Transgenic skin biomechanical properties following first lifesaving epidermal regeneration using combined gene and cell therapy.

BACKGROUND: In 2017, we reported the first life-saving regeneration of virtually an entire epidermis by combined gene and stem cell therapy. Recently, we demonstrated excellent long-term stability of this transgenic epidermis. Skin quality in this experimental approach and its potential application in other conditions were elucidated here regarding long-term outcomes of biomechanical properties. PATIENTS AND METHODS: Analysis of biomechanical properties including skin elasticity, anisotropy and friction was performed on multiple body sites 24, 36 and 60 months following transplantation. Firstly, the sites were matched against and compared to remaining stable non-transgenic areas as well as to a control group of 13 healthy subjects. Parameters for skin elasticity, deformation and friction were assessed non-invasively. RESULTS: Biomechanical properties of the transgenic epidermis showed encouraging results in comparison to both the remaining stable non-transgenic skin as well as healthy controls. Skin elasticity was comparable to the controls. Skin friction showed some decrease in both transgenic and non-transgenic areas as compared to the controls. CONCLUSIONS: The excellent functional outcomes of the transgenic epidermis demonstrate stable long-term results of this novel combined gene and stem cell therapy for epidermal regeneration. Thus, other applications for this technology, such as treatment of specific burns, should be explored.

Breaking the circle-effectiveness of liposuction in lipedema.

BACKGROUND: Lipedema is a common chronic fat distribution disorder often aligned with pain and reduced quality of life affecting 6-10% of the female population. Although lipedema has acquired more scientific attention in the last decade, validated diagnosis and treatment still remain challenging for specialists. PATIENTS AND METHODS: In this article we evaluate the effect of liposuction on appearance, pain and coexisting diseases of 860 patients with lipedema. Comparison among stages of lipedema pre- and post-liposuction was performed by using t-Tests for independent samples and Kruskal-Wallis-Tests. RESULTS: Our study demonstrates the positive effect on pain reduction in patients with lipedema after liposuction (NRS 2.24) compared with pre-liposuction pain perception (NRS 6.99) and pain perception of patients with conservative treatment (NRS 6.26). Significant differences were shown in the perception between the stages of lipedema and in the reduction of pain perception by liposuction. Furthermore we examined co-diseases in patients with lipedema, primarily menstruation complaints (43%), sleeplessness (36%) and migraine (35%). CONCLUSIONS: A progress of lipedema disease leads not only to a change of appearance and proportion but also to a progressive increase of pain. Liposuction shows a significant effect on pain reduction -independent of the patients' stage of lipedema.

Breast Reconstruction- Developing a Volumetric Outcome Algorithm.

Postoperative loss of breast volume represents a significant parameter for outcome evaluation of breast reconstruction. Breast volume broadly varies- depending of reconstruction method as well as surgical differences. A structural pattern of breast volume loss provides an essential parameter for preoperative design, helps to reduce postoperative breast asymmetry rate and thereby the need for reoperation. Therefore we hereby compare volume change of the three main reconstruction techniques: autologous flap-based, prosthesis-based and autologous fat transplantation breast reconstruction. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Volumetry in Breast Reconstruction: Always New, Always Better?

Although breast surgeries for aesthetic or reconstructive purposes are regularly performed, no focus has been laid on establishing an adequate and reliable volumetry method. While CT and MRI scan represent methods that are already in clinical use, the 3D scan  is a novel and promising tool, easy to use with the possibility to measure the anatomic breast volume in an upright position. Nevertheless, its reliability is broadly underinvestigated. LEVEL OF EVIDENCE V : This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Changes in acute and trauma hand surgery in the first Covid-19 lockdown in a German trauma center: a retrospective analysis of 338 cases.

