Effects of Preoperative Extracorporeal Shockwave Therapy on Scar Formation-A Pilot Study on 24 Subjects Undergoing Abdominoplasty Surgery.

OBJECTIVES: Extracorporeal shockwave therapy (ESWT) has been demonstrated as a feasible noninvasive method to improve wound healing. This effect was demonstrated to result from increased perfusion and angiogenesis due to systemic growth factor expression. We, therefore, hypothesized that preoperative ESWT reduces scar formation after surgery. METHODS: A prospective, controlled pilot study on 24 patients undergoing abdominoplasty was conducted and the efficacy of preoperative unfocused, low energy EWST was evaluated. The right and left half of the operative area were randomly allocated to ESWT or placebo treatment in intrapatient control design. At 6 and 12 weeks after surgery, scar formation was evaluated by 19 different scar parameters included in the patient, observer scar assessment, and the Vancouver scar scale. RESULTS: The overall rating of the Vancouver and POSAS scale with Mann-Whitney (MW) analysis revealed a clear trend favoring ESWT. At week 6, 7 of 19 parameters clearly favored ESWT (MW > 0.53). At week 12, 8 of 19 parameters clearly favored ESWT. The largest differences were observed in thickness and overall impression (Vancouver scar scale). CONCLUSIONS: ESWT presumably reduces scar formation and postoperative symptoms after abdominoplasty surgery. Further studies are required to confirm ESWT efficacy with statistical significance. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Redefining the vascular anatomy of the peroneus brevis muscle flap.

The peroneus brevis flap can be used as either proximally or distally based flap for coverage of small to medium-sized defects in the lower leg. The purpose of this study was to clarify the vascular anatomy of the peroneus brevis muscle. An anatomical dissection was performed on 17 fixed adult cadaver lower legs. Altogether, 87 segmental branches (mean 5.1 ± 1.6 per leg) either from the fibular or anterior tibial artery to the muscle were identified. Sixty-two were branches from the fibular artery (mean 3.4 ± 1.1 per fibular artery), whereas 25 (mean 1.4 ± 0.9 per anterior tibial artery) originated from the anterior tibial artery. The distance between the most distal vascular branch and the malleolar tip averaged 4.3 ± 0.6 cm. An axial vascular bundle to the muscle could be identified in all cadavers; in one leg two axial supplying vessels were found. Their average length was 5.5 ± 2.4 cm and the average arterial diameter was 1.1 ± 0.5 mm, the average venous diameter was 1.54 ± 0.7 mm. The constant blood supply to the peroneus brevis muscle by segmental branches from the fibular and tibial artery make this muscle a viable option for proximally or distally pedicled flap transfer. The location of the most proximal and distal branches to the muscle and conclusively the pivot points for flap transfer could be determined. Furthermore, a constant proximal axial vascular pedicle to the muscle may enlarge the clinical applications. Perfusion studies should be conducted to confirm these findings.

Aesthetic Breast Augmentation Mastopexy Followed by Post-surgical Pyoderma Gangrenosum (PSPG): Clinic, Treatment, and Review of the Literature.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare autoinflammatory neutrophilic ulcerative skin disease, often developing after a trauma or surgical wounds. In the literature there are several reports of post-surgical PG (PSPG) of the breast. The authors of this article experienced an impressive case of PSPG after an aesthetic breast augmentation mastopexy. PSPG is a rare but severe complication in this elective aesthetic surgical procedure. METHOD: A systematic review of the literature was performed, focusing on PSPG after aesthetic breast surgery (augmentation mammoplasty/mastopexy). The online databases Pubmed, Medline, and Cochrane were used and additionally a Google© search was conducted. We compared the data obtained from a systematic literature review to an index case of PSPG after esthetic augmentation mammoplasty. RESULTS: The literature search identified seven articles describing eight cases of PSPG after aesthetic breast surgery. In four of these cases augmentation mammoplasty had been carried out, in two cases mastopexy and in two cases augmentation mammoplasty and mastopexy (augmentation mastopexy). The patient we treated and describe in this paper underwent an augmentation mastopexy outside our clinic. Eight patients suffered from local disease, at the site of surgical wounds, one patient had disseminated disease. Leukocytosis was present in five cases (out of nine). Eight patients had received corticosteroid treatment, one patient refused such treatment. The duration of corticosteroid treatment was on average for 41 days (range 21-60 days). In all cases, the areola had been spared. Complete healing of PSPG was observed on average after 5 months (range 1.5 months-1 year). DISCUSSION: PSPG of the breast after aesthetic breast surgery is rare, but every plastic surgeon should consider this possibility, especially if skin disease develops post-surgery, mimicking wound infection that does not respond to broad-spectrum antibiotic treatment. CONCLUSION: Although the literature does not recommend this step, implant removal is recommended by the authors because bacterial wound infection normally cannot be ruled out definitely in the early stages of disease. Additional surgical intervention should be limited to the absolute necessary and performed only under adequate systemic immunosuppressive therapy.

