Abdominoplasty in a Patient With Type 3 von Willebrand Disease: A Case Report.

ABSTRACT: von Willebrand disease (vWD) is an inherited bleeding disorder that is characterized by a quantitative or qualitative deficiency of the von Willebrand factor (vWF). Type 3 is the most severe form of vWD with a near-complete absence of vWF and a significantly increased risk of excessive bleeding and hematoma during a surgical procedure. To date, no data on surgical and hemostatic management of a type 3 vWD patient undergoing body-contouring surgery has been published. We report the case of a 47-year-old woman with type 3 vWD requiring medically indicated abdominoplasty after massive weight loss due to bariatric surgery. The case was successfully managed with individualized bodyweight-adapted substitution of recombinant vWF vonicog alfa and tranexamic acid under close monitoring of vWF and factor VIII activity. For further risk stratification, we propose the multidisciplinary treatment of patients with severe vWF undergoing elective plastic surgery in specialized centers providing around-the-clock laboratory testing and access to a blood bank. In addition, strict hemostasis during surgery and early postoperative mobilization with fitted compression garments are recommended to further reduce the risk of bleeding and thromboembolic complications.

Diagnostic power of ChatGPT 4 in distal radius fracture detection through wrist radiographs.

Distal radius fractures rank among the most prevalent fractures in humans, necessitating accurate radiological imaging and interpretation for optimal diagnosis and treatment. In addition to human radiologists, artificial intelligence systems are increasingly employed for radiological assessments. Since 2023, ChatGPT 4 has offered image analysis capabilities, which can also be used for the analysis of wrist radiographs. This study evaluates the diagnostic power of ChatGPT 4 in identifying distal radius fractures, comparing it with a board-certified radiologist, a hand surgery resident, a medical student, and the well-established AI Gleamer BoneView™. Results demonstrate ChatGPT 4's good diagnostic accuracy (sensitivity 0.88, specificity 0.98, diagnostic power (AUC) 0.93), surpassing the medical student (sensitivity 0.98, specificity 0.72, diagnostic power (AUC) 0.85; p = 0.04) significantly. Nevertheless, the diagnostic power of ChatGPT 4 lags behind the hand surgery resident (sensitivity 0.99, specificity 0.98, diagnostic power (AUC) 0.985; p = 0.014) and Gleamer BoneView™(sensitivity 1.00, specificity 0.98, diagnostic power (AUC) 0.99; p = 0.006). This study highlights the utility and potential applications of artificial intelligence in modern medicine, emphasizing ChatGPT 4 as a valuable tool for enhancing diagnostic capabilities in the field of medical imaging.

Epidemiology of hand injuries that presented to a tertiary care facility in Germany: a study including 435 patients.

BACKGROUND: Hand injuries compose up to 30% of all injuries in emergency care. However, there is a lack of epidemiological data reflecting patient or accident-related variables, injury types, injured anatomical structures or trauma localization. OBJECTIVE: The objective of this study is (1) to provide epidemiological information on hand injuries and their patterns and (2) to visualise the frequencies of affected areas of the hand in relation to the most common trauma mechanisms using color-coded heatmaps. METHODS: This prospective single-center observational trial conducted at a surgical emergency department in Germany collected data of hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, diagnostic and therapeutic measures were analyzed. Color-coded heatmaps were generated marking anatomic danger zones. RESULTS: 435 patients with a mean age of 39.5 were included. Most patients admitted on their own initiative (79%). Leisure and sport injuries were most frequent (75%). Digiti II-V were injured most commonly (43%), followed by metacarpals (19%) and the thumb (14%). Blunt trauma and cuts accounted for most injuries (74%). Hand-graphics depicted color-coded frequencies of the affected areas of the palmar and dorsal aspect of the hand for the most common types of injury, as well as the most frequent circumstances of accident. Elective surgery was recommended in 25% of cases, and hand surgical follow-up was proposed in over 50% of cases. CONCLUSIONS: The dorsal aspect of the hand including the 5th metacarpal, the radial wrist and thenar region, as well as the fingertips of Digiti II/III represent anatomic danger zones to injury of the hand. Due to the large variety of potentially injured structures, diagnosis and treatment is not trivial. Specific training is required for all surgical specialties in emergency care, to increase quality of diagnostic work-up and management of hand injuries.