INTRODUCTION: Although Covid-19 and especially lockdown periods have affected our everyday live, its impact on hand traumatology is under investigated. MATERIALS AND METHODS: We retrospectively analyzed all patients presenting at a FESSH accredited HTRC and level 1 trauma center in Germany during the Covid-19 lockdown period and an equivalent timeframe in 2019 regarding incidence of hand trauma, injury mechanism, type of injury and hand surgeries. RESULTS: 338 patients presented at our department with acute hand injuries. A significant reduction of work-related accidents was found during lockdown contrary to an increase of do-it-yourself related trauma. Although the incidence of hand trauma decreased during lockdown by 18%, the rate of hand surgery increased in absolute and relative numbers. CONCLUSIONS: Although Covid-19 has negatively impacting elective and semi-elective surgeries, acute hand surgery has gained in importance represented by a shift from work related to do-it-yourself trauma and an increased rate of surgical treatment. LEVEL OF EVIDENCE: IV (therapeutic).

Understanding Breast Implant Illness: Etiology is the Key.

Because breast augmentation is one of the most popular cosmetic procedures, the issue of implant-related complications has been widely debated ever since the FDA approved the use of implants in 1962. Although decades have passed, breast implant illness (BII) still represents a poorly defined and controversial complication. With ongoing nonscientific discussion in the mainstream media and on social media, revealing the etiology of BII is urgent because knowledge of this subject ultimately influences patients' decisions. Little or no scientific research is currently available on BII and no final conclusions regarding its etiology, clinical manifestations, diagnostic criteria, or treatment have been made. This review aims to give an overview of the hypotheses on the etiology of BII and seeks inspiration to improve the conditions of BII patients.

Social Media Marketing: What Do Prospective Patients Want to See?

BACKGROUND: Platforms such as Instagram, Facebook, Twitter, and Google+ have created a worldwide audience of almost 3 billion people. Society is dramatically changing, demanding evolution of marketing strategies by plastic surgeons and aesthetic doctors alike. This unknown territory provides excellent opportunities, but creates many pitfalls as well; uncertainty remains as to the most effective manner to promote one's practice/services. OBJECTIVES: The aim of this study was to design a social experiment based on Instagram to give guidance for efficient self-promotion. METHODS: An Instagram account called "doctor.aesthetics" was created. Content was produced, and categorized into 4 groups: Aesthetics, Private Life, Disease, and Science. No bots or other Instagram-based promotion were utilized. Every post was evaluated regarding likes, comments, clicks, new followers, impressions, and savings. RESULTS: After 5 months and 37 posts, 10,500 people followed the account. "Scientific" posts were excluded from the analysis due to a low response rate. A significantly enhanced number of likes for "Private" postings was found. Additionally, "Private" posts led to most clicks and new followers, whereas "Aesthetics" posts were saved by most people. CONCLUSIONS: To benefit the most from social media advertising, it is necessary to offer insights into private life. Although "Aesthetics" and "Disease" postings showed similar response rates, "Scientific" posts failed to attract people.

Comparison of surgical and patient-reported outcomes between 85 profunda artery perforator flaps and 122 deep inferior epigastric perforator flaps as first-choice treatment for breast reconstruction.

BACKGROUND: The profunda artery perforator (PAP) flap for breast reconstruction was first published in 2012. Since then, many centers implemented its application as second-line treatment for breast reconstruction in cases where patient characteristics make the deep inferior epigastric perforator (DIEP) flap not feasible to perform. In our center, we established the PAP flap as a first-line procedure for a multitude of reasons for a specific patient population. This study describes perioperative measure, clinical outcomes, and patient-reported outcome measures in comparison to the gold standard, the DIEP flap. METHODS: In this study, we analyzed all PAP flaps and DIEP flaps performed in a single center between March 2018 and December 2020. We present patient characteristics, surgical technique, perioperative care, surgical outcomes, and complications. The Breast-Q was used to assess patient-reported outcome measures. RESULTS: A total of 85 PAP flaps and 122 DIEP flaps were performed within 34 months. Average follow-up was 11.6 ± 5.8 months for the PAP group and 11.1 ± 5.8 months for the DIEP group (p = 0.621). Patients' average body mass index was higher in the DIEP flap recipients. Operation time was shorter and ambulation faster in PAP flap recipients. DIEP flap application resulted in higher Breast-Q scores. CONCLUSIONS: While the PAP flap demonstrated favorable perioperative measures, outcome measures were better with the DIEP flap. The PAP flap is fairly new and demonstrates high potential while still showing a need for refinement compared to the DIEP flap.

