[Scars from Nonsuicidal Self-Injury - What Plastic Surgery Can Do]. / Narben aus nichtsuizidalem selbstverletzendem Verhalten ­ therapeutische Möglichkeiten der plastischen Chirurgie.

Scars from Nonsuicidal Self-Injury - What Plastic Surgery Can Do Abstract. Objective: Nonsuicidal self-injury (NSSI) can induce characteristic scar patterns indicating the origin of these scars. This frequently results in the stigmatization of the involved patients with far-reaching consequences for their daily routine and quality of life. Despite patients being highly interested in scar correction, the potential of surgical therapy to alleviate NSSI-prone behavior and its help in destigmatizing surgical corrections and esthetic improvements in these situations are not well-known. Method: Over a period of 5 years, we analyzed 600 patients requesting NSSI scar treatment in our outpatient clinic. We collected data on the motivation for a scar correction, on the maturity of the scars, the involved body parts, and potential prior scar treatments as well as the amount, localization, and type of performed surgical procedures in our institution. Results: Stigmatization (57 %) and limitations in choice of clothing (18 %) were the most frequent reasons given for scar correction. We performed 358 dermabrasions and 55 serial excisions on these patients, nine combinations of both, and 13 other procedures. Conclusions: Plastic surgery offers multiple possibilities to reduce the stigmatization of patients with NSSI scars, who should thus be informed early about their choices.

Comparison of venous couplers versus hand-sewn technique in 4577 cases of DIEP-flap breast reconstructions - A multicenter study.

INTRODUCTION: Venous anastomosis remains to be a challenging step in microsurgical tissue transfer and venous complications constitute to a common reason for free flap failure. While several studies have compared mechanical vs. hand-sewn venous anastomoses, there is no large-series study comparing the type of anastomosis exclusively in DIEP flap breast reconstructions. PATIENTS AND METHODS: Between 2011 and 2019, 3926 female patients underwent 4577 free DIEP-flap breast reconstructions in 22 different breast cancer centers. Patient data was collected via an online database, files were screened and cases were divided into a hand- (HA) and a coupler-anastomosis (CA) group. Complications were accounted for and the two groups were then compared. RESULTS: Mean ischemia time was significantly shorter in the CA group (46.88 ± 26.17 vs. 55.48 ± 24.70 min; p < .001), whereas mean operative time was comparable (316 ± 134.01 vs. 320.77 ± 120.29 minutes; p = .294). We found no significant difference between both groups regarding the rate of partial (CA: 1.0% vs. HA: 1.3%) and total flap loss (CA: 2.2% vs. HA: 1.8%). However, revision rates were significantly higher in the CA group (CA: 10.5% vs. HA: 7.9%; p = .003), with higher numbers of arterial (2.3 vs. 0.9%; p < .001) and venous thromboses (3.4 vs. 1.8%; p = .001) accounting for this finding. CONCLUSIONS: All taken into account, our findings do support the feasibility of venous coupler anastomoses in principle, however the inflationary use of coupler devices should be evaluated critically.

Donor Defect Morbidity of Intrinsic Flaps in the Posttraumatized Hand.

INTRODUCTION: There are many types of intrinsic flaps to cover wound defects on the hand, which have been well described in scientific literature. However, the donor sites are often neglected in such studies. Therefore, we aimed to evaluate donor site morbidity for homodigital island flaps, cross-finger flaps, Foucher's pedicle flaps, and flaps of the dorsal metacarpal artery system (DMCA). MATERIALS AND METHODS: A total of 106 intrinsic flap procedures were performed on 106 patients (16 women, 90 men). The donor sites were retrospectively followed up after an average of 3.4 years by a questionnaire, a Disability of the Arm, Shoulder and Hand score, and clinical examination. Donor sites of different flap types were compared for aesthetic outcome, trophic level, and sensation, including 2-point discrimination, temperature, sharp/dull discrimination, the Semmes-Weinstein monofilament test, pain (visual analog scale), and functionality. RESULTS: In general, primarily closed donor sites showed more favorable results than did grafted donor sites. Satisfaction among patients regarding aesthetics of the donor site was highest in patients who had received homodigital island flaps. Grip strength and pain at the operated hand were very heterogeneous and rather influenced by the primary trauma than the type of flap. Homodigital island flap donor sites demonstrated the best results for 2-point discrimination and sharp/dull discrimination, and those for DMCA flaps in the Semes-Weinstein test. CONCLUSIONS: Overall, intrinsic flaps demonstrated low donor site morbidity with reliable coverage of the defects. Of these, the DMCA (especially after primary closure) and homodigital island flaps seemed to produce the best donor site results.