Visualization of the location and level of pain in common wrist pathologies using color-coded heatmaps.

BACKGROUND: Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon. OBJECTIVE: The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies. METHODS: This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities. RESULTS: 120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology. CONCLUSIONS: Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain.

Analysis of severe hand trauma injury frequency during "Munich's Oktoberfest" within the last 9 years in comparison to years with absence due to the COVID-19 pandemic.

INTRODUCTION: Within its 2 week period, the Oktoberfest attracts around 6 million visitors yearly to Munich, Germany. Due to alcohol intake, congested halls, and disorderly activities, numerous accidents occur. Although many hand injuries are observed, the impact of Oktoberfest on severe hand trauma injury frequency is under investigated. MATERIALS AND METHODS: Data from the regional emergency medical service (EMS) was analyzed over a 9 year period regarding the frequency of severe hand injuries during the world's largest fair and compared to the corresponding period in the years 2020 and 2021 where the event was cancelled due to the world-wide COVID-19 pandemic. Additionally, we compared the patient numbers during the same period in one Emergency Department of a level-1-trauma and hand trauma center located close to the venue. RESULTS: An exploratory description is made from data collected over a 9 year period (2013-2021) with focus on hand injuries before, during and after the "Oktoberfest". A total of 4017 hand injuries were allocated to hospitals by EMS. There was an increase in severe hand injuries by 66% during the 2-weeks-Oktoberfest-period compared to years where the Oktoberfest did not take place. Pre-pandemic statistics show an increasing severe hand trauma frequency of 57.5% in September, compared to EMS-referrals during the remanding year. CONCLUSION: The risk of injuring relevant structures of the hand during Oktoberfest is extremely high as compared to other parts of the body due to beer stein and fall-associated injuries. These injuries can lead to lifelong impairments. Our data are the first that quantifies and pinpoints the risk of severe injury to the hand during Oktoberfest and therefore, it is of great interest for visitors, hand surgeons, paramedics and emergency department healthcare workers.

Adipose-Derived Stem Cells Improve Angiogenesis and Lymphangiogenesis in a Hypoxic Dermal Regeneration Model In Vitro.

Background and Objectives: Impaired wound healing represents an unsolved medical issue with a high impact on patients' quality of life and global health care. Even though hypoxia is a significant limiting factor for wound healing, it reveals stimulating effects in gene and protein expression at cellular levels. In particular, hypoxically treated human adipose tissue-derived stem cells (ASCs) have previously been used to stimulate tissue regeneration. Therefore, we hypothesized that they could promote lymphangiogenesis or angiogenesis. Materials and Methods: Dermal regeneration matrices were seeded with human umbilical vein endothelial cells (HUVECs) or human dermal lymphatic endothelial cells (LECs) that were merged with ASCs. Cultures were maintained for 24 h and 7 days under normoxic or hypoxic conditions. Finally, gene and protein expression were measured regarding subtypes of VEGF, corresponding receptors, and intracellular signaling pathways, especially hypoxia-inducible factor-mediated pathways using multiplex-RT-qPCR and ELISA assays. Results: All cell types reacted to hypoxia with an alteration of gene expression. In particular, vascular endothelial growth factor A (VEGFA), vascular endothelial growth factor B (VEGFB), vascular endothelial growth factor C (VEGFC), vascular endothelial growth factor receptor 1 (VEGFR1/FLT1), vascular endothelial growth factor receptor 2 (VEGFR2/KDR), vascular endothelial growth factor receptor 3 (VEGFR3/FLT4), and prospero homeobox 1 (PROX1) were overexpressed significantly depending on upregulation of hypoxia-inducible factor 1 alpha (HIF-1a). Moreover, co-cultures with ASCs showed a more intense change in gene and protein expression profiles and gained enhanced angiogenic and lymphangiogenic potential. In particular, long-term hypoxia led to continuous stimulation of HUVECs by ASCs. Conclusions: Our findings demonstrated the benefit of hypoxic conditioned ASCs in dermal regeneration concerning angiogenesis and lymphangiogenesis. Even a short hypoxic treatment of 24 h led to the stimulation of LECs and HUVECs in an ASC-co-culture. Long-term hypoxia showed a continuous influence on gene expressions. Therefore, this work emphasizes the supporting effects of hypoxia-conditioned-ASC-loaded collagen scaffolds on wound healing in dermal regeneration.

