Early postoperative infection in patient with IgM deficiency.

Selective IgM deficiency is a rare immunological disorder, with patients presenting with recurrent infections and allergic manifestations. However, the association with early postoperative infection has not been widely reported in the literature. We describe a rare case of a patient who had an early wound infection 1 day after excision of a Merkel cell carcinoma from his right buttock and was later found to have decreased IgM levels. Selective IgM deficiency should therefore be considered in patients presenting with recurrent infections or in patients who have previously undergone surgery and subsequently developed early infection postoperatively. In this subset of patients, extra precautions may need to be taken pre- and postoperatively to reduce the risk of developing a postoperative infection.

The Effect on Venous Congestion of Diverting Arterial Flow in the Arterialized Venous Flap.

An arterialized venous flap is a cutaneous flap based solely on subcutaneous veins. The flap is perfused by nonphysiologic flow of blood from the vein into the peripheral tissue. This nonphysiologic perfusion limits the indications for an arterialized venous flap, and its postoperative complications make it an unpopular choice for reconstruction. When venous flaps are designed following the direction of venous valves (antegrade) in a flow-through fashion, the blood may bypass the peripheral tissue without perfusing the flap. A higher pressure within the efferent end of the vein impedes venous return from the peripheral tissue into this draining vein. Thus, venous congestion of the arterialized venous flap becomes inevitable. We describe our approach to designing an arterialized venous flap in which direct arteriovenous shunting is largely eliminated, thereby transmitting a higher pressure in the periphery of the flap while maintaining a physiologic venous pressure in the efferent vein. This restriction of shunting can be accomplished in a number of ways, depending on the venous pattern within the flap.

Human Wharton's Jelly Mesenchymal Stem Cell-Mediated Sciatic Nerve Recovery Is Associated with the Upregulation of Regulatory T Cells.

The acceleration of peripheral nerve regeneration is crucial for functional nerve recovery. Our previous study demonstrated that human Wharton's jelly-derived mesenchymal stem cells (hWJ-MSC) promote sciatic nerve recovery and regeneration via the direct upregulation and release of neurotrophic factors. However, the immunomodulatory role of hWJ-MSC in sciatic nerve recovery remains unclear. The effects of hWJ-MSC on innate immunity, represented by macrophages, natural killer cells, and dendritic cells, as well as on adaptive immunity, represented by CD4+ T, CD8+ T, B, and regulatory T cells (Tregs), were examined using flow cytometry. Interestingly, a significantly increased level of Tregs was detected in blood, lymph nodes (LNs), and nerve-infiltrating cells on POD7, 15, 21, and 35. Anti-inflammatory cytokines, such as IL-4 and IL-10, were significantly upregulated in the LNs and nerves of hWJ-MSC-treated mice. Treg depletion neutralized the improved effects of hWJ-MSC on sciatic nerve recovery. In contrast, Treg administration promoted the functional recovery of five-toe spread and gait stance. hWJ-MSC also expressed high levels of the anti-inflammatory cytokines TGF-ß and IL-35. This study indicated that hWJ-MSC induce Treg development to modulate the balance between pro- and anti-inflammation at the injured sciatic nerve by secreting higher levels of anti-inflammatory cytokines.

Technical refinements of the free medial sural artery perforator (MSAP) flap in reconstruction of multifaceted ankle soft tissue defects.

BACKGROUND: Peri-ankle defects are difficult to reconstruct due to sharp contours, thin skin, aesthetic value, function and footwear impact. The medial sural artery perforator flap (MSAP) is increasing in popularity as a thin and pliable flap. This study aims to demonstrate its versatility in reconstructing defects around the ankle area and our approach to insetting these flaps in difficult areas around the ankle without the need for subsequent flap revisions. METHODS: A retrospective review of the senior author's series of peri-ankle reconstructions using the MSAP flap was undertaken. RESULTS: Between 2011-2015, 15 patients underwent peri-ankle reconstruction with the MSAP flap. There were 4 dorsal foot, 4 medial malleolar, 4 lateral malleolar, and 3 tendo-achilles defects. All flaps in this series survived. There was one episode of partial flap necrosis in one patient and no incidences of donor site dehiscence. All patients returned to full ambulation and none required subsequent flap revision. CONCLUSIONS: The MSAP flap offers the benefits of a fasciocutaneous flap, whilst providing a thin, pliable, single stage and robust reconstruction for peri-ankle defects, with a cosmetically ideal donor site.

Application of Concatenated Arterialized Venous Flaps in Finger Reconstruction.