Pharmaceutical Preconditioning With Nitric Oxide Synthase and L-Arginine in Ischemic Tissues.

BACKGROUND: Nitric oxide (NO) is a multifunctional signaling molecule involved in regulating vascular tone and tissue oxygenation. It is also an important cytoprotective agent against ischemia-reperfusion injury (IRI). Enhancing NO bioavailability via exogenous NO synthases (NOSs) and L-arginine promotes conversation to NO, circumventing the problem of nonfunctioning NOSs under hypoxic and acidic conditions. In this study, the authors evaluated the therapeutic efficacy of neuronal, inducible, and endothelial NOS and L-arginine on reperfusion-induced skin flap alterations. METHODS: The vascular pedicle isolated rat skin flap model was used and underwent 3 hours of ischemia. At 30 minutes before ischemia, normal saline, endothelial-, inducible-, and neuronal NOSs (1/2 IU) and L-arginine (100 mg/kg body weight) were administered by means of intravenous infusion. The IRI-induced alterations were measured 5 days after the operation. RESULTS: The 3 isoforms of NOS increased the flap vitality rate (VR) from 10% to 23% compared with the control group. L-Arginine treatment also increased the VR by approximately 15%. The combination of L-arginine with NOS resulted in even higher flap VRs. The best results could be achieved with the combination of endothelial NOS (2 IU) and L-arginine. CONCLUSIONS: Modulation of NO bioavailability via exogenous application of NOSs and L-arginine significantly improved VRs in a skin flap rat model. This pharmacologic preconditioning has the potential to attenuate IRI-induced alterations in skin flaps.

Inducible Nitric Oxide Synthase and L-Arginine Optimizes Nitric Oxide Bioavailability in Ischemic Tissues Under Diabetes Mellitus Type 1.

BACKGROUND: The mechanisms influencing the balance of nitric oxide (NO) bioavailability in tissues are negatively affected under diabetic and also under ischemic conditions. Free tissue transplantation for diabetic patients has to deal with both ischemic and diabetic circumstances, which lead to a significantly decrease in providing NO, thus increasing ischemia-reperfusion injury. In previous studies, we could prove that enhancing NO bioavailability leads to attenuated ischemia-reperfusion injury macrocirculatory and microcirculatory alterations in healthy and also in diabetes type 2 rats. This study is evaluating the role of inducible nitric oxide synthase in different dosages and L-arginine under diabetes type 1 conditions. METHODS: Diabetic type 1 conditions were established via streptozotocin over a period of 4 weeks and verified via blood sugar, insulin, and C-peptide levels. Vascular pedicle isolated rat skin flap model that underwent 3 hours of ischemia was used. At 30 minutes before ischemia, normal saline, inducible nitric oxide synthase (NOS) (1/2 IE), and L-arginine (50 mg/kg body weight) were administered systemically. Ischemia/reperfusion (I/R)-induced alterations were measured 5 days after the operation. RESULTS: The inducible NOS (iNOS) attenuated I/R-induced alterations under diabetic type 1 conditions significantly with vitality rates of 16.1% compared with control group (5.5%). Best results could be achieved with the combination of iNOS (1 IE) and L-arginine displaying vitality rates of 43%. Increased dosage of inducible nitric oxide (2 IE) led to decreased vitality rates (22.2%/27.4% without/with L-arginine). CONCLUSIONS: Supporting the mechanisms of NO bioavailability via exogenous application of iNOS and L-arginine significantly attenuated I/R-induced alterations in a skin flap rat model. This pharmacologic preconditioning could be an easy and effective interventional strategy to uphold conversation of L-arginine to NO even on ischemic and type 1 diabetic conditions.

Long-Term Outcome after Successful Lower Extremity Free Flap Salvage.

