Vascular territories of the medial upper arm-an anatomic study of the vascular basis for individualized flap design.

BACKGROUND: Fasciocutaneous flaps supplied by discrete perforator arteries can be raised in numerous parts of the human body and are routinely used in plastic surgery. The aim of this anatomical investigation was to provide a description of the vascular supply of the medial upper arm, to localize and measure the perforator arteries and to define potential perforator flap dimensions in pendency of individual anatomical conditions. MATERIAL AND METHODS: A total of 20 upper limbs from 11 fresh cadavers were examined. The brachial arteries were exposed and the medial perforator arteries selectively injected with methylene blue and india ink in an alternating sequence. The size of the angiosomes, the diameter and length of the perforators' pedicles and distances between the arteries and the medial epicondyle and apex of the axilla respectively were measured. RESULTS: On average, 4.55 ± 1.47 perforating arteries arose from the brachial artery and it's medial off branching arteries. Their mean diameter was 0.68 ± 0.27 mm and their pedicles had an average length of 3.62 ± 1.61 cm measured from suprafascial until arborisation. In 80% the first proximal perforator was present in an area of 4 cm radius at centre coordinates of (20/2). A constant distal perforator was found within a circle of 3 cm radius, of which the centre had the coordinates (8/1). The average size of the angiosomes was 121.1 ± 58.5 cm2 . Direct branches of the brachial artery feed circular shaped vascular territories, whereas superior ulnar collateral arteries (SUCAs) feed oblong shaped territories. CONCLUSION: This anatomical study provides valuable data of the medial arm flap in order to be applied clinically. © 2016 Wiley Periodicals, Inc.

Barbed Sutures in Body-Contouring: Outcome Analysis of 695 Procedures in 623 Patients and Technical Advances.

INTRODUCTION: Surgical wound closure is often complicated by suture-related issues. The recent introduction of knotless barbed sutures may address the shortcomings of conventional sutures and offer the additional benefit of reduced operating time. In this paper, we describe our experience with barbed sutures for body-contouring procedures. We share technical insights and evaluate postoperative complications. PATIENTS AND METHODS: A retrospective assessment of prospectively collected data over a period of more than 5 years was undertaken. Six hundred twenty-three consecutive patients underwent 695 body-contouring procedures with barbed suture closure. Patients were followed for at least 12 weeks postoperatively. Patient demographics, operation time as well as suture-related complications, such as wound dehiscence and wound site infection were recorded and analyzed. RESULTS: Barbed sutures can facilitate skin closure, rectus plication, quilting, and deep layer closure in body-contouring procedures. The average operating time in our study cohort was 108 min with reduction mammoplasty being the quickest (94 min) and bodylift (156 min) being the slowest procedure. Sixty-eight patients experienced suture-related complications resulting in an overall complication rate of 9.7 % with thigh lift having the most (15 %) and reduction mammoplasty (7 %) the fewest adverse events. CONCLUSION: The use of barbed sutures allows quick closure of lengthy body-contouring incision lines with low complication rates. Our observations support that barbed sutures are safe, convenient and effective. In our hands barbed sutures appear to be superior to traditional wound-closure techniques in body-contouring procedures. LEVEL OF EVIDENCE IV: 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 .

Median Nerve Traction Caused by Palmaris Profundus Muscle: A Case Report.

The palmaris longus muscle is one of the most variant muscles in the human body. Its variations such as the palmaris profundus can cause nerve compression symptoms. Here, we present a case of severe nerve affection due to a palmaris profundus muscle. The palmaris profundus tendon was partially resected at intervention. Pain symptoms started immediately after wearing off of the local anesthetic, and revision surgery had to be performed. Severe traction on the median nerve by the palmaris profundus tendon could be observed at revision. The resection of the palmaris profundus tendon instantly eased the patient's severe pain. At preoperative examination and planning of surgery, the palmaris profundus was not detected. As there is no test for the detection of anatomic variations of the palmaris longus muscle at physical examination, discovering such anomalies is not possible without imaging tools. Ultrasonographic examinations aid in preoperative planning of carpal tunnel release, especially at revision surgeries.