Seasonal Impact on Free Flap Surgery in Terms of Flap Loss and Wound Healing Disorders: A Retrospective Cohort Study of 158 Free Flaps.

(1) Background: Postoperative flap loss and wound healing disorders are severe complications after microsurgical free flap surgery. Despite multiple clinical observations, a possible influence of season and external temperature on outcome are largely missing. (2) Methods: Retrospectively, data were collected from 151 patients receiving microsurgical free flaps from March 2018 to August 2019. Patients were divided into two cohorts. The winter group includes all patients who underwent surgery from October 2018 to March 2019 and the summer group al those who underwent surgery from April 2018 to September 2018. Data included demographic information, pre-existing conditions, flap characteristics, and postoperative complications like flap losses and wound healing problems. External temperatures during the first 14 postoperative days were documented and the predictor of flap loss and wound healing disorders was detected. (3) Results: In the winter group (October-March; Ø 7.24 °C) 72 patients (46 female, 24 males; Ø 57.0 years) and in the summer group (April-September; Ø 18.79 °C) 81 patients (48 female, 33 males; Ø 56.0 years) received free flap surgery. There were no significant differences in demography (age: p = 0.593; gender: p = 0.419; BMI: p = 0.141). We found a significant increase in flap loss during summer (χ2(1) = 6.626; p = 0.010; V = 0.209) strengthened by logistic regression analysis (p = 0.037; Exp(B) = 9.655). Additionally higher average temperatures 14 days postoperatively represents another main driver (p = 0.023, Exp(B) = 1.161) for postoperative flap loss. (4) Conclusions: The data confirm a significantly higher postoperative flap loss in the summer group. This information may potentially contribute to optimization of perioperative management and planning of elective and semi-elective surgeries.

Scapholunate ligament reconstruction using a part of the extensor carpi radialis brevis tendon through a dorsal approach.

Thirty-six patients were assessed after scapholunate ligament reconstruction using a portion of the extensor carpi radialis brevis through a dorsal approach. The median age was 53 years. Most (27/38) were graded as scapholunate advanced collapse Grade I. At a median of 47 months after treatment, hand function using the Disabilities of Arm, Shoulder and Hand Questionnaire was 12. The postoperative range of wrist flexion and extension movement was 77% and grip strength 92% compared with the uninjured side. The median patient satisfaction was rated as 9/10. Median pain scores without and with load, using the numeric pain scale (0-10), were 1 and 3, respectively. This reconstruction leads to initial normalization of radiological features, such as scapholunate interval, scapholunate and radiolunate angles, but a notable loss of the immediate postoperative reduction was observed in long-term follow-up, which was not accompanied by any deterioration in the clinical examination. This technique, even in scapholunate advanced collapse type I wrists, resulted in long-term, improved outcomes compared with other techniques.Level of evidence: IV.

[Stacked PAP flap for unilateral breast reconstruction: a case report]. / Der stacked PAP-Lappen zur unilateralen Brustrekonstruktion ­ ein Fallbericht.