BACKGROUND: Vascular occlusion after free flap surgery has become a rare complication but still poses a major challenge. It necessitates urgent re-exploration, but the logistic challenge to provide sufficient resources for the emergency intervention remains. The aim of this study was to analyze the long-term outcome after successful lower extremity free flap salvage. METHODS: A single-center retrospective study including long-term follow-up was approved by the local ethics committee. From January 1999 to December 2010, a total of 581 free flaps were performed for lower extremity reconstruction. Eighty-six flaps required emergency re-exploration, of which 65 could be salvaged. Fifteen salvaged flaps were excluded from the study because of secondary amputation. Of 50 patients, 29 (6 females and 23 males) were eligible for follow-up. The mean follow-up time was 54.5 ± 32.9 months. Health-related quality of life (Short Form 36 [SF-36]) and scar quality (Vancouver Scar Scale [VSS]) were analyzed. RESULTS: The overall flap survival rate was 94.7% and the total loss rate was 5.3%. The re-exploration rate was 14.8% (86 of 581 flaps). The salvage rate was 75.6% (65 of 86 flaps). Twenty-one free flaps were totally lost (24.4%). Partial flap loss occurred in 12 cases (14.0%); 67.5% of the vascular complications occurred during the first 24 hours, 20.9% between 24 and 72 hours, and 11.6% after more than 72 hours. The mean time from the first signs of impaired flap perfusion to re-exploration was 1.3 ± 0.4 hours, and from free tissue transfer to re-exploration was 16.2 ± 1.9 hours. The overall scar appearance was good with an average VSS score of 4.0 points. The average SF-36 physical component score was 54.4 ± 5.4 and the mental component score was 63.1 ± 10.7. CONCLUSION: Careful monitoring and the opportunity for urgent re-exploration are the key to success for free flaps salvage. Following these principles, an acceptable long-term outcome can be achieved.

Enhancing Nitric Oxide Bioavailability via Exogen Nitric Oxide Synthase and L-Arginine Attenuates Ischemia-Reperfusion-Induced Microcirculatory Alterations.

BACKGROUND: Nitric oxide (NO) is an important cytoprotective agent against ischemia and reperfusion injury (IRI). Enhancing NO bioavailability via exogen NO synthases (NOSs) and L-arginine promotes conversation to NO, circumventing the problem of nonfunctioning NOSs under hypoxic and acidic conditions. In this study, the authors evaluated the therapeutic efficacy of endothelial, inducible and neuronal NOS, and L-arginine on reperfusion-induced microcirculatory alterations and hemodynamic adverse effects in the microvasculature of skeletal muscle. METHODS: Vascular pedicle isolated rat cremaster model was used that underwent 2 hours of warm ischemia followed by 1 hour of reperfusion. At 30 minutes before ischemia, normal saline (control group with/without ischemia), endothelial-, inducible-, and neuronal NOSs (2 IE) and L-arginine (50 mg/kg BW) were administered systemically (IV). Ischemia-reperfusion-induced microcirculatory alterations were measured after 1 hour of reperfusion. Mean arterial blood pressure and heart frequency were measured throughout the experiment to determine hemodynamic adverse effects. RESULTS: The isoforms of NOSs and L-arginine attenuated ischemia-reperfusion-induced vasoconstriction, improved red blood cell velocity, capillary flow, and leukocyte adherence to the endothelium wall. Hemodynamics was stable throughout the experiment. CONCLUSIONS: Enhancing NO bioavailability via exogen application of NOSs and L-arginine significantly attenuated ischemia-reperfusion-induced microcirculatory alterations in the microvasculature of skeletal muscle. Significant hemodynamic adverse effects were not present, thus demonstrating this approach might be useful for therapeutic intervention. This "pharmacologic preconditioning" could be an easy and effective interventional strategy to uphold conversation of L-arginine to NO under ischemic conditions.

Fingertip and Thumb Tip Wounds: Changing Algorithms for Sensation, Aesthetics, and Function.

Management of fingertip and thumb tip injuries has recently undergone substantial changes. The time-proven traditional armamentarium of local flaps has been expanded and replaced by a wide variety of flaps. Simultaneous with the development of new flaps, the conservative treatment of fingertip and thumb tip injuries with semiocclusive dressings has also become a more acceptable treatment for these injuries. The excellent results with respect to restoring contour, sensibility of the pulp, and aesthetics of the finger justify this more tedious and time-consuming treatment of fingertip and thumb tip injuries. This article gives an update of the most commonly used flaps and the semiocclusive dressing treatments of fingertip and thumb tip injuries.

