Intraoperative Heparin Bolus and Postoperative Anticoagulation with Low Molecular Weight Heparin Increase Reliability of Microsurgical Free Flaps for Upper Extremity Reconstruction.

BACKGROUND: Microsurgery is an indispensable tool of upper extremity reconstruction addressing defect coverage and the restoration of function. Perioperative anticoagulation and antiplatelet therapy are controversially discussed with impact on microsurgical outcome, but without clear evidence. This study aims to evaluate the impact of perioperative anticoagulation and antiplatelet therapy in microsurgical upper extremity reconstruction. METHODS: All eligible patients treated with microsurgical upper extremity reconstruction between January 2000 and July 2014 were included in a comparative analysis to define a superior anticoagulation and antiplatelet regime in a retrospective study. Endpoints were all major complications (e.g., total flap loss, arterial and venous thrombosis) as well as minor complication. RESULTS: A total of 183 eligible free flaps to the upper extremity were transferred in 169 patients. Altogether, 11 arterial (6.0%) and 9 venous (4.9%) thromboses, 11 total flap losses (6.0%), and 16 cases with hematoma (8.7%) were detected. In the subgroup analysis, patients who did not receive any heparin intraoperatively (n = 21; 11.5%) had a higher rate of major complications (p = 0.001), with total flap loss being the most frequent event (p = 0.004). A trend was shown for intraoperative bolus administration of 501 to 1,000 units unfractionated heparin (UFH) intravenously to have the lowest rate of major complications (p = 0.058). Intraoperative administration of acetylsalicylic acid (n = 13; 8.1%) did not have any influence on the rate of major complications. Postoperative anticoagulation with continuous UFH intravenously (n = 68; 37.2%) resulted in more frequent complications (p = 0.012), for example, an increased rate of total flap loss (p = 0.02) and arterial thrombosis (p = 0.02). CONCLUSION: The results of the present study favor administration of 501 to 1,000 units UFH intravenously as an intraoperative bolus (e.g., 750 units UFH intravenously). Postoperative low molecular weight heparin subcutaneous application in a prophylactic dose given once or twice a day was associated with less complications compared with continuous infusion of UFH, although continuously applied UFH may reflect an increased risk profile.

Standardising the management of open extremity fractures: a scoping review of national guidelines.

INTRODUCTION: Open extremity fractures can be life-changing events. Clinical guidelines on the management of these injuries aim to standardise the care of patients by presenting evidence-based recommendations. We performed a scoping systematic review to identify all national clinical practice guidelines published to date. MATERIALS AND METHODS: A PRISMA-compliant scoping systematic review was designed to identify all national or federal guidelines for the management of open fractures, with no limitations for language or publication date. EMBASE and MEDLINE database were searched. Article screening and full-text review was performed in a blinded fashion in parallel by two authors. RESULTS: Following elimination of duplicates, 376 individual publications were identified and reviewed. In total, 12 clinical guidelines were identified, authored by groups in the UK, USA, the Netherlands, Finland, and Malawi. Two of these focused exclusively on antibiotic prophylaxis and one on combat-related injuries, with the remaining nine presented wide-scope recommendations with significant content overlap. DISCUSSION: Clinical practice guidelines serve clinicians in providing evidence-based and cost-effective care. We only identified one open fractures guideline developed in a low- or middle-income country, from Malawi. Even though the development of these guidelines can be time and resource intensive, the benefits may outweigh the costs by standardising the care offered to patients in different healthcare settings. International collaboration may be an alternative for adapting guidelines to match local resources and healthcare systems for use across national borders.

Evaluation of Research Opportunities and Limitations for Plastic Surgery Residents: An International Survey.

