Aesthetic Surgery Fellowship at Akademikliniken Stockholm: Survey among Graduates.

BACKGROUND: Aesthetic Surgery is one of the most competitive fields of plastic surgery. Although there is a certain demand for highly educated surgeons in this field, training in cosmetic procedures remains challenging. Akademikliniken Stockholm offers a highly appreciated fellowship program for aesthetic plastic surgeons and trained more than 200 surgeons from all over the world. OBJECTIVES: The aim of the present work was to provide insights into this fellowship program, analyze what graduates have learned and if this had implications on their further professional orientation. METHODS: Participants of the Akademikliniken fellowship program, who graduated between 10/2008 and 10/2018 (n = 66) were invited to take part in an online survey which included 30 questions about general demographics and about experience before, during and after the fellowship. RESULTS: Thirty-four graduates participated in the survey (52%). Twenty-four graduates (71%) had been already specialists in plastic surgery before commencing the fellowship program. Mean length of fellowship was 7 months (range 3-24months). Numbers of aesthetic procedures performed by the applicants significantly increased after the fellowship, and moreover, the scope of daily clinical practice shifted toward aesthetics in almost all applicants. CONCLUSIONS: A well-designed dedicated aesthetic surgery fellowship can improve the lack of training, aesthetic surgeons have during their residency. Graduates of our fellowship program reported great improvements in confidence in performing aesthetic procedures and a benefit for their future career. LEVEL OF EVIDENCE III: 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 .

Patient-reported Outcomes Utilizing the Breast-Q Questionnaire After Breast Conserving Surgery With and Without Oncoplastic Breast Surgery: A Systematic Review and Meta-analysis.

Oncoplastic breast surgery (OBS) arose to decrease the deformity following breast conserving surgery (BCS) for breast cancer. In this meta-analysis (MA), we pool Breast-Q™ questionnaire data to compare quality of life (QOL) in breast cancer patients who received BCS alone or in combination with Level I or II oncoplastic breast surgery (BCS+OBS). All relevant databases were searched following the PRISMA and QUOROM guidelines. All prospective or retrospective studies with a BCS or BCS+OBS cohort that reported QOL as assessed with the Breast-Q™ questionnaire were eligible. Fifty-five studies (75 distinct patient cohorts; 11,186 patients) were included in the MA, with 12 studies reporting both pre- and postoperative values and eligible for a pairwise MA. The pairwise MA showed a significant postoperative improvement in the overall satisfaction with the breast (MD +8.0%, p=0.003) and in the psychosocial well-being (MD +9.2%, 3.5-14.8, p=0.001) of the entire cohort (BCS and BCS+OBS). A subgroup MA of proportions highlighted a superiority of BCS+OBS to BCS in terms of overall satisfaction with the breast (72.0%, 68.0-76.1, versus 62.9%, 58.3-67.5; p=0.02) and psychosocial well-being (78.9%, 71.5-86.4, versus 73.3%, 67.3-76.5, p=0.0001). A leave-one-out sensitivity analysis confirmed the results of the pairwise MA and the MA of proportions. Oncoplastic breast surgery effectively improves QoL based on the patient-reported outcomes assessed using the Breast-Q™ questionnaire. The improvements were associated with acceptable complication rates, further supporting the use of BCS followed by OBS where mastectomy would otherwise be necessary.

Enzymatic Debridement in Geriatric Burn Patients-A Reliable Option for Selective Eschar Removal.

The treatment of geriatric burn patients represents a major challenge in burn care. The objective of this study was to evaluate the efficacy of enzymatic debridement (ED) in geriatric burn patients. Adult patients who received ED for treatment of mixed pattern and full thickness burns (August 2017-October 2022) were included in this study and grouped in the younger (18-65 years) and geriatric (≥65 years) groups. Primary outcome was a necessity of surgery subsequent to ED. Both groups (patient characteristics, surgical and non-surgical treatment) were compared. Multiple logistic and linear regression models were used to identify the effect of age on the outcomes. A total of 169 patients were included (younger group: 135 patients, geriatric group: 34 patients). The burn size as indicated by %TBSA (24.2 ± 20.4% vs. 26.8 ± 17.1%, p = 0.499) was similar in both groups. The ASA (2.5 ± 1.1 vs. 3.4 ± 1.1, p < 0.001) and ABSI scores (6.1 ± 2.8 vs. 8.6 ± 2.3, p < 0.001) were significantly higher in the geriatric group. The %TBSA treated with ED (5.4 ± 5.0% vs. 4.4 ± 4.3%, p = 0.245) were similar in both groups. The necessity of additional surgical interventions (63.0 % vs. 58.8 %, p = 0.763) and the wound size debrided and grafted (2.9 ± 3.5% vs. 2.2 ± 2.1%; p = 0.301) were similar in both groups. Regression models yielded that age did not have an effect on efficacy of ED. We showed that ED is reliable and safe to use in geriatric patients. Age did not have a significant influence on the surgical outcomes of ED. In both groups, the size of the grafted area was reduced and, in many patients, surgery was avoided completely.