ADSCs in a fibrin matrix enhance nerve regeneration after epineural suturing in a rat model.

BACKGROUND: Due to their unique properties, adipose derived stem cells (ADSCs) obtain promising potential to enhance nerve regeneration. The aim of this study was to investigate if fibrin-glue embedded ADSCs were a beneficial adjunct to primary coaptation in a rat sciatic nerve model. MATERIALS AND METHODS: Fifty male Lewis rats underwent sciatic nerve transection and subsequent epineural suture repair. The treatment group received ADSCs re-suspended in fibrin glue, while the control group received fibrin glue only. After 7, 21, 35, and 63 days, analysis involved axon count, myelin sheath thickness as well as N- and G-ratios. Additionally, muscle weight quotient (operated vs. non-operated site of the same animal) was calculated and compared between treatment and control groups. For co-detection of vital ADSCs, vessel walls, and Schwann cells, immunolabeling was performed with CM-DiI, SMA, and S-100 antibodies, respectively. RESULTS: ADSCs led to a significant increase of myelinization at day 21 (0.508 ± 0.085 µm vs. 0.381 ± 0.044 µm, P = 0.025) and day 35 (0.872 ± 0.09 µm vs. 0.495 ± 0.078 µm; P = 0.01) after surgery. Axon count was significantly increased at day 21 (420 ± 119 vs. 129 ± 63; P = 0.003) and day 63 (284 ± 137 vs. 111 ± 26; P = 0.046) after surgery. N- and G-ratios were significantly different compared with control indicating enhanced nerve regeneration due to ADSC treatment at each time point (P < 0.05). Muscle weight quotient was significantly higher in the treatment group compared with the control at day 21 (44.01% ± 6.16% vs. 35.03% ± 2.61%; P = 0.014) and day 63 (65.49% ± 2.81% vs. 58.79% ± 4.06%; P = 0.009) after surgery. Co-detection of immunolabeled cells showed vital ADSCs at the neuronal repair site and in close proximity to intraneuronal vessels indicating active participation of ADSCs in the process of nerve regeneration and associated angiogenesis. CONCLUSION: ADSCs embedded in a fibrin matrix can significantly enhance regeneration of peripheral nerve injuries after primary coaptation. © 2015 Wiley Periodicals, Inc. Microsurgery 36:491-500, 2016.

Management of thumb tip injuries.

The management of thumb tip injuries has undergone great changes in recent years. The traditional armamentarium of flaps has been expanded and replaced by a wide variety of flaps with more versatility and less donor side morbidity. Parallel to the development of new flaps, the conservative treatment of thumb tip injuries with semi-occlusive dressing has gained ground in the treatment of these injuries. Although tedious and time-consuming, and requiring intensive communication with the patient to explain the look and occasionally fetid smell of the wound, this technique yields excellent results with respect to restoring contour and sensibility in pulp injuries. The article gives an update on the current options for treating thumb tip injuries including the most commonly applied flaps.

Impact of Timing of Admission and Microvascular Reconstruction on Free Flap Success Rates in Traumatic Upper Extremity Defects.

BACKGROUND: Despite a growing body of knowledge, the timing of microsurgical reconstruction for the upper extremity remains a controversial topic. Most of the available literature deals with lower extremity reconstruction and the few reports on microsurgical reconstruction of the upper extremity are mostly concerned with infection rates and rarely consider thrombosis and changes in coagulation parameters. METHODS: We performed a retrospective review of all free flaps performed for upper extremity reconstruction at our institution from 2000 to 2010. Only acute, isolated traumatic defects of the upper extremity requiring a free flap for reconstruction were included in this study. A review of medical records was performed to assess, among others, comorbidities, timing of reconstruction, and platelet levels. RESULTS: A total of 41 patients were included in this study, 70% of whom were male. Mean age at the time of surgery was 40.8 ± 15.4 years. Patients who were directly referred to our hospital underwent reconstruction significantly faster than those who were transferred secondarily (p = 0.0001). The number of surgical revisions as well as the flap loss rate was higher in patients undergoing reconstruction more than 1 week after trauma (p = 0.09 and 0.033, respectively). A significantly higher platelet count was seen in the patients undergoing delayed reconstruction (p = 0.002). CONCLUSION: In our study, early microsurgical reconstruction of the upper extremity yielded better results in terms of lower rates of surgical revisions and flap loss. This might be partly because of a trauma-induced thrombocythemia, with a maximum level of platelets in the 2nd week post trauma. We, therefore, advocate a timely coverage of these defects along with an anticoagulatory regimen including some form of platelet inhibition.