[An innovative concept for microsurgical training: a feedback analysis]. / Mikrochirurgisches Training ­ ein innovatives, modulares Ausbildungskonzept: eine Feedbackanalyse.

BACKGROUND: There has been a shift in microsurgical education towards simulation training. Hence a number of training programs are being proposed to educate aspiring microsurgeons. However, it is challenging to master the skill of microsurgery and no program has proposed a fully satisfactory training model to date. Therefore, we present an innovative course concept and assess the participants' feedback. METHODS: Being offered a four-step modular curriculum, participants can tailor their program to their individual needs and reinforce specific aspects of their training. The program is characterised by exercises ranging from basic techniques performed on avital biologic models to specific surgical techniques performed on human anatomic specimens. In our feedback questionnaire we ask participants to evaluate the parameters "course design", "expectations" and "overall satisfaction" based on a Likert scale with 5 items (100 %, 75 %, 50 %, 25 % and 0 %). RESULTS: From 2015 to 2017, 274 students completed and evaluated individual courses. The average values exceeded 90 % for all three parameters. DISCUSSION: In conclusion, we have developed and evaluated an innovative training program with a constantly high satisfaction rate and a rising number of participants, thus contributing to the advancement of microsurgical skills in Central Europe.

A Head-to-Head Comparison of the Vascular Basis of the Transverse Myocutaneous Gracilis, Profunda Artery Perforator, and Fasciocutaneous Infragluteal Flaps: An Anatomical Study.

BACKGROUND: Perforator flaps of the upper thigh or buttock provide a valuable secondary choice in autologous breast reconstruction. The purpose of this study was to compare the vascular territories and supplying vessels of the transverse myocutaneous gracilis flap, the profunda artery perforator flap, and the fasciocutaneous infragluteal flap. METHODS: In total, 26 lower limbs from 13 fresh specimens were investigated. All flap pedicles were selectively injected with methylene blue, eosin red, or green ink. The pedicle external diameters, lengths, and locations were measured. The dimensions of angiosomes, their intraindividual and interindividual correlations, and their relations to anatomical landmarks were analyzed. RESULTS: The profunda artery perforator pedicle had the greatest mean external diameter with 3.6 ± 0.7 mm, followed by the transverse myocutaneous gracilis and fasciocutaneous infragluteal pedicles with 2.9 ± 0.6 mm and 2.9 ± 0.7 mm, respectively. The fasciocutaneous infragluteal pedicle was longest with a mean length of 12.5 ± 1.5 cm, whereas the profunda artery perforator and transverse myocutaneous gracilis pedicles had lengths of 8.8 ± 1.0 cm and 6.7 ± 1 cm on average. The profunda artery perforator angiosome provided the largest size, with a mean area of 98.5 ± 26.7 cm(2), followed by the fasciocutaneous infragluteal angiosome (77.2 ± 9.0 cm(2)) and the transverse myocutaneous gracilis angiosome (74.1 ± 32.1 cm(2)). CONCLUSIONS: The authors' anatomical findings about the transverse myocutaneous gracilis, profunda artery perforator, and fasciocutaneous infragluteal territories provide clinically valuable data for flap selection in breast reconstruction if an abdominal flap is not feasible.

Seasonal Impact on Surgical-Site Infections in Body Contouring Surgery: A Retrospective Cohort Study of 602 Patients over a Period of 6 Years.

