Deficit of Omega-3 Fatty Acids in Acne Patients-A Cross-Sectional Pilot Study in a German Cohort.

Omega-3 fatty acids (ω-3 FAs) exert anti-inflammatory effects, including the downregulation of pro-inflammatory cytokines, eicosanoids, and insulin-like growth factor-1. Therefore, they may improve acne severity as an adjunct treatment. However, there is a paucity of data regarding patients' existing deficits. The aim of this study was to determine ω-3 FA levels in acne patients in correlation with self-reported dietary preferences and clinical severity. A single-center, cross-sectional study of 100 acne patients was conducted. Patients' blood parameters, including ω-3 FAs levels, were assessed using the HS-omega-3 Index® in erythrocytes (Omegametrix® GmbH, Martinsried, Germany). Dietary preferences were assessed using a standardized food frequency questionnaire. Clinical dermatologic evaluation was performed using the Investigator Global Assessment (IGA) of acne. The values of the HS-omega-3 Index® were outside the recommended range of 8-11% in 96 patients (mean 5.15%), independent of the clinical severity or affected anatomic sites. A severe deficit (HS-omega-3 Index® < 4%) was seen more commonly in men than in women (p = 0.021). The regular consumption of legumes was significantly associated with higher ω-3 FA levels (p = 0.003), as was oral ω-3 FA supplementation (p = 0.006) and the lack of sunflower oil intake (p = 0.008). This pilot study demonstrated a deficit of ω-3 FAs in a German acne cohort. Higher ω-3 FAs levels were observed in patients with regular legume intake and oral ω-3 FAs supplementation. Further prospective studies are needed to investigate whether the clinical severity of acne improves in patients with normal HS-omega-3 Index®.

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / "Wahl der Lappenplastik zur Phalloplastik ­ was ist zeitgemäßer Standard" ­ Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Surgical site infection in skin surgery-An observational study.

BACKGROUND: Surgical site infection (SSI) has a significant impact on patients' morbidity and aesthetic results. OBJECTIVE: To identify risk factors for SSI in dermatologic surgery. PATIENTS AND METHODS: This prospective, single-centre, observational study was performed between August 2020 and May 2021. Patients that presented for dermatologic surgery were included and monitored for the occurrence of SSI. For statistical analysis, we used a mixed effects logistic regression model. RESULTS: Overall, 767 patients with 1272 surgical wounds were included in the analysis. The incidence of SSI was 6.1%. Significant risk factors for wound infection were defect size over 10cm2 (OR 3.64, 95% confidence interval [CI] 1.80-7.35), surgery of cutaneous malignancy (OR 2.96, CI 1.41-6.24), postoperative bleeding (OR 4.63, CI 1.58-13.53), delayed defect closure by local skin flap (OR 2.67, CI 1.13-6.34) and localisation of surgery to the ear (OR 7.75, CI 2.07-28.99). Wound localisation in the lower extremities showed a trend towards significance (OR 3.16, CI 0.90-11.09). Patient-related factors, such as gender, age, diabetes, or immunosuppression, did not show a statistically significant association with postoperative infection. CONCLUSION: Large defects, surgery of cutaneous malignancy, postoperative bleeding, and delayed flap closure increase the risk for SSI. High-risk locations are the ears and lower extremities.

Investigations on the donor limb after harvest of lymphatic vessels for lymphedema surgery.

OBJECTIVE: Microsurgical lymphatic vessel transplantation is one of the well-established therapies for lymphedema. Lymphatic vessels are harvested from a healthy thigh and transplanted into lymphedematous limbs to create a lymphatic bypass. Its benefit on lymphatic drainage has already been proven. However, to the best of our knowledge, the effect on the lymphatic function of the donor site has not yet been studied. Our aim was to evaluate the long-term postoperative lymphatic function in the donor site by clinical and scintigraphic examinations and a patient questionnaire. METHODS: A consecutive series of 25 women (mean age, 57.2 years) who had undergone follow-up after lymph vessel transplantation to treat secondary lymphedema of the arm comprised the study group. Lymphatic vessel function of the donor site was evaluated by circumferential measurements of the limb and, in nine cases, by lymphatic scintigraphy. Additionally, a questionnaire was used to assess the patients' pre- and postoperative complaints for the donor limb and quality of life. Separately, the medical records of 100 patients who had undergone lymphatic harvest and been followed up were reviewed for documented signs of lymphatic function of the donor limb. RESULTS: The lymphatic grafts were harvested from the thigh (left, n = 9; right, n = 16) and transplanted to bridge the region of lymphatic obstruction in the axilla. The mean follow-up period was 4.5 years after surgery. None of the patients had shown significant changes in the circumference of the donor limb or pathologic findings via lymphatic scintigraphy. None of the patients had reported any impairment in the donor leg or showed symptoms of postoperative lymphedema or erysipelas. CONCLUSIONS: Our results have shown that harvesting lymphatic vessels from the thigh for lymphatic vessel transplantation is possible without significant donor site morbidity.