Venous flaps from the distal volar forearm are said to be suitable flaps for finger reconstruction. The pliability of the forearm venous flap makes it easy to follow the curvature of the finger contour. The thickness of the flap makes it appropriate as a flap for finger resurfacing. Following the venous network at the palmar forearm, diverse patterns of the venous flaps can be designed. This article describes the use of a 2-concatenated paddle, flow-through arterialized venous flap design for simultaneous resurfacing of 2 separate defects on a single digit. A technique that can be used to reduce postoperative venous congestion will be highlighted in this article.

Venous Congestion in Pedicled Frontal Branch Superficial Temporal Artery Flaps Reconstructions for Head and Neck Defects: A Review.

The superficial temporal artery (STA) flap is a versatile flap for head and neck defect reconstruction. It can be based on the frontal branch of the STA and an islanded 360-degree rotation arc for various defects on the scalp, cheek, and auricular region. It provides a nonmicrosurgical option for reconstructing such defects, which is itself relatively easy to perform. However, venous congestion is a problem than often can cause worry to the clinician and hence preclude its use. In this review, we revisit this flap in head and neck reconstruction, with case examples used for reconstruction of defects on the scalp, maxilla, lip, ear, and retroauricular area. The STA flap in our review can be used either as a fasciocutaneous flap or with its fascia alone. The main issue with the STA flap is that it is generally a high-inflow flap with variable outflow. Venous congestion is frequently encountered in our practice, and adequate management of the venous drainage in the postoperative period is crucial in ensuring its success as a versatile and viable option for head and neck reconstruction.

Sensation-Sparing Correction of Inverted Nipples Using the 'Drawbridge' Flap Approach.

INTRODUCTION: An inverted nipple can cause significant functional and psychologic disturbance to women. The holy grail of any surgical technique to correct this is to restore adequate nipple projection and at the same time, try to preserve lactation and nipple sensation. We describe our experience using an inferior dermal nipple-areolar interposition flap to correct the inverted nipple alongside with selective release of the lactiferous ducts of the nipple. MATERIALS AND METHODS: We have employed this technique successfully in 97 cases of inverted nipples in 60 patients with follow-up periods of up to 2 years. Twenty-three of them had unilateral inversion, and 37 of them had bilateral nipple inversion. RESULTS: The appearance of the nipple was good to excellent. Seventy to 80% of the initial postoperative nipple projection at the end of 1 year was maintained. Postoperative complications included stitch abscess in one patient (n = 1) and an epidermal cyst in another (n = 1). Nipple sensation was preserved in 100% of cases. There was no recurrence of inversion in any of the nipples. DISCUSSION: By identifying the root cause of inverted nipples in each individual case, and selectively targeting them, we minimize surgical morbidity with a simple technique that avoids any form of traction or compression of the nipple and minimizes the risk of altered nipple sensation. 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 .

Anterolateral Thigh Flap Combined with Reconstruction Plate Versus Double Free Flaps for Composite Mandibular Reconstruction: A Propensity Score-Matched Study.

OBJECTIVE: This study was designed to examine the comparative effectiveness of oromandibular defect reconstruction via anterolateral thigh flap and bridging plate (ALT only) versus simultaneous soft tissue and vascularized bone flap (DFF), with regards to long-term plate exposure and complications. METHODS: A propensity score-matched analysis of patients with an oncologic head and neck defect who underwent microvascular reconstruction was performed. Two surgical groups, i.e., ALT only and DFF, were created. Incidence and subsequent management strategies for postoperative plate exposure were evaluated along with complications, overall survival, and postoperative quality of life (QoL). RESULTS: Sixty-two patients were 1:1 propensity matched (31 per group). The DFF group had a significantly larger soft tissue and bone defect than the single-flap group. The 5-year probability of not having a plate exposure was 45.5 and 47.4% for the double-flaps and single-flap groups, respectively (p = 0.186). The ALT-only group had a significantly higher rate of wound infections (38.7% vs. 12.9%, p = 0.02). The incidence of flap loss, reexploration, inpatient mortality, plate fracture, medical complications, and overall survival were not significantly different. Although mean score for pain was significantly worse in the ALT-only group (75.2 vs. 88.5, p < 0.001), the remainder of our QoL assessments (cosmesis, swallow, employment, and speech) were comparable. CONCLUSIONS: The utilization of an ALT with plate strategy is associated with competitive rates of plate exposure and overall survival relative to DFF but higher wound infections and long-term pain. These results have considerable salience for patient-counseling regarding expectations for functional and clinical outcomes.