Implications of Vascularized Composite Allotransplantation in Plastic Surgery on Legal Medicine.

BACKGROUND: When a patient receives a transplant-be it classically an organ or bone marrow or, more recently, composite allotransplantations of the limb or face-it can result in artificial chimerism. Such chimerism raises considerations in forensic medicine, a field that relies on the collection and identification of biological samples from crime scenes. Beyond this chimerism, composite allotransplantations create further challenges. METHODS: After screening the literature and press releases, we provide a brief history and summary of some of the technologies used in forensic identification, explaining their advantages and pitfalls in the light of transplantation and cautioning against misidentifying those who evade justice by taking advantage of such considerations. RESULTS: With face transplantation, patients can receive the skin, hair, salivary glands, teeth, and oral and nasal mucosa of their donors, components which hold great importance in forensic science. Modern technologies such as computer-assisted facial recognition, although gradually becoming more accurate over time, also face new challenges in this post-transplantation era as facial recognition software can be misled by surgical alterations of the face or face transplantation. With limb transplantation, there is an impact on fingerprint identification. CONCLUSIONS: Both surgical transplantation techniques and forensic technologies have seen incomprehensibly great innovation in the past century. Given the growing rate of successful composite transplantation in the USA and worldwide, it is now important for law enforcement agents to be aware of the new possibility of having two sets of genetic material, hair, saliva, fingerprints, or even facial recognition data for the same individual.

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.

Effective or Harmful-Evaluation of Locally Applied Antibiotics on Adipose Tissue during Lipofilling to the Breast-An In Vitro Study.

Lipofilling is a frequently used and safe procedure for breast reconstruction. One of the most feared complications is soft tissue infection following lipofilling. Because of this, some surgeons propose the practice of rinsing fat grafts with antibiotics. This study investigates the effect of antibiotic rinses on fat grafts in an in vitro model. Adipocytes and stem cells were isolated from fat tissue harvested during 24 lipofilling procedures and incubated with different doses of clindamycin or cefazolin. Cell viability, metabolism, proliferation, and differentiation capacities were analyzed by gross morphology, fluorescence staining, -(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromid (MTT-), and Glyceraldehyde 3 Phosphate Dehydrogenase (G3PD)-assay as well as reactive oxygen species (ROS)-assay. Cefazolin and clindamycin led to significant reduction of cell viability of adipocytes. High doses of both antibiotics led to a rupture of adipocytes with visible free lipid droplets. Cell metabolism was significantly decreased after incubation with both antibiotics. There was a significant increase in ROS production. Exposure to clindamycin and cefazolin led to morphological changes in stem cells in a dose- and time-dependent manner. Furthermore, differentiation potential was significantly reduced. Antibiotic susceptibility testing, however, showed that low concentrations of antibiotics effectively inhibited bacterial growth in contaminated fat grafts. This study confirms that rinsing fat grafts with clindamycin or cefazolin not only overly prevents infection but also has cytotoxic and metabolic effects on adipocytes. Therefore, based on these results, the routine clinical application in high doses cannot be recommended.

Patient-Reported Outcomes After Reduction Mammoplasty Using BREAST-Q: A Systematic Review and Meta-Analysis.