BACKGROUND: Postoperative surgical-site infections are severe complications following body contouring surgery. Here, the authors evaluate whether surgical-site infection rates are influenced by higher temperatures during the summer season. METHODS: We enrolled 602 patients who underwent body contouring surgery between 2009 and 2015 in a retrospective cohort study. Data collected included demographics, surgical data, and postoperative outcome. Body contouring surgery procedures included lower and upper body lift, abdominoplasty, breast reduction, mastopexy, brachioplasty, and thigh lift. Infection rates were calculated on a seasonal basis and compared using Fisher's exact test and logistic regression analysis. RESULTS: There were 136 patients (125 women and 11 men) in the warm season [June to August; with an average temperature of 67.622°F (19.79°C)] and 466 patients (438 women and 28 men) in the cold seasons group [September to May, with an average temperature of 45.45 °F (7.47°C)]. The composition of the study cohorts was comparable. The average age was 40 years and the average body mass index was 27 kg/m. From a total of 602 patients, the authors observed 33 surgical-site infections, representing a rate of 5.48 percent. A statistically significant increase of postoperative surgical-site infections could be detected during summer (10.29 percent versus 4.08 percent; p = 0.0071), representing an increase of 150 percent. In addition, a logistic regression analysis determined "season" as the strongest predictor for surgical-site infections, with a risk increase of 2.693 times in the warm season. CONCLUSIONS: Body contouring operations are elective procedures, making careful risk consideration an absolute prerequisite. The authors demonstrate a significantly increased infection risk during summer and establish a causal link between the warm season and surgical-site infection accumulation. Consequently, preoperative patient information and operative planning should be adjusted accordingly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.

Recent advances in microvascular autologous breast reconstruction after ablative tumor surgery.

Breast cancer is a ubiquitous disease and one of the leading causes of death in women in western societies. With overall increasing survival rates, the number of patients who need post-mastectomy reconstruction is on the rise. Especially since its psychological benefits have been broadly recognized, breast reconstruction has become a key component of breast cancer treatment. Evolving from the early beginnings of breast reconstruction with synthetic implants in the 1960s, microsurgical tissue transfer is on the way to become the gold standard for post oncology restoration of the breast. Particularly since the advent of perforator based free flap surgery, free tissue transfer has become as safe option for breast reconstruction with low morbidity. The lower abdominal skin and subcutaneous fat tissue typically offer enough volume to create an aesthetically satisfying breast mound. Nowadays, the most commonly used flap from this donor site is the deep inferior epigastric artery perforator flap. If the lower abdomen is not available as a donor site, the gluteal area and thigh provide a number of flaps suitable for breast reconstruction. If the required breast volume is small, and there is enough tissue available on the upper medial thigh, then a transverse upper gracilis flap may be a practicable method to reconstruct the breast. In case of a higher amount of required volume, a gluteal artery perforator flap is the best choice. However, what is crucial in addition to selecting the best flap option for the individual patient is the timing of the operation. In patients with confirmed post-mastectomy radiation therapy, it is advisable to perform microvascular breast reconstruction only in a delayed fashion.

Concomitant Liposuction Reduces Complications of Vertical Medial Thigh Lift in Massive Weight Loss Patients.

BACKGROUND: Medial thigh lift procedures in the massive weight loss population have been associated with significant complication rates. Liposuction-assisted medial thighplasty has recently been introduced as a technical advancement to improve outcomes. To date, no study is available directly comparing the traditional approach and this new technique. Here, the authors evaluate outcomes and complications of both techniques in a retrospective cohort study. METHODS: Outcomes of 59 patients undergoing vertical medial thighplasty at the authors' institution between 2008 and 2014 were assessed retrospectively. Evaluated parameters include age, sex, body mass indices, method of weight loss, comorbidities, and complications (e.g., seroma, infection, wound dehiscence, hematoma, and surgical revision). Appropriate statistical analysis was performed. RESULTS: There were 29 patients in the excision-only group and 30 patients in the liposuction-assisted group (all women; average age, 41.5 years). The overall complication rate was significantly reduced in the liposuction-assisted group (13 percent versus 59 percent; p < 0.001). The incidence of individual complications such as seroma formation (zero patients versus 10 patients; p < 0.001) and wound infection (one patient versus eight patients; p = 0.01) was significantly less in the liposuction-assisted group. In addition, we observed a significantly shorter hospital stay (6.0 days versus 7.8 days), reduced number of follow-up visits (2.0 versus 4.4), and reduced time to drain removal (1.8 days versus 4.1 days; p < 0.001) in the liposuction-assisted group. CONCLUSIONS: Liposuction-assisted medial thighplasty led to a significant reduction of complications and faster recovery in the massive weight loss patient population. As a consequence, the excision-only vertical thigh lift has been completely abandoned in the authors' clinical practice. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Ultrasound-Assisted Liposuction Does Not Compromise the Regenerative Potential of Adipose-Derived Stem Cells.

