[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgery (DGPRÄC) and Research Funding Report 2021/2022]. / Register Forschungsförderung der Deutschen Gesellschaft für Plastische, Rekonstruktive und Ästhetische Chirurgie (DGPRÄC) und Forschungsförderungs-Bericht 2021/2022.

BACKGROUND: Research is an integral part of academic medicine. In plastic surgery, it sets the course for innovations in the specialty. The purpose of this study is to present the research performance of plastic surgeons in Germany for the period 2021/2022 and to compare it with previous periods. MATERIALS AND METHODS: The directors of plastic surgical academic institutions reported all requested/approved and rejected research applications to public, non-public and industrial funding organizations. Data was gathered within an established online database. In addition, the DFG´s public database GEPRIS was screened for plastic surgical research grants. Data was also collected regarding research infrastructure and organization at the participating centers. RESULTS: 105 applications were reported to 54 different funding agencies from 20 plastic surgery centers. 37 funding applications were submitted to the major public funding agencies DFG, BMBF, BMWi, BMG, BMVg, G-BA and EU. Of these, 59,5% (22/37) were DFG, 13,5% (5/37) each BMBF and EU, 5,4% (2/37) BMWi, and 2,7% (1/37) each BMG, BMVg, and G-BA applications. The average funding volume of these proposals was 401,515 euros. Approved DFG proposals were most frequently assigned to the review board 205-27 Orthopedics, Trauma Surgery, Reconstructive Surgery (n=10/16, 62,5%). Over time, the research registry shows an increase in the number of proposals in general and those granted. 70,0% (14/20) of participating sites had their own experimental research laboratory, while only 40,0% (8/20) had their own clinical trial center. CONCLUSION: The 2021/2022 Research Funding Report once again highlights the impressive research accomplishments of the plastic surgery community.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2019/2020]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungsbericht 2019/2020.

BACKGROUND: Since 2015/16 the DGPRÄC collects, evaluates and publishes the research activities of academic sections, departments and clinics for plastic surgery at university hospitals in Germany, in order to raise the awareness of plastic surgical research performance. MATERIALS AND METHODS: The directors of plastic surgical academic institutions were contacted via the DGPRÄC and asked to report any requested/approved and rejected research applications to public, non-public and industrial funding organizations. Data was collected in our previously established online database: https://docs.google.com/forms/d/e/1FAIpQLSe6F5xmTyw-k7VKJx_2jkPA4LBXsA0sgBGMrC3rx_4bHj6uzQ/viewform?usp=sf_link. In addition, applications were identified via the DFG's public database GEPRIS. RESULTS: A total of 41 funding applications to the public funding institutes DFG, BMBF, BMWi, BMG and EU were identified. 75.6 % (31/41) of the applications had already been approved at the time of data collection, of which 77.4 % (24/31) were DFG, 9.7 % (3/31) were BMWi, 6.5 % (2/31) were EU and 3.2 % (1/31) were BMBF or BMG applications. The average funding amounted to 358 301 Euro. In 50.0 % (12/24) of the cases, the approved DFG proposals were assigned to the subject review board 205-27 Orthopedics, Trauma Surgery, Reconstructive Surgery. CONCLUSION: The continuous publication of plastic surgical research funding reports submitted by the convention of university plastic surgeons of the DGPRÄC portraits the excellent, collaborative research activity in the field of plastic surgery.

[The "safe" flap - Preoperative perforator-mapping and intraoperative perfusion assessment to reduce flap-associated morbidity - Consensus statement of the German Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels]. / Der sichere Lappen ­ Präoperatives Gefäß-Mapping und intraoperative Perfusionsmessung zur Reduktion der lappenbedingten Morbidität.