BACKGROUND: The BREAST-Q questionnaire reduction module is an established tool for outcomes after reduction mammoplasty. OBJECTIVES: This systematic review and meta-analysis assess key parameters affecting pre- and postoperative scores, with specific foci on patient characteristics and tissue resection weights. METHODS: This study was conducted per PRISMA guidelines. PUBMED (National Institutes of Health; Bethesda, MD), Google Scholar (Google; Mountain View, CA), and Web of Science (Clarivate Analytics; Philadelphia, PA) were searched. All studies published before August 1, 2021, were assessed for eligibility by 2 independent reviewers. Inclusion criteria were prospective or retrospective studies in 6 languages that reported quality of life after reduction mammoplasty employing the BREAST-Q questionnaire reduction module. Quality of included studies was assessed employing the Newcastle-Ottawa-Scale. Analysis was performed per Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines. RESULTS: A total of 28 papers were included in the systematic review, 13 for preoperative meta-analysis, and 17 for postoperative meta-analysis. Postoperative scores in all 3 quality of life domains (psychosocial, physical, and sexual well-being) and satisfaction with breasts increased significantly after reduction mammoplasty compared with preoperative scores. Satisfaction with breasts showed the greatest improvement, from 22.9 to 73.0. Preoperative scores were lower than normative data, with improvement to comparable scores as the healthy population postoperatively. Improvements in BREAST-Q scores did not correlate with patient comorbidities, complication rates, or amount of breast tissue resected. CONCLUSIONS: Reduction mammoplasty provides marked improvement in BREAST-Q patient-reported quality of life as well established in literature. However, these improvements do not correlate with tissue resection weights, warranting further inquiry of insurance-defined resection requirements.

30-Day Postoperative Outcomes in Adults with Obstructive Sleep Apnea Undergoing Upper Airway Surgery.

Background: Obstructive sleep apnea (OSA) is a chronic disorder of the upper airway. OSA surgery has oftentimes been researched based on the outcomes of single-institutional facilities. We retrospectively analyzed a multi-institutional national database to investigate the outcomes of OSA surgery and identify risk factors for complications. Methods: We reviewed the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2008−2020) to identify patients who underwent OSA surgery. The postoperative outcomes of interest included 30-day surgical and medical complications, reoperation, readmission, and mortality. Additionally, we assessed risk-associated factors for complications, including comorbidities and preoperative blood values. Results: The study population included 4662 patients. Obesity (n = 2909; 63%) and hypertension (n = 1435; 31%) were the most frequent comorbidities. While two (0.04%) deaths were reported within the 30-day postoperative period, the total complication rate was 6.3% (n = 292). Increased BMI (p = 0.01), male sex (p = 0.03), history of diabetes (p = 0.002), hypertension requiring treatment (p = 0.03), inpatient setting (p < 0.0001), and American Society of Anesthesiology (ASA) physical status classification scores ≥ 4 (p < 0.0001) were identified as risk-associated factors for any postoperative complications. Increased alkaline phosphatase (ALP) was identified as a risk-associated factor for the occurrence of any complications (p = 0.02) and medical complications (p = 0.001). Conclusions: OSA surgery outcomes were analyzed at the national level, with complications shown to depend on AP levels, male gender, extreme BMI, and diabetes mellitus. While OSA surgery has demonstrated an overall positive safety profile, the implementation of these novel risk-associated variables into the perioperative workflow may further enhance patient care.

Microsurgical Strategies after Free Flap Failure in Soft Tissue Reconstruction of the Lower Extremity: A 17-Year Single-Center Experience.

Background: There is no clear consensus on the optimal surgical strategy for providing safe coverage in salvage free flap surgery after total free flap failure. Methods: A retrospective study was conducted to evaluate patients with total failure of the primary free flap in lower extremity reconstruction between 2000 and 2017. Results: In a cohort of 1.016 patients, we identified 43 cases of total flap failure (4.2%). A total of 30 patients received a salvage free flap with a success rate of 83.3% (25/30). One patient received a secondary salvage free flap. Overall limb salvage after primary free flap loss was 83.7% (36/43). Conclusions: Microsurgical management of free flap loss in the lower extremity is challenging and requires a decisive re-evaluation of risk factors and alternative strategies. This should include reconsidering the flap choice with a tendency towards traditional and safe workhorse flaps, a low-threshold switch to different recipient vessels, including arteriovenous (AV) loops, bypasses (especially in case of venous insufficiency) and back-up procedures, such as negative pressure wound therapy or dermal regeneration templates with skin grafting in cases of lower demand and critically ill patients. We derived one suggestion from our previous practice: replacing perforator flaps with axial pattern flaps ("safe workhorses").

The impact of previous surgery on scaphoid nonunion reconstruction: a retrospective study of 95 cases.