Aging of the Neck Decoded: New Insights for Minimally Invasive Treatments.

BACKGROUND: Many signs of aging manifest in the neck region, including platysmal bands, excess skin, horizontal neck lines and decreasing contour of the neck. While the clinical signs of an aged neck are well-known, data determining the underlying aging process are limited. OBJECTIVE: To decode aging of the neck. MATERIALS AND METHODS: This prospective study investigated elasticity and firmness of skin, muscle activity and skin displacement upon muscular contraction in the neck in 77 young-, middle- and old-age individuals. Objective outcome measures, including 3-dimensional imaging, cutometry and surface electromyography, were utilized for all assessments. RESULTS: Mean firmness of skin decreased significantly from young to old individuals (0.37 ± 0.13 mm, 0.30 ± 0.12 mm and 0.26 ± 0.12 mm in young, middle and old subjects, respectively; p < 0.001). Gross elasticity decreased significantly from 75.1 ± 13.0% in young subjects, to 64.53 ± 15.7% in middle-aged subjects and 55.79 ± 13.0% in old subjects (p < 0.001). The mean y-axis skin displacement increased from 2.48 ± 4.33 mm in young subjects, to 3.11 ± 4.49 mm in middle-aged subjects and 3.61 ± 5.38 mm in old subjects (p = 0.006). The mean signal-to-noise ratio decreased significantly from 16.74 ± 5.77 µV in young subjects, to 14.41 ± 4.86 µV in middle-aged subjects and to 12.23 ± 5.99 µV in old subjects (p < 0.001). CONCLUSION: This study provides insights into the interplay between skin elasticity, muscular activity and the reflected movement of the skin of the neck. Appreciation of these age-related changes lays the fundament for aesthetic treatments in this delicate region. 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 .

The 72-Hour Microcirculation Dynamics in Viable Free Flap Reconstructions.

BACKGROUND: The risk for vascular complications is the highest within the first 24 hours after free flap transfer. Clinical signs of critical perfusion are often recognized with time delay, impeding flap salvage. To detect failing flaps as soon as possible and to prevent persisting microvascular impairments, knowledge of physiological perfusion dynamics in free flaps is needed. Aim of this study was to investigate the physiological perfusion dynamics of viable free flaps using the Oxygen to See (O2C) device for continuous monitoring. METHODS: Microcirculation was continuously monitored in 85 viable free flaps over a period of up to 72 hours following microvascular anastomosis using tissue spectrophotometry and laser Doppler flowmetry (O2C, LEA Medizintechnik, Gießen, Germany). The parameters investigated included capillary-venous blood flow (flow), oxygen saturation (SO2), and relative amount of hemoglobin (rHB). RESULTS: Microcirculatory blood flow increased significantly overall, especially within the first 18 hours after microsurgical anastomosis, after which peak formation was occurred. Mean values of SO2 showed a decreasing trend and the steepest decrease of SO2 (slope: 1.0) occurred during the steepest increase of flow between 3 and 6 hours (slope: 4.7) postanastomosis. The rHB values remained fairly constant throughout the study period. CONCLUSION: Hyperemia after free flap transfer accounts for a significant increase of microvascular flow. Tissue oxygenation is reduced, likely due to an increase of oxygen consumption after anastomosis. A better understanding of physiological perfusion dynamics in free flaps can aid surgeons in recognizing compromised vasculature earlier and improve free flap salvage.

Extending the Indication of the Superior Thyroid Artery as a Recipient Vessel for Complex Upper Body Defects.

