Patient-Reported Outcomes Following Breast Reconstruction With the Transverse Myocutaneous Gracilis Flap Using the BREAST-Q and Lower Extremity Function Scale.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap is a viable and safe option for breast reconstruction in patients with limited abdominal tissue or other contraindications for abdominal-based flaps. Although it is one of the most common flaps employed for breast reconstruction, data on patient-reported outcomes is limited. OBJECTIVES: The authors seek to evaluate patient satisfaction and aesthetic outcome after breast reconstruction with the TMG flap. METHODS: All patients who underwent breast reconstruction with a TMG flap between March 2010 and October 2020 were identified. Invitation to a digital version of the BREAST-Q reconstructive module and the Lower Extremity Function Scale (LEFS) was sent to 105 patients. Patient demographics, complications, and surgical details were collected and retrospectively analyzed. BREAST-Q and LEFS scores were calculated and compared to the literature. RESULTS: Eighty-two patients participated in the study. Median follow-up was 5.9 years, with a mean patient age of 45.7 years. Most patients (90.2%) received treatment due to previous cancer of the breast, and 17.1% underwent immediate reconstruction. The mean score for "Satisfaction with Breast" was 66/100. Postoperative lower extremity function was high, with a median LEFS score of 78/80. A LEFS score below the median value was found to be significantly associated with active smoking (P = .049). Patients also reported high satisfaction with donor sites (8/11). CONCLUSIONS: Patient satisfaction and aesthetic outcome after breast reconstruction with TMG flaps is high and comparable to other common techniques. Lower extremity function is not impaired after flap harvest.

Management of donor-site complications after breast reconstruction with the transverse musculocutaneous gracilis flap: Proposal of a treatment algorithm.

BACKGROUND: The transverse myocutaneous gracilis (TMG) flap is a popular choice for autologous breast reconstruction due to its consistent anatomy and reliability, especially for slim patients. While the incidence of donor-site morbidity is comparable with other free flaps, there is no literature about the management of donor-site complications available. Our study aims to provide an overview of encountered complications, associated risk factors and their management using a standardized algorithmic approach. METHODS: A retrospective review of all patients receiving breast reconstruction with a TMG flap at our institution between September 2010 and May 2021 was performed. Demographic data (age, BMI), comorbidities (diabetes, smoking), complication rates (major, minor) and treatment were evaluated. Medical records were screened for reasons and timing of performed reconstructions. Adapted from the Clavien-Dindo classification system, severity of complication was categorized as either class I-II minor or class IIIa-IIIb major. Data on follow-up procedures was collected. A treatment algorithm for the management of commonly occurring donor-site complications was created, based on our long-running institutional experience. RESULTS: Two-hundred and twenty-five patients (288 flaps) were included in our retrospective analysis. There were 43 (14.9%) minor and 4 (2.7%) major donor-site complications overall. Minor complications included superficial wound breakdown (26/9%), infection (10 cases, 3.5%) and hematoseroma (7 cases, 2.4%). Hematoseroma (2 cases, 0.7%) and severe wound breakdown (2 cases, 0.7%) needing revision surgery were the most common major complications. Patients with lower BMI (mean 22.9 kg/m2 vs. 24.0 kg/m2 ; p = .047) and active tobacco use (14.1% vs. 6.3%; p = .046; Relative risk = 1.71 95% CI 1.02-2.88) had a higher occurrence of donor-site complications. Age and operating time were not associated with higher complication rates. Four patients (1.4%) received donor-site refinement surgery. CONCLUSION: The TMG flap provides a reliable and safe alternative for breast reconstruction and most donor-site complications can be managed conservatively. Our proposed treatment algorithm aids with decision making in the management of donor-site complications.

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

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

Evaluation of Safety and Efficacy of Laser Hair Removal With the Long-Pulsed 755 nm Wavelength Laser: A Two-Center Study With 948 Patients.