Anterograde Injection of Alteplase Salvages Deep Inferior Epigastric Perforator Flap in Reconstructive Breast Surgery.

The DIEP flap is currently considered the gold standard for autologous reconstructive breast surgery. Postoperative flap failure due to microvascular postanastomotic thrombotic occlusion is a rare but severe complication. Alteplase, a thrombolytic agent typically used in the setting of an ischemic stroke, myocardial infarction, or pulmonary embolism, has also been injected into the microcirculation of flaps as a rescue procedure due to imminent flap loss. The purpose of this article is to provide an overview and detailed guidance for such a thrombolytic procedure due to suspected thrombotic microsurgical failure in free flap surgery. We report the case of a 43-year-old woman who underwent unilateral breast reconstruction with a DIEP flap at our department. Approximately 12 hours postoperatively, an arterial inflow problem was suspected and revision surgery was performed. Peripheral flap perfusion remained absent without an obvious cause and distal thrombosis was assumed to be present. Therefore, alteplase was gradually injected into the arterial pedicle in the anterograde direction just distal to the anastomosis while clamping the artery proximally. About 3 hours after selective flap thrombolysis, microcirculation of the flap was successfully restored without complications. Anterograde injection of alteplase can successfully salvage a free flap. To our knowledge, evidence for optimal dosing and delivery of alteplase for the treatment of thrombosed DIEP flaps has not been published to date. Our approach presents a therapeutic option that both maximizes alteplase concentration in the flap and minimizes the dosage required for flap salvage to significantly reduce systemic adverse effects.

Microsurgical Scalp Replantation: Lessons Learned and Technical Considerations.

Total scalp avulsion is defined as a severe soft-tissue injury which involves the hairy scalp and commonly occurs in women as a result of the entrapment of long hair in high-speed rotating industrial machinery. The first microvascular replantation of an avulsed scalp was described by Miller et al in 1976 when both superficial temporal arteries along with five veins were successfully reanastomosed. Our patient was managed with a vein graft measuring 8 cm in length for reanastomosis of the superficial temporal artery. Furthermore, after successful replantation, we used an expander for aesthetic refinement and achieved an excellent outcome. A scalp replantation should be performed in every possible case. Despite partial skin necrosis, hair growth in the remaining areas is possible. In cases of partial skin necrosis, it is possible to eliminate the hairless areas by implanting an expander and excising the hairless area. A pressure-related ulcer at the occiput is likely due to immobility of the head postoperatively and may be avoided by using a halo fixation device.

The use of confidence intervals in reporting orthopaedic research findings.

Conflict between clinical importance and statistical significance is an important problem in medical research. Although clinical importance is best described by asking for the effect size or how much, statistical significance can only suggest whether there is any difference. One way to combine statistical significance and effect sizes is to report confidence intervals. We therefore assessed the reporting of confidence intervals in the orthopaedic literature and factors influencing this frequency. In parallel, we tested the predictive value of statistical significance for effect size. In a random sample of predetermined size, we found one in five orthopaedic articles reported confidence intervals. Participation of an individual trained in research methods increased the odds of doing so fivefold. The use of confidence intervals was independent of impact factor, year of publication, and significance of outcomes. The probability of statistically significant results to predict at least a 10% between-group difference was only 69% (95% confidence interval, 55%-83%), suggesting that a high proportion of statistically significant results do not reflect large treatment effects. Confidence intervals could help avoid such erroneous interpretation by showing the effect size explicitly.

Occult papillary thyroid cancer presenting as cystic metastasis of the lateral neck: A case report.

