Multifocal epithelial tumors and field cancerization from loss of mesenchymal CSL signaling.

It is currently unclear whether tissue changes surrounding multifocal epithelial tumors are a cause or consequence of cancer. Here, we provide evidence that loss of mesenchymal Notch/CSL signaling causes tissue alterations, including stromal atrophy and inflammation, which precede and are potent triggers for epithelial tumors. Mice carrying a mesenchymal-specific deletion of CSL/RBP-Jκ, a key Notch effector, exhibit spontaneous multifocal keratinocyte tumors that develop after dermal atrophy and inflammation. CSL-deficient dermal fibroblasts promote increased tumor cell proliferation through upregulation of c-Jun and c-Fos expression and consequently higher levels of diffusible growth factors, inflammatory cytokines, and matrix-remodeling enzymes. In human skin samples, stromal fields adjacent to multifocal premalignant actinic keratosis lesions exhibit decreased Notch/CSL signaling and associated molecular changes. Importantly, these changes in gene expression are also induced by UVA, a known environmental cause of cutaneous field cancerization and skin cancer.

Impact of etiology leading to abdominoperineal resection with anterolateral thigh flap reconstruction: A retrospective cohort study.

BACKGROUND: Large and deep perineal defects following abdominal perineal resection (APR) are a challenge for reconstructive surgeons. Even if generally performed for oncological reasons, APR can be indicated as well in extended infection-related debridement for Hidradenitis suppurativa, Fournier's gangrene, or Crohn's disease. We aimed to compare the outcomes of two groups of patients with different indications for APR (infectious vs. oncological) after pedicled anterolateral thigh (ALT) flap coverage RESULTS: Forty-four consecutive pedicled ALT flap used for coverage after APR in 40 patients were analyzed. 26 patients (65%) underwent APR for oncological reasons and 14 patients (35%) for infectious reasons. The overall postoperative complications rate was significantly higher for infectious cases (76.5% vs. 40.7%, p = 0.0304). Major complications occurred in 52.9% of infectious cases versus 11.1% of oncological cases (p = 0.0045). Obesity and infectious etiology were independent risk factors for overall and major complications, respectively. CONCLUSION: Patients undergoing APR for acute or chronic infections had significantly more overall and major complications than patients having oncological APR. Modified care might be considered, especially in obese patients, in terms of surgical debridement, antibiotic treatment modalities, and postoperative management.

Indocyanine green lymphography as novel tool to assess lymphatics in patients with lipedema.

OBJECTIVE: Lipedema is a chronic and progressive disease associated with lymphatic impairment at later stages. The aim of our study was to describe the functional status and anatomy of lower limb superficial lymphatic system using indocyanine green (ICG) lymphography in patients with lipedema. METHODS: Following ICG injection at the dorsum of the foot, distance (cm) covered by the dye at 10 (T10') and 25 min (T25') was measured and normalized for limb length. If the dye did not reach the groin within 25 min, patients were classified as "drainage-needing" group (DNG). Values of fat and lean distribution assessed by dual-energy X-ray absorptiometry were extracted, and correlation analysis was performed. Furthermore, anatomical patterns of superficial lymphatics were assessed. RESULTS: Overall, 45 women were included, 25 (56%) of whom were classified as DNG. Symptoms duration was significantly associated with DNG status at multivariate analysis (odds ratio 1.07; 95% CI 1.01-1.14; p = 0.047). Moreover, Spearman's analysis showed a negative correlation between symptoms duration and T25' dye migration (r = -0.469; p = 0.037). Overall, no major anatomical lymphatic changes were found. CONCLUSIONS: Present study suggests that lymphatic functioning in patients with lipedema correlates with symptoms duration. Further research on larger cohorts should verify our findings and clarify their potential therapeutic implications. Overall, ICG lymphography may be promising technique to assess both lymphatic anatomy and functioning in patients with lipedema.

Outcomes of the Composite Anterolateral Thigh Flap for Perineal Reconstruction After Postoncological Abdominoperineal Resection.