Reconstructive microsurgery using free and pedicled flaps has become a reliable method with a high success rate. Preoperative perforator mapping and intraoperative assessment of perfusion might further reduce flap-associated morbidity.There are various techniques for perforator mapping and perfusion measurement, but no guidelines regarding their use. Therefore, an expert panel at the 40th Annual Meeting of the German-Speaking Working Group for Microsurgery of the Peripheral Nerves and Vessels (DAM) discussed and critically reviewed the current literature. The consensus statement represents the expert opinion based on the available literature and provides recommendations regarding the use of preoperative perforator mapping and intraoperative perfusion measurement.

[Breast pain and fever in a 46-year-old immunosuppressed patient with breast implants]. / Schmerzen im Bereich der Mamma und Fieber bei einer 46­Jährigen mit Immunsuppression und Mammaaugmentation.

A 46-year-old immunosuppressed patient presented with a breast implant-associated infection 10 years after breast augmentation in Southeast Asia. No pathogen was identified in the initial conventional microbiological workup. Subsequently, infection with Mycobacterium abscessus-a nontuberculous mycobacteria-was diagnosed using a special culture technique. Increased rates of such infections are reported after cosmetic surgery in foreign countries, presumably due to inoculation with these ubiquitous pathogens. This case highlights the fact that the differential diagnosis and thus the microbiological workup should be extended in cases without initial pathogen detection.

Color Doppler ultrasound and computed tomographic angiography for perforator mapping in DIEP flap breast reconstruction revisited: A cohort study.

INTRODUCTION: Preoperative imaging by Computed Tomographic Angiography (CTA) has been promoted a gold standard tool for perforator mapping in abdominally based microsurgical breast reconstruction, while Color Doppler Ultrasound (CDU) has lost its popularity. As the CTA X-ray exposure might have long-term consequences for patients, CDU has regained importance for preoperative workup in our center. Our aim was to revisit the role of CDU by comparing the reliability of CDU and CTA in predicting intraoperative perforator selection. MATERIALS AND METHODS: We performed a retrospective chart review study of patients who underwent microsurgical breast reconstructions with DIEP flaps at our institution. Both CTA and CDU were performed prior to the surgery, and both imaging entities were thoroughly examined by the surgical team. Perforator identification, number, size, and location were assessed and correlated with CTA and CDU data and with intraoperative findings. RESULTS: We identified 98 patients who received 125 DIEP flap surgeries. A significantly stronger correlation was found between CDU and intraoperative findings of perforator detection and size (p<0.0001) and selection (r = 0.9987, CI 0.9981-0.9991, p < 0.0001 and r = 0.01, CI -0.18-0.2, p = 0.91, respectively), when compared with CTA data. If none of the preoperative imaging studies matched intraoperative perforator selection, an association with a higher incidence of flap loss (Odds ratio 4.483, CI 0.5068-39.65, p = 0.2171) was found. CONCLUSIONS: Our data suggests that CDU might regain relevance as a safe and reliable preoperative imaging study, without the risk and potential consequences of X-ray exposure. Preoperative imaging tools like CDU and CTA should be considered part of the gold standard in abdominally based free flap breast reconstruction.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2017/2018]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungs-Bericht 2017/2018.

INTRODUCTION: This report serves to publicize the research of academic institutions for Plastic Surgery within our society DGPRÄC in 2017/2018 and sequels the funding report of 2015/2016. Applications to public, non-public, or industrial funding organizations were evaluated. At the same time, this paper analyses the number of approved DFG applications in Plastic, Thoracic and Vascular Surgery in the GEPRIS system. Contrary to these specialties, Plastic Surgery is not classified as an independent speciality in the subject structure of the DFG review board which results in a lack of transparency concerning Plastic Surgery research work. MATERIALS AND METHODS: Our previously established online database (https://docs.google.com/forms/d/1OaSnHyKTysawiI1ie7kfUxDf7nJP_RiTUJTsnb7Mq_E/edit) for reporting requested/ approved and rejected research applications to public, non-public and industrial funding organizations was continued and evaluated together with applications found in the DFG's public database GEPRIS. RESULTS: Compared to the previous year's report, the number of approved applications from public research organizations (DFG, BMBF, BMWi, EU) was increased from 23 to 27. We identified 19 approved DFG applications from Plastic Surgery, as compared to 9 and 8 applications by Thoracic and Vascular Surgery, respectively. SUMMARY: Taken together, this data emphasizes that our research is at least equal to that of other newly established surgical specialties within the framework of the DFG. Accordingly, we hope to provide further arguments for an adaptation of the DFG review boards subject structure to include Plastic Surgery as an independent specialty as it is for Vascular Surgery and Thoracic Surgery.