We retrospectively compared 64 scaphoid reconstructions in cases that had not undergone previous surgery with 31 cases in which previous surgery had been performed. The characteristics of the groups were similar except that there were more smokers in the group without previous surgery and a more frequent use of vascularized bone grafts in the group with previous surgery. At final follow-up, 66 and 65 months, respectively, after reconstruction, union incidence was 89% and 90%. In patients with previous surgery, grip strength was higher but not when expressed in percent of the contralateral hand. There were no differences in pinch strength, active wrist motion, functional scores, carpal height or scapholunate angle. We conclude that repeat surgery to the scaphoid did not seem to be a major risk factor for the overall outcomes, keeping in mind that a vascularized bone graft was more frequently used for secondary reconstructions.Level of evidence: III.

The modified 5-item frailty index is a predictor of perioperative risk in breast reconstruction: An analysis of 40,415 cases.

BACKGROUND: The aging population has presented surgeons with new challenges as they increasingly must operate on greater numbers of frail patients. The modified frailty index 5 (mFI-5) is a concise comorbidity-based scale that has been shown to accurately predict adverse surgical outcomes. In this study, we sought to evaluate the ability of the mFI-5 to predict the risk of postoperative outcomes in breast reconstruction patients. METHODS: Utilizing the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified 40,415 patients who underwent breast reconstruction, of which 29,562 were implant-based reconstructions and 10,853 were autologous breast reconstructions. Demographic and preoperative variables as well as 30-day postoperative outcomes, including mortality, operation duration, length of hospital stay, medical and surgical complications, and discharge destination, were extracted. RESULTS: Increases in the mFI score correlated with higher rates of reoperation (mFI≥3: 13.5% vs. mFI=0: 5.9%), unplanned readmission (mFI≥3: 10.8% vs. mFI=0: 3.6%), surgical (mFI≥3: 12.2% vs. mFI=0: 4.3%) and medical complications (mFI≥3: 6.8% vs. mFI=0: 1.2%), and lower rates of home discharge (mFI≥3: 96% vs. mFI=0: 99.5%). Multivariate analysis to control for confounders verified significantly higher rates of reoperation (OR=0.01, 95%CI 0.005-0.016), unplanned readmission (OR=0.009, 95%CI 0.005-0.014), and occurrence of surgical complications (OR=0.014, 95%CI 0.009-0.019) and medical complications (OR=0.005, 95%CI 0.002-0.008). Stratification by age showed that the mFI-5 was a stronger risk predictor in younger patients who are frail. Stratification by type of reconstruction showed that increased mFI scores significantly correlated with complications in both autologous and implant-based reconstruction, but the correlation was greater in autologous procedures. CONCLUSION: The mFI-5 is identified as a powerful risk predictor in breast reconstruction. The application of this easily accessible tool in the preoperative risk stratification of patients undergoing breast reconstruction can enhance treatment planning and support, optimizing patient counseling, informed consent, and decision-making.

The collagenase of the bacterium Clostridium histolyticum does not favor metastasis of breast cancer.

BACKGROUND: Breast cancer is the most common malignancy among women worldwide. As survival rates increase, breast reconstruction and quality of life gain importance. Of all women undergoing breast reconstruction, approximately, 70% opt for silicone implants and 50% of those develop capsular contracture, the most prevalent long-term complication. The collagenase of the bacterium Clostridium histolyticum (CCH) showed promising results in the therapy of capsule contracture; however, its influence on residual cancer cells is unknown. The aim of this study was to investigate whether CCH-treatment negatively impacts breast cancer cells in vitro and in vivo. METHODS: MDA-MB-231 and MCF-7 cells were used in this study. In vitro, we tested the influence of CCH on proliferation, wound healing, migration and cell cycle by MTT-assay, scratch-assay, transwell-migration-assay, and flow cytometry. In vivo, solid tumors were induced in immune-deficient mice. CCH was injected into the tumors and tumor growth and metastasis formation was monitored by caliper measurement, in vivo bioluminescence imaging and histology. Gene expression analysis was performed by microarray including 27,190 genes. RESULTS: CCH-incubation led to a dose-dependent reduction in proliferation for both cell lines, while wound healing was reduced only in MDA-MB-231 cells. No morphological alterations were monitored in cell cycle or apoptosis. In vivo, bioluminescence imaging and histology did not show any evidence of metastasis. Although CCH led to changes in gene expression of breast cancer cells, no relevant alterations in metastasis-related genes were monitored. CONCLUSION: CCH has no impact on tumor growth or metastasis formation in vitro and in vivo. This paves the way for first clinical trials.