Animal models in plastic and reconstructive surgery simulation-a review.

BACKGROUND: The use of live and cadaveric animal models in surgical training is well established as a means of teaching and improving surgical skill in a controlled setting. We aim to review, evaluate, and summarize the models published in the literature that are applicable to Plastic Surgery training. MATERIALS AND METHODS: A PubMed search for keywords relating to animal models in Plastic Surgery and the associated procedures was conducted. Animal models that had cross over between specialties such as microsurgery with Neurosurgery and pinnaplasty with ear, nose, and throat surgery were included as they were deemed to be relevant to our training curriculum. A level of evidence and recommendation assessment was then given to each surgical model. RESULTS: Our review found animal models applicable to plastic surgery training in four major categories namely-microsurgery training, flap raising, facial surgery, and hand surgery. Twenty-four separate articles described various methods of practicing microsurgical techniques on different types of animals. Fourteen different articles each described various methods of conducting flap-based procedures which consisted of either local or perforator flap dissection. Eight articles described different models for practicing hand surgery techniques. Finally, eight articles described animal models that were used for head and neck procedures. CONCLUSIONS: A comprehensive summary of animal models related to plastic surgery training has been compiled. Cadaveric animal models provide a readily available introduction to many procedures and ought to be used instead of live models when feasible.

A challenging case of calcific myonecrosis of tibialis anterior and hallucis longus muscles with a chronic discharging wound.

The occurrence of calcific myonecrosis of the anterior compartment of the leg is rare. Common risk factors include a history of trauma, although little is known about the exact pathophysiology, latency period or triggering factors resulting in disease progression. Macroscopically, it begins with a single muscle being replaced by a fusiform calcified mass, which progresses peripherally. We present a rare case of a 7-year history of chronic discharging sinus overlying the site with protruding calcified muscle and discuss the senior author's wound management strategy and surgical considerations. The initial approach used dressing applications to reduce wound exudate while obtaining repeated imaging for disease progression comparison. Repeated CT scans showed significant disease progression from a single solitary amorphous soft tissue calcification to disseminated scattered calcified myonecrosis. In planning such surgeries, extensive debridement and temporary wound coverage is the first stage. Subsequent definitive coverage includes skin grafting of the remaining defect.

Serial abdominal closure with Gore-tex mesh and Rives-Stoppa for an open abdomen secondary to intra-abdominal hypertension in burns.

Intra-abdominal hypertension (IAH) leading to abdominal compartment syndrome (ACS) commonly occurs in major burns. To relieve the excess pressure, decompressive laparotomy is done which can lead to an open abdomen. Closure of the abdomen after a decompressive laparotomy is very difficult with bowel oedema. We describe our technique of closing the open abdomen in such situations with a combination of serial abdominal wall closure with a layered mesh and the Rives-Stoppa component separation technique.

The 5th world symposium for lymphedema surgery-Recent updates in lymphedema surgery and setting up of a global knowledge exchange platform.

The successful completion of the 5th World Symposium for Lymphedema Surgery (WSLS) marks another milestone in the development and advancement of the management of lymphedema. We present our experience in organizing such a scientific lymphedema conference as well as a summary of seven variable live surgeries used for treating lymphedema. An update of current knowledge and determination of future direction in the treatment of lymphedema was made possible via WSLS 2016. J. Surg. Oncol. 2017;115:6-12. © 2016 Wiley Periodicals, Inc.

An improved dual approach to post bariatric contouring - Staged liposuction and modified medial thigh lift: A case series.

OBJECTIVE: Following massive weight loss (MWL) medial contouring of the thigh is frequently requested to improve appearance and function. Thigh lifting can be associated with significant complications. We present a case series of post bariatric patients undergoing thigh lift using staged the liposuction, a modified T incision and a buried de-epithelialised dermal flap. MATERIALS AND METHODS: From January to December 2012, 21 consecutive patients underwent a modified medial thigh lift. A retrospective review of the case notes was performed to assess complications that occurred. RESULTS: There were no major post-operative complications in terms of reoperation, hematoma, thromboembolism and no seromas. Seven patients, all of which were smokers had minor superficial wound healing complications. Aesthetic outcomes were satisfactory for all patients at a minimum follow-up of 6 months. CONCLUSIONS: The modified 'T' incision with staged liposuction is described. We have found the technique to be useful for a variety of different thighs. It is a reproducible method for contouring the medial thigh in MWL patients. In this series, our overall complications were low, and no seromas occurred.

Potential Application of Modified mRNA in Cardiac Regeneration.

