous technique using a radial forearm free flap reinforced by rib cartilage has been recently described for tracheal reconstruction. We report here two cases of complex tracheal reconstruction with a modification of this technique, which consists of the creation of two independent skin paddles to allow the reconstruction of the trachea and a second adjacent defect (eg, cervical skin, esophagus). Airway patency was achieved with no stenosis, prolonged stenting, fistula, or necrosis after 26 and 44 months, respectively. We suggest that the satisfactory outcome obtained with this modified technique is a valuable option for tracheal and adjacent defect reconstruction without the need for a second flap.

Tissue engineering technologies are new and promising techniques in fat tissue reconstruction. However, to assess their efficacy before any clinical application, in vivo experiments are mandatory. This study assesses whether microcomputed tomography (CT) scan imaging is suitable to analyze in vivo the behavior of injected engineered polymer and changes in fat tissue. The volume of mice inguinal fat pads and the resorption rate of different polymers were analyzed by CT scan for up to 3 months. Different biomaterials were used, including our innovative microspheres loaded with oleic acid. We were able to follow in vivo the polymer and the fat volume of the same animals during a long-term follow-up of 90 days. Semiautomatic three-dimensional quantification allowed to determine the fat volume enhancement after injection, as well as the resorption rate of our product compared to other biomaterials (i.e., polylactic and hyaluronic acid) until 90 days. Our results demonstrate the encouraging proof-of-principle evidence for the application of micro-CT scan technology to follow in vivo biodegradable polymers in a fat tissue engineering approach. This noninvasive technique offers the advantages of the long-term follow-up of fat tissue and synthetic materials in the same animals, which allows both a scientific evaluation of the measurements and the reduction of the number of animals used in in vivo protocols in accordance with the 3 "R" principles governing the use of animals in science.

Our understanding of the role of oxygen in cell physiology has evolved from its long-recognized importance as an essential factor in oxidative metabolism to its recognition as an important player in cell signaling. With regard to the latter, oxygen is needed for the generation of reactive oxygen species (ROS), which regulate a number of different cellular functions including differentiation, proliferation, apoptosis, migration, and contraction. Data specifically concerning the role of ROS-dependent signaling in cutaneous wound repair are very limited, especially regarding wound contraction. In this review we provide an overview of the current literature on the role of molecular and reactive oxygen in the physiology of wound repair as well as in the pathophysiology and therapy of chronic wounds, especially under ischemic and hyperglycemic conditions., Competing Interests: The authors declare no conflict of interest.

Introduction: Some surgeons consider a high body mass index (BMI) or important abdominal fat excess as contraindications for breast reconstruction with free deep inferior epigastric perforator (DIEP) flap. This study aimed to identify factors associated with post-operative complications by using this type of flap, with an emphasis on BMI and abdominal subcutaneous fat thickness., Methods: A retrospective chart review of 105 consecutive patients who underwent DIEP flap breast reconstruction at our institution was performed to assess post-operative complications. Among other risk factors, we specifically studied the influence of BMI and abdominal wall thickness on complication occurrence. Abdominal wall thickness was measured at 10 different points on the angio-computed tomography scan performed pre-operatively., Results: Median age was 49.8 years (range, 27-69); average BMI was 25.57 kg/m 2 (range, 18.07-41.91). Immediate breast reconstruction was performed for 35% of patients, and five patients (4.7%) underwent bilateral reconstruction. Twenty-six patients (24.8%) presented 29 post-operative complications; 12 concerned abdominal complications (delayed wound healing [n = 6] and seroma [n = 6]) and 17 were related to complications of the reconstructed breast (six minimal necrosis treated conservatively, eight minor necrosis requiring surgical debridement and three total flap loss). The complication rate was not correlated with increased BMI or abdominal wall thickness. The only factor that significantly predicts DIEP flap complications was pre-operative radiotherapy (odds ratio = 4.05; p = 0.03)., Conclusions: No significant correlation was observed between BMI of 25-35 kg/m 2 or abdominal wall thickness and post-operative complications of the donor site or DIEP flap. Therefore, these factors should not be considered as contraindication criteria., (Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

We report two rare cases of inflammatory reactions with multiple subcutaneous facial painful collections after Hyaluronic acid injections, expose their management and discuss aetiologic hypothesis. Due to unfavourable evolution despite antibiotic treatment, surgical drainage was performed. Immune-mediated delayed hypersensitivity reactions were the most probable cause.