BACKGROUND: The vertical rectus abdominis flap is considered the gold standard in perineal reconstruction after oncological abdominoperineal resection; however, it has a nonnegligible donor site morbidity. The anterolateral thigh flap offers reliable soft tissue coverage. OBJECTIVE: The aim was to analyze long-term outcomes of composite anterolateral thigh-vastus lateralis flaps in oncological abdominoperineal resections. DESIGN: We conducted a retrospective cohort analysis of a prospectively maintained database. SETTINGS: This study was conducted in the Lausanne University Hospital. Annually, approximately 10 oncological abdomioperineal resections are performed. Literature reports 7% to 20% of patients undergoing abdominoperineal resection require flap reconstruction; in our institution, approximately 2 patients with large defects after abdominoperineal resections required reconstruction. PATIENTS: Twenty-nine pedicled anterolateral thigh-vastus lateralis flaps in 27 consecutive patients (mean age 63 years +/-11.2, 23 with radiochemotherapy) after abdominoperineal resection to cover large defects (median 190 cm2, 48-600 cm2) were analyzed. INTERVENTION: Pedicled composite anterolateral thigh-vastus lateralis flaps were performed after oncological abdominoperineal resection. MAIN OUTCOME MEASURES: Descriptive statistical analysis was conducted. Short- and long-term outcomes were analyzed, univariate and multivariate analyses were performed. Median follow-up was 16 months (12-48 months). RESULTS: Flap-related postoperative complications occurred in 16 flaps; flap-survival was 100%. Multivariate logistic analysis identified initial defect size as predictive for complications. Patients with larger defects (≥ 190 cm2) had higher complication rates (p = 0.006). Long-term analysis revealed 3 chronic fistulae, 2 tumor recurrences, 1 flap dysesthesia, and one perineal acne inversa. LIMITATIONS: Limitations include retrospective analysis, selection bias, and lacking a control group. Sample size limits statistical power. CONCLUSIONS: The pedicled anterolateral thigh-vastus lateralis flap offers reliable, stable tissue with low morbidity and good long-term outcomes. Complications compared favorably with current literature describing perineal reconstructions with rectus abdominis flaps. The composite anterolateral thigh flap is a valid alternative without the setback of abdominal donor site morbidity. See Video Abstract at http://links.lww.com/DCR/B757.RESULTADOS DEL COLGAJO COMPUESTO ANTEROLATERAL DE MUSLO PARA LA RECONSTRUCCIÓN PERINEAL DESPUÉS DE LA RESECCIÓN ABDOMINOPERINEAL POST ONCOLÓGICAANTECEDENTES:El colgajo vertical de recto abdominal se considera el estándar de oro en la reconstrucción perineal después de la resección abdominoperineal oncológica, sin embargo, tiene una morbilidad no despreciable en el sitio donante. El colgajo anterolateral del muslo ofrece una cobertura confiable de los tejidos blandos.OBJETIVO:El objetivo fue analizar los resultados a largo plazo de los colgajos compuestos anterolaterales del muslo - vasto lateral - en resecciones abdominoperineales oncológicas.DISEÑO:Realizamos un análisis, retrospectivo, de tipo cohorte, de una base de datos mantenida prospectivamente.AJUSTES:Este estudio fue realizado en el hospital universitario de Lausanne. Anualmente se realizan aproximadamente 10 resecciones abdominoperineales oncológicas. La literatura reporta que entre el 7 y el 20% de los pacientes que se someten a una resección abdominoperineal requieren de reconstrucción con colgajo; en nuestra institución, aproximadamente 2 pacientes con grandes defectos tras la resección abdominoperineal requirieron reconstrucción.PACIENTES:Fueron analizados veintinueve colgajos pediculados anterolaterales de muslo - vasto lateral - en 27 pacientes consecutivos (edad media 63 años +/- 11,2, 23 con radio quimioterapia) después de la resección abdominoperineal para cubrir defectos grandes (mediana 190 cm2, 48-600 cm2).INTERVENCIÓN:Tras la resección abdominoperineal oncológica se realizaron colgajos pediculados compuestos anterolaterales de muslo - vasto lateral.PRINCIPALES MEDIDAS DE RESULTADO:Fue realizado un análisis estadístico descriptivo. Fueron analizados los resultados a corto y largo plazo - fueron realizados así mismo análisis uni y multivariados. La mediana de seguimiento fue de 16 meses (12-48 meses).RESULTADOS:Complicaciones postoperatorias relacionadas con el colgajo ocurrieron en 16 colgajos, la supervivencia del colgajo fue del 100%. El análisis logístico multivariado identificó al tamaño del defecto inicial como predictor de complicaciones. Aquellos pacientes con defectos más grandes (≥190 cm2) tuvieron mayores tasas de complicaciones (p = 0,006). El análisis a largo plazo reveló tres fístulas crónicas, dos recidivas tumorales, una disestesia de colgajo y un acné perineal inverso.LIMITACIONES:Las limitaciones incluyen análisis retrospectivo, sesgo de selección y falta de grupo de control. El tamaño de la muestra limita el poder estadístico.CONCLUSIONES:El colgajo pediculado anterolateral de muslo - vasto lateral - ofrece tejido confiable y estable con baja morbilidad y buenos resultados a largo plazo. Los resultados de las complicaciones se mostraron favorables con respecto a la literatura actual que describe reconstrucciones perineales con colgajos de recto abdominal. El colgajo compuesto anterolateral de muslo es una alternativa válida sin el revés de la morbilidad del sitio donante abdominal. Consulte Video Resumen en http://links.lww.com/DCR/B757. (Traducción-Dr. Osvaldo Gauto).