RATIONALE: Papillary thyroid cancer accounts for up to 85% of all cases of thyroid carcinoma. This disease entity is notorious for metastatic invasion of adjacent lymph nodes, including the cervical lymph nodes, potentially presenting as a growing lateral neck mass. However, these lesions tend to be recognized and diagnosed soon due to the palpable mass. PATIENT CONCERNS: This report describes a very rare case of a huge slow-growing neck metastasis based on a 6 mm papillary thyroid microcarcinoma. This patient presented with a painless, but continuously growing right lateral neck mass. Aside from that, no specific complaints were mentioned. DIAGNOSIS: The underlying cause of this patient's neck mass turned out to be an occult papillary thyroid microcarcinoma (Ø 6 mm) with metastatic invasion and subsequent cystic degeneration of cervical lymph nodes. Accurate diagnosis was made after surgical intervention through histopathological analysis. INTERVENTIONS: The patient underwent complete resection of the cervical mass in conjunction with total thyroidectomy and right cervical neck dissection, followed by adjuvant iodine- and chemotherapy. OUTCOME: Margin free surgical resection without any postoperative complications could be achieved. The patient received iodine supplementation and remained free of recurrence during regular clinical follow-ups for 2 years. The therapy was curative. LESSONS: This case report emphasizes the importance of a thorough diagnostic work-up including preoperative tissue sampling of any cervical neck mass, since a benign appearance on imaging does not exclude a malignant process.

Surgical decompression of the lateral femoral cutaneous nerve (LFCN) for Meralgia paresthetica treatment: Experimental or state of the art? A single-center outcome analysis.

Meralgia paresthetica (MP) is a rare lateral femoral cutaneous nerve-(LFCN)-mononeuropathy. Treatment for this disorder includes conservative and operative approaches; the latter is considered if conservative therapy fails. The most commonly used surgical approaches are decompression/neurolysis and avulsion/neurectomy. However, there are no definitive guidelines on the optimal surgical approach to be used. The purpose of this study was to evaluate the outcome of surgical decompression of the LFCN for the treatment of persistent MP with preservation of sensation along the distribution of the LFCN.We evaluated the outcomes of LFCN procedures performed between 2015 and 2016. A total of 16 surgical decompressions could be identified. Retrospective analysis of prospectively collected patient data was performed, as well as systematic evaluation of the postoperative course, with regular follow-up examinations based on a standardized protocol. Pain was analyzed using an NRS (numeric rating scale). Several postsurgical parameters, including temperature hypersensitivity and numbness in the LFCN region, were compared with the presurgical data.Sixty-nine percent of patients had histories of trauma or surgery, which were designated as the onset of pain. Of these patients, 78% had hip prostheses, 2 had previous falls. Postoperatively, a significant reduction of 6.6 points in the mean NRS pain value was observed. All other evaluated parameters also improved postoperatively. Patient satisfaction was high, with 86% reporting complete satisfaction, and 14% reporting partial satisfaction.Previous studies favor either avulsion/neurectomy as the preferred procedure for MP treatment, or provide no recommendation. Our findings instead confirm the decompression/neurolysis approach as the primary surgical procedure of choice for the treatment of MP, if conservative treatment fails.

Thighplasty: improving aesthetics through revival of the medial, horizontal procedure: A safe and scar-saving option.

INTRODUCTION: Thighplasty is a common bodycontouring procedure, but also associated with a high complication rate. The purpose of this study was to access the outcome of the medial horizontal thigh lift as it is a common surgical technique regarding thigh deformity correction performed at the authors' department. Surgical keysteps, clinical applications, advantages and disadvantages of the procedure are shown. Postoperative evaluation took place with special focus on individual patient satisfaction. METHODS: Retrospective analysis of 25 bilateral thigh lifts with single medial horizontal incision line was performed. Evaluated data include patient age, sex, body mass index, combined procedures, additional liposuction, weight loss, former bariatric surgery, comorbidities, smoking status and surgical complications. Follow-up was performed with a standardized protocol and the scar was accessed according to the Vancouver-Scare-Scale. Additionally the patients were asked to complete a questionnaire divided into the sections 'scars', 'postoperative result' and 'sexuality'. RESULTS: Average patient-age was 43 years. Average follow-up was 2 years and 8 months. Average weight loss before surgery was 57 kg. 36% of all patients additionally received a liposuction of the medial thigh. In six cases (24%), we observed complications, which were designated as 'minor complications' in five times (conservative management without problems) and 'major complication' in one time (surgical revision). Postoperative patient-satisfaction was high. DISCUSSION AND CONCLUSION: Compared to the horizontal and vertical combined thigh lift with the classic T-shaped incision lines we observed fewer complications and a reduction of postoperative morbidity. Additionally patient satisfaction was very high. We estimate that the main reason therefore is the avoidance of the vertical scar and its associated short- and longterm problems. The evaluated data confirm the medial horizontal thighplasty as a good and valuablesurgical option for the management of thigh deformities with moderate skin and tissue excess, localized in the upper part of the thigh.