The interdisciplinary management of patients with multiple organ injuries after lightning strike is of paramount importance. Cutaneous burns can be associated to other organ injuries requiring emergency and life-support treatment. We report the case of a lightning strike victim who presented with burns as well as cardiologic and neurologic complications.

Introduction: Reconstruction of facial bone defects in children is challenging. The use of well-vascularized bone is mandatory to obtain stable lasting results. This study reports our experience of facial bone reconstruction using prefabricated vascularized calvarium flaps., Methods: Retrospective case series of 50 patients who underwent 52 maxillary, malar, and mandibular reconstructions between 1988 and 2014 using prefabricated vascularized calvarium flaps. Forty-nine patients suffered from noma sequels; one patient had craniofacial cleft Tessier 3-11. Surgery consisted of a two-step procedure beginning with flap delay and prelamination with skin grafting on the galea. Flap harvest followed at least 2 weeks later (range, 2-16 weeks), including a full-thickness calvarium fragment, which was set into the facial defect., Results: Early complications concerned wound healing and infections requiring surgical revision in six patients at the recipient and six at the donor site. There was one flap loss. Clinical long-term assessment at 15-year median follow-up (range, 1-27 years) showed good results, assuring facial height and contour. Radiological long-term results demonstrated excellent integration of the flap to the adjacent facial skeleton of the growing child., Conclusions: Prefabricated vascularized calvarium flaps are an effective, safe and lasting method for reconstruction of facial bone defects in children., (Copyright © 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.)

The treatment of chronic wounds remains inconsistent and empirical. Hyperbaric oxygen therapy (HBOT) is a promising method to improve wound repair but there is still a lack of understanding of its mechanisms of action and its indications are not yet clearly defined. We studied the effects of HBOT in four different wound conditions by inflicting bilateral wounds on the dorsal aspect of the feet of nonischemic or ischemic limbs in normoglycemic or hyperglycemic rats. To create an ischemic condition, arterial resection was performed unilaterally. Forty-four animals received HBOT five times a week until complete wound closure. Wound repair was compared with 44 rats receiving standard dressing only. HBOT increased blood flow and accelerated wound closure in ischemic and hyperglycemic wounds, most significantly when the two conditions were combined. Wound contraction and reepithelialization were similarly stimulated by HBOT. The acceleration of wound contraction was not associated with increased myofibroblasts expression, nor fibroblast recruitment or higher cell count in the granulation tissue. Of note, we observed a significant increase in collagen deposition in early time points in ischemic wounds receiving HBOT. This data emphasizes that an early application of HBOT might be crucial to its efficacy. We concluded that wounds where ischemia and hyperglycemia are combined, as it is often the case in diabetic patients, have the best chance to benefit from HBOT., (© 2016 The Authors Wound Repair and Regeneration published by Wiley Periodicals, Inc. on behalf of The Wound Healing Society.)

Introduction: Most post-bariatric patients seek body contouring procedures to correct skin excess after massive weight loss. Among these procedures, some surgeons are still wary of circular abdominoplasty, mainly because it is considered a major intervention associated with a high complication rate. The aim of this study was to assess the complication rate of circular abdominoplasty performed on patients presenting with massive weight loss, with a particular emphasis on patient selection and surgical technique., Methods: Fifty-six consecutive patients who underwent circular abdominoplasty following massive weight loss between January 2001 and March 2015 were included in the study. The indications for the procedure were abdominal skin excess extending to the flanks and the posterior region of the lower trunk. Data were collected retrospectively through medical charts and photographs., Results: Forty-nine patients were female. The mean age was 39.8 years, with a mean preoperative body mass index of 25.7 kg/m 2 . The mean time between bariatric surgery and circular abdominoplasty was 3.3 years. The overall complication rate was 23.2%, mostly minor, with only one (1.7%) early surgical revision under local anesthesia for delayed wound healing. Blood transfusion was required for 8.9% of patients., Conclusion: Patient selection (e.g., body mass index < 30 kg/m 2 ), precise preoperative planning and markings, and simple and careful surgical technique with minimal liposuction and undermining are crucial. Ensuring these key factors renders circular abdominoplasty a reliable and safe procedure, with low complication rates., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