Quality of life and predictors of long-term outcome after severe burn injury.

The aim of this study was to identify the long-term quality of life after severe burn injury. In a prospective longitudinal design, N = 265 burn patients were examined 6, 12, 24, and 36 months after burn injury. A multilevel approach was used to measure stability and change in self-reported health status. Besides injury-related variables, self-report instruments included measures of quality of life, psychological distress, personality, and specific burn outcome measures. Fitting of unconditional growth models indicated that there was significant intra- and inter-individual variation in self-reported physical and mental health short form-12. Over the course of 3 years, participants reported on average a slight improvement of physical quality of life. Physical health was mainly predicted by mobility and level of burn severity. Variance in mental health status was mainly predicted by gender, mobility, neuroticism, level of depression and posttraumatic stress disorder (PTSD)-related avoidance. Thus mobility (i.e., simple abilities) seems a crucial variable for overall quality of life. An early identification and treatment of patients with high levels of depression and PTSD-related avoidance may contribute to better mental health.

Surgical treatment of primary gynecomastia in children and adolescents.

PURPOSE: Idiopathic gynecomastia is a common diagnosis in children and adolescents. Though medical treatments reveal potentially harmful side effects, surgical interventions are performable in numerous techniques. In children and adolescents, only minimal evidence exists. This retrospective study presents our experiences with two common surgical techniques, namely subcutaneous mastectomy and combination with liposuction. PATIENTS AND METHODS: This retrospective study included all patients <18 years who underwent surgery due to idiopathic gynecomastia. Height, weight and grade of gynecomastia according to Simon's classification before surgery were reviewed in all patients' files. Additionally, duration of surgery, inpatient stay and postoperative complications were documented. Follow-up examinations were performed with assessment of scar formation, numbness and retraction of the nipple region. Furthermore, patients were asked to report on general satisfaction with surgery (satisfactory/not satisfactory) and esthetic outcome on a numeric scale (1 = good, 6 = bad). RESULTS: 37 patients underwent surgery for verified idiopathic gynecomastia. Grade of gynecomastia was I° in 13.5% (n = 5), II° in 40.5% (n = 15) and III° in 46% (n = 17) of cases. Subcutaneous mastectomy was applied in 11 patients (group I, 30%) and both subcutaneous mastectomy and liposuction in 26 patients (group II, 70.3%). Postoperative complications occurred in two patients. Long-term follow-up was performed in 32 patients after a median of 34 months (range 6-96 months). Hypertrophic scar formation was seen in one patient (3%) and nipple retraction in two patients (5%). Recurrence of gynecomastia occurred in two patients (5%). Patient rating was satisfactory in 9% of cases and esthetic outcome was received with a median of 2.0 (1-5). In comparing both surgical techniques, combination of mastectomy and liposuction revealed better results in every measure except for surgical duration (median 73 vs. 90 min). CONCLUSION: Surgical correction of gynecomastia remains a purely elective intervention. In contrast to adults, skin in children and adolescents provides high retractability. Therefore, open reduction combined with minimally invasive liposuction was proven useful.

Pulsed acoustic cellular expression (PACE) reduces capsule formation around silicone implants.