Lumbar Perforator Flaps for Coverage of Extensive Defects With Osteomyelitis.

INTRODUCTION: Lumbar osteomyelitis is a rare, although serious condition if not appropriately treated, potentially leading to neurologic complications, such as radiculopathy. Traditionally, studies have suggested the preferred use of muscle or myocutaneous flaps to prevent recurrent infections. However, late evidence suggests that radical debridement and dead space obliteration are more important than the type of flap. The lumbar perforator flap is a reliable local option with low donor site morbidity. It is a powerful tool for local trunk reconstruction, but its use in case of osteomyelitis is scarcely described. We aimed to report long-term outcomes of lumbar perforator flaps to cover lumbar soft tissue defects with chronic osteomyelitis. MATERIAL AND METHODS: This retrospective investigation was performed on a prospectively maintained database including 7 consecutive patients (10 flaps), all presenting extensive defects of the posterior midline at L2-S1 level (defect size 287 ± 136 cm [average ± SD]). Four patients presented defects after recurrent tumor resection, whereas in 2 patients, the defect was due to vascular jeopardy of internal iliac arteries with consequent necrosis. Last defect derived from debridement of a neglected wound in a paraplegic patient. All patients had concomitant bone infection. Infectious details and postoperative complications were recorded. RESULTS: Patients were in general poor medical condition (including peripheral arterial disease, hypertension, diabetes, or a combination of these). Eight flaps were raised as propeller perforator, whereas 2 as V-Y perforator. One propelled flap had venous congestion on postoperative day 1 and required a revision surgery to be converted to V-Y. Subsequent partial flap necrosis was treated conservatively. One patient presented a wound dehiscence that required surgical revision. All flaps were closed primarily except for 1 patient whose flap presented a mild intraoperative congestion, which was treated by delayed closure on postoperative day 6, with uneventful outcome. Time to complete healing was 29 ± 17 days (mean ± SD). No flap loss occurred, and all patients benefited from effective coverage at a mean follow-up of 20 months. CONCLUSIONS: Lumbar perforator flap is a reliable option to cover large soft tissue defects in the lumbar area despite chronic osteomyelitis, with low morbidity and acceptable cosmetic outcome.

Antimicrobial Peptide Dendrimers and Quorum-Sensing Inhibitors in Formulating Next-Generation Anti-Infection Cell Therapy Dressings for Burns.

Multidrug resistance infections are the main cause of failure in the pro-regenerative cell-mediated therapy of burn wounds. The collagen-based matrices for delivery of cells could be potential substrates to support bacterial growth and subsequent lysis of the collagen leading to a cell therapy loss. In this article, we report the development of a new generation of cell therapy formulations with the capacity to resist infections through the bactericidal effect of antimicrobial peptide dendrimers and the anti-virulence effect of anti-quorum sensing MvfR (PqsR) system compounds, which are incorporated into their formulation. Anti-quorum sensing compounds limit the pathogenicity and antibiotic tolerance of pathogenic bacteria involved in the burn wound infections, by inhibiting their virulence pathways. For the first time, we report a biological cell therapy dressing incorporating live progenitor cells, antimicrobial peptide dendrimers, and anti-MvfR compounds, which exhibit bactericidal and anti-virulence properties without compromising the viability of the progenitor cells.

Efficient decellularization of equine tendon with preserved biomechanical properties and cytocompatibility for human tendon surgery indications.