BACKGROUND: Conducting research during specialty training provides an opportunity to develop critical thinking and leadership skills along with a better understanding of the scientific literature. However, trainees often find it difficult to undertake research, in the context of labor-intensive surgical training. The aim of this study is to evaluate the research output and limitations of plastic surgery residents in different countries. METHODS: An international cross-sectional study involving plastic surgery trainees and recent postgraduates from Brazil, Chile, Germany, and the United Kingdom was conducted. A survey inquiring into academic productivity, limitations to conducting research, and working-hours patterns was distributed among eligible participants. RESULTS: From September to December 2019, 106 surveys were retrieved. Most respondents declared having participated in at least 1 project that resulted in a presentation or publication during their training (90.6% in national presentations, 68% international presentations, 67% in national publications, and 66% international publications). Having completed a previous research fellowship was associated with a statistically higher academic output (P < 0.05). Seventy-nine percent of respondents felt that their participation in research activities would have been greater if limiting factors had been addressed, including lack of time (72.5%) and insufficient supervision and mentoring (55%). CONCLUSIONS: Optimizing plastic surgery trainees' participation in scientific research is beneficial both for residents and their mentors. Research fellowships can provide an opportunity for academically oriented trainees to further develop their research skills. Protected time and adequate mentoring can help not only to increase residents' research output, but also to recruit the next generation of academic plastic surgeons.

Lymphatic Tissue Engineering: A Further Step for Successful Lymphedema Treatment.

BACKGROUND: Secondary lymphedema, caused by oncologic surgery, radiation, and chemotherapy, is one of the most relevant, nononcological complications affecting cancer survivors. Severe functional deficits can result in impairing quality of life and a societal burden related to increased treatment costs. Often, conservative treatments are not sufficient to alleviate lymphedema or to prevent stage progression of the disease, as they do not address the underlying etiology that is the disruption of lymphatic pathways. In recent years, lymphatic surgery approaches were revolutionized by advances in microsurgical technique. Currently, lymphedema can effectively be treated by procedures such as lymphovenous anastomosis (LVA) and lymph node transfer (LNT). However, not all patients have suitable lymphatic vessels, and lymph node harvesting is associated with risks. In addition, some data have revealed nonresponders to the microsurgical techniques. METHODS: A literature review was performed to evaluate the value of lymphatic tissue engineering for plastic surgeons and to give an overview of the achievements, challenges, and goals of the field. RESULTS: While certain challenges exist, including cell harvesting, nutrient supply, biocompatibility, and hydrostatic properties, it is possible and desirable to engineer lymph nodes and lymphatic vessels. The path toward clinical translation is considered more complex for LNTs secondary to the complex microarchitecture and pending final mechanistic clarification, while LVA is more straight forward. CONCLUSION: Lymphatic tissue engineering has the potential to be the next step for microsurgical treatment of secondary lymphedema. Current and future researches are necessary to optimize this clinical paradigm shift for improved surgical treatment of lymphedema.

A Structured, Microsurgical Training Curriculum Improves the Outcome in Lower Extremity Reconstruction Free Flap Residency Training: The Ludwigshafen Concept.

BACKGROUND: Risk stratification, economic pressure, and a flat learning curve make the realization and development of proper microsurgical skills and competences a challenging task in the daily clinical practice. In previous studies, we were able to show that microsurgical procedures, e.g., free flaps and replantations, are safe training procedures and teachable in daily clinical practice in view of certain issues of risk stratification. The present study aims to evaluate further improvements in terms of safety and complication rates for free flaps as a training procedure after introduction and continuous implementation of a structured in-house training curriculum for microsurgical skills and competences and a 24-hour free accessible microsurgical training facility for the plastic surgery resident. METHODS: This retrospective comparative cohort study was conducted to review whether microsurgical skills for free flaps to the lower extremity can further be improved after implementation of the curriculum and a 24-hour accessible training facility. Therefore, we compared cohort A before (2009-2012) and B after (2014-2017) implementation. Patient demographics, procedural characteristics, and outcome parameters for free tissue transfer of the lower extremity were evaluated. RESULTS: The comparison of both cohorts showed a significantly reduced postoperative complication rate for cohort B (p <0.05). Furthermore, operation time was shorter, and the hospital stay could be significantly decreased (p <0.01). Workhorse flaps for plastic surgical training were the anterior lateral thigh (ALT) flap or the musculus latissimus dorsi (LD) flap. However, even more complex procedures with arteriovenous loops could be safely performed by plastic surgery residents under the supervision of the senior surgeon in exceptional cases. CONCLUSION: The implementation of a regularly held, microsurgical in-house training curriculum with 24-hour accessible training facility improves procedural and outcome parameters for free flaps to the lower extremity for surgical residents and is an elementary part of skills and competency training. However, risk stratification, repeated surgical exposure, expertise, and institutional infrastructures are essential and must be taken into consideration.