BACKGROUND: Reconstruction of complex chest and upper back defects can pose a challenge to microsurgeons, especially when prior surgery, scarring, tumor resection, or radiotherapy, have caused a shortage of recipient vessels. Although already being a standard approach for head and neck reconstructions, we investigated whether the indication of the superior thyroid artery (STA) as a safe and universal recipient vessel could be extended for reconstruction in aforementioned regions. METHODS: Seventeen patients received free myocutaneous vastus lateralis (MVL) muscle flaps for reconstruction of upper body defects (chest n = 11; upper back n = 6). In all cases, the STA was used for microvascular anastomosis because of a lack of standard recipient vessels. A retrospective chart review was performed and the data was screened for patients' demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Patients had a minimum follow-up of 6 months. RESULTS: Defects resulted from infections after cardiac surgery (n = 10), infections after spinal neurosurgery (n = 2) or tumor resection (n = 5). Average defect size measured 144.6 (range, 40-286 cm2; ±67.9 cm2), with a mean size of the MVL free flaps of 266.8 (range, 160-384 cm2; ±69.5 cm2). The flap success rate was 100%, with minor complications in 4 patients. No major complications were observed in any of the patients. CONCLUSIONS: The STA is a viable and safe alternative as a recipient vessel for reconstruction of upper body defects, especially when other vessels in proximity to the defect are deprived.

Digital Leg Volume Quantification: Precision Assessment of a Novel Workflow Based on Single Capture Three-dimensional Whole-Body Surface Imaging.

Whole-body three-dimensional surface imaging (3DSI) offers the ability to monitor morphologic changes in multiple areas without the need to individually scan every anatomical region of interest. One area of application is the digital quantification of leg volume. Certain types of morphology do not permit complete circumferential scan of the leg surface. A workflow capable of precisely estimating the missing data is therefore required. We thus aimed to describe and apply a novel workflow to collect bilateral leg volume measurements from whole-body 3D surface scans regardless of leg morphology and to assess workflow precision. For each study participant, whole-body 3DSI was conducted twice successively in a single session with subject repositioning between scans. Paired samples of bilateral leg volume were calculated from the 3D surface data, with workflow variations for complete and limited leg surface visibility. Workflow precision was assessed by calculating the relative percent differences between repeated leg volumes. A total of 82 subjects were included in this study. The mean relative differences between paired left and right leg volumes were 0.73 ± 0.62% and 0.82 ± 0.65%. The workflow variations for completely and partially visible leg surfaces yielded similarly low values. The workflow examined in this study provides a precise method to digitally monitor leg volume regardless of leg morphology. It could aid in objectively comparing medical treatment options of the leg in a clinical setting. Whole-body scans acquired using the described 3DSI routine may allow simultaneous assessment of other changes in body morphology after further validation.

Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging.

Facial flap surgery depends strongly on thorough preoperative planning and precise surgical performance. To increase the dimensional accuracy of transferred facial flaps, the methods of ultrasound and three-dimensional (3D) surface scanning offer great possibilities. This study aimed to compare different methods of measuring distances in the facial region and where they can be used reliably. The study population consisted of 20 volunteers (10 males and 10 females) with a mean age of 26.7 ± 7.2 years and a mean body mass index of 22.6 ± 2.2 kg/m2. Adhesives with a standardized length of 20 mm were measured in various facial regions through ultrasound and 3D surface scans, and the results were compared. Regardless of the facial region, the mean length measured through ultrasound was 18.83 mm, whereas it was 19.89 mm for 3D surface scans, with both p < 0.0001. Thus, the mean difference was 1.17 mm for ultrasound measurements and 0.11 mm for 3D surface scans. Curved facial regions show a great complexity when it comes to measuring distances due to the concavity and convexity of the face. Distance measurements through 3D surface scanning showed more accurate distances than the ultrasound measurement. Especially in "complex" facial regions (e.g., glabella region and labiomental sulcus), the 3D surface scanning showed clear advantages.

Evaluation of the Usability of a Low-Cost 3D Printer in a Tissue Engineering Approach for External Ear Reconstruction.