BACKGROUND AND OBJECTIVES: Laser hair removal is the most common laser therapy and the third most commonly performed procedure with more than one million treatments in United States in 2016. This retrospective study was conducted to assess long-term efficacy and safety of the 755 nm laser for hair removal. STUDY DESIGN/MATERIALS AND METHODS: Nearly, 3,606 laser treatments were performed with the long-pulsed 755 nm wavelength laser equipped with an epidermal cooling device between 1997 and 2005 and were followed till 2013. Standardized assessments were conducted by two treating physicians and patients at two follow-up intervals. At first follow-up, clearance was assessed by two physicians and clearance and satisfaction by patients. At the second follow-up, patients were assessed if hair clearance sustained compared with the first follow-up. RESULTS: Nine hundred and forty-eight patients with Fitzpatrick skin types I-IV were treated with a total of 3,606 laser treatments in this study. The mean age at the beginning of the study was 35 years (±11), 95.1% of patients were female (n = 902) and 4.9% male (n = 46). Five hundred and seventy-four patients received a minimum of three treatments and an average of 5.31 (3-16) treatments on axilla, back, bikini, breast, abdomen, face, lower extremity, or upper extremity region. First, follow-up was conducted 3.9 (±1.5) years after the final laser treatment. Seventy-four percent of these patients received 75-100% clearance as reported by the physician and 48% clearance as reported by the patient. Fifty-two percent of patients reported slower hair growth and 42% change in hair texture. Ninety percent of patients treated on axilla, 82% treated on the bikini area, and 79% treated on lower extremities experienced 75% or more clearance after three treatments. Facial, as well as breast and abdomen treatments, only showed a 66% and 62%, respectively, after three treatments. For these locations, five and more treatments were needed to achieve a quote of 79% (face) or 80% (breast and abdomen) for a 75-100% clearance. Upper extremity and back treatments did not have enough physician ratings to draw conclusions. Long-term adverse events were minimal and were all located on the face (one patient scar, four patients herpes infection). Second follow-up of 173 patients was conducted after 11.5 years (±2.0) and 87.9% of patients reported that their improvement sustained. CONCLUSIONS: The long-pulsed 755 nm alexandrite laser is a safe and efficacious treatment for the reduction of unwanted body hair with permanent results and high patient satisfaction. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Significant skin-tightening by closure of fractional ablative laser holes.

BACKGROUND AND OBJECTIVE: Ablative fractional laser treatment uses thousands of very small laser beam wounds to damage a fraction of the skin, which stimulates tissue remodeling. Each open micro-wound heals without scarring, but the amount of skin tightening achieved is limited. This animal study was performed to test the hypothesis that immediate temporary closure of fractional laser wounds could increase skin tightening after fractional ablative laser treatment. MATERIALS AND METHODS: Four adult swine were used for the study; 98 square test sites (3 × 3 cm) were tattooed on the abdomen and flanks of each pig. An ablative fractional Erbium:YAG laser (Sciton Profile, Sciton Inc, Palo Alto, CA) was used to treat the test areas. A laser micro-spot fluence of 375 J/cm2 was delivered in 150-250 microseconds pulses, resulting in an array of ablation channels extending 1.5 mm deep into the skin, with a spot size of 250 µm, with 10% treatment density. Immediately following laser exposure the resulting holes were closed using a stretched elastic adhesive dressing, which, when applied, recoiled and compressed the diameter of the ablation holes. The compressive dressings were removed after 7 days. This procedure was compared to removing the same amount of skin (10%) mechanically by specially designed 19 gauge coring needles, as well as to the same laser and coring methods without compression closure. Area and shape of test sites were measured by digital photography before and 28 days after treatment. Data analysis included compensation for animal growth, as measured by increase in the area of the untreated control sites. RESULTS: All treated and control sites healed within a week, without scarring evident at 28 days. Laser treatment combined with compressive wound closure caused significant shrinkage at 28 days compared with untreated control sites. The treated skin area was reduced by 11.5% (P = 0.0001). Needle coring with wound closure produced similar, significant shrinkage (8%, P < 0.0021), whereas laser and needle coring treatment without closure did not result in significant area reduction (P = 0.1289) compared with untreated control sites. CONCLUSION: Significant skin tightening can be achieved by immediate temporary non-invasive wound closure after short pulse Er:YAG fractional ablative laser treatment, as well as after mechanically removing skin with a coring needle. This approach may improve skin tightening after ablative laser treatments. Further clinical studies are necessary to confirm successful application in humans. Lasers Surg. Med. 50:64-69, 2018. © 2017 Wiley Periodicals, Inc.