Patient-dependent risk factors for wound infection after skin surgery: A systematic review and meta-analysis.

Postoperative wound infection in dermatologic surgery causes impaired wound healing, poor cosmetic outcome and increased morbidity. Patients with a high-risk profile may benefit from perioperative antibiotic prophylaxis. The objective of this systematic review was to identify risk factors for surgical site infection after dermatologic surgery. In this article, we report findings on patient-dependent risk factors. The literature search included MEDLINE, EMBASE, CENTRAL and trial registers. We performed meta-analysis, if studies reported sufficient data to calculate risk ratios with 95% confidence intervals. Study quality was assessed according to the Newcastle-Ottawa-Scale. Seventeen observational studies that analysed 31213 surgical wounds were eligible for inclusion. Fourteen studies qualified for meta-analysis. Nine studies showed good, three fair and five poor methodological quality. The reported incidence of surgical site infection ranged from 0.96% to 8.70%. Meta-analysis yielded that male gender and immunosuppression were significantly associated with higher infection rates. There was a tendency towards a higher infection risk for patients with diabetes, without statistical significance. Meta-analysis did not show different infection rates after excision of squamous cell carcinoma or basal cell carcinoma, but studies were substantially heterogenous. There was no significant association between risk for wound infection and smoking, age over 60 years, oral anti-aggregation or anti-coagulation or excision of malignant melanoma. In conclusion, the risk for surgical site infection in dermatologic surgery is low. Infection rates were increased significantly in male as well as immunosuppressed patients and non-significantly in diabetics.

Development and biomechanical evaluation of a new biodegradable intramedullary implant for osteosynthesis of midshaft fractures of small hollow bones.

BACKGROUND: Up to date there is no intramedullary, biodegradable osteosynthesis commercially available to treat non-comminuted midshaft fractures of small hollow bones applying not only a stable osteosynthesis but an additional axial compression to the fracture site. OBJECTIVE AND METHODS: Therefore we (1) designed different implant profiles and simulated the inner tension/volume using CAD. (2) Thereafter we manufactured a prototype with the best volume/tension-ratio using 70:30 poly-(L-lactide-co-D, L-lactide) (PLLA/PDLLA) and poly-ε-caprolactone (PCL) by injection moulding. Both materials are resorbable, licensed for medical use and show a slow degradation over at least one year. (3) The implants were tested in a universal testing machine (Zwick/RoellZ010) using a 3-point-bending-setup. (4) We compared the implants with different types of commercially available Ti6Al4V 6-hole 2, 3 mm-plates including interlocking systems (Leibinger Set, Stryker) (each group n= 6) using a 4-point-bending-test-setup with artificial metacarpal bones (Sawbones®). RESULTS: The 3-point-bending-test-results showed that mean failure-force of PCL-tubes was 57.94 ± 4.28 N whereas the PLLA/PDLLA-tubes had an approximately four-fold higher value of 227.24 ± 1.87 N (p< 0.001). Additionally, the 4-point-bending-test-results showed that the maximum load of PLLA/PDLLA tubes (61.97 ± 3.58 N) was significantly higher than the strongest 6-hole metacarpal plate (22.81 ± 0.76 N) (p< 0.001). CONCLUSION: The study showed that the new type of biodegradable, intramedullary tension-osteosynthesis made of PLLA/PDLLA is even more stable than common plate osteosynthesis in a small-hallow-bone-model. Further in vivo investigation should be performed to evaluate the surgical technique and long-term healing process of the bone and biodegradation process of the implant.

In vivo tracking of adipose tissue grafts with cadmium-telluride quantum dots.