Reconstructive microsurgical approach for the treatment of pyoderma gangrenosum.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare type of autoimmune disease that results in progressive ulcers with or without previous trauma. However, PG is not well understood to date, and its treatment therefore remains a challenge. Because of the disease's systemic characteristic and the unpredictability of the clinical course, no gold standard treatment is available, especially concerning the surgical procedures to treat pyodermic lesions. Often, PG is not recognized during routine clinical practice, and standard ulcer treatment (conservative wound care, debridement, skin grafting, and local flap coverage) is initiated; this induces an autoinflammatory response, resulting in disastrous ulcers, thereby making free flap coverage necessary. The purpose of this study was to assess the outcome of microvascular free-tissue transfer as a treatment option for extended soft-tissue defects resulting from PG. MATERIALS AND METHODS: We retrospectively evaluated 8 cases in 5 patients suffering from PG of the lower extremity who received defect closure with a microvascular free-tissue transfer under immunosuppressive and corticosteroid therapy. RESULTS: The average patient age was 60 years; three were male, and two were female. Seven defects were covered with free gracilis muscle flap. One patient received an anterolateral thigh flap. The average defect size was 93 cm2. No flap loss was observed during follow-up. All patients received broad-spectrum antibiotic treatment and corticosteroids. Two patients also received infliximab. DISCUSSION AND CONCLUSION: PG once diagnosed is not a contraindication for microvascular free-tissue transfer. Multidisciplinary evaluation of each case is fundamental. All surgical treatments should be performed only with sufficient protective immunosuppression therapy. If the defect requires free flap coverage, it should be considered as a surgical option despite the potential risk of a pathergic response in PG and was a safe treatment option in all our cases. In conclusion, we share our experience regarding preoperative, intraoperative, and postoperative care of patients with PG receiving free flap surgery.

Minimizing the Short-term Reoperation Rate in Abdominoplasty Procedures by Prolonged Postoperative Immobilization.

BACKGROUND: Abdominoplasty is a common procedure in postbariatric surgery. Over the years, a high number of technical refinements of the procedure have been established to improve safety and reduce associated complications. Nevertheless, the complication rate is high. The purpose of this study was to examine the incidence of postoperative complications in patients undergoing abdominoplasty in association with prolonged postoperative immobilization. METHODS: Retrospective analysis of 82 patients who underwent abdominoplasty was performed. Patients were divided in two study groups regarding their immobilization period. Group 1 included patients with an immobilization period defined as strict bed rest for at least 45 h after surgery. Group 2 included all patients with shorter immobilization time, but earliest mobilization in the evening on the day of surgery. RESULTS: Overall, complication rate was 27%. Major complications were observed in 15% in group 1 and in 23% in group 2. Hematoma requiring surgical revision was observed in 5% in group 1 and in 14% in group 2. Surgical revisions within the first 60 days were necessary in 5% in group 1 and in 20% in group 2. CONCLUSION: Prolonged immobilization after abdominoplasty does not crucially lower the overall complication rate, but influences the severity of complications in a positive way. Increasing the duration of postoperative immobilization up to 45 h after abdominoplasty significantly decreases the reoperation rate in our practice. The risk for a surgical revision is nearly four times higher if the patient leaves bed earlier. Surgeons should consider this option especially in patients with a high risk for complication development.

A double-blind randomized prospective study comparing prilocaine versus ropivacaine in upper blepharoplasty.

BACKGROUND: Upper blepharoplasties are a common procedure in plastic surgery. This procedure can be performed effectively under local anesthesia with or without sedation. The ideal local anesthetic should cause less intraoperative bleeding and less postoperative edema. Our study aimed to show the difference between the two local anesthetics 1% prilocaine (Xylonaest) in combination with epinephrine 1:100,000 and ropivacaine (Naropin) in combination with epinephrine 1:100,000 including sodium chloride, particularly in regard to swelling and bleeding in patients undergoing upper blepharoplasties. MATERIAL AND METHODS: In this double-blind, prospective, randomized study, 31 patients between March 2014 and September 2014 were included. The anesthetic agents used in all cases were 1% prilocaine (Xylonaest) in combination with epinephrine 1:100,000 for one side and ropivacaine consisting of 10-mg Naropin, 5-ml sodium chloride, and 1-ml epinephrine for the other side. The data presented in this study were collected by one of the surgeons performing the surgery. Intraoperative bleeding and postoperative edema were both calculated using a score of five points for each. RESULTS: The average bleeding tendency was 3.39 for prilocaine and 1.71 for local ropivacaine, showing a significant difference (p < 0.0001) between both local anesthetics in bleeding tendency. There was also a significant minor swelling at all times on the side on which ropivacaine was used. DISCUSSION: In our study, we demonstrated that ropivacaine (Naropin) has less intra- and postoperative side effects including swelling and bleeding compared with prilocaine (Xylonaest).