Micro-fractional, directional skin tightening: A porcine model.

BACKGROUND AND OBJECTIVE: Skin changes are among the most visible signs of aging. Fractional ablative lasers improve skin quality by making small skin wounds that heal rapidly without scarring. While they improve skin texture and discoloration, there is minimal effect on skin laxity. This study was performed to assess skin shrinkage performed by removing multiple small full-thickness skin columns with coring needles combined with wound closure. MATERIALS AND METHODS: In 5 swine 116 squares (3 cm(2) ) were demarcated for treatment and control sites. In treatment sites 10% of the skin was removed by full-thickness skin coring needles (19 gauge) and afterwards closed and compressed with an elastic adhesive dressing. This procedure was compared to puncturing the skin with standard hypodermic needles (without tissue removal) and subsequent closure with compressive dressing. Area and shape of sites were measured before and 28 days after treatment. RESULTS: Test and control sites healed within a week without scarring. Coring with wound closure caused significant shrinkage after 28 days. The treated skin area was reduced by 9% (P < 0.0001) and the direction of shrinkage was influenced by the direction of wound closure. Coring without wound closure and puncturing the skin without tissue removal produced an insignificant 3% decrease in area. CONCLUSION: Significant minimally invasive skin tightening in a preferred direction can be achieved by removing skin with coring needles followed by wound closure. The direction of shrinkage is influenced by the direction of micro-hole closure, irrespective of the skin tension lines. This approach may allow reshaping the skin in a desired direction without scarring.

Redefining the vascular anatomy of the peroneus brevis muscle flap.

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

[Breast implant removal and simultaneous aesthetic optimization : Possibilities, technical considerations and outcome analysis]. / Brustimplantatentfernung und simultane ästhetische Optimierung : Möglichkeiten, technische Überlegungen und Ergebnisanalyse.

BACKGROUND: Breast augmentation is currently the leading aesthetic surgical procedure worldwide. Thus, there is a high prevalence of women with breast implants demanding serious know-how and expertise concerning long-term complication management. Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. The authors of this article have also been confronted more and more with the unspecified complex of symptoms named breast implant disease (BID), also called breast implant illness (BII). The treatment of choice for BID is implant removal. OBJECTIVE: Analysis of problems and solutions regarding implant removal. Specific patient analysis according to patients' breast and body configuration. Technical considerations for surgery and preoperative planning. Evaluation of the authors' techniques. PATIENTS AND METHODS: Evaluation of all patients over a period of 3 years requesting implant removal after esthetic augmentation mammoplasty at the authors' department. All patients were treated according to their specific demands regarding breast shape after implant removal. They either received additional mastopexy, lipofilling or both or simple implant removal without further intervention. Demographic, implant-specific, perioperative and postoperative data have been evaluated for all patients. Additionally, all patients were asked to complete a questionnaire regarding satisfaction and outcome. RESULTS: We observed a trend for more satisfied patients with less invasive procedures (simple implant removal or simultaneous lipofilling vs. explantation and mastopexy ± lipofilling, 1.8 vs. 2.0 or 2.6, p = 0.198). Patients' average scoring was better if they suffered from an implant rupture (1.55 vs. 2.17, p = 0.053). Overall, a high patient satisfaction has been observed for all procedures. CONCLUSION: Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. Exactly these patients, consulting their doctor for those problems and questions seem to profit from implant removal. Simultaneous lipofilling and mastopexy of the breast are good options to nevertheless generate an esthetically pleasing result.