UNLABELLED: Capsular contracture remains a major complication after reconstructive or aesthetic breast augmentation. Formation of capsular fibrosis is a multifactorial process. An initial inflammatory reaction appears to be key to the development of capsular contracture. Recent studies have shown that pulsed acoustic cellular expression (PACE) has significant antiinflammatory effects. Thus, this study aimed to determine the potential of PACE to prevent or attenuate capsular contracture around silicone implants in a rodent model. For this study, 36 Lewis rats were divided into two groups, and a textured silicone implant was placed in a dorsal submuscular pocket. One group received PACE treatment, whereas the other group served as the control group and received no treatment. Follow-up evaluations were performed after 10, 35, and 100 days. Capsule thickness, collagen density, myofibroblasts, vascular density, and a semiquantitative real-time polymerase chain reaction that addressed differential gene expression were assessed. The PACE treatment significantly reduced capsule thickness on days 10, 35, and 100 compared with the control group (day 10: 632.9 ± 164.5 vs 932.6 ± 160.8, p < 0.05; day 35: 709.5 ± 175 vs 825.9 ± 313.3, p < 0.0.5; day 100: 736.3 ± 198.1 vs 1,062.3 ± 151.9, p < 0.05). This was accompanied by a significant suppression of proinflammatory genes (cluster of differentiation 68, monocyte chemotactic protein-1, CCL4) and synergistic alterations of pro- and antifibrotic proteins (transforming growth factor-beta 1, matrix metalloproteinase-2). This study showed that the PACE application significantly reduces capsular contracture around silicone implants. A decrease in capsular thickness after PACE treatment seems to be associated with a downregulation of proinflammatory genes and proteins. The study identifies PACE technology as a potential low-cost technique that is easy to use for reduction of capsular contracture after augmentation using silicone implants. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Free Flap Reconstruction of Sternal Defects after Cardiac Surgery: An Algorithmic Approach for Dealing with Sparse Recipient Vessels.

Background: Sparsity of recipient vessels poses a challenge for microsurgical free flap reconstruction of sternal defects following deep sternal wound infection after cardiac surgery. Methods: From January 2013, a standardized algorithm for dealing with sparse recipient vessels was strictly followed. In this retrospective study including 75 patients, we compared operative details, surgical complications, and reconstructive outcomes of patients treated according to this algorithm (group A: January 2013-May 2021; n = 46) with a historical control group (group B: January 2000-December 2012, n = 29). Results: The left internal mammary artery had been harvested for arterial bypass grafting in 40 of 46 cases (87%) in group A and in all cases in group B. The right internal mammary artery (RIMA) and right internal mammary vein (RIMV) were the first choice as recipient vessels. In case of unsuitability of the RIMV, a right cephalic vein (CV) turndown was used for venous outflow. If both RIMA and RIMV proved insufficient, a single-stage arterio-venous loop (AVL) between the CV and subclavian artery (CV-SA AVL), CV and thoracoacromial artery (CV-TA AVL), or subclavian artery and subclavian vein (SA-SV AVL) was established. The algorithmic approach significantly reduced partial flap necrosis [group A: n = 3 (7%) versus group b: n = 7 (24%); P = 0.04], and overall operation time [group A: 360 ±â€…88 min versus group B: 415 ±â€…80 min; P = 0.01]. Conclusions: Standardized approaches improve clinical outcomes in microsurgical free flap sternal reconstruction after cardiac surgery.

Bed isolation in experimental flap studies in rats: a dispensable procedure.

Review of the literature regarding rodent experimental flap models reveals fundamental differences in applied surgical procedures. Although some authors isolate the flap from its wound bed, others do not. This study was planned to investigate to what extent the insertion of a silicone sheet affects physiological wound healing in experimental flap surgery. An extended epigastric adipocutaneous flap (6 × 10 cm) was raised in 16 male Lewis rats. In the control group (group C), flaps were immediately inset without any intervention. In the experimental group (group M), a silicone sheet barrier was placed between the flap and the wound bed. Mean flap survival area and flap perfusion were evaluated. Microvessel density was visualized by immunohistochemistry, and semiquantitative real-time polymerase chain reaction addressed differential gene expression. All animals were investigated on postoperative day 5. Flap survival area and flap perfusion were found to be similar. Immunohistochemistry, however, demonstrated a significantly increased number of CD31-positive small vessels in group C. The insertion of the silicone sheet barrier (group M) was accompanied by a significantly enhanced expression of proinflammatory genes and a suppression of proangiogenic genes. Our results show that although the silicone membrane has no influence on the surgical outcome in terms of flap survival and perfusion, it does lead to significant molecular alterations in pathways involved in physiological wound healing. These alterations are artificially induced by the foreign body material and conceal the true driving forces of the healing process. As the latter might include relevant therapeutic targets to ameliorate surgical results, we regard wound bed isolation as a dispensable procedure in the study of rodent flap models.

Free tissue transfer in patients with severe peripheral arterial disease: functional outcome in reconstruction of chronic lower extremity defects.