The use of alloplastic materials instead of autologous cartilage grafts offers a new perspective in craniofacial reconstructive surgery. Particularly for regenerative approaches, customized implants enable the surgeon to restore the cartilaginous framework of the ear without donor site morbidity. However, high development and production costs of commercially available implants impede clinical translation. For this reason, the usability of a low-cost 3D printer (Ultimaker 2+) as an inhouse-production tool for cheap surgical implants was investigated. The open software architecture of the 3D printer was modified in order to enable printing of biocompatible and biologically degradable polycaprolactone (PCL). Firstly, the printing accuracy and limitations of a PCL implant were compared to reference materials acrylonitrile butadiene styrene (ABS) and polylactic acid (PLA). Then the self-made PCL-scaffold was seeded with adipose-tissue derived stem cells (ASCs), and biocompatibility was compared to a commercially available PCL-scaffold using a cell viability staining (FDA/PI) and a dsDNA quantification assay (PicoGreen). Secondly, porous and solid patient-customized ear constructs were manufactured from mirrored CT-imagining data using a computer-assisted design (CAD) and computer-assisted manufacturing (CAM) approach to evaluate printing accuracy and reproducibility. The results show that printing of a porous PCL scaffolds was possible, with an accuracy equivalent to the reference materials at an edge length of 10 mm and a pore size of 0.67 mm. Cell viability, adhesion, and proliferation of the ASCs were equivalent on self-made and the commercially available PCL-scaffolds. Patient-customized ear constructs could be produced well in solid form and with limited accuracy in porous form from all three thermoplastic materials. Printing dimensions and quality of the modified low-cost 3D printer are sufficient for selected tissue engineering applications, and the manufacturing of personalized ear models for surgical simulation at manufacturing costs of EUR 0.04 per cell culture scaffold and EUR 0.90 (0.56) per solid (porous) ear construct made from PCL. Therefore, in-house production of PCL-based tissue engineering scaffolds and surgical implants should be further investigated to facilitate the use of new materials and 3D printing in daily clinical routine.

Zone-Dependent Architecture and Biochemical Composition of Decellularized Porcine Nasal Cartilage Modulate the Activity of Adipose Tissue-Derived Stem Cells in Cartilage Regeneration.

Previous anatomical studies have shown different functional zones in human nasal septal cartilage (NC). These zones differ in respect to histological architecture and biochemical composition. The aim of this study was to investigate the influence of these zones on the fate of stem cells from a regenerative perspective. Therefore, decellularized porcine septal cartilage was prepared and subjected to histological assessment to demonstrate its equivalence to human cartilage. Decellularized porcine NC (DPNC) exposed distinct surfaces depending on two different histological zones: the outer surface (OS), which is equivalent to the superficial zone, and the inner surface (IS), which is equivalent to the central zone. Human adipose tissue-derived stem cells (ASCs) were isolated from the abdominal fat tissue of five female patients and were seeded on the IS and OS of DPNC, respectively. Cell seeding efficiency (CSE), vitality, proliferation, migration, the production of sulfated glycosaminoglycans (sGAG) and chondrogenic differentiation capacity were evaluated by histological staining (DAPI, Phalloidin, Live-Dead), biochemical assays (alamarBlue®, PicoGreen®, DMMB) and the quantification of gene expression (qPCR). Results show that cell vitality and CSE were not influenced by DPNC zones. ASCs, however, showed a significantly higher proliferation and elevated expression of early chondrogenic differentiation, as well as fibrocartilage markers, on the OS. On the contrary, there was a significantly higher upregulation of hypertrophy marker MMP13 (p < 0.0001) and GAG production (p = 0.0105) on the IS, whereas cell invasion into the three-dimensional DPNC was higher in comparison to the OS. We conclude that the zonal-dependent distinct architecture and composition of NC modulates activities of ASCs seeded on DPNC. These findings might be used for engineering of cartilage substitutes needed in facial reconstructive surgery that yield an equivalent histological and functional structure, such as native NC.