Are Genetics the Predicting Factor for the Success of Migraine Surgery? A Report on Identical Twins.

Migraine affects more than 1 billion people globally, with distinct genetic variations influencing susceptibility. Thereby, genetic variations play a key role in the probability of developing migraine. However, personalized genetic analysis-based treatment options in migraine treatments are limited. Notably, surgical deactivation of extracranial trigger has shown efficacy in the treatment of migraine patients with identifiable trigger points in specific anatomical locations in the head and neck region. We present the first case of monozygotic twin sisters, both experiencing occipital and temporal-triggered migraine headaches with identical history and characteristics and without response to conservative migraine treatments. After surgical intervention, targeting the greater and lesser occipital nerves as well as auriculotemporal nerves, both twin sisters exhibited an over 99% reduction in symptoms without postoperative complications. This case suggests a potential correlation between genetic background, irrespective of environmental factors, and the effectiveness of surgical deactivation of trigger points in migraine management.

Photometric Comparison of Skin Color Match between Abdominal- and Thigh-Based Free Flaps for Breast Reconstruction in Caucasian Patients".

BACKGROUND: With the increasing demand for autologous breast reconstruction, different surgical techniques have emerged to provide patients with the best possible result tailored to their individual needs. The upper thigh provides an alternative tissue resource in patients where abdominal based flaps are not feasible. While surgical outcomes and donor-site morbidity demonstrate favorable results using abdominal as well as thigh based free flaps for autologous breast reconstruction, the differences in skin constitution and color between the two flap donor-sites have not been investigated. METHODS: From our flap data base, 60 patients who underwent unilateral secondary breast reconstruction with free DIEP or TMG flaps where randomly selected from our database. In both cohorts, postoperative pictures were used for photometric color evaluation of the reconstructed breast using the Delta E 2000 score at Time A (1.5 - 3 months), Time B (6 - 8 months) and Time C (12 - 20 months). Standard univariate descriptive statistics and group comparisons were performed. RESULTS: The DIEP flap demonstrated a better skin color match at Time A (p < 0.001), Time B (p = 0.003) and Time C (p = 0.009). Over time, both flaps showed improved Delta E 2000 values, and patient age was only associated with higher Delta E 2000 values in TMG flaps after 1.5 - 3 months (p = 0.021). CONCLUSION: The study provides the first objective analysis of skin color match in secondary autologous breast reconstruction. The DIEP flap reconstruction shows a preferable color match compared to the TMG flap. Both free flaps demonstrate an improved skin color match 12 - 20 months after secondary breast reconstruction.

["Sequential Chimeric Osteocutaneous DCIA-Perforator-SIEA Flap to Reconstruct an Osteocutaneous Defect in the Lower Extremity and the Importance of Preserving the Ascending Branch - A Case Report"]. / "Sequenzieller chimärer Beckenkamm-SIEA-Lappen zur Rekonstruktion eines osteokutanen Defektes des Unterschenkels und die Wichtigkeit zur Schonung des Ramus Ascendens ­ ein Fallbericht".

BACKGROUND: The deep circumflex iliac artery (DCIA) perforator flap is an established method to reconstruct osteocutaneous defects. However, the cutaneous perforators come with a great anatomic variability. To deal with this problem, we used a sequential chimeric osteocutaneous free flap for reconstruction. PATIENTS AND METHODS: A 58-year-old man presented with an open tibial fracture after an avalanche accident resulting in an extended osteocutaneous defect in the lower extremity. The injury required osteocutaneous free flap coverage. We reconstructed the defect with a sequential chimeric osteocutaneous DCIA-perforator-SIEA flap. RESULTS: The preservation of the ascending branch of the deep circumflex iliac vessels offered us the possibility to effectively cover an extended osteocutaneous defect in the lower extremity with a sequential chimeric osteocutaneous DCIA-perforator-SIEA flap. In our patient, the sequential chimeric osteocutaneous DCIA-perforator-SIEA flap healed without complications. A small hernia developed at the inguinal donor site area, but it healed without further complications after surgical treatment. The patient regained an adequate function and returned to daily life and physical exercise. CONCLUSION: While preparing the DCIA-perforator free flap, it is important to preserve the ascending branch of the deep circumflex iliac vessels and the vessels needed to harvest either a SIEA or SCIP flap.