BACKGROUND: In recent years, the PAP (profunda artery perforator) flap has gained popularity in reconstructive breast surgery. However, the tissue available for flap harvest is usually limited. Therefore, grafting two PAP flaps to form a stacked PAP flap for unilateral reconstruction of large breasts is a safe and reliable option. Patient We present the case of a 59-year-old patient arriving at our unit with prior bilateral nipple-sparing mastectomy and implant-based reconstruction after diagnosis of BRCA-2 mutation and breast cancer. Autologous reconstruction with a DIEP flap was the initial treatment suggested to our patient. Preoperative CT scans showed subpar perforators not suitable for anastomosis, ultimately resulting in unilateral DIEP flap reconstruction on the left side. After an uneventful postoperative period, the patient requested autologous conversion of the right side due to persistent symptomatic capsular contracture. To achieve symmetry with the contralateral breast, we decided to perform a stacked PAP flap for unilateral breast reconstruction. RESULTS: The combined flaps provided enough tissue to achieve a satisfactory aesthetic result and symmetry and weighed 600 g in total, while the single DIEP flap on the left side weighed 716 g. There were no complications during the surgical procedure. Postoperative recovery was uneventful, and the patient was discharged after seven days. There were no signs of adipose tissue necrosis at the most recent check-up. On the left donor side, there was a small wound healing defect, which healed well non-surgically. The patient was satisfied with the results. CONCLUSION: The PAP flap has become an established alternative to standard breast reconstruction procedures. The stacked PAP flap can provide a safe and efficient method for unilateral reconstruction of large breasts. Perfusion and drainage through the inferiorly anastomosed flap showed sufficient outflow and did not lead to increased adipose tissue necrosis. In our case, the total surgery time was not substantially longer than in single PAP flap surgery. Furthermore, the possibility of unilateral placement of two flaps may avoid follow-up operations such as multiple lipotransfers to equalise both breasts.

Measurement of Postoperative Quality of Pain in Abdominoplasty Patients-An Outcome Oriented Prospective Study.

(1) Background: Postoperative pain is a frequently underestimated complication significantly influencing surgical outcome and patient satisfaction. While abdominoplasty is one of the most commonly performed plastic surgery procedures, studies investigating postoperative pain are limited in current literature. (2) Methods: In this prospective study, 55 subjects who underwent horizontal abdominoplasty were included. Pain assessment was performed by using the standardized questionnaire of the Benchmark Quality Assurance in Postoperative Pain Management (QUIPS). Surgical, process and outcome parameters were then used for subgroup analysis. (3) Results: We found a significantly decreased minimal pain level in patients with high resection weight compared to the low resection weight group (p = 0.01 *). Additionally, Spearman correlation shows significant negative correlation between resection weight and the parameter "Minimal pain since surgery" (rs = -0.332; p = 0.013). Furthermore, average mood is impaired in the low weight resection group, indicating a statistical tendency (p = 0.06 and a Χ2 = 3.56). We found statistically significant higher maximum reported pain scores (rs = 0.271; p = 0.045) in elderly patients. Patients with shorter surgery showed a statistically significant (Χ2 = 4.61, p = 0.03) increased claim for painkillers. Moreover, "mood impairment after surgery" shows a dramatic trend to be enhanced in the group with shorter OP duration (Χ2 = 3.56, p = 0.06). (4) Conclusions: While QUIPS has proven to be a useful tool for the evaluation of postoperative pain therapy after abdominoplasty, only continuous re-evaluation of pain therapy is a prerequisite for constant improvement of postoperative pain management and may be the first approach to develop a procedure-specific pain guideline for abdominoplasty. Despite a high satisfaction score, we detected a subpopulation with inadequate pain management in elderly patients, patients with low resection weight and a short duration of surgery.

Development of Open Backend Structures for Health Care Professionals to Improve Participation in App Developments: Pilot Usability Study of a Medical App.