Chronic and acute tendon injuries are frequent afflictions, for which treatment is often long and unsatisfactory. When facing extended injuries, matrices and scaffolds with sufficient biomechanical properties are required for surgical repair and could additionally serve as supports for cellular therapies to improve healing. In this study, protocols of either commonly used detergents only (SDS 1%, Triton 1%, TBP 1%, and Tween-20 1%) or a combination of freeze/thaw (F/T) cycles with decellularization agents (NaCl 1M, ddH2 O) were evaluated for the decellularization of horse equine superficial digital flexor tendon (SDFT) for hand flexor or extensor tendon reconstruction. Decellularization efficiency was assessed microscopically by histological staining (HE, DAPI) and DNA quantification. Macroscopical structure and biomechanical integrity of the tendon matrices were further assessed by gross observation, histological staining (SR), and mechanical testing (ultimate strain and stress, Young's modulus, energy to failure) for select protocols. Decellularization with hypertonic NaCl 1M in association with F/T cycles produced the most robust tendon matrices, which were nontoxic after 10 days for subsequent recellularization with human fetal progenitor tendon cells (hFPTs). This standardized protocol uses a less aggressive decellularization agent than current practice, which allows subsequent reseeding with allogenic cells, therefore making them very suitable and bioengineered tendon matrices for human tendon reconstruction in the clinic.

Anterolateral Thigh Flap With Vascularized Fascia Lata Associated With Thigh Flaps: A Case Report of an All-in-One Reconstruction of the Suspensory Ligament and Penoscrotal District After Fournier Gangrene.

Radical surgical debridement after Fournier gangrene (FG) can totally change anatomical balance between structures and compromise urogenital function. This is particularly true when the suspensory ligament and the lower abdominal wall are involved, leading to erection and sexual intercourse dysfunction.We present the case of a 48-year-old man, who underwent emergency debridement and split-thickness skin graft (STSG) of inferior abdominal wall, pubis, scrotal bag and penile shaft after Fournier gangrene.Five months after the emergency procedure, bilateral medial thigh flaps recreated the scrotal compartment, whereas a pedicled composite anterolateral thigh flap including fascia lata could cover the lower abdominal wall and rebuilt the penile suspensory ligament (PSL).Healing was uneventful and the patient returned to a normal sexual life with satisfactory erection and intercourse.Composite and/or chimeric anterolateral thigh fascia lata flaps have been previously used as a reliable option for complex defects, including tendon and ligaments. We describe here, the first case in the literature of a penile suspensory ligament reconstruction.

Reverse-Flow Versus Perforator Propeller Lateral Arm Flap for Elbow Reconstruction.

BACKGROUND: The lateral arm flap (LAF) represents an attractive option for elbow reconstruction, due to low donor site morbidity and a consistent surgical anatomy. It has been described as reverse-flow and as perforator propeller flap (radial collateral artery perforator [RCAP]). We compared the 2 techniques in terms of immediate- and long-term outcomes, together with functional and aesthetic evaluation. METHODS: We retrospectively reviewed 15 patients, 9 males and 6 females, according to the department prospectively maintained database. Ethiology of the defects and patient comorbidities were listed together with flap and clinical data (operative time, time to healing, hospital stay, etc). Functional outcomes were measured according to Quick Disability of Arm Shoulder and Hand score at the time of the last follow-up. RESULTS: Seven LAF flaps were raised in a reverse-flow fashion, whereas 8 were RCAP flaps. No patients described any major elbow functional limitations, and they were generally satisfied with the aesthetic appearance. When comparing the 2 groups of reconstruction, harvest of RCAP flap resulted significantly faster and patients needed less hospitalization days (*P < 0.05). Aesthetic scores were lower where a cutaneous bridge was left intact during rotation (leading to a dogear), which was always the case in reverse-flow flap. Among complications, a partial RCAP flap necrosis occurred in a highly comorbid patient and required a skin graft coverage, whereas 4 reverse-flow flaps presented distal venous congestion which, in 1 patient, led to a secondary flap procedure. CONCLUSIONS: In our practice, elbow reconstruction using the RCAP flap required less hospital stay and operative time. Being less prone to venous congestion, in presence of sizeable perforators, it should be preferred to the reverse-flow LAF flap.

Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm.

BACKGROUND: Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity. OBJECTIVES: This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer. METHODS: Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm. RESULTS: Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention. CONCLUSIONS: A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.

The periosteal-cutaneous chimeric medial femoral condyle free flap for subtotal ear reconstruction: A case report.