Placebo controlled, prospectively randomized, double-blinded study for the investigation of the effectiveness and safety of the acoustic wave therapy (AWT(®)) for cellulite treatment.

Placebo controlled double-blinded, prospectively randomized clinical trial with 17 patients (11 verum, 5 placebo) for evaluation of cellulite treatment with Acoustic Wave Therapy, (AWT(®)) was performed. The patients were treated once a week for 7 weeks, a total of 8 treatments with the D-ACTOR(®) 200 by Storz Medical AG. Data were collected at baseline, before 8th treatment, at 1 month (follow-up 1) and at 3 months (follow-up 2) after the last treatment with a patients' questionnaire, weight control, measurement of circumference and standardized photography. Treatment progress was further documented using a specially designed 3D imaging system (SkinSCAN(3D), 3D-Shape GmbH) providing an objective measure of cellulite (primary efficacy criteria). Patient's questionnaire in the verum group revealed an improvement in number and depth of dimples, skin firmness and texture, in shape and in reduction of circumference. The overall result (of skin waviness, Sq and Sz, surface and volume of depressions and elevations, Vvv and Vmp) at two follow-up visits indicates a more than medium sized superiority (MW = 0.6706) and is statistically significant (pWei-Lachin = 0.0106). The placebo group revealed no statistical significance. No side effects were seen. This indicates the efficacy and safety of AWT(®) for patients with cellulite.

Risk of perioperative hormonal breast cancer therapy for microvascular flap complications in breast reconstruction.

BACKGROUND: Hormone therapy with selective estrogen modulators (tamoxifen) and aromatase inhibitors is commonly used in the treatment of breast cancer. While the increased risk for thromboembolic events has been known since their early application, the potential risk in microsurgical breast reconstruction is still debated. This study aimed to evaluate the risk for microvascular flap complications in patients with perioperative hormone therapy. METHODS: All patients who underwent microsurgical breast reconstruction with a deep inferior epigastric perforator (DIEP) or transverse myocutaneous gracilis flap at our institution between March 2010 and November 2020 were retrospectively identified in our records. Patients were grouped according to the type and use of perioperative hormone therapy. Flap-related thromboembolic events, flap loss, and revision procedures were compared and analyzed between groups. Risk factors associated with postoperative microsurgical complications were determined. RESULTS: A total of 560 patients (656 flaps) were included in our analysis. One hundred ninety-eight patients (224 flaps) received perioperative hormone therapy (35.4%) and 50 (8.9%) postoperative microsurgical events occurred. Tamoxifen and aromatase inhibitors were not associated with postoperative microsurgical events (p = 0.254), full flap loss (p = 0.702), or partial flap loss (p = 0.916). Patients receiving DIEP flaps had a higher risk for postoperative microsurgical complications (OR 2.36, p = 0.004) and partial flap loss (OR 14.66, p < 0.001). A BMI > 30 was associated with an increased risk for partial flap loss (OR 4.2; p < 0.001) CONCLUSION: This article presents one of the largest single-center datasets for the risks of hormone therapy in microsurgical breast reconstruction. Our results show that perioperative hormone therapy does not increase the risk for microsurgical complications. The findings of our study do challenge the common practice of discontinued hormone therapy before microsurgical breast reconstruction.

Anatomical Analysis of the Lateral Femoral Cutaneous Nerve and Its Passage beneath the Inguinal Ligament.