Role, Management, and Outcome of Free Flap Reconstruction for Acute Full-Thickness Burns in Hands.

INTRODUCTION: Severe thermal trauma to the hand can result in major impairment and reduced function due to defective healing or even extremity loss. Full-thickness injuries frequently incur exposure of tendons or bone and require an early and stable coverage with soft tissue transplants to allow for rapid induction of exercise and to preserve structures and hand function. Free tissue transfer to the hand after thermal trauma is a rare indication, and safety, management, and outcome of free flap surgery for severe acute burn injuries to the hand remains underreported. METHODS: Patients with primary reconstructions of full-thickness burn injuries to the hand undergoing microsurgical free tissue transfer surgery were retrospectively assessed in a period from 2013 to 2016. Salvage strategy of the extremity, postoperative complications, length of hospital stay, and primary reconstructive result were quantified and analyzed. Functional outcome measures (range of motion and grip strength) were assessed during clinical follow-up examinations. RESULTS: During the investigated period, 13 patients were identified undergoing reconstruction of 14 hands via free flap transplantation after severe burn injury in the acute phase. Nine anteriolateral thigh flaps (64%), 3 latissimus dorsi flaps (18%), 1 serratus anterior flap, and 1 tensor fasciae lata flap (7%) were performed. In all cases, salvage of the affected extremity was achieved, although 1 flap (7%) was lost during the early postoperative period requiring secondary reconstruction via pedicled groin flap. Further complications were venous thrombosis (n = 2; 14%) and hematoma (n = 2; 14%). Mean length of hospital stay was 51 days. Functional outcome during follow-up examination after an average of 9.3 months was inhomogeneous depending on the pattern of injury and ranged from complete recovery to nearly entire loss of hand function. CONCLUSIONS: Free flap transfer can be a mandatory and valuable tool to cover full-thickness burn injuries of the hand early in the clinical course of thermal trauma and may provide extremity salvage by favorable means of reconstruction to achieve acceptable functional outcomes, in the most severe cases. Although microsurgical failure rates in burn patients are slightly higher than in free flap transfer to the upper extremity in general, it can be performed with reasonable risk-to-benefit ratio.

Negative pressure wound therapy with instillation and dwell time (NPWTi-d) with V. A. C. VeraFlo in traumatic, surgical, and chronic wounds-A helpful tool for decontamination and to prepare successful reconstruction.

For nearly two decades, Negative Pressure Wound Therapy (NPWT) has been used for temporary wound coverage as well as wound bed preparation. The addition of instillation and dwell time as an adjunct to NPWT (NPWTi-d) enables wound bed cleaning and improved wound bed granulation. Thirty patients with different types of colonised wounds (traumatic, surgical, and chronic) were treated with NPWTi-d using saline for instillation. Patient data, microbiological data and wound characteristics were collected and analysed. Endpoints were bacterial decontamination (count and type), effect on wound bed granulation, and successful reconstruction. Additionally, subgroup analyses for traumatic, surgical, and chronic wounds as well as patients pretreated with conventional NPWT or isolated gram-positive or negative germs were performed. NPWTi-d was applied on average for 13 days with a total hospitalisation time of 51 days. After NPWTi-d, decontaminated wounds were detected in 23% of cases. The number of different bacteria as well as bacterial count could be significantly reduced from 2.38 to 1.16 and 3.9 to 1.3, respectively. This was similar for all subgroups except surgical wounds, in which NPWTi-d did not lead to a significant reduction of the bacterial count. NPWTi-d resulted in a significant stimulation of granulation tissue. Successful reconstruction was achieved in 90% of cases. NPWTi-d enabled wound pre-conditioning by powerfully reducing or decontaminating the bacterial load and spectrum in most of the wounds. The wound bed integrity was re-established to prepare successful reconstruction.

