Auto-Augmentation Mastopexy: Inferiorly Based Parenchymal Flap Technique and Evaluation of Outcomes Using BREAST-Q After 151 Consecutive Patients.

BACKGROUND: Mastopexy is one of the most performed annual plastic surgery procedures; hence, various techniques are described over the last decades. It varies from simple skin incisions to internally shaped pedicle designs. In this study, the authors present their modified auto-augmentation mastopexy technique and the resulting patient satisfaction. PATIENTS AND METHODS: For this retrospectively conducted study, 151 female patients were included. The average age was 40.6 years (range, 27-72 years). All patients underwent auto-augmentation mastopexy which is a combination of a superior pedicle for the nipple-areola complex and an inferiorly based soft-tissue flap which is shaped like an implant. Additionally, the BREAST-Q for Reduction/Mastopexy was used to analyze patient-reported satisfaction and quality of life after mastopexy. RESULTS: All breast corrections were successfully performed. General complication rate was 9%, and no major complication was observed. In two patients, local surgical revision due to hypertrophic scarring and nipple asymmetry was necessary. Analysed surveys of the BREAST-Q showed statistically significantly improved results. CONCLUSION: Depending on the breast-shape and the grade of ptosis, the selection of mastopexy technique is crucial. Our described mastopexy procedure is a safe and easily reproducible technique for almost all shapes of ptotic breasts which fulfill patient desires as well as aesthetic satisfaction and quality of life. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Three-Hour Lower Body Lift: Evolution of a Technique and Personal Experience after 155 Consecutive Cases.

BACKGROUND: Body-contouring is a surgical field in growing demand, as the number of massive weight loss patients following bariatric surgery is increasing. The purpose of this study was to provide a straightforward and time-efficient circumferential body lift technique to achieve optimal lower truncal contouring. PATIENTS AND METHODS: A total of 155 massive weight loss patients (133 women and 22 men) underwent lower body lift surgery between 2006 and 2018. The mean preoperative weight reduction and body mass indices were 56.5 ± 16.6 kg and 26.7 ± 4.7 kg/m2, respectively. The preoperative markings focused on the back and gluteal region, and the modified surgical technique are described. Additionally, improvements of intra-operative repositioning of the patient and how to deal with sterilization and dressings are elucidated. RESULTS: The average intra-operative time was 178 ± 54.6 minutes. The mean follow-up of all patients was 8.2 ± 2.4 years. The most common complications were related to wound dehiscence (n = 38) and seroma (n = 18). The mean weight of the resected tissue was 3 056 ± 1 816.5 g. CONCLUSION: The lower body lift represents an effective and safe body contouring procedure to treat massive weight loss patients with multiple regions of concern. The current study describes a modified surgical technique that reduces operating time and complications, notably. 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 http://www.springer.com/00266 .

De-epithelialized Dermal Flap to Reduce Sacral Wound Healing Complications After Lower Body Lift Procedure.

BACKGROUND: Lower or circumferential body lift procedures in the massive-weight-loss population have been associated with significant complication rates. Particularly, the sacral area is at risk of wound-healing problems due to high wound tension or shear forces. OBJECTIVES: The authors introduced a de-epithelialized dermal flap to reinforce the sacral area. METHODS: Within this retrospective study, outcomes of 40 consecutive patients who underwent lower body lift between 2017 and 2021 were analyzed. The patient population was divided into 2 study groups (sacral flap vs no flap) including 20 patients each. Demographic and surgical data as well as complications were evaluated and compared. Appropriate statistical analysis was performed. RESULTS: Thirty-seven female and 3 male patients with a median age of 36.5 years (range, 23-54 years) and a mean weight loss of 46.3 ±â€…12 kg participated in the study. The most common complication was sacral wound dehiscence (n = 7, 17.5%), and its occurrence was statistically significantly lower in the sacral flap group (P = 0.037). The odd ratios for complications when executing the sacral flap procedure were reduced to 0.306 (95% confidence interval = 0.075 to 1.246) and 0.261 (95% confidence interval = 0.055 to 1.250) for the uncorrected and corrected logistic regressions, respectively. In addition, findings showed a significantly shorter hospital stay as well as statistical trends towards a lower occurrence of overall complications in the sacral flap group. Concerning the remaining data, no statistically significant differences between study groups were detected. CONCLUSIONS: The presented de-epithelialized dermal flap leads to a significant reduction of sacral wound-healing complications and a shorter hospital stay for patients. This surgical technique is easily reproduceable, rapid, and effective; therefore, we would recommend it for each circumferential or lower body lift procedure.