BACKGROUND: Fat grafting, or lipofilling, represent frequent clinically used entities. The fate of these transplants is still not predictable, whereas only few animal models are available for further research. Quantum dots (QDs) are semiconductor nanocrystals which can be conveniently tracked in vivo due to photoluminescence. METHODS: Fat grafts in cluster form were labeled with cadmium-telluride (CdTe)-QD 770 and transplanted subcutaneously in a murine in vivo model. Photoluminescence levels were serially followed in vivo. RESULTS: Tracing of fat grafts was possible for 50 days with CdTe-QD 770. The remaining photoluminescence was 4.9%±2.5% for the QDs marked fat grafts after 30 days and 4.2%± 1.7% after 50 days. There was no significant correlation in the relative course of the tracking signal, when vital fat transplants were compared to non-vital graft controls. CONCLUSIONS: For the first-time fat grafts were tracked in vivo with CdTe-QDs. CdTe-QDs could offer a new option for in vivo tracking of fat grafts for at least 50 days, but do not document vitality of the grafts.

Microsurgical Lymphatic Vessel Transplantation.

BACKGROUND: Lymphedema often arises after a regional interruption during cancer treatment, for example after lymph node resection the axilla or the groin. Lymphatic vessels as vascular grafts may overcome these lymphatic gaps. METHOD: Experiments in rats and dogs were performed for developing this method. Volume measurements, lymphoscintigraphies, proof of patency by MRI and radiology as well as quality of life studies were performed in patients. RESULTS: Long-term follow-up studies revealed significantly reduced volumes, significant improvement of lymphatic outflow shown by lymphoscintigraphy, long-term patency of the grafts for more than 10 years, and improved quality of life after surgery compared with the situation with conservative treatment before surgery. CONCLUSION: Vascular grafts using the patients own lymphatic vessels are able to successfully reconstruct a locally interrupted lymphatic pathway.

Primary lymphedema of the lower limb: the clinical utility of single photon emission computed tomography/CT.

OBJECTIVE: The aim of this prospective study was to determine whether the additional use of the single photon emission computed tomography/CT (SPECT/CT) technique improves the diagnostic value of planar lymphoscintigraphy in patients presenting with primary lymph edema of the lower limb. MATERIALS AND METHODS: For a defined period of three years (April 2011-April 2014) a total of 34 consecutive patients (28 females; age range, 27-83 years) presenting with swelling of the leg(s) suspicious of (uni- or bilateral, proximal or distal) primary lymphedema were prospectively examined by planar lymphoscintigraphy (lower limbs, n = 67) and the tomographic SPECT/CT technique (anatomical sides, n = 65). RESULTS: In comparison to pathological planar scintigraphic findings, the addition of SPECT/CT provided relevant additional information regarding the presence of dermal backflow (86%), the anatomical extent of lymphatic disorders (64%), the presence or absence of lymph nodes (46%), and the visualization of lymph vessels (4%). CONCLUSION: As an adjunct to planar lymphoscintigraphy, SPECT/CT specifies the anatomical correlation of lymphatic disorders and thus improves assessment of the extent of pathology due to the particular advantages of tomographic separation of overlapping sources. The interpretation of scintigraphic data benefits not only in baseline diagnosis, but also in physiotherapeutical and microsurgical treatments of primary lymphedema.

Lymphedema of the upper limb: evaluation of the functional outcome by dynamic imaging of lymph kinetics after autologous lymph vessel transplantation.

PURPOSE: The aim of this study was to evaluate by lymphoscintigraphy the functional outcome after autologous lymph vessel transplantation (Tx) of the upper limb. METHODS: One hundred seventy-seven patients (172 female, 5 male; median age, 56 years; range, 12-84 years) presenting with Tx situs in an upper limb were included. For correlation of scintigraphic data versus reduction of volume (RV) surplus measurements, we examined at 4 different time points as follows: preoperatively (T0), within 2 weeks after Tx (T1), 6 to 12 months after Tx (T2), and 32 to 38 months after Tx (T3). An additional long-term follow-up after at least 8 years (T4) was available in some cases. RESULTS: The maximum individual postoperative observation period was 19 years. In 169 of 177 cases, lymphedema had been caused by treatment of breast cancer (mastectomy, n = 103/169; breast preserving, n = 66/169) and/or radiation therapy (n = 130/177), but 2 patients presented with primary lymphedema. The remaining 6 cases of lymphatic disorders were caused by treatment of malignant melanoma, Hodgkin lymphoma, axillary Ewing sarcoma, non-Hodgkin lymphoma, hemangioma, or abscess removal.At T1, the mean RV of the affected limb was 73%, and the mean improvement of transport index (TI) was 28%. At T2, the RV was 64% and the TI was 23%, and at T3, the RV was 63% and the TI was 25%. Long-term follow-up after at least 8 years (T4: range, 9-19.2; mean, 14.1 years) was available in 19 of 177 patients, in whom persistent improvement in the scintigraphic data (25% decrease in TI) was confirmed by a mean clinical RV of 68%. The mean overall correlation was by a factor of 2.64. CONCLUSIONS: Our findings in this large set of patients undergoing autologous lymph vessel Tx to an upper limb confirm that this microsurgical technique significantly and persistently improves lymph drainage in patients with lymphedema. The findings of lymphoscintigraphy correlated well with volume measurements at long-term follow-up.