[Use of hyperbaric oxygenation for wound management]. / Uso de oxígeno hiperbárico para el manejo de heridas: bases físicas, biológicas y evidencia disponible.

Hyperbaric oxygenation consists in exposing patients to increased gas pressures while inhaling pure oxygen. It involves the use of hyperbaric chambers that can double or triple gas pressure inside them. Hyperbaric oxygenation may be useful in different clinical situations, but mostly for the treatment of decompression syndrome. In the last decades, it has been used for the management of different kinds of wounds. Hyperbaric oxygenation not only increases the delivery of oxygen to damaged tissues, but also stimulates angiogenesis, collagen synthesis, stem cell migration and local immune response. Clinical trials that have addressed the use of hyperbaric oxygenation are difficult to compare due to their heterogeneity in terms of experimental design, kind of injuries involved and assessment of outcome. Even though, most studies support the concept that hyperbaric oxygenation accelerates the healing process.

Characterization of Immune Cell Infiltration and Collagen Type III Disorganization in Human Secondary Lymphedema: A Case-control Study.

Background: Secondary lymphedema (SL) affects 120 million people globally, posing a lifelong burden for up to 37% of cancer survivors. Chronic inflammation and progressive fibrosis are key drivers of SL, yet detailed characterization of immune cell subpopulations across lymphedema stages is lacking. This study aimed to investigate the immunologic profile of lymphedematous skin and its association with extracellular matrix changes, which could serve as clinical biomarkers or therapeutic targets. Methods: This case-control study analyzed the skin from 36 patients with and without SL, using immunofluorescence to quantify T cells, B cells, macrophages, and their subpopulations. Collagen quantity and composition were examined using picrosirius red staining, and mast cell infiltration was assessed with toluidine blue staining. Early and late SL stages were compared to identify histomorphological and immunologic correlates of stage progression. Results: We found a predominance of CD4+ T cells and mast cells in SL skin (1.4/mm² versus 1.0/mm², P < 0.01; 1.2/mm² versus 0.2/mm², P < 0.0001) and a higher ratio of collagen III to collagen I fibers (51.6% versus 75.0%, P < 0.001). M2 macrophages were more abundant in late-stage than in early-stage lymphedema (1.7/mm² versus 1.0/mm², P = 0.02). Conclusions: This study demonstrated a shift toward CD4+ T cell and mast cell infiltration in SL skin, correlating with extracellular matrix disorganization and an altered collagen III/I ratio. These findings enhance our understanding of the cellular and morphological changes in SL, potentially guiding future diagnostic and therapeutic strategies.

[Evidence of modern diagnostic, conservative, and surgical therapy of secondary lymphoedema]. / Evidenz der modernen Diagnostik, der konservativen und chirurgischen Therapie des sekundären Lymphödems.

BACKGROUND: Secondary lymphoedema (SL) is one of the most common and, at the same time, most significant consequences and complications of modern oncological therapy. Although a thorough patient history and physical examination are sufficient to substantiate a suspicion, it is essential to perform functional imaging of the lymphatic system for a targeted diagnosis and determination of severity. For this purpose, techniques such as MR and ICG lymphography as well as ultra-high-frequency ultrasound examinations have been developed and validated in recent years. The selective use of these techniques has allowed for individualized indications and successful stage-dependent treatment using (super)microsurgical techniques to restore regional lymphatic drainage in the context of intensified conservative therapy. METHOD: Systematic review of the literature on the diagnosis and treatment of SL with subsequent analysis and classification of the results into evidence levels according to the Oxford Centre for Evidence-Based Medicine and the GRADE Scale. RESULTS: The established and validated diagnosis of SL includes imaging (ICG fluorescence lymphography, MR lymphography and Tc-99 functional lymphoscintigraphy) in case of a clinical suspicion and in high-risk patients. Complex physical decongestion therapy (CPE) is superior to physical therapy or compression alone. (Super)microsurgery of SL allows for a postoperative reduction in the frequency of CPE, a reduction of erysipelas rates, a volume reduction of the lymphomatous extremity and, if carried out prophylactically, a lower incidence of SL. Suction-assited lipectomy can produce long-term, stable reductions in circumference and an improvement in quality of life. CONCLUSION: Patients with SL benefit from conservative therapy with regular re-evaluation. Patients with a high risk for SL or with clinical deterioration or persistent symptoms under guideline-based conservative therapy can benefit from (super)microsurgical therapy after an individualized functional diagnostic evaluation of the lymphatic system. Excisional dermolipectomies or lympholiposuctions are available and effective for advanced and refractory stages.