Chronic wounds of the lower extremity are difficult to treat, especially in patients with peripheral arterial disease (PAD). This patient population frequently suffers from multiple comorbidities, which further impairs wound healing. Local flaps are often not available, or are insufficient to cover these defects, and limbs are frequently amputated, although they could possibly be salvaged by free tissue transplantation. Although there is a growing evidence that free tissue transfer may be feasible in these patients with otherwise doomed extremities, previous studies have mostly focused on short-term flap survival, but not long-term ambulatory status and independence. Therefore, we investigated the long-term results of limb salvage, ambulatory status, and social independence in patients with PAD who underwent free tissue transfer for chronic wounds of the lower extremities.In this study we retrospectively reviewed 38 patients who underwent free tissue transfer because of nontraumatic, chronic wounds of the lower extremities at our institution. All patients suffered from a nontraumatic occlusion of at least one major lower leg artery verified by angiography. After a mean time period of 34 months we assessed flap survival and limb preservation as well as pre- and postoperative ambulatory status and social independence. A subgroup of 14 patients with a "single-vessel-leg" was evaluated separately.It was observed that anterolateral thigh and latissimus dorsi musculocutaneous flaps were most often used to cover the defects. Overall 29 out of the 38 flaps healed completely (9 flap failures) and 34 extremities were salvaged, including 12 out of 14 single-vessel-legs. One patient had to be amputated despite a vital free flap because of persistent calcaneal osteomyelitis. After failure of free tissue transfer, six extremities could still be salvaged by secondary procedures (two secondary free flaps, two local flaps, and two skin grafts). Total 22 out of 34 patients with salvaged limbs maintained or improved their ambulatory status. In the amputee group, two patients remained on their preoperative level of mobility, while two declined. All patients with amputated limbs required assistance in activities of daily living while this was only true for 4 out of the 34 remaining patients.It was concluded that free tissue transfer is a valid option for salvaging lower extremities in patients with PAD. Long-term limb salvage can be achieved in a high percentage of cases, which allows the patients to ambulate freely and remain socially independent.

Locally applied vascular endothelial growth factor A increases the osteogenic healing capacity of human adipose-derived stem cells by promoting osteogenic and endothelial differentiation.

Human adipose-derived stem cells (hASCs) are known for their capability to promote bone healing when applied to bone defects. For bone tissue regeneration, both sufficient angiogenesis and osteogenesis is desirable. Vascular endothelial growth factor A (VEGFA) has the potential to promote differentiation of common progenitor cells to both lineages. To test this hypothesis, the effects of VEGFA on hASCs during osteogenic differentiation were tested in vitro. In addition, hASCs were seeded in murine critical-sized calvarial defects locally treated with VEGFA. Our results suggest that VEGFA improves osteogenic differentiation in vitro as indicated by alkaline phosphatase activity, alizarin red staining, and quantitative real-time polymerase chain reaction analysis. Moreover, local application of VEGFA to hASCs significantly improved healing of critical-sized calvarial defects in vivo. This repair was accompanied by a striking enhancement of angiogenesis. Both paracrine and, to a lesser degree, cell-autonomous effects of VEGFA-treated hASCs were accountable for angiogenesis. These data were confirmed by using CD31(-) /CD45(-) mouse ASCs(GFP+) cells. In summary, we demonstrated that VEGFA increased osteogenic differentiation of hASCS in vitro and in vivo, which was accompanied by an enhancement of angiogenesis. Additionally, we showed that during bone regeneration, the increase in angiogenesis of hASCs on treatment with VEGFA was attributable to both paracrine and cell-autonomous effects. Thus, locally applied VEGFA might prove to be a valuable growth factor that can mediate both osteogenesis and angiogenesis of multipotent hASCs in the context of bone regeneration.

Zur medizinischen Indikation bei ästhetisch-plastischen Operationen.

The concept of indication is used in many ways in medicine and in the healthcare industry. In connection with "medical" and/or "physician-based", it is often used to describe the path that a doctor and a patient take - after weighing up all available information - to describe a common treatment goal and to define measures derived from that goal. From today's perspective, however, there is a third factor that plays a role: the healthcare industry, here in particular in the form of health insurance (both statutory health insurance and private health insurance), but more recently also in the form of financial administration. Plastic surgery is faced with the dilemma that, although there is a medically proven indication in many cases, neither the payers nor the financial courts or offices are willing to follow the medical assessment and reject the indication (usually without justification). This article offers support in defining an indication for aesthetic plastic surgery.