When costal graft is contraindicated or refused by the patient, autologous total/subtotal auricular reconstruction represent a real challenge as limited surgical options has been described. Aim of present report is to offer a novel possible autologous reconstruction of the ear frame using a chimeric free medial femoral condyle (MFC) flap. We present a case of a 29 years old patient who had total loss of the upper 2/3 of the right ear after bombing in Somalia and secondary infected condritis (considered a relative contraindication for costal cartilage graft). The MFC flap was harvested with a chimeric skin paddle (7 × 5 cm), a thin sheet of femoral cortex (6.5 × 8 cm) was used as basal ear frame, while part of the contralateral concha was trimmed as support for the helix, with the periosteal component of the flap wrapping around the whole framework. The chimeric skin paddle assured the retroauricular skin coverage, while the anterior part of the construct was covered by a thinned dermal flap. Postoperative course was uneventful. A defatting procedure of the posterior skin paddle was performed at 2 months post-op. At 6 months post-op, the patient was satisfied with the result, could wear glasses and was socially integrated. This new application of the free chimeric MFC flap, despite being not the primary choice for ear reconstruction, guaranteed satisfactory results in terms of ear shape and infection prevention and may be considered when ordinary cartilage rib reconstruction is refused, contraindicated, or failed.

Bipedicled distally based medial plantar artery perforator flap for forefoot reconstruction: A case report.

Reconstruction of soft-tissue defects in the foot weight-bearing area should encompass sensate and robust skin. Regarding forefoot defects, distally based medial plantar artery (MPA) flap is an ideal option. However, considering variation of the terminal branches of the MPA, reverse flow flaps can be unreliable with an increasing risk of venous congestion or insufficient arterial flow. In this report, we present a case of the use of reverse flow MPA flaps with dual flow vascularization. The patient was a 37-year-old female who presented a 7 × 3 cm soft-tissue defect of the right forefoot after wide local excision following melanoma. Reconstruction happened with a perforator distally based bipedicled flap (8 × 4 cm) on the MPA though keeping an enhanced vascularization through both superficial (sMPA) and deep (dMPA) medial plantar arteries. Donor site was closed with skin graft. Patient was discharged from hospital at postoperative Day 10 and healed uneventfully with progressive start walk was possible again. A full weight bearing with normal shoes was possible after 8 weeks. Good healing and no functional impairment were present after 9 months of follow-up. We believe this dual vascularization concept may be adopted when possible to improve the overall circulation of the flap and to prevent risks of vascular insufficiency or vein congestion.

[Advances in the treatment of complex venous malformation: endovenous laser]. / Nouveautés dans le traitement des malformations veineuses complexes : le laser endoveineux.

Congenital venous malformations (VMs) are the most common vascular abnormalities. Their treatment can be complex, depending on their size and surrounding tissues involvement. To date, sclerotherapy is considered the gold standard for the treatment of VMs. This technique, which aims to destroy the endothelium and thus cause fibrosis and retraction of the vascular lesion, is less effective in voluminous VMs. Endovenous thermal ablation is a widely validated treatment in the management of venous insufficiency, showing better efficacy than sclerotherapy in terms of trans-parietal vessel destruction. This approach has therefore also been described in the treatment of VMs. This technique has been introduced for the treatment of complex VMs at the Centre for Malformations and Rare Vascular Diseases of the CHUV.

Les malformations veineuses (MV) congénitales sont les anomalies vasculaires les plus fréquentes. Leur traitement peut être complexe en fonction de leur taille ou de l'atteinte des tissus avoisinants. À ce jour, la sclérothérapie est considérée comme le Gold Standard du traitement des MV. Cette technique, qui vise à détruire l'endothélium et à causer ainsi une fibrose et une rétraction de la lésion vasculaire, est moins efficace dans le cas des grandes MV. L'ablation thermique endoveineuse, largement validée dans le traitement de l'insuffisance veineuse, s'est révélée plus efficace que la sclérothérapie pour la destruction transpariétale d'un vaisseau. Cette approche a donc également été décrite dans le traitement des MV et la technique est actuellement employée pour le traitement des MV complexes au Centre des malformations et des maladies vasculaires rares du CHUV.

Nonvascularized human skin chronic allograft rejection.