Racial disparities in short-term outcomes after breast reduction surgery-A National Surgical Quality Improvement Project Analysis with 23,268 patients using Propensity Score Matching.

BACKGROUND: Evidence of widespread disparities in healthcare for racial and ethnic minorities is well documented. This study aims to evaluate differences in surgical outcomes after breast reduction surgery (BRS) according to patients' ethnicities. METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database (2005-2018) was utilized to analyze two propensity score matched patient cohorts-White and non-White-that underwent BRS. Preoperative variables assessed included demographic data and comorbidities such as diabetes mellitus, hypertension, and obesity. Postoperative outcomes assessed were medical complications, minor and major surgical complications, as well as mortality. RESULTS: In total, 23268 patients underwent BRS and met the inclusion criteria. After propensity score matching, the two cohorts were matched with respect to these preoperative variables, and 7187 patients were included in each cohort of White and non-White patients (total 14374). After matching, overall 30-day major complications were not significantly different between White and non-White cohort (2.25% vs 2.14%, p=0.65). After accounting for differences in confounding variables at the patient and socioeconomic level, racial and ethnic minorities who underwent breast reduction were found to experience fewer minor surgical complications. The analysis of temporal trends identified an overall rise in the number of patients seeking BRS, with a higher increase noted in the non-White population. CONCLUSION: Overall, our findings are reassuring exemptions to prevalent racial and ethnic health inequalities and can serve as a positive example for adequate and fair provision of surgical care.

The Impact of Metabolic Syndrome on Microvascular Head and Neck Reconstruction: An ACS-NSQIP data analysis.

BACKGROUND: Metabolic syndrome (MetS) can predispose patients to poorer surgical outcomes. In this study, we sought to evaluate the impact of MetS on the postoperative outcomes of head and neck microvascular reconstruction. METHODS: Review of the 2015-2019 NSQIP database identified 5,323 cases of microvascular reconstruction, of which 3,809 were head and neck cases. Of the included patients, 184 had MetS and 3625 did not. The groups were compared in terms of demographics and comorbidities. Postoperative outcomes assessed included mortality, average operative time and length of hospital stay, surgical and medical complications, and nonhome discharge. RESULTS: The MetS group had higher rates of medical complications (p<0.0001), sepsis (p=0.02), septic shock (p=0.01), and skilled care-discharge (p=0.0004). Analysis by flap type revealed that MetS patients receiving free skin flaps experienced higher rates of organ space infection (p=0.02), sepsis (p<0.0001), and lower home-discharge (p=0.01). In the free muscle group, superficial incisional infection (p=0.04), UTI (p=0.02), and septic shock (p=0.01) were higher in MetS patients. Stratification by surgical site showed that the occurrence of sepsis was significantly higher in the patients receiving microvascular flap reconstruction of the larynx (p=0.04) or tongue(p=0.03). Stratification of the MetS patients according to treatment for diabetes showed that patients receiving insulin experienced a higher rate of superficial incisional infection (p=0.04). A multivariate analysis verified significantly higher rates of medical complications (p<0.0001), sepsis (p=0.03) and septic shock (p=0.01) in the MetS group. CONCLUSION: Patients with MetS undergoing head and neck microvascular reconstruction are at increased risk of postoperative medical complications, including sepsis and septic shock, and are more likely to be discharged to a skilled care facility. Surgical outcomes were found to depend on the type of flap and site of surgery.

Software-based Detection of Acute Rejection Changes in Face Transplant.

BACKGROUND: An objective, non-invasive method for redness detection during acute allograft rejection in face transplantation (FT) is lacking. METHODS: A retrospective cohort study was performed with 688 images of 7 patients with face transplant (range, 1 to 108 months post-transplant). Healthy controls were matched to donor age, sex, and had no prior facial procedures. Rejection state was confirmed via tissue biopsy. An image-analysis software developed alongside VicarVision (Amsterdam, Netherlands) was used to produce R, a measure of differences between detectable color and absolute red. R is inversely proportional to redness, where lower R values correspond to increased redness. Linear mixed models were used to study fixed effect of rejection state on R values. Estimated marginal means of fitted models were calculated for pairwise comparisons. RESULTS: Of 688 images, 175, 170, 202, and 141 images were attributable to Banff Grade 0,1,2, and 3, respectively. Estimated change in R value of facial allografts decreased with increasing Banff Grade (p = 0.0001). The mean R value of clinical rejection (Banff Grade ⅔) (16.67, 95% Confidence Interval [CI] 14.79-18.58) was lower (p = 0.005) than non-rejection (Banff Grade 0/1) (19.38, 95%CI 17.43-21.33). Both clinical and non-rejection mean R values were lower (p = 0.0001) than healthy controls (24.12, 95%CI 20.96-27.28). CONCLUSION: This proof-of-concept study demonstrates that software-based analysis can detect and monitor acute rejection changes in FT. Future studies should expand on this tool's potential application in telehealth and as a screening tool for allograft rejection.