CT-guided sacroiliac percutaneous screw placement in unstable posterior pelvic ring injuries: accuracy of screw position, injury reduction and complications in 71 patients with 136 screws.

BACKGROUND: Sacroiliac-percutaneous-screw-placement (SPSP) for unstable-posterior-pelvic-ring-injuries (UPPRI) might be associated with severe neurovascular complications because of screw-mal-position. The aim of the present study was to analysis the effectivity of computer-tomography-guided (CTG)-SPSP including accuracy of screw-placement, quality of injury-reduction and documentation of perioperative-complications. Additionally, procedure-dependent radiation-dose and outcome should be analysed. METHODS: A consecutive cohort of 71 patients with UPPRI was operated by CTG-SPSP at a single trauma level 1 hospital. 136 sacroiliac screws were inserted to S1 and S2. Postoperatively, by the use of a computerised-radiologic-work-station all screws were visualised three-dimensionally. Their distancesmin to the sacral-borders in anterior-posterior and cranio-caudal direction as well as to the neuroforamen S1/S2 were determined. After CTG-SPSP, injury-dislocation in anterior-posterior and cranio-caudal direction was quantified. Local and general complications were documented during the 30-day-period. In 55 patients (77.5%) a follow-up-investigation (29.1±19.1 months) was performed. RESULTS: 132 screws (97.1%) were placed completely intraosseous, 3 screws (2.2%) perforated up to 1.0 mm (n(S1)=one screw; n(S2)=two screws), and one screw (0.7%) extended 2.2 mm into the S2-neuroforamen without contact to neural structures. Postoperative dislocationanterior-posterior was 1.3±0.9 mm and dislocationcranio-caudal 1.5±0.9 mm. No procedure-associated-complication was observed. Operation time showed a significant "learning curve" during the six-year study period (initially: 88.6±60.3 min; finally: 44.3±24.6 min). Perioperative effective-radiation-dose for patientsmale was 5.9±3.1 mSv and for patientsfemale 8.7±4.5 mSv. All injuries healed and 33 patients (46.5%) had metal removal after 11.0 (±4.9) months. Only two (5.0%) out of 40 patients complained persistent UPPRI-related pain so they were not able to restart work. CONCLUSIONS: The CTG-SPSP is a safe procedure for UPPRI-stabilisation especially in S1 but also in S2. Injury reduction was excellent and no procedure associated complications were observed.

The free groin flap in the rat: a model for improving microsurgical skills and for microvascular perfusion studies.

The goal of this study was to evaluate the free groin flap in the rat transplanted to the neck as a tool for extending microsurgical skills and to assess its suitability as a model for microvascular perfusion studies following secondary venous ischaemia. An analysis of 60 consecutive groin flap transplantations was performed in male Sprague Dawley rats with special regard to anatomy and operation times (Part I, animals No. 1-60). Following flap transplantation, the animals No. 10-30 (n = 21) were used for the determination of the critical time period of a complete venous stasis of the free groin flap resulting in a total flap loss (Part II). The flaps of animals No. 31-41 (n = 11) were used for assessing the feasibility and reproducibility of intra-vital video microscopy (IVM) of the flaps (Part III). The mean total operation time decreased from 166 (± 26) minutes ins the first 10 animals to 126 (± 21) minutes and 130 (± 12) minutes in the latter two groups of 10 animals, respectively. After a critical period of 35 minutes of a complete artificial venous stasis a complete flap necrosis occurred. IVM detected a higher functional capillary density of the skin of the transplanted groin flaps in the animals in which the flaps were rinsed with 1 ml of Ringer's lactated solution prior to I/R. In conclusion, this model is simple and reliable. The model may be a useful tool for evaluating and comparing the effects of various anticoagulants or vasomotor drugss on microvascular perfusion in critically compromised free flaps.

Correction of asymmetric pectus excavatum using a virtually designed silicone implant.