Lymphedema-associated fibroblasts are a TGF-ß1 activated myofibroblast subpopulation related to fibrosis and stage progression in patients and a murine microsurgical model.

BACKGROUND: The driver of secondary lymphedema (SL) progression is chronic inflammation, which promotes fibrosis. Despite advances in preclinical research, a specific effector cell subpopulation as a biomarker for therapy response or stage progression is still missing for SL. METHODS: Whole skin samples of 35 murine subjects of a microsurgical-induced SL model and 12 patients with SL were collected and their fibroblasts were isolated. These lymphedema-derived fibroblasts (LAF) were cultured in a collagen I-poly-D-Lysine 3D hydrogel to mimic skin conditions. Fibroblasts from non-lymphedema skin were used as negative control and TGF-ß-stimulated fibroblasts were used to recreate profibrotic myofibroblasts. Quantitative immunocytofluorescence confocal microscopy analysis and invasion functional assays were performed in all subpopulations and statistically compared. RESULTS: In contrast to normal skin fibroblasts, LAF exhibit α-SMA-positive stress fibers and a reduced number of tight junctions in 3D hydrogel conditions. The switch from normal E-cadherin high phenotype to an N-cadherin high-E-cadherin low morphology suggests epithelial to mesenchymal transition for expansion and proliferation. This pathological behavior of LAF was confirmed by live cell imaging analysis of invasion assays. The significant activation of markers of the TGFBR2-Smad pathway and collagen synthesis (HSP-47) in LAF supports EMT phenotypic changes and previous findings relating to TGF-ß1 and fibrosis with lymphedema. CONCLUSIONS: A characteristic SL myofibroblast subpopulation was identified and translationally related to fibrosis and TGF-ß1-associated stage progression. This SL-related subpopulation was termed lymphedema-associated fibroblasts. A comprehensive stage-related characterization is required to validate LAF as a reliable biomarker for SL disease progression.

Stem Cell-Enriched Hybrid Breast Reconstruction Reduces Risk for Capsular Contracture in a Hybrid Breast Model.

BACKGROUND: Hybrid breast reconstruction (HBR) combines silicone implants with fat grafting to improve implant coverage, treating local tissue deficiencies and leading to a more natural breast appearance. Recent data also indicated less capsular contracture after HBR. The authors developed a novel technique and animal model of cell-assisted (CA) HBR to illuminate its effects on capsular contracture. METHODS: Animals received silicone implants in a dorsal submuscular pocket. Although animals of the HBR group received fat grafting around the implant without stem cell enrichment, rats of the CA-HBR1 and the CA-HBR2 groups received stem cell-enriched fat grafting with 2 × 10 6 and 4 × 10 6 adipose-derived stem cells immediately after implant insertion. On day 60, animals underwent sonography and elastography imaging and were euthanized, and outcome analysis was performed by means of histology, immunohistochemistry, chemical collagen quantification, and gene expression analysis. RESULTS: With this novel technique, long-term survival of adipose-derived stem cells within the implant pocket was demonstrated after 60 days after implant insertion. CA-HBR led to significantly reduced thickness and collagen density of capsular contractures. In addition, CA-HBR resulted in reduced fibrotic responses with less occurrence of collagen type I and transforming growth factor-ß in capsule tissue. Moreover, the addition of stem cells suppressed fibrotic and inflammatory responses on a genetic level with significant underexpression of collagen type I and transforming growth factor-ß1. CONCLUSIONS: With this new technique and animal model, the authors observed a preventive effect on capsular contracture substantiating the basis of clinical outcomes of HBR. The authors propose that the addition of stem cells to HBR might booster its beneficial results. CLINICAL RELEVANCE STATEMENT: Stem cell-enriched fat grafting around silicone implants may reduce the risk for capsular contracture after silicone breast implantation. While fat grafting alone already shows beneficial effects, the addition of stem cells to the fat graft can potentiate this effect.