Heart failure remains the leading cause of human death worldwide. After a heart attack, the formation of scar tissue due to the massive death of cardiomyocytes leads to heart failure and sudden death in most cases. In addition, the regenerative ability of the adult heart is limited after injury, partly due to cell-cycle arrest in cardiomyocytes. In the current post-COVID-19 era, urgently authorized modified mRNA (modRNA) vaccines have been widely used to prevent severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Therefore, modRNA-based protein replacement may act as an alternative strategy for improving heart disease. It is a safe, effective, transient, low-immunogenic, and integration-free strategy for in vivo protein expression, in addition to recombinant protein and stem-cell regenerative therapies. In this review, we provide a summary of various cardiac factors that have been utilized with the modRNA method to enhance cardiovascular regeneration, cardiomyocyte proliferation, fibrosis inhibition, and apoptosis inhibition. We further discuss other cardiac factors, modRNA delivery methods, and injection methods using the modRNA approach to explore their application potential in heart disease. Factors for promoting cardiomyocyte proliferation such as a cocktail of three genes comprising FoxM1, Id1, and Jnk3-shRNA (FIJs), gp130, and melatonin have potential to be applied in the modRNA approach. We also discuss the current challenges with respect to modRNA-based cardiac regenerative medicine that need to be overcome to apply this approach to heart disease. This review provides a short description for investigators interested in the development of alternative cardiac regenerative medicines using the modRNA platform.

Risk factors for postoperative adverse airway events in patients with primary oral cancer undergoing reconstruction without prophylactic tracheostomy.

OBJECTIVE: To identify risk factors associated with adverse airway events (AAEs) in primary oral cancer patients undergoing tumor ablation followed by free tissue transfer without prophylactic tracheostomy. METHODS: We retrospectively collected primary oral cancer patients who underwent tumor ablation surgery following free-tissue transfer without prophylactic tracheostomy during February 2017 to June 2019 in Chang Gung Memorial Hospital, Linkou Medical Center, Taiwan. 379 patients were included. Data were analysed from 2020 to 2021. Demographics, comorbidities, intraoperative variables and postoperative respiration profile were obtained from the medical record. Main outcome was postoperative AAEs, including requirement of endotracheal intubation after extubation and tracheostomy after prolonged intubation. RESULTS: Of the 379 patients, postoperative AAEs happened in 29 patients (7.6 %). In reintubation group, patients were older with more diabetes mellitus, hypertension and cerebrovascular disease. These patients had lower preoperative hemoglobin, creatinine, and albumin level with more intraoperative blood transfusion. In postoperative respiration profile, rapid shallow breathing index (RSBI) and PaO2/FiO2 (PF) ratio were poorer. On multivariate analysis, patient's age, tumor location, and cross-midline segmental mandibulectomy and a lower PF ratio were independent risk factors for postoperative AAEs. CONCLUSIONS: In head and neck cancer patients that underwent tumor ablation followed by free tissue transfer without prophylactic tracheostomy, patient's age, tumor location, cross-midline segmental mandibulectomy and P/F ratio are associated with postoperative AAEs.

Sustained Release of Tacrolimus Embedded in a Mixed Thermosensitive Hydrogel for Improving Functional Recovery of Injured Peripheral Nerves in Extremities.

Vascularized composite allotransplantation is an emerging strategy for the reconstruction of unique defects such as amputated limbs that cannot be repaired with autologous tissues. In order to ensure the function of transplanted limbs, the functional recovery of the anastomosed peripheral nerves must be confirmed. The immunosuppressive drug, tacrolimus, has been reported to promote nerve recovery in animal models. However, its repeated dosing comes with risks of systemic malignancies and opportunistic infections. Therefore, drug delivery approaches for locally sustained release can be designed to overcome this issue and reduce systemic complications. We developed a mixed thermosensitive hydrogel (poloxamer (PLX)-poly(l-alanine-lysine with Pluronic F-127) for the time-dependent sustained release of tacrolimus in our previous study. In this study, we demonstrated that the hydrogel drug degraded in a sustained manner and locally released tacrolimus in mice over one month without affecting the systemic immunity. The hydrogel drug significantly improved the functional recovery of injured sciatic nerves as assessed using five-toe spread and video gait analysis. Neuroregeneration was validated in hydrogel-drug-treated mice using axonal analysis. The hydrogel drug did not cause adverse effects in the mouse model during long-term follow-up. The local injection of encapsulated-tacrolimus mixed thermosensitive hydrogel accelerated peripheral nerve recovery without systemic adverse effects.