The Impact of Breast Symmetry on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

BACKGROUND: The objective assessment of beauty remains challenging despite ongoing research efforts. A new method of objectively determining the aesthetic appeal of body features by analyzing gaze patterns and eye movements has recently been investigated. OBJECTIVES: The objective of this study was to assess, by means of objective eye-tracking technology, differences in the gaze patterns of observers presented with standardized 3-dimensional images showing different degrees of breast asymmetry. METHODS: A total of 83 Caucasian study participants with a mean age of 38.60 (19.8) years were presented with 5 images depicting varying degrees of breast asymmetry. In addition to the assessment of eye movements, participants were asked to rate the aesthetic appeal and the asymmetry of the breasts on a 5-point Likert scale. RESULTS: Overall, the data showed that participants' rating of the breasts' aesthetic appeal was inversely related to the level of asymmetry. The mean [standard deviation] time until fixation was shortest for the image depicting the greatest breast asymmetry (50 cc) at 0.77 [0.7] seconds (P < 0.001). In addition, the mammary region was also viewed longest in this image at 3.76 [0.5] seconds (P < 0.001). A volume difference of 35 cc between breasts deflected the observers' gaze significantly toward the larger of the asymmetric breasts (P < 0.001). CONCLUSIONS: Surgeons should focus on achieving symmetric breast volume (ie, differences <35 cc between breasts) to avoid noticeable asymmetry with regard to breast size.

How Does Wearing a Facecover Influence the Eye Movement Pattern in Times of COVID-19?

BACKGROUND: Since the emergence of the COVID-19 pandemic facecovers have become a common sight. The effect of facecovers on the gaze when looking at faces has not yet been assessed. OBJECTIVES: The aim of the present study was to investigate any potential differences in eye movement pattern in observers exposed to images showing a face without and with a facecover to identify if there is truly a change of gaze when identifying (masked) facial features. METHODS: The eye movement of 64 study participants (28 males and 36 females) with a mean [standard deviation] age of 31.84 [9.0] years was analyzed in this cross-sectional observational study. Eye movement analysis was conducted based on positional changes of eye features within an x- and y-coordinate system while two images (face without/with facecover) were displayed for 8 seconds. RESULTS: The results of this study revealed that the sequence of focusing on facial regions was not altered when wearing a facecover and followed the sequence: perioral, nose, periorbital. Wearing a facecover significantly increased the time spent focusing on the periorbital region and also increased the number of repeated eye fixations during the 8-second visual stimulus presentation. No statistically significant differences were observed between male and female participants in their eye movement pattern across all investigated variables (P > 0.433). CONCLUSIONS: The altered eye movement pattern caused by wearing facecoverings that this study has revealed suggests that, during the COVID-19 pandemic, aesthetic practitioners might consider developing marketing and treatment strategies that principally target the periorbital area.

Understanding Facial Muscle Aging: A Surface Electromyography Study.

BACKGROUND: Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood. OBJECTIVES: The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers. METHODS: The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles. RESULTS: The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity). CONCLUSIONS: The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.

Onset of occupational hand eczema among healthcare workers during the SARS-CoV-2 pandemic: Comparing a single surgical site with a COVID-19 intensive care unit.

BACKGROUND: As a result of the COVID-19 outbreak, hygiene regulations have been revised and hand sanitation has been intensified. OBJECTIVE: To investigate the onset of hand eczema during the COVID-19 pandemic in healthcare workers (HCWs) directly involved in intensive care of COVID-19 patients and HCWs without direct contact with COVID-19 patients. Hereby, we aim at increasing awareness about occupational hand eczema and preventive measures that can be adopted. METHOD: A survey was distributed amongst 114 HCWs at a single surgical centre and at a COVID-19 intensive care unit of the university hospital Ludwig Maximilian University Munich, Germany. Participants were questioned about the daily frequency of hand hygiene prior to and during the pandemic. Participants self-reported the onset of hand eczema and associated symptoms. RESULTS: Our study revealed a significant increase in hand washing, disinfection, and use of hand cream across all participants (P-value <.001), regardless of having direct contact with COVID-19 patients. A high prevalence of symptoms associated with acute hand dermatitis of 90.4% was found across all HCWs, whereas hand eczema itself was underreported (14.9%). CONCLUSION: The increase in hand sanitation during the COVID-19 pandemic impairs the skin of the hands across all HCWs, independent of direct intensive care of affected patients.