A contemporary case series of Fournier's gangrene at a Swiss tertiary care center-can scoring systems accurately predict mortality and morbidity?

Background: Fournier's gangrene (FG) is a life-threatening infection of the genital, perineal, and perianal regions with a morbidity range between 3 and 67%. Our aim is to report our experience in treatment of FG and to assess whether three different scoring systems can accurately predict mortality and morbidity in FG patients. Methods: All patients that were treated for FG at the Department of Urology of the University Hospital Basel between June 2012 and March 2017 were included and assessed retrospectively by chart review. Furthermore, we calculated Fournier's Gangrene Severity Index (FGSI), the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC), and the neutrophil-lymphocyte ratio (NLR) in every patient and assessed whether those scores correlate with the patients' morbidity and mortality. Results: Twenty patients were included, with a median (IQR) age of 66 (46-73) years. Fifteen of twenty (75%) patients required treatment on an intensive care unit, and three died (mortality rate: 15%). The mean FGSI, LRINEC, and NLR scores were 13.0, 9.3, and 45.3 for non-survivors and 7.7, 6.5, and 26 for survivors, respectively. None of the risk scores correlated significantly with mortality; however, all three significantly correlated with infection- and surgically-induced morbidity. Conclusions: In our series, Fournier's gangrene was associated with a mortality rate of 15% despite maximum multidisciplinary therapy at a specialized center. All risk scores were able to predict the morbidity of the disease in terms of local extent and the required surgical measures.

PDGF-BB regulates splitting angiogenesis in skeletal muscle by limiting VEGF-induced endothelial proliferation.

VEGF induces normal or aberrant angiogenesis depending on its dose in the microenvironment around each producing cell in vivo. This transition depends on the balance between VEGF-induced endothelial stimulation and PDGF-BB-mediated pericyte recruitment, and co-expression of PDGF-BB normalizes aberrant angiogenesis despite high VEGF doses. We recently found that VEGF over-expression induces angiogenesis in skeletal muscle through an initial circumferential vascular enlargement followed by longitudinal splitting, rather than sprouting. Here we investigated the cellular mechanism by which PDGF-BB co-expression normalizes VEGF-induced aberrant angiogenesis. Monoclonal populations of transduced myoblasts, expressing similarly high levels of VEGF alone or with PDGF-BB, were implanted in mouse skeletal muscles. PDGF-BB co-expression did not promote sprouting and angiogenesis that occurred through vascular enlargement and splitting. However, enlargements were significantly smaller in diameter, due to a significant reduction in endothelial proliferation, and retained pericytes, which were otherwise lost with high VEGF alone. A time-course of histological analyses and repetitive intravital imaging showed that PDGF-BB co-expression anticipated the initiation of vascular enlargement and markedly accelerated the splitting process. Interestingly, quantification during in vivo imaging suggested that a global reduction in shear stress favored the initiation of transluminal pillar formation during VEGF-induced splitting angiogenesis. Quantification of target gene expression showed that VEGF-R2 signaling output was significantly reduced by PDGF-BB co-expression compared to VEGF alone. In conclusion, PDGF-BB co-expression prevents VEGF-induced aberrant angiogenesis by modulating VEGF-R2 signaling and endothelial proliferation, thereby limiting the degree of circumferential enlargement and enabling efficient completion of vascular splitting into normal capillary networks despite high VEGF doses.

The "nugget design": A modified segmental gracilis free flap for small-sized defect reconstruction on the lower extremity.