Teaching Microsurgical Breast Reconstruction-A Retrospective Cohort Study.

Microsurgical breast reconstruction demands the highest level of expertise in both reconstructive and aesthetic plastic surgery. Implementation of such a complex surgical procedure is generally associated with a learning curve defined by higher complication rates at the beginning. The aim of this study was to present an approach for teaching deep inferior epigastric artery perforator (DIEP) and transverse upper gracilis (TUG) flap breast reconstruction, which can diminish complications and provide satisfying outcomes from the beginning. DIEP and TUG flap procedures for breast reconstruction were either performed by a senior surgeon (>200 DIEP/TUG, "no-training group"), or taught to one of five trainees (>80 breast surgeries; >50 free flaps) in a step-wise approach. The latter were either performed by the senior surgeon, and a trainee was assisting the surgery ("passive training"); by the trainee, and a senior surgeon was supervising ("active training"); or by the trainee without a senior surgeon ("after training"). Surgeries of each group were analyzed regarding OR-time, complications, and refinement procedures. A total of 95 DIEP and 93 TUG flaps were included into this study. Before the first DIEP/TUG flap without supervision, each trainee underwent a mean of 6.8 DIEP and 7.3 TUG training surgeries (p > 0.05). Outcome measures did not reveal any statistically significant differences (passive training/active training/after training/no-training: OR-time (min): DIEP: 331/351/338/304 (p > 0.05); TUG: 229/214/239/217 (p > 0.05); complications (n): DIEP: 6/13/16/11 (p > 0.05); TUG: 6/19/23/11 (p > 0.05); refinement procedures (n): DIEP:71/63/49/44 (p > 0.05); TUG: 65/41/36/56 (p > 0.05)), indicating safe and secure implementation of this step-wise training approach for microsurgical breast reconstruction in both aesthetic and reconstructive measures. Of note, despite being a perforator flap, DIEP flap required no more training than TUG flap, highlighting the importance of flap inset at the recipient site.

Donor Site Morbidity in Unilateral and Bilateral Transverse Musculocutaneous Gracilis (TMG) Flap Breast Reconstruction: Sensation, Function, Aesthesis and Patient-Reported Outcomes.

The transverse musculocutaneous gracilis (TMG) flap has become a popular choice for breast reconstruction. This study aimed to compare the donor site morbidity in unilateral and bilateral procedures. Patients receiving a TMG flap (January 2008-October 2019) were invited to a follow-up and grouped according to unilateral (UL group) or bilateral (BL group) breast reconstruction. Outcome criteria included sensation, function and aesthesis of the thighs. Patient-reported outcomes were surveyed using validated questionnaires. The number and kind of refinement procedures for aesthetic purposes on the donor thighs were evaluated. Thirty-eight patients with 59 TMG flaps were included in the study (UL group: n = 17, BL group: n = 21). Normal to slightly diminished superficial skin sensation was maintained in most of the thigh skin (98.4%). Strength and mobility were without impairment in >80% of the thighs in both groups. Thigh symmetry was achieved in both groups. Symmetrisation procedures were significantly more often performed in the UL group (p = 0.005). The total number of refinement procedures was similar in both groups. Patient-reported outcomes were similar with good appearance of the thighs and scars, excellent function and low pain levels. The TMG flap offers excellent function and sensation on the donor thigh. Thigh symmetry and good patient satisfaction may be achieved in both unilateral and bilateral breast reconstructions.

The Impact of Digital Nerve Injury on the Outcome of Flexor Tendon Tenolysis: A Retrospective Case-Control Study.