Impact of Smoking Status in Free Deep Inferior Epigastric Artery Perforator Flap Breast Reconstruction: A Multicenter Study.

BACKGROUND: Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions. METHODS: In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models. RESULTS: Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p < 0.001) and wound-healing disturbances requiring revision surgery (donor site: 1.5 vs. 4.0; recipient site: 1.3 vs. 3.6%, both p < 0.001) was significantly higher in smokers. Multivariable analysis identified smoking to be an independent risk factor for revision surgery (p = 0.001) and partial flap loss (p < 0.0001). CONCLUSION: Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

Clinical Validation of the Surface Volume Coefficient for Minimally Invasive Treatment of the Temple

Objective: The aim of the present study is to compare the temporal surface volume coefficient obtained in the cadaveric model from subdermal and supraperiosteal injections to the clinical setting when treating temporal hollowing. Material and Methods: A total of 36 subjects were included in this investigation, 17 patients (16 females, 1 male; 46.3 ± 8.9 years; 25.5 ± 2.8 kg/m2) and 19 cadaveric specimens (11 females, 8 males; 76.4 ± 11.5 years; 24.0 ± 5.1 kg/m2). Subdermal and supraperiosteal injections were performed and live subjects were evaluated and followed for 12 months. The surface volume coefficients were calculated using 3D surface volume scanning and compared for validity. Results: No statistically significant difference was detected between the clinical outcome scores of the subdermal vs supraperiosteal injection technique. The supraperiosteal injection technique utilized significantly more product 1.20 ± 0.5 cc [range: 0.50 ­ 2.6 cc] compared to the subdermal 0.71 ± 0.2 cc [range: 0.30 ­ 1.20 cc] vs with P< 0.001. This difference was consistent with the different values of the cadaveric surface volume coefficient (subdermal vs supraperiosteal): 1.00 ± 0.2 vs 0.70 ± 0.2. At 12-month follow-up, the product loss was 19% for the subdermal injection and 21% for patients treated with supraperiosteal injections. Conclusion: The results of the study support the clinical validity of the surface volume coefficient. They demonstrate that the different injection volumes necessary to deliver aesthetically appealing results when utilizing the subdermal vs the supraperiosteal technique can be explained by the region-specific surface volume coefficient. J Drugs Dermatol. 2019;18(6):533-540.

3D Mammometric Changes in the Treatment of Idiopathic Gynecomastia.

BACKGROUND: Three-dimensional surface imaging (3DSI) has shown promise for plastic surgeons to objectively assess changes in body contour and breast volume. OBJECTIVES: To assess the surgical outcome after bilateral subcutaneous mastectomy (BSM) and water jet-assisted liposuction (WAL) as treatment for idiopathic gynecomastia, using 3DSI to document changes regarding nipple-areolar complex (NAC) and breast volume. METHODS: Thirty male patients (Simon II A to B) receiving BSM and WAL were enrolled. Eight subjects received additional mastopexy and NAC reduction. Use of a Vectra 3D Imaging System® before and 6 months after surgery provided data regarding changes of NAC placement and NAC and breast dimensions. The sum volume of intraoperatively approximated lipoaspirate before and after centrifugation and mastectomy specimens quantified using water displacement were compared with 3D-assessed differences in volume. RESULTS: When compared to the NAC dimensions defined during surgery, patients receiving NAC reductions showed nonsignificant postoperative changes in NAC dimensions. Patients without additional mastopexy showed a significant (p < 0.001) vertical (15.7 ± 14.3%) and horizontal (17.1 ± 15.0%) reduction in NAC diameter. 3D volume changes (92.8 ± 26.4 mL) showed significant differences (p < 0.001) 6 months after surgery compared to the intraoperatively measured lipoaspirate before (182 ± 54.5 mL) and after (120 ± 34.6 mL) centrifugation. CONCLUSION: Although it is clear that patient satisfaction must remain the prime focus of surgical body contouring, 3DSI has proven valuable to objectively demonstrate both the anticipated outcome and further findings regarding treatment of idiopathic gynecomastia. 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 .