BACKGROUND: Efficient digitization in medicine still is in its infancy but undeniably has great potential for current and future challenges in health care. Thus far, the rollout of medical apps has not resulted in widespread use of smartphones in the German health care sector-the reasons for this have not been clarified so far. Nevertheless, the lack of user involvement in the development process and content creation might contribute to low acceptance of these products. OBJECTIVE: This study aims to outline an approach to involve medical expertise without any coding knowledge for developing medical app content and functions. METHODS: An end user-operable backend was built. Its usability was evaluated using a usability evaluation test protocol. The results of the usability tests were evaluated by the app development team, and the usability test was repeated for optimizing backend usability. In total, 40 criteria to measure the ease of app usage were defined a priori. The usability test comprised 20 tasks that had to be fulfilled. Usability tasks were analyzed for completion, dropout, and test duration. Due to the COVID-19 pandemic, digital videoconferencing platforms (Zoom and QuickTime Player) were used to complete usability questionnaires. Finally, several backend-based apps for several specialties (infectiology, plastic and reconstructive surgery, and orthopedics) were developed by health care professionals as prototypes. RESULTS: Initial usability testing was conducted with 5 participants (4 men and 1 woman; mean age 39.2, SD 5.97 years). All of them could complete the assigned backend tasks with only a few workflow interruptions and some minor errors. After usability optimization, the workflow completion time decreased from 5.03 minutes to 3.50 minutes, indicating a time saving. The basic backend structure was clear to all test users and the handling was intuitive to learn. Some minor errors in the backend occurred during the test rounds. The apps developed using the aforementioned approach are in clinical use as a proof of concept. CONCLUSIONS: Backends offering operability for medical professionals might have great potential for app development in the mobile health sector. Sophisticated and time-saving usability are pivotal for the acceptance of medical software, as illustrated by the backend-based apps presented herein, which are in clinical use as a proof of concept. Basic interventions are essential and sufficient for adequate usability optimization. Practicable, well-structured software usability evaluation is possible based on the usability evaluation test protocol.

Understanding the Vicious Circle of Pain, Physical Activity, and Mental Health in Lipedema Patients-A Response Surface Analysis.

Lipedema is a widespread disease with painful accumulations of subcutaneous fat in the legs and arms. Often, obesity co-occurs. Many patients suffer from impairment in mobility and mental health. Obesity and mental health in turn can be positively influenced by physical activity. In this study, we aimed to examine the interrelations between pain and physical activity on mental health in lipedema patients. In total, 511 female lipedema patients (age M = 40.16 ± 12.45 years, BMI M = 33.86 ± 7.80 kg/m2) filled in questionnaires measuring pain, physical activity, and mental health (PHQ-9; WHOQOL-BREF with subscales mental, physical, social, environmental, and overall health). Response surface analyses were calculated via R statistics. The explained variance was high for the model predicting depression severity (R2 = 0.18, p < 0.001) and physical health (R2 = 0.30, p < 0.001). Additive incongruence effects of pain and physical activity on depression severity, mental, physical, and overall health were found (all p < 0.001). In our study, physical activity and pain synergistically influenced physical, mental, and overall health. The pain not only led to low mental health but also interfered with the valuable potential of engaging in physical activity in lipedema patients.

Patient-Reported Outcomes of Liposuction for Lipedema Treatment.

BACKGROUND: Lipedema, as a disabling and consequential disease, is gaining more awareness due to its potential omnipresence. Patients suffering from lipedema show a characteristic painful display of symmetric accumulations of adipose tissue. The combination of swelling, pain and decreased quality of life (QOL) is outstanding for the diagnosis. The aim of this study was to identify the effect of liposuction in terms of the QOL for patients and underline important factors of current and pending research regarding surgical therapy of lipoedema. METHODS: Patients suffering from lipedema prior to and after receiving liposuction at our hospital were included in this study. Patients completed a lipedema-specific self-designed 50 item questionnaire: the World Health Organization Quality of Life BREF (WHOQOL-BREF) and the Patient Health Questionnaire 9 (PHQ-9). A linear mixed model was used for outcome analysis. RESULTS: In total, 511 patients completed a questionnaire prior to the surgery at primary presentation to the hospital and a total number of 56 patients completed a questionnaire after liposuction. A total of 34 of these patients filled in both questionnaires prior to and after surgery. The general characteristics of the disease, such as daily symptoms and psychological health, pertinently improved after surgery. CONCLUSIONS: Liposuction can have a general improving effect on the QOL of patients, both in private and professional life. Liposuction may currently be the most evident and promising method in the treatment of lipedema.