NADPH oxidases (NOX) mediate redox signaling by generating superoxide and/or hydrogen peroxide, which are involved in biosynthetic pathways, e.g. thyroid hormone generation, dityrosine crosslinking, as well as bacterial killing. Data investigating the role of NOX enzymes in cutaneous wound repair is limited and specifically their function in skin myofibroblast expression is unknown. The isoform NOX4 was recently shown to be a pre-requisite for the differentiation of cardiac and pulmonary myofibroblasts. In this study we investigate the role of NOX4 in wound repair using a wound model in NOX4 knockout mice (n=16) and wildtype mice (n=16). Wounds were photographed daily until complete wound closure. Mice were sacrificed at day 3, 7, 14; wound tissue was harvested. NOX4-deficient mice healed significantly slower (22 days, SD=1.9) than wild-type mice (17 days, SD=1.4, p<0.005). However, there was no difference in myofibroblast expression. Strong dityrosine formation was observed, but was significantly weaker in NOX4-/- mice (p<0.05). NOX2, HIF1α and CD31 expression was significantly weaker in NOX4-/- mice (p<0.05). In this study we show for the first time that NOX4 plays a role in cutaneous wound repair. Our data suggests that NOX4 mediates HIF1α expression and neoangiogenesis during wound repair. NOX4 deletion led to a decreased expression of NOX2, implying a role of NOX4 in phagocytic cell recruitment. NOX4 was required for effective wound contraction but not myofibroblast expression. We suggest that myofibroblast contraction in NOX4-deficient mice is less effective in contracting the wound because of insufficient dityrosine-crosslinking of the ECM, providing the first indication for a physiological function of dityrosine crosslinking in higher animals., (Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Hyperglycemia is known to adversely affect the outcome of ischemic insults, but its interaction with ischemia has not been investigated in wound repair yet. In this study, we develop a new animal model allowing to investigate the interaction between hyperglycemia and ischemia during the wound repair process. We focus on myofibroblast differentiation, a key element of wound repair., Methods: Ischemia was inflicted in Wistar rats by resection of the femoral to popliteal arteries on the left side, whereas arteries were dissected without resection on the right side. Full-thickness skin wounds (1 cm(2)) were created on both feet. Hyperglycemia was induced by injection of streptozotocin. Normoglycemic animals served as control (n = 23/group). Blood flow, wound closure, and myofibroblast expression were measured., Results: Wound closure was significantly delayed in ischemic compared with nonischemic wounds in all rats. This delay was almost 5-fold exacerbated in hyperglycemic rats compared with normoglycemic rats, while hyperglycemia alone showed only a slight effect on wound repair. Delayed wound repair was associated with impaired wound contraction and myofibroblast differentiation., Conclusions: Our model allows to specifically quantify the effect of hyperglycemia and ischemia alone or in combination on wound repair. We show that hyperglycemia amplifies the inhibitory effect of ischemia on wound repair and myofibroblast expression. Our data reveal for the first time the synergic aspect of this interaction and therefore stress the importance of a strict glycemic control in the management of ischemic wounds.

Currently the use of non-autologous cell culture media (e.g., animal-derived or allogeneic serum) for clinical applications of mesenchymal stem cells (MSCs) is criticized by regulatory agencies. Autologous platelet-rich plasma (PRP) is proposed as a safer alternative medium supplement for adipose-derived mesenchymal stem cells (AT-MSC) culture. To study its efficiency on cell proliferation, AT-MSCs were cultured for 10 days in media supplemented with different concentrations of autologous non-activated PRP (nPRP) or thrombin-activated PRP (tPRP) (1-60%). AT-MSC proliferation, cell phenotype, multipotency capacity, and chromosome stability were assessed and compared to AT-MSCs expanded in a classical medium supplemented with 10% of fetal bovine serum (FBS). Culture media supplemented with nPRP showed dose-dependent higher AT-MSC proliferation than did FBS or tPRP. Twenty percent nPRP was the most effective concentration to promote cell proliferation. This condition increased 13.9 times greater AT-MSC number in comparison to culture with FBS, without changing the AT-MSC phenotype, differentiation capacity, and chromosome status. We concluded that 20% autologous nPRP is a safe, efficient, and cost-effective supplement for AT-MSC expansion. It should be considered as an alternative to FBS or other nonautologous blood derivatives. It could serve as a potent substitute for the validation of future clinical protocols as it respects good manufacturing practices and regulatory agencies' standards.