BACKGROUND: Meralgia paraesthetica is a mononeuropathy of the lateral femoral cutaneous nerve. According to the literature, the nerve travels beneath the inguinal ligament 1.3 to 5.1 cm medial to the anterior superior iliac spine. Compression at this site may cause pain and paresthesia. The aim of this study was to provide more accurate measurements to improve the diagnostic and surgical management of meralgia paraesthetica. METHODS: The lateral femoral cutaneous nerve was dissected bilaterally in 50 Thiel-embalmed human cadavers. Measurements were performed with a standard caliper at the superior and inferior margins of the inguinal ligament. The distance from the inner lamina of the anterior superior iliac spine to the medial margin of the lateral femoral cutaneous nerve was measured. Data were collected and statistical analysis was performed with R. RESULTS: Ninety-three lateral femoral cutaneous nerves of 50 cadavers were dissected. In 6 percent of cadavers, the lateral femoral cutaneous nerve could not be found. The mean distance from the inner lamina of the anterior superior iliac spine to the lateral femoral cutaneous nerve's medial border was 2.1 ± 1.3 cm (range, 0.2 to 6.4 cm; 95 percent CI, 1.8 to 2.4 cm) at the superior margin of the inguinal ligament and 1.9 ± 1.4 cm (range, 0.2 to 3.0 cm; 95 percent CI, 1.6 to 2.2 cm) at the inferior border of the inguinal ligament. CONCLUSION: This anatomical study shows that the majority of the lateral femoral cutaneous nerve passes beneath the inguinal ligament in a very narrow area of 0.6 cm.

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

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

Microsurgical Scalp Replantation: Lessons Learned and Technical Considerations.

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

Lessons Learned from 30 Years of Transverse Myocutaneous Gracilis Flap Breast Reconstruction: Historical Appraisal and Review of the Present Literature and 300 Cases.

BACKGROUND: Happy 30th birthday to the transverse myocutaneous gracilis (TMG) flap. Since 1991 the TMG flap has been used to reconstruct a wide variety of defects and became a workhorse flap and reliable alternative to the deep inferior epigastric perforator (DIEP) flap in many breast reconstruction services worldwide. This manuscript sheds light on the history and success of the TMG flap by critically reviewing the present literature and a series of 300 patients receiving a breast reconstruction. PATIENTS AND METHODS: The present literature and history of the TMG flap was reviewed and a retrospective double center cohort study of 300 free TMG free flaps for autologous breast reconstruction was conducted. Patient demographics, perioperative data, and post-operative complications were recorded and compared with literature findings. RESULTS: Mean flap weight was 320 g. Mean pedicle length was 70 mm. Complications included 19 (6.3%) flap loss. 10 patients (3.3%) had postoperative cellulitis and 28 (9.3%) wound healing disturbance of the donor site. CONCLUSION: Recipient and donor site complications were comparable to other free flaps used for breast reconstruction. A low BMI or the lack of an abdominal based donor site do not represent a limitation for breast reconstruction and can be overcome using the TMG flap.

Age and Overweight Are Not Contraindications for a Breast Reconstruction with a TMG-Flap-A Risk and Complication Analysis of a Retrospective Double Center Study Including 300 Patients.

INTRODUCTION: The transverse myocutaneous gracilis (TMG) flap has become a popular and reliable alternative for autologous breast reconstruction. Initially described as a valuable tissue source for women with low body-mass index, indications nowadays have widely expanded. The Western civilization demographic development with its aging population and the steady growing average BMI has led to increasing breast reconstructions with TMG flaps in overweight and aged individuals. PATIENTS AND METHODS: A total of 300 TMG free flaps for unilateral autologous breast reconstruction were evaluated in the form of a retrospective double center cohort study. Data extraction, study group formation and statistical analysis (One-way analysis of variance (ANOVA), Pearson's chi-squared statistical analysis and relative risk calculation) were done specifically to evaluate age and BMI as risk factors for postoperative complications and outcome. RESULTS: No significant differences in patients' age and BMI in the complication groups compared to the no-complication group could be found. No significant difference regarding the occurrence of complications could be found in any of the formed risk-groups. No significant increase of minor-, major- or overall complications, flap loss or revision surgeries were found in the elderly patient groups or for patients with overweight. CONCLUSION: Age and overweight do not significantly increase the risk for postoperative complications after breast reconstructions with free TMG flaps. The findings of this study support the fact that microsurgical breast reconstruction with a free TMG flap should not solely be reserved for younger patients and females with a lower BMI.