BACKGROUND: Little attention has been given to the segmental free gracilis muscle flap supplied by secondary proximal pedicles. We introduce a technical refinement for small-sized three-dimensional defect reconstruction on the foot. METHODS: Between November 2013 and August 2016, three patients with a mean age of 66 years (range 47-70 years) were included. A segmental gracilis free flap supplied by the most proximal secondary pedicle was harvested according to a modified "nugget design" to treat small-sized defects on the lower extremity requiring dead space reconstruction. Minor and major complications, sensitivity with Semmes-Weinstein monofilament test, soft tissue stability and patient satisfaction at final follow-up were recorded. RESULTS: In one case, a segmental gracilis muscle was used for dorsal foot reconstruction after debridement of metatarsal phalanx I with osteomyelitis. In two cases, the segmental gracilis free muscle was harvested for defect reconstruction on the right plantar foot after excision of a melanoma. The first patient required revision after partial failure of the initial segmental gracilis free muscle flap. Overall, good results in foot function and a high degree of patient satisfaction was achieved (Likert scale 9.7, range 9-10) after a mean follow-up of 13 months (range 3-24 months). CONCLUSIONS: Taken from the very proximal dorsal part of the gracilis muscle supplied by the most proximal secondary pedicle and leaving the vast majority of the muscle intact preserves the option to harvest a normal gracilis flap. This technique is especially suitable for small, three-dimensional defects on the lower extremity.

Low osmolality and shear stress during liposuction impair cell viability in autologous fat grafting.

BACKGROUND: Liposuction and subsequent autologous fat grafting have become essential techniques for fat augmentation in plastic surgery. However, standard harvesting techniques that ensure the survival of adipocytes and stromal vascular fraction (SVF) cells and thus preserve the transplanted fat volume are lacking. In particular, the effect of different parameters of the tumescent solution has not been studied in this context. We hypothesized that the osmolality of the tumescent solution could have a significant effect on the survival of adipocytes and SVF cells. METHODS: We developed two distinct in vitro models based on freshly harvested excision fat from patients undergoing surgical treatment. First, we investigated the effect of osmolality by incubating excision fat in different tumescent solutions and analyzed the total cell survival and the differentiation potential of SVF cells. Vital whole-mount staining, isolation yield of SVF cells, clonogenicity, and osteogenic and adipogenic differentiation capacities were analyzed. Second, we addressed the additional effect of mechanical stress by simulating a liposuction on pieces of excision fat after incubation with the tumescent solutions. RESULTS: Osmolality of the tumescent solution by itself did not have a significant effect on adipocyte and SVF viability or SVF differentiation. However, when osmolality was combined with liposuction, a significant trend toward lower viability and more lipid droplets with lower osmolality was observed. Especially, SVF viability was significantly lower after liposuction with a hypotonic (150 mOsm/kg) solution. CONCLUSION: This study demonstrates the considerable effect of osmolality during liposuction and may lead to the development of "cell-protective" tumescent solutions.

Standardization of oncoplastic breast conserving surgery.

The emphasis on esthetic outcomes and quality of life after breast cancer surgery has motivated surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of the techniques. The present article attempts to standardize OPS nomenclature, indications, and reconstruction choice selection embedded in a thorough review of the literature. We propose four breast conserving surgery (BCS) categories: Conventional tumorectomy, oncoplastic mastopexy, oncoplastic tumorectomy and oncoplastic reduction mammoplasty. The main volume displacement techniques are glandular re-approximation, use of tailored glandular or dermoglandular flaps and nipple-areola complex pedicles. We developed an indication algorithm based on the size and shape of the breast as well as the size and location of the tumor. A reconstruction algorithm suggests a selection of suitable tailored flaps and pedicles based on tumor location and vascular supply of the breast. The application of these algorithms results in known and novel OPS techniques, which are presented here with long-term results. We designed the algorithms to help tailor every operation to the individual patient in a standardized manner, since OPS is now on the rise, more than two decades after the publication of the first techniques. A rapidly increasing body of observational evidence suggests comparable rates of local recurrence between OPS and conventional BCS. Importantly, the rates of clear resection margins are in favor of OPS despite extended indications to larger tumors. Finally, OPS optimizes patient satisfaction by improving esthetic outcomes after BCS.