Introduction. Medical tourism for aesthetic surgery is popular. Nontuberculous mycobacteria (NTM) occasionally cause surgical-site infections. As NTM grow in biofilms, implantations of foreign bodies are at risk. Due to late manifestation, infections occur when patients are back home, where they must be managed properly. Case Report. A 39-year-old healthy female was referred for acute infection of the right gluteal area. Five months before, she had breast implants replacement, abdominal liposuction, and gluteal lipofilling in Mexico. Three months postoperatively, implants were removed for NTM-infection in Switzerland. Adequate antibiotic treatment was stopped after seven days for drug-related hepatitis. At entrance, gluteal puncture for bacterial analysis was performed. MRI showed large subcutaneous collection. Debridement under general anaesthesia was followed by open wound management. Total antibiotic treatment was 20 weeks. Methods. Bacterial analysis of periprosthetic and gluteal liquids included Gram-stain plus acid-fast stain, and aerobic, anaerobic and mycobacterial cultures.  Results. In periprosthetic fluid, Mycobacterium abscessus, Propionibacterium, and Staphylococcus epidermidis were identified. The same M. abscessus strain was found gluteally. The gluteal wound healed within six weeks. At ten months' follow-up, gluteal asymmetry persists for deep scarring. Conclusion. This case presents major complications of multisite aesthetic surgery. Surgical-site infections in context of medical tourism need appropriate bacteriological investigations, considering potential NTM-infections.

Background: The positive impact of Roux-en-Y gastric bypass on weight, comorbidities, and health-related quality of life is well documented. However, 50 percent of patients regain some of the lost weight after 2 years with Roux-en-Y gastric bypass and present a mean weight regain of 10 to 15 percent after several years, partially losing the previously obtained benefits. The authors hypothesize that body contouring could decrease weight regain, leading to better long-term weight control after Roux-en-Y gastric bypass., Methods: In a matched control study, variations in weight for 98 patients with body contouring after Roux-en-Y gastric bypass were compared with those of 102 matched control patients with Roux-en-Y gastric bypass alone. Data were collected prospectively at 1, 3, 6, 9, 12, and 18 months after Roux-en-Y gastric bypass and then yearly until 7 years., Results: After a massive mean weight loss of 45.2 kg during the first 2 years after Roux-en-Y gastric bypass, patients with Roux-en-Y gastric bypass alone presented a higher continuous mean weight regain than those with Roux-en-Y gastric bypass and body contouring (1.78 kg/year versus 0.51 kg/year of weight regain, respectively; p = 0.001). After 7 years, patients with Roux-en-Y gastric bypass presented significantly higher mean weight regain than patients with Roux-en-Y gastric bypass and body contouring (i.e., 10.8 percent versus 3.6 percent mean weight gain, respectively; p < 0.001). Netting out mean skin excision weight of 2.04 kg by body contouring, the weight regain was 22.9 kg for patients with Roux-en-Y gastric bypass alone and only 6.2 kg for those with Roux-en-Y gastric bypass and body contouring., Conclusions: The authors demonstrated that patients with body contouring present better long-term weight control after Roux-en-Y gastric bypass. Therefore, body contouring must be considered as a reconstructive operation in the treatment of morbid obesity., Clinical Question/level of Evidence: Therapeutic, III.

Background: Shockwave (SW) application has been shown to limit flap necrosis. However, the underlying microhemodynamic mechanisms remain unclear. Therefore, the objective of this study was to analyze the effect of SW application on a microcirculatory level., Methods: We treated 12 C57BL/6 mice with local SW application (500 shockwave impulses at 0.15 mJ/mm(2)) either 24 h before (preconditioning [PRE]) or 30 min after (postconditioning [POST]) flap elevation. Animals with an untreated flap (CON) or without a flap served as controls. We applied dorsal skinfold chambers to the animals and performed epifluorescence microscopy over a 10-d period to assess microcirculatory parameters (arteriolar diameter, red blood cell velocity, blood flow, functional capillary density, and intercapillary distance) as well as inflammation, apoptotic cell death, and necrosis., Results: SW application significantly decreased tissue necrosis independently of the application time point (PRE: 29% ± 7%; POST: 25% ± 7% versus CON: 47% ± 2%; day 10, P < 0.05). Arteriolar diameter, red blood cell velocity, and blood flow were not statistically significantly different among the 3 flap groups. However, SW (PRE and POST) resulted in an early and persistent increase in functional capillary density and consequently decreased intercapillary distance compared with CON and the group without a flap (P < 0.05). Also, SW resulted in a significantly decreased inflammatory response (P < 0.05) and induced an angiogenic response, as indicated by new functional microvessel formation observed 5 d after therapy., Conclusions: Local SW application improved tissue survival by recruitment of sleeping capillaries within the non ischemic tissue and maintenance of capillary perfusion within the critically perfused tissue after induction of ischemia, which was independent of the application time point. Neoangiogenesis occurred beyond the ischemic tolerance of the tissue, and therefore does not seem to contribute to improved tissue survival., (Copyright © 2013 Elsevier Inc. All rights reserved.)