Supermicrosurgical treatment for lymphedema: a systematic review and network meta-analysis protocol.

BACKGROUND: Lymphedema is a condition that affects up to 130 million subjects worldwide. Since it is related to several complications and a significant reduction in terms of quality of life, it is a heavy burden not only to the patients but also for the healthcare system worldwide. Despite the development of supermicrosurgery, such as vascularized lymph node transfer (VLNT) and lymphovenous anastomosis LVA, the indications and outcomes of these complex groups of interventions remain a controversial topic in the field of reconstructive plastic surgery. METHODS: This systematic review and network meta-analysis aims to assess the evidence of outcomes of LVA and VLNT in patients with lymphedema. Secondary aims of the project are to determine if for any outcomes, LVA or VLNT is superior to conservative therapy alone, and whether the available evidence favors any kind of supermicrosurgical interventions for lymphedema patients. This study will include original studies of patients with lymphedema on the extremities indexed in PubMed, EMBASE, CENTRAL, PASCAL, FRANCIS, ISTEX, LILACS, CNKI, and IndMED that reported microsurgery (supermicrosurgery) of all techniques aiming the re-functionalization of the lymphatic system. As comparators, mere observation, conservative treatment of any kind, and the other subgroups of supermicrosurgery are planned. The primary outcome of this systematic review and network meta-analysis is the difference of the limb volume, while the secondary outcomes of interest will be erysipelas rates, major and minor complications, postoperative necessity of continuous compression garments, and patient satisfaction, measured by already published and validated scores for quality of life. DISCUSSION: We will provide an overview and evidence grade analysis of the scientific literature available on the effectiveness of the subcategories of supermicrosurgical interventions for lymphedema.

Lymphovenous anastomoses with three-dimensional digital hybrid visualization: improving ergonomics for supermicrosurgery in lymphedema.

The conventional approach of looking down a microscope to perform microsurgical procedures is associated with occupational injuries, anti-ergonomic postures, and increased tremor and fatigue, all of which predispose microsurgeons to early retirement. Recently, three-dimensional (3D) visualization of real-time microscope magnification has been developed as an alternative. Despite its commercial availability, no supermicrosurgical procedures have been reported using this technology to date. Lymphovenous anastomoses (LVAs) often require suturing vessels with diameters of 0.2-0.8 mm, thus representing the ultimate microsurgical challenge. After performing the first documented LVA procedure using 3D-augmented visualization in our unit and gaining experience with this technique, we conducted an anonymized in-house survey among microsurgeons who had used this approach. The participants considered that 3D visualization for supermicrosurgery was equivalent in terms of handling, optical detail, depth resolution, and safety to conventional binocular magnification. This survey revealed that team communication, resident education, and ergonomics were superior using 3D digital hybrid visualization. Postoperative muscle fatigue, tremor, and pain were also reduced. The major drawbacks of the 3D visualization microscopic systems are the associated costs, required space, and difficulty of visualizing the lymphatic contrast used.

Accuracy of infrared thermography for perforator mapping: A systematic review and meta-analysis of diagnostic studies.

INTRODUCTION: Infrared thermography allows the detection of infrared radiation which can be reliably associated with skin temperature. Modern portable thermography devices have been used to identify the location of skin perforators by detecting subtle differences in skin temperature. The aim of this study is to conduct a diagnostic accuracy systematic review to determine the specificity and sensitivity of infrared thermography. MATERIALS AND METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted, scrutinising PUBMED and EMBASE databases for diagnostic studies measuring the accuracy of infrared thermography for perforator identification. Article screening, review and data gathering was conducted in parallel by two independent authors. Eligible studies were subject to a formal risk of bias was assessment using the QUADAS2 instrument. RESULTS: A total of 254 entries were obtained, of which 7 satisfied our pre-established inclusion criteria. These studies reported a total of 435 perforators in 133 individuals. The most commonly investigated locations were the antero-lateral thigh and abdominal wall. Reported sensitivity values ranged from 73.7% to 100%. A meta-analysis demonstrated a cumulative sensitivity of 95%. Specificity was not routinely reported. All studies presented a moderate to high risk of bias according to QUADAS2. DISCUSSION: Affordable infrared thermography devices are an interesting alternative to traditional preoperative investigations for perforator mapping. They are sensitive enough to reliably identify a large proportion of perforators as "hot-spots". However, there is limited evidence to estimate the specificity of this technology, as studies have failed to report true negative values associated with "cold-spots".