Comparison of Energy-Based Tissue Dissection Techniques in Abdominoplasty: A Randomized, Open-Label Study Including Economic Aspects.

BACKGROUND: Abdominoplasty is one of the most common procedures in plastic surgery, and energy-based tissue dissection techniques have become the gold standard. Despite its frequency, abdominoplasty is still associated with high complication rates. OBJECTIVES: The authors compared clinical and economic data of 4 methods of energy-based tissue dissection in a randomized, open-label study. METHODS: A total of 57 patients were preoperatively randomized into 4 groups: electrocautery, Ultracision Harmonic Scalpel, argon plasma coagulation, and PEAK-Plasmablade. Demographic and operational data as well as information on the postoperative course and complications were collected. For economic analysis, quotes were obtained from the device companies or official suppliers. RESULTS: Duration of surgery, drainage quantity, and wound healing complications did not differ significantly between groups. The Ultracision method caused significantly greater blood loss compared with all other techniques (P < 0.01). PEAK and Ultracision devices entailed greater surgical costs compared with APC and electrocautery. CONCLUSIONS: All methods evaluated can be applied safely and effectively in abdominoplasty procedures. However, these data demonstrate a significantly higher blood loss for the Ultracision Harmonic Scalpel. Considering the clinical data, the higher costs of PEAK and Ultracision methods appear unjustified.

Suction assisted liposuction does not impair the regenerative potential of adipose derived stem cells.

BACKGROUND: Adipose-derived stem cells (ASCs) have been identified as a population of multipotent cells with promising applications in tissue engineering and regenerative medicine. ASCs are abundant in fat tissue, which can be safely harvested through the minimally invasive procedure of liposuction. However, there exist a variety of different harvesting methods, with unclear impact on ASC regenerative potential. The aim of this study was thus to compare the functionality of ASCs derived from the common technique of suction-assisted lipoaspiration (SAL) versus resection. METHODS: Human adipose tissue was obtained from paired abdominoplasty and SAL samples from three female donors, and was processed to isolate the stromal vascular fraction. Fluorescence-activated cell sorting was used to determine ASC yield, and cell viability was assayed. Adipogenic and osteogenic differentiation capacity were assessed in vitro using phenotypic staining and quantification of gene expression. Finally, ASCs were applied in an in vivo model of tissue repair to evaluate their regenerative potential. RESULTS: SAL specimens provided significantly fewer ASCs when compared to excised fat tissue, however, with equivalent viability. SAL-derived ASCs demonstrated greater expression of the adipogenic markers FABP-4 and LPL, although this did not result in a difference in adipogenic differentiation. There were no differences detected in osteogenic differentiation capacity as measured by alkaline phosphatase, mineralization or osteogenic gene expression. Both SAL- and resection-derived ASCs enhanced significantly cutaneous healing and vascularization in vivo, with no significant difference between the two groups. CONCLUSION: SAL provides viable ASCs with full capacity for multi-lineage differentiation and tissue regeneration, and is an effective method of obtaining ASCs for cell-based therapies.

Barbed Sutures in Body-Contouring: Outcome Analysis of 695 Procedures in 623 Patients and Technical Advances.

INTRODUCTION: Surgical wound closure is often complicated by suture-related issues. The recent introduction of knotless barbed sutures may address the shortcomings of conventional sutures and offer the additional benefit of reduced operating time. In this paper, we describe our experience with barbed sutures for body-contouring procedures. We share technical insights and evaluate postoperative complications. PATIENTS AND METHODS: A retrospective assessment of prospectively collected data over a period of more than 5 years was undertaken. Six hundred twenty-three consecutive patients underwent 695 body-contouring procedures with barbed suture closure. Patients were followed for at least 12 weeks postoperatively. Patient demographics, operation time as well as suture-related complications, such as wound dehiscence and wound site infection were recorded and analyzed. RESULTS: Barbed sutures can facilitate skin closure, rectus plication, quilting, and deep layer closure in body-contouring procedures. The average operating time in our study cohort was 108 min with reduction mammoplasty being the quickest (94 min) and bodylift (156 min) being the slowest procedure. Sixty-eight patients experienced suture-related complications resulting in an overall complication rate of 9.7 % with thigh lift having the most (15 %) and reduction mammoplasty (7 %) the fewest adverse events. CONCLUSION: The use of barbed sutures allows quick closure of lengthy body-contouring incision lines with low complication rates. Our observations support that barbed sutures are safe, convenient and effective. In our hands barbed sutures appear to be superior to traditional wound-closure techniques in body-contouring procedures. 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 .