BACKGROUND: Tenolysis is an established treatment for flexor tendon adhesions at the hand. Concomitant finger nerve injuries with incomplete reinnervation may negatively influence outcomes. This study investigates the impact of finger nerve injuries on outcomes of flexor tendon tenolysis. METHODS: A retrospective pair-matched study was conducted, including patients undergoing tenolysis for flexor tendon adhesion after primary repair of isolated superficial and deep flexor tendon injury and both finger nerves (test group [TG]). These were compared with patients (control group [CG]) with similar injuries without affection of nerves and pair-matched in age, zone of injury and follow-up. Patients' demographics, finger sensitivity, total active range of motion (TAM) before and after tenolysis and complications were retrieved. RESULTS: For both study groups, 10 patients each were included in this study. There were no significant differences regarding patients' demographics and follow-up. Mean follow-up was 37 (CG) and 41 (TG) months. Total active range of motion was preoperatively 81 ± 47° (CG) and 68 ± 54° (TG) and reached postoperatively 125 ± 57° (CG) and 79 ± 43° (TG). Hence, TAM improvement was significantly higher in patients without nerve damage (58 ± 16 vs 21 ± 11%; P > 0.05). Tendon ruptures occurred significantly more frequent in patients with nerve injury (n = 0.4 ± 0.52) compared with patients of the CG (n = 0; P < 0.05). CONCLUSIONS: This study shows that finger nerve injury with incomplete recovery after combined flexor tendon and nerve injuries of the finger negatively influences the outcomes of flexor tendon tenolysis.

The transverse musculocutaneous gracilis flap for autologous breast reconstruction: focus on donor site morbidity.

PURPOSE: The transverse musculocutaneous gracilis (TMG) flap is as a valuable alternative in autologous breast reconstruction. The purpose of this study was to evaluate the donor site morbidity and secondary refinement procedures after TMG flap breast reconstruction. METHODS: A retrospective study was conducted, including all patients who received TMG flap breast reconstructions, from January 2012 to August 2019. Primary outcomes were surgical site complications of the donor site and secondary refinement procedures carried out for aesthetic or reconstructive purposes for the medial thigh. Secondary outcomes of interest were lipofilling procedures for optimization of the reconstructed breasts. RESULTS: Ninety-nine patients received 159 TMG flaps for breast reconstruction. Patients' mean BMI was 23.5 (15.6-32.5) kg/m2. Bilateral breast reconstructions were performed in 60.6%. The mean flap volume was 330 (231-440) g. Surgical site complications occurred in 14.5% of the TMG donor sites and wound dehiscence was the most common complication (9.4%). Lymphedema occurred in 1.8% of the donor thighs. Aesthetic refinement procedures were performed in 25.2% on the donor thigh or contralateral thigh. Secondary lipofilling was performed in 54.1% of the reconstructed breasts and fat was harvested in only 11.9% from the legs. CONCLUSION: The TMG flap breast reconstruction combines low donor site morbidity with adequate volume for appealing breast results, particularly in slim-to-normal weight patients. However, patients should be informed about the likelihood of secondary refinement procedures on the donor site and the need of lipofilling to optimize the breast shape and volume.

Safety and donor site morbidity of the transverse musculocutaneous gracilis (TMG) flap in autologous breast reconstruction-A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVES: The transverse musculocutaneous gracilis (TMG) flap has gained popularity for breast reconstruction. However, the literature regarding its donor site morbidity is heterogeneous. This systematic review sought to clarify the evidence on donor site morbidity. METHODS: A systematic literature search was conducted. We included all articles reporting on donor-site morbidity of the TMG flap for breast reconstruction. The results were analyzed in R and its extension meta. A generalized linear mixed model was used to combine proportions and their 95% confidence intervals (CIs) in a random-effects meta-analysis. RESULTS: Nineteen articles provided an overall sample of 843 TMG flaps. The total flap loss was low at 2% (95% CI, 1%-3%). All patients were normal weight (pooled body mass index 22.75, 95% CI, 21.88-23.63). The incidence of wound dehiscence (8%, 95% CI, 4%-16%), seroma (4%, 95% CI, 2%-7%), hematoma (2%, 95% CI, 1%-4%) and infection (0%-5%) on the TMG donor site was low. Functional impairments included sensory disturbance (0%-74%), motoric deficits (0%-50%), and changes in the genital region (0%-24%), all of which were modest. CONCLUSIONS: This review confirms the safety and low donor site morbidity of the TMG flap in normal-weight patients, which is comparable to that of other popular free flaps in breast reconstruction.