Three-Loop Technique for Pulley Reconstruction-A Retrospective Cohort Analysis of 23 Patients.

Twenty-three patients with a mean age of 52.7 years underwent pulley reconstruction using the Okutsu double- or triple-loop technique after iatrogenic or traumatic rupture of at least two adjacent flexor tendon pulleys in the finger and distal palm; mean age of injury was 4.77 years. The mean follow-up was 4.66 years after reconstruction of mostly A2 pulleys in a single surgeon setting. Outcome measures included ROM, NRS pain, satisfaction, Disabilities of Arm, Shoulder and Hand Questionnaire (DASH) and Krimmer score, Buck-Gramcko score, Jamar grip strength, pinch grip, and vigorimetry compared to the uninjured side. The median patient satisfaction score was 6.6/10. Hand function using the DASH score was 9.5. Grip strength on the Jamar Dynamometer showed only a slight reduction of 13% compared to the uninjured side. The resultant force of the operated fingers on the vigorimeter is almost 60% of that of the contralateral side, and the finger-palm distance of the operated finger was reduced from 2.2 cm to 1.45 cm. Other functional scores, such as Krimmer (82.2) and Buck-Gramcko (10.9), support these good results. The follow-up of patients more than 4.5 years after reconstruction of the A2 and A3 flexor tendon pulley using the double- or triple-loop technique showed acceptable patient satisfaction and good function of the finger in everyday life.

Factors Influencing Quality of Life after Massive Weight Loss-What Makes the Difference?

Although weight reduction in obesity and morbid obesity has been shown to improve associated comorbidities, there is currently no information on what influences quality of life after a large reduction in body weight. The present study looks at differences in patients' quality of life classified by mode and amount of weight loss. MATERIAL AND METHODS: A cross-sectional study was designed using a validated German version of the BODY-Q questionnaire. The internet-based questionnaire was distributed to patients via social media. RESULTS: 460 patients (443 female, 17 male) were interviewed for this study via "Surveymonkey". The comparison of conservative and surgical weight loss showed no significant difference in the patients' quality of life (p > 0.05). A high BMI correlates negatively with body image (p = 0.023 *), as does the specific assessment of most body regions. For example, a negative correlation was found between a high BMI and satisfaction with skin appearance (p < 0.001 *) and satisfaction with the inner thigh (p = 0.011 *). CONCLUSION: Increased weight loss is associated with a greater ability to maximise quality of life. The type of weight loss, whether conservative or surgical, can be neglected based on the present study. Bariatric surgery cannot be considered a universal solution to obesity. Body contouring interventions should also become a focus of therapy.

Complication Rates after Breast Surgery with the Motiva Smooth Silk Surface Silicone Gel Implants-A Systematic Review and Meta-Analysis.

BACKGROUND: In an era where textured devices are being phased out due to concerns about BIA-ALCL, the Motiva SilkSurface breast implants intend to alleviate historical prosthesis-related complications. However, its safety and feasibility remain unelucidated. METHODS: An analysis of Pubmed, Web of Science, Ovid, and Embase databases was performed. A total of 114 studies were identified initially, and 13 of these met the inclusion criteria and were assessed regarding postoperative parameters such as complication rate or follow-up period. RESULTS: In 4784 patients who underwent breast augmentation with Motiva SilkSurface breast implants, a total of 250 (5.2%) complications were observed. Short- and medium-term complication rates ranged from 2.8-14.4% and 0.32-16.67%, respectively. The most common complication was early seroma (n = 52, overall incidence = 1.08%), followed by early hematoma (n = 28, overall incidence = 0.54%). The incidence of capsule contracture was 0.54% and breast implant-associated-anaplastic large cell lymphoma was not observed. DISCUSSION: Although the majority of the studies in the current literature suggest the distinction of the Motiva SilkSurface breast implants in terms of postoperative complications and capsular contracture, its safety and feasibility need to be further elucidated with well-designed, large-scale, multicenter, prospective case-control studies. Other: No funding was received.