Cutaneous innervation of the ankle: an anatomical study showing danger zones for ankle surgery.

Three nerves innervate the skin in the foot and ankle region: the saphenous, sural, and superficial peroneal nerves. Because they are close to the medial and lateral malleoli, these nerves are at significant risk during orthopedic interventions. The aims of this study were to investigate the distal courses of the three cutaneous nerves of the ankle and to determine their exact relationships with easily identifiable bony landmarks. Ten freshly frozen and 40 embalmed lower extremities of adults were dissected. The positions of the superficial peroneal, sural, and saphenous nerves were determined using reference lines based on easily palpable osseous landmarks. The frequencies and distributions of all three nerves and their branches were converted into absolute numbers. A danger zone for each nerve was established on the basis of the distribution of crossings between the nerves and the different reference lines. Determination of the exact orientation of the nerves around the ankle should help minimize the nerve injury rate during surgical approaches in this area. Using this easily translatable new grid system, the course and danger zones of each cutaneous nerve around the ankle can be estimated clinically.

Undiagnosed Patent Foramen Ovale and Thrombophilic Gene Mutations Resulting in Pulmonary Embolism with Cryptogenic Stroke after Cosmetic Breast Surgery.

Undiagnosed disorders or gene mutations can lead to life-threatening events even in cosmetic surgery. Herein, the authors present a case of a young and supposedly healthy 36-year-old woman who survived an episode of bilateral pulmonary embolism and cryptogenic stroke after cosmetic breast augmentation-mastopexy. Two days after cosmetic surgery, the patient presented at the emergency stroke unit after she collapsed at home, following frequent generalized seizures. After she was transferred to the intensive care unit, it was revealed that the patient had an undiagnosed patent foramen ovale and several thrombophilic gene mutations. During the stay, two episodes of active bleeding and beginning nipple-areola complex hypoperfusion led to bilateral implant removal. As a final result, the patient lost her breast implants and experienced persistent hypoesthesia of the entire left hemi body. However, this case might highlight deficits in current venous thromboembolism risk assessment and prophylaxis due to the missing considerations of undiagnosed disorders or gene mutations. Further, recommendations on dealing with implants or aesthetic outcome in crucial episodes should be introduced.

Augmentation-Mastopexy: Analysis of 95 Consecutive Patients and Critical Appraisal of the Procedure.

Single-stage mastopexy-augmentation has been demonstrated to be a safe procedure. However, revisions may still be necessary. We evaluate 95 consecutive patients undergoing mastopexy-augmentation and introduce a new surgical technique for the procedure: the modified dual plane technique. In this retrospective study, 95 patients (mean age 34 ± 11 years) underwent mastopexy-augmentation between 2009 and 2019. The procedures were classified as subglandular, dual plane, or modified dual plane technique. The outcome measures included major and minor complications. A total of 19 patients underwent a subglandular procedure, 32 patients a dual plane procedure, and 44 patients a modified dual plane procedure. We observed a high overall complication rate in the subglandular group (n = 12, 63%), dual plane group (n = 15, 47%), and modified dual plane group (n = 10, 23%). Complications leading to implant loss/change occurred in seven patients in the subglandular group (37%), six patients in the dual plane group (19%), and no patient in the modified dual plane group. While we observed a high complication rate in patients undergoing mastopexy-augmentations, the modified dual plane technique was associated with a lower complication rate.

The Versatility of the Fasciocutaneous Infragluteal (FCI) Flaps for locoregional or free flap reconstruction.