A 65-year-old man had extensive burns of the lower legs in 1991, at the age of 40 years. He was treated by nonvascularized and de-epithelialized, allogeneic split-thickness skin allograft and cyclosporine monotherapy for 2 months. Ulcers developed between 10 and 25 years after transplantation and a surgical debridement on the lower extremities was required. Analyses of the removed tissue allografts showed chronic antibody-mediated and cellular rejection with extensive and dense fibrosis, and diffuse capillary C4d deposits. An anti-DRB1*08:01, donor-specific antibody was present. A unique clinical condition with late immunopathological features of human skin chronic allograft rejection is reported.

Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients.

INTRODUCTION: The "traditional" method to perform vaginoplasty in male-to-female transgender surgery consists in inverting the penoscrotal skin into a surgically created cavity in the perineum between the rectum and the bladder creating a neovagina. To overcome the noteworthy disadvantage of lack of depth, the use of a rectosigmoid graft can be preferred over the penile skin inversion. AIM: The aim of this study was to compare 2 methods for vaginoplasty in male-to-female transgender surgery in regard of the functional and cosmetic long-term result. Additionally this study aims to understand key factors leading to secondary sigmoid vaginoplasty in patients with previous penile skin inversion. METHODS: This is a retrospective survey of outcomes and complications of 43 patients who underwent neovaginoplasty by the same senior surgeon, between 2007 and 2017. 13 patients underwent a secondary rectosigmoid neovagina later (30.2%). Moreover, we performed an aesthetic and functional evaluation on 28 patients (65%) at long-term follow-up. Mean follow-up was 32.6 ± 3.5 months (average ± SEM). Patients were also evaluated by a questionnaire to assess both aesthetic and functional (penetration, orgasm, and pain) outcomes. Statistical analysis was used to compare results between groups. MAIN OUTCOME MEASURE: Patient satisfaction was assessed by a questionnaire sent to all 43 patients and was made of 5 questions (Q1 to Q5) designed in a way to evaluate patient outcomes in terms of both functionality and cosmesis of the neovagina. RESULTS: Our findings showed that the use of a rectosigmoid graft in secondary cases significantly decreased sexual pain during intercourse. Both techniques had similar aesthetic and functional outcomes with mostly satisfied patients (no statistical significance). CLINICAL IMPLICATIONS: The use of sigmoid vaginoplasty could improve functional outcomes when compared to penile skin inversion vaginoplasty. STRENGTH & LIMITATIONS: This study strength is its retrospective nature conducted on a prospectively-maintained database limiting biases with 43 consecutive vaginoplasties, performed by the same surgeon. Relative limitation was that not all patients returned our questionnaire and, thus, only 65% of our patients were evaluated for satisfaction. CONCLUSION: This study reports long-term outcomes in transgender surgery using 2 different techniques for neovagina creation. The use of sigmoid vaginoplasty showed better functional outcomes than penile skin inversion, whereas cosmetic results were similar. di Summa PG, Watfa W, Krähenbühl S, et al. Colic-Based Transplant in Sexual Reassignment Surgery: Functional Outcomes and Complications in 43 Consecutive Patients. J Sex Med 2019;16:2030-2037.

A Systematic Review of Outcomes After Genital Lymphedema Surgery: Microsurgical Reconstruction Versus Excisional Procedures.

INTRODUCTION: Genital lymphedema (GL) surgery can be either palliative or functional. Palliative procedures involve excision of the affected tissue and reconstruction by either local flaps or skin grafts. Reconstructive procedures aim to restore lymphatic flow through microsurgical lymphaticovenous anastomoses (LVAs). This systematic analysis of outcomes and complication rates aims to compare outcomes between these surgical treatment options for GL. METHODS: A systematic review of the PubMed database was performed with the following search algorithm: (lymphorrhea or lymphedema) and (genital or scrotal or vulvar) and (microsurgery or "surgical treatment"), evaluating outcomes, and complications after surgical treatment of GL. RESULTS: Twenty studies published between 1980 and 2016 met the inclusion criteria (total, 151 patients). Three main surgical treatments for GL were identified. Surgical resection and primary closure or skin graft was the most common procedure (46.4%) with a total complication rate of 10%. Surgical resection and flap reconstruction accounted for 39.1% of the procedures with an overall complication rate of 54.2%. Lympho venous shunt (LVA) procedures (14.5%) had a total complication rate of 9%. CONCLUSIONS: This review demonstrates a lack of consensus in both the preoperative assessment and surgical management of GL. Patients receiving excisional procedures tended to be later stage lymphedema. Patients in the excision and flap reconstruction group seemed to have the highest complication rates. Microsurgical LVAs may represent an alternative approach to GL, either alone or in combination with traditional procedures.

Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes.

BACKGROUND: We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one-stage procedure. METHODS: We performed a retrospective investigation including 21 "functional" ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection-debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm-elbow (four cases), and hand-wrist level (three cases). RESULTS: Nineteen flaps were raised as free flaps, while two as distally-based propeller flaps. Average follow-up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05). CONCLUSION: The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure.

MatriDerm Decreases Donor Site Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery.

BACKGROUND: Phalloplasty with the radial forearm free flap is associated with a large donor site defect. AIM: To compare two methods of donor site closure for functional and cosmetic long-term results: full-thickness skin grafting vs split-thickness skin grafting with MatriDerm. METHODS: Thirty-seven transgender patients had a neophallus created from a radial forearm free flap, and all were operated on by the same senior surgeon. Eight patients had their donor site defect closed by total skin grafting and 29 patients, operated on after 2009, received a split-thickness skin graft with MatriDerm closure. All 37 patients were evaluated by questionnaire and by careful clinical examination. Pressure perception was assessed with the Semmes-Weinstein monofilament test. Sensory recovery, skin quality, and cosmetic result also were compared. The contralateral arm was used as the control. OUTCOMES: Pressure perception values showed better sensory return in the MatriDerm group. Split-thickness skin grafting with MatriDerm achieved superior results in skin sensibility, superficial radial nerve recovery, and cosmetic aspect. RESULTS: Our findings support the hypothesis that MatriDerm can be used to preserve sensory function and decrease morbidity of the donor site. CLINICAL IMPLICATIONS: The use of a dermal substitute decreases the morbidity of the forearm free flap donor site. STRENGTHS AND LIMITATIONS: The strength of this study is its retrospective nature conducted of a prospectively maintained database of 37 consecutive radial forearm free flaps with superimposable dimensions and location performed by the same surgeon, thus limiting biases. A limitation is its small sample (particularly for the control group). CONCLUSION: Our experience showed that the combination of a split-thickness skin graft with MatriDerm substantially decreases postoperative complications at the donor site defect on the forearm of transgender patients. Watfa W, di Summa PG, Meuli J, et al. MatriDerm Decreases Donor Site Morbidity After Radial Forearm Free Flap Harvest in Transgender Surgery. J Sex Med 2017;14:1277-1284.

Reticular Perineurioma of the Hand: Diagnosis and Treatment of a Rare Case of Hand Mass.

Reticular perineurioma is a rare and recently delineated morphologic variant of benign perineurioma of skin and soft tissues. Because of its nonspecific gross appearance, varying histologic patterns, and potential range of cellularity, perineurioma of the hand is likely to be confused with more commonly encountered tumor or tumor-like conditions such as schwannoma, neurofibroma, fibromyxoid tumors, and giant tumor of tendon sheath. We report the case of a 20-year-old woman who presented with a slowly growing mass of the hand, which was eventually identified as a reticular perineurioma.

First Insights into Human Fingertip Regeneration by Echo-Doppler Imaging and Wound Microenvironment Assessment.

Fingertip response to trauma represents a fascinating example of tissue regeneration. Regeneration derives from proliferative mesenchymal cells (blastema) that subsequently differentiate into soft and skeletal tissues. Clinically, conservative treatment of the amputated fingertip under occlusive dressing can shift the response to tissue loss from a wound repair process towards regeneration. When analyzing by Immunoassay the wound exudate from occlusive dressings, the concentrations of brain-derived neurotrophic factor (BDNF) and leukemia inhibitory factor (LIF) were higher in fingertip exudates than in burn wounds (used as controls for wound repair versus regeneration). Vascular endothelial growth factor A (VEGF-A) and platelet-derived growth factor (PDGF) were highly expressed in both samples in comparable levels. In our study, pro-inflammatory cytokines were relatively higher expressed in regenerative fingertips than in the burn wound exudates while chemokines were present in lower levels. Functional, vascular and mechanical properties of the regenerated fingertips were analyzed three months after trauma and the data were compared to the corresponding fingertip on the collateral uninjured side. While sensory recovery and morphology (pulp thickness and texture) were similar to uninjured sides, mechanical parameters (elasticity, vascularization) were increased in the regenerated fingertips. Further studies should be done to clarify the importance of inflammatory cells, immunity and growth factors in determining the outcome of the regenerative process and its influence on the clinical outcome.