BACKGROUND: An extended asymmetric funnel chest deformity with the breast gland located in the thoracic mold can lead to a fictitious aplasia of the breast. The authors termed this condition "pseudo-Amazon syndrome" because the breast tissue and the pectoralis muscle are fully developed. METHODS: This report presents a detailed technical approach to the fabrication of a precise-fitting custom-made silicone implant. The design of the implant was achieved using a computed tomography (CT) data set and rapid prototyping. The volumes of the "hidden" and the normal breasts measured preoperatively by processing the CT data were similar. These volumes were compared with the breast volumes measured by three-dimensional photography 4 years postoperatively to assess the predictability of the volume congruency. The silicone implant was surgically placed in the epicostal plane and extended almost over the right hemithorax. RESULTS: The implantation was performed without the necessity of further trimming. Both the surgeon and the patient rated the aesthetic and functional long-term result as good in terms of symmetry and the possibility of exercise without restrictions. The final breast volume of the surgically treated side was 95 % of the volume of the normal contralateral breast. CONCLUSION: The described method reduces the operation time and the operative trauma by primary implant fit. However, the method is rather elaborate and the production process is expensive. This in turn reduces the generation of proceeds to a minimum. 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 .

Decompression of inflammatory edema along with endothelial cell therapy expedites regeneration after renal ischemia-reperfusion injury.

Increased pressure due to postischemic edema aggravates renal ischemia-reperfusion injury (IRI). Prophylactic surgical decompression using microcapsulotomy improves kidney dysfunction after IRI. Supportive cell therapy in combination with microcapsulotomy might act synergistically protecting kidney function against IRI. The effects of therapeutic endothelial cell application alone and in combination with microcapsulotomy were investigated in a xenogenic murine model of 45-min warm renal ischemia. Renal function and perfusion were determined before as well as 2 and 18 days postischemia by (99m)Tc-MAG3 imaging and laser Doppler. Histological analysis included H&E stains and immunohistology for endothelial marker MECA-32, cell proliferation marker Ki-67, and macrophage marker F4/80. Histomorphological changes were quantified using a tubular injury score. Ischemia of 45 min led to severe tissue damage and a significant decrease in renal function and perfusion. Microcapsulotomy and cell therapy alone had no significant effect on renal function, while only surgical decompression significantly increased blood flow in ischemic kidneys. However, the combination of both microcapsulotomy and cell therapy significantly improved kidney function and perfusion. Combination therapy significantly reduced morphological injury of ischemic kidneys as determined by a tubular injury score and MECA-32 staining. Macrophage infiltration evidenced by F4/80 staining was significantly reduced. The Ki-67 proliferation index was increased, suggesting a regenerative environment. While microcapsulotomy and cell therapy alone have limited effect on renal recovery after IRI, combination therapy showed synergistic improvement of renal function, perfusion, and structural damage. Microcapsulotomy may create a permissive environment for cell therapy to work.

Technique and proof of patency of microsurgical lympho-lymphonodular anastomoses: a study in the rat model.

BACKGROUND: Lymphedemas due to local lymphatic blocks can be treated by microsurgical transplantation or transposition of lymphatic vessels. Here, the anastomoses are usually made end-to-end between lymphatics, but occasionally appropriate lymphatic recipient vessels are missing. In such cases, reconstructing lymph drainage by connection to a lymph node could be another technical option. The purpose of this study was to examine the patency rate of such lympho-lymphonodular anastomoses in an experimental animal model. METHODS: Male Sprague-Dawley rats were anesthetized, and the retroperitoneum was exposed. Patent blue dye was injected into the left foot to stain lymphatic structures. In group A (n = 8), the left lumbar trunk was cut centrally, the distal part was turned over to the right lumbar lymph node, and a microsurgical lympho-lymphonodular anastomosis was performed. In group B (n = 8), the left lumbar trunk was cut. After 8 weeks, the lumbar region was surgically re-explored, and the lymphatic drainage was examined by injection of Patent blue dye into the left lumbar lymph node. RESULTS: In 8/8 animals of group A, patent transposed lymphatics were found. The patency of the anastomosis was proven directly by observation of blue dye transit and indirectly by observation of blue staining of the right lumbar lymph node. In 6/8 animals of group B, no lymphatic connection to the right lumbar lymphatic system was observed. CONCLUSIONS: This is the first report of the microsurgical technique and the proof of patency of lympho-lymphonodular anastomoses. The novel animal model for testing the patency of transposed lymphatics is discussed.