Human mesenchymal stem cells (MSCs) have recently become a focus of regenerative medicine, both for their multilineage differentiation capacity and their excretion of proregenerative cytokines. Adipose-derived mesenchymal stem cells (ASCs) are of particular interest because of their abundance in fat tissue and the ease of harvest via liposuction. However, little is known about the impact of different liposuction methods on the functionality of ASCs. Here we evaluate the regenerative abilities of ASCs harvested via a third-generation ultrasound-assisted liposuction (UAL) device versus ASCs obtained via standard suction-assisted lipoaspiration (SAL). Lipoaspirates were sorted using fluorescent assisted cell sorting based on an established surface-marker profile (CD34+/CD31-/CD45-), to obtain viable ASCs. Yield and viability were compared and the differentiation capacities of the ASCs were assessed. Finally, the regenerative potential of ASCs was examined using an in vivo model of tissue regeneration. UAL- and SAL-derived samples demonstrated equivalent ASC yield and viability, and UAL ASCs were not impaired in their osteogenic, adipogenic, or chondrogenic differentiation capacity. Equally, quantitative real-time polymerase chain reaction showed comparable expression of most osteogenic, adipogenic, and key regenerative genes between both ASC groups. Cutaneous regeneration and neovascularization were significantly enhanced in mice treated with ASCs obtained by either UAL or SAL compared with controls, but there were no significant differences in healing between cell-therapy groups. We conclude that UAL is a successful method of obtaining fully functional ASCs for regenerative medicine purposes. Cells harvested with this alternative approach to liposuction are suitable for cell therapy and tissue engineering applications. Significance: Adipose-derived mesenchymal stem cells (ASCs) are an appealing source of therapeutic progenitor cells because of their multipotency, diverse cytokine profile, and ease of harvest via liposuction. Alternative approaches to classical suction-assisted liposuction are gaining popularity; however, little evidence exists regarding the impact of different liposuction methods on the regenerative functionality of ASCs. Human ASC characteristics and regenerative capacity were assessed when harvested via ultrasound-assisted (UAL) versus standard suction-assisted liposuction. ASCs obtained via UAL were of equal quality when directly compared with the current gold standard harvest method. UAL is an adjunctive source of fully functional mesenchymal stem cells for applications in basic research and clinical therapy.

Stem Cell-Based Therapeutics to Improve Wound Healing.

Issues surrounding wound healing have garnered deep scientific interest as well as booming financial markets invested in novel wound therapies. Much progress has been made in the field, but it is unsurprising to find that recent successes reveal new challenges to be addressed. With regard to wound healing, large tissue deficits, recalcitrant wounds, and pathological scar formation remain but a few of our most pressing challenges. Stem cell-based therapies have been heralded as a promising means by which to surpass current limitations in wound management. The wide differentiation potential of stem cells allows for the possibility of restoring lost or damaged tissue, while their ability to immunomodulate the wound bed from afar suggests that their clinical applications need not be restricted to direct tissue formation. The clinical utility of stem cells has been demonstrated across dozens of clinical trials in chronic wound therapy, but there is hope that other aspects of wound care will inherit similar benefit. Scientific inquiry into stem cell-based wound therapy abounds in research labs around the world. While their clinical applications remain in their infancy, the heavy investment in their potential makes it a worthwhile subject to review for plastic surgeons, in terms of both their current and future applications.