Self-assembly of differentiated progenitor cells facilitates spheroid human skin organoid formation and planar skin regeneration.

Self-assembly of solid organs from single cells would greatly expand applicability of regenerative medicine. Stem/progenitor cells can self-organize into micro-sized organ units, termed organoids, partially modelling tissue function and regeneration. Here we demonstrated 3D self-assembly of adult and induced pluripotent stem cell (iPSC)-derived fibroblasts, keratinocytes and endothelial progenitors into both, planar human skin in vivo and a novel type of spheroid-shaped skin organoids in vitro, under the aegis of human platelet lysate. Methods: Primary endothelial colony forming cells (ECFCs), skin fibroblasts (FBs) and keratinocytes (KCs) were isolated from human tissues and polyclonally propagated under 2D xeno-free conditions. Human tissue-derived iPSCs were differentiated into endothelial cells (hiPSC-ECs), fibroblasts (hiPSC-FBs) and keratinocytes (hiPSC-KCs) according to efficiency-optimized protocols. Cell identity and purity were confirmed by flow cytometry and clonogenicity indicated their stem/progenitor potential. Triple cell type floating spheroids formation was promoted by human platelet-derived growth factors containing culture conditions, using nanoparticle cell labelling for monitoring the organization process. Planar human skin regeneration was assessed in full-thickness wounds of immune-deficient mice upon transplantation of hiPSC-derived single cell suspensions. Results: Organoids displayed a distinct architecture with surface-anchored keratinocytes surrounding a stromal core, and specific signaling patterns in response to inflammatory stimuli. FGF-7 mRNA transfection was required to accelerate keratinocyte long-term fitness. Stratified human skin also self-assembled within two weeks after either adult- or iPSC-derived skin cell-suspension liquid-transplantation, healing deep wounds of mice. Transplant vascularization significantly accelerated in the presence of co-transplanted endothelial progenitors. Mechanistically, extracellular vesicles mediated the multifactorial platelet-derived trophic effects. No tumorigenesis occurred upon xenografting. Conclusion: This illustrates the superordinate progenitor self-organization principle and permits novel rapid 3D skin-related pharmaceutical high-content testing opportunities with floating spheroid skin organoids. Multi-cell transplant self-organization facilitates development of iPSC-based organ regeneration strategies using cell suspension transplantation supported by human platelet factors.

The life in a gradient: calcium, the lncRNA SPRR2C and mir542/mir196a meet in the epidermis to regulate the aging process.

The turnover of the epidermis beginning with the progenitor cells in the basal layer to the fully differentiated corneocytes is tightly regulated by calcium. Calcium more than anything else promotes the differentiation of keratinocytes which implies the need for a calcium gradient with low concentrations in the stratum basale and high concentrations in the stratum granulosum. One of the hallmarks of skin aging is a collapse of this gradient that has a direct impact on the epidermal fitness. The rise of calcium in the stratum basale reduces cell proliferation, whereas the drop of calcium in the stratum granulosum leads to a changed composition of the cornified envelope. We showed that keratinocytes respond to the calcium induced block of cell division by a large increase of the expression of several miRNAs (hsa-mir542-5p, hsa-mir125a, hsa-mir135a-5p, hsa-mir196a-5p, hsa-mir491-5p and hsa-mir552-5p). The pitfall of this rescue mechanism is a dramatic change in gene expression which causes a further impairment of the epidermal barrier. This effect is attenuated by a pseudogene (SPRR2C) that gives rise to a lncRNA. SPRR2C specifically resides in the stratum granulosum/corneum thus acting as a sponge for miRNAs.