Safety and effectiveness of early compression of free flaps following lower limb reconstruction: A systematic review.

INTRODUCTION: Early postoperative compression of free flaps for lower limb reconstruction remains controversial. It may reduce venous congestion and promote the resolution of oedema. However, concerns remain regarding inadvertent pedicle compression, which may lead to flap failure. The aim of this systematic review was to determine the safety and effectiveness of this intervention. METHODS: A systematic review was designed in compliance with PRISMA. MEDLINE and EMBASE databases were searched. Parallel screening, selection of eligible studies, and data gathering were carried out by two independent authors. A formal risk of bias assessment was included along with the appraisal of outcomes. RESULTS: A total of 847 abstracts were retrieved and 262 free flaps for lower limb reconstruction were identified in ten eligible articles. The overall flap failure rate for patients who underwent early postoperative compression was 1.6%. Apart from flap failure rates, there were no other outcomes consistently reported and none of the studies included a no-compression group for comparison. DISCUSSION: All included studies had methodological flaws, resulting in a high risk of bias. Nevertheless, there was consistent reporting of flap failure as a postoperative outcome. Compression of free flaps in the context of lower limb reconstruction does not appear to be associated with a higher flap failure rate compared with other series. Compression bandages may reduce the pain associated with dangling regimes. However, there is no evidence to support that free flap compression in the context of lower limb reconstruction is associated with any other clinical benefit.

Managing Complications in Abdominoplasty: A Literature Review.

BACKGROUND: Abdominoplasty, with or without liposuction, is among the most frequently performed aesthetic procedures. Its main objective is to improve the body contour by means of excising redundant skin and fat tissue. Although abdominoplasty is considered a safe procedure with high satisfaction rates, intraoperative and postoperative complications can become a challenge for the surgical team. The aim of this article is to offer a synopsis of the most common complications arising after abdominoplasty, along with evidence-based guidelines about how to prevent and treat them. METHODS: A systematic MEDLINE search strategy was designed using appropriate Medical Subject Headings (MeSH) terms, and references were scanned for further relevant articles. RESULTS: According to the published case series, local complications are considerably more common than complications with systemic repercussions. Approximately 10% to 20% of patients suffer a local complication following abdominoplasty, while fewer than 1% suffer a systemic complication. Prevention and management strategies are critically discussed for complications including seroma, haematoma, infection, skin necrosis, suture extrusions, hypertrophic scars, neurological symptoms, umbilical anomalies, deep venous thrombosis and pulmonary thromboembolism, respiratory distress, and death. CONCLUSIONS: The complications of abdominoplasty vary in severity and in the impact they have on the aesthetic outcomes. Recommendations for prevention and management are based on various levels of evidence, with a risk of observer bias. However, most complications can be treated appropriately following the current standards, with satisfactory results.

Uso de oxígeno hiperbárico para el manejo de heridas: bases físicas, biológicas y evidencia disponible / Use of hyperbaric oxygenation for wound management

Hyperbaric oxygenation consists in exposing patients to increased gas pressures while inhaling pure oxygen. It involves the use of hyperbaric chambers that can double or triple gas pressure inside them. Hyperbaric oxygenation may be useful in different clinical situations, but mostly for the treatment of decompression syndrome. In the last decades, it has been used for the management of different kinds of wounds. Hyperbaric oxygenation not only increases the delivery of oxygen to damaged tissues, but also stimulates angiogenesis, collagen synthesis, stem cell migration and local immune response. Clinical trials that have addressed the use of hyperbaric oxygenation are difficult to compare due to their heterogeneity in terms of experimental design, kind of injuries involved and assessment of outcome. Even though, most studies support the concept that hyperbaric oxygenation accelerates the healing process.