The medial femoral trochlea flap with a monitor skin island-Report of two cases.

In this report, we present two cases of the bony reconstruction with the medial trochlea (MFT) flap including a skin island that was used to monitor the perfusion of flap in the postoperative period. Between March 2013 and April 2015, we performed surgery on two patients who suffered from scaphoid and talus non-union after trauma and initial treatment by osteosynthesis. A skin island (1 cm × 1 cm and 3 cm × 1 cm, respectively) was included with the osseous flap (1.6 cm × 1 cm × 1 cm and 2 cm × 3 cm × 2 cm, respectively) to assess the perfusion of the flap. The design of the skin island was based on either the saphenous artery perforator or a cutaneous perforator of the descending genicular artery. Both flaps remained viable throughout the postoperative period, and there were no donor site complications. After a follow-up of 36 and 11 months, bony union was observed in both patients with a high degree of satisfaction. Thus, a MFT flap with a skin island could be a tool to assess the perfusion of the flap in the early postoperative period. © 2016 Wiley Periodicals, Inc. Microsurgery 37:431-435, 2017.

[Consensus of the Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) on Autologous Fat Grafting]. / Konsensus der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) zur Eigenfett-Transplantation.

On occasion of the Munich Plastic Symposium in Munich the board of the Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) together with a group of experts who were also involved in the preparation of the recently published S2K guideline "Autologous Fat Grafting", prepared a consensus statement from a plastic-surgical point of view so to evaluate current spects and taking into account the current legal framework: 1. Autologous Fat Grafting is a long established treatment in plastic surgery and does not differ from other tissue grafts. 2. Mechanical processing of autologous fat does not provide any substantial change tot he tissue. 3. If other treatment methods to enrich progenitor cells of autolous fat i. e. by an enzymatic process have evidence that autologous adipose tissue or cells were substantially changed, classification as a drug could come in question under current german law (application of AMG/ATMP).

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2015/2016]. / Register Forschungsförderung der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und Forschungsförderungs-Bericht 2015/2016.

In addition to the impact factor, research funding also plays a central role in evaluating the academic performance and quality of a researcher, a clinic or a surgical specialty. The scope and quality of research in Plastic Surgery are usually very little known, so that even large funding institutions do not get a full view of research funding in our specialty. Therefore, sometimes traditional structures are not adapted to new needs by the developing younger surgical fields. In peer review sometimes peers are not chosen from the same surgical specialty, but from a different surgical fields being peers in large field of surgery. By this a bias can easily be generated which would not be advantageous for subspecialties such Plastic Surgery. The goal of this paper is to establish an overview in the form of a registry of the German Society of Plastic Reconstructive and Aesthetic Surgeons (DGPRÄC) in order to make the joint academic achievements more visible in the future. At the same time, a research funding report is to be published for the years 2015 and 2016.

[Perioperative Management in Microsurgery - Consensus Statement of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / Perioperatives Management in der Mikrochirurgie - Konsensus-Statement der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

Perioperative management of microsurgery is not well standardised. Due to a lack of evidence, different regimes are established in different microsurgical centres. However, trends towards less aggressive perioperative interventions can be identified in recent years, since treatment algorithms without systematic evidence are being progressively abandoned. The available evidence on perioperative issues, such as temperature control, fluid resuscitation, blood transfusions, application of vasodilators or - pressors, as well as anticoagulants, were discussed during the consensus conference on perioperative management at the annual meeting of the German Speaking Society for Microsurgery of Peripheral Nerves and Vessels. Common basic standards were identified and a consensus was reached that is described in the following manuscript.