BACKGROUND: The wide range of reconstructive purposes requires specific demands and considerations for appropriate flap selection. One versatile and reliable option, which is rarely reported in current literature, is the fasciocutaneous infragluteal (FCI) flap. In this study, we present our results of performing the FCI flap for different clinical indications. PATIENTS AND METHODS: This retrospectively study was conducted between September 2011 and September 2019. We included 30 patients (21 females and 9 males) who underwent reconstruction with either pedicled or free FCI flap. Indications for performing FCI flap were uni- or bilateral autologous breast reconstruction, perineal reconstruction, congenital thoracic deformity, lower extremity coverage, and vulva reconstruction. RESULTS: Forty-one FCI flaps were performed (34 free and 7 pedicled flaps). The average flap dimension was 7  ×  20 cm (range, 7-8  ×  19-21) and the mean length of the pedicle was 13.4 cm (range, 10.5-15.5). The mean diameter of the artery was 2.5 mm (range, 2.2-3.2), the mean diameter of the accompanying vein was 3 mm (range, 2.4-3.3). The flap survival rate was 97.6% (one flap loss). The most common minor complications were infragluteal wound healing disorders and hematoma. CONCLUSION: The FCI flap provides constant and reliable anatomy with a long vascular pedicle as well as enough soft tissue bulk and a well-hidden scar. In our clinical practice, this flap has emerged as a first choice in perineal/vulvar reconstruction and a reliable alternative in breast reconstruction if the gold standard procedure cannot be performed. LEVEL OF EVIDENCE: IV (Therapeutic).

Preauricular pull through flap for reconstruction of the auricle.

INTRODUCTION: Reconstruction of the crus of the antihelix after tumor resection is a significant surgical challenge and to date no ideal method has been described. The authors present a novel approach using a pedicled flap from preauricular excess skin, which is tunneled through the helix to the anterior auricular surface. MATERIAL AND METHODS: The presented technique was successfully applied in a series of three patients requiring reconstruction of the superior and inferior crus of the antihelix after resection of skin malignancies. Technique and outcomes are described in detail. RESULTS: Postoperative course was uneventful in all patients and all flaps healed with excellent esthetic results. Initial flap edema was observed in two cases that resolved spontaneously. CONCLUSION: The preauricular pull-through flap is a versatile, straightforward, and reliable method for reconstruction of auricular defects located at the superior and inferior crus of the antihelix, including the triangular fossa, using the natural preauricular skin excess.

Microvascular free flaps from the lower abdomen for preservation of amputation length in the lower extremity.

BACKGROUND: The length of the amputation stump is crucial for optimal prosthetic fitting and rehabilitation. Especially in traumatic amputation, direct closure of the stump may be challenging, and bone shortening is frequently needed. To avoid excessive bone shortening, coverage of exposed bone with free flaps is a versatile option. OBJECTIVE: Here we present our experience with the utilization of free flaps from the lower abdomen for the coverage of amputations stumps of the lower extremity. METHODS: Between March 2008 and October 2010, five patients (three female, two male) with complex wounds on amputation stumps of the lower extremity were treated with a mean age of 50 years (range: 15-72 years). Six abdominal free flaps were performed in five patients (one bilateral case), including four deep inferior epigastric artery (DIEP-) and two muscle-sparing transverse rectus abdominis muscle (ms-TRAM-) flaps. Patient's and operative data were collected retrospectively. RESULTS: One complete flap failure occurred (overall success rate: 83.3%). Three of five patients gained full ambulatory status. CONCLUSIONS: Due to the low donor site morbidity a long vascular pedicle and the large amount of available tissue, abdominal based free flaps represent our first choice for microsurgical reconstruction of lower extremity stumps.

A modified microvascular "Tube-in-Tube" concept for penile construction in female-to-male transsexuals: Combined radial forearm free flap with anterolateral thigh flap.

INTRODUCTION: Phalloplasty is a complex surgical task and remains a significant challenge in plastic surgery. To date, there are various techniques; however, complication rates are still not satisfactory. Here, we present our surgical approach of a modified tube-in-tube concept combining a radial forearm free flap and an anterolateral thigh flap and assess its outcome in a series of female-to-male transsexuals. PATIENTS AND METHODS: In this report, 21 female-to-male transsexual patients were included. The first surgical step includes colpectomy and elongation of the fixed part of the urethra with a full-thickness skin graft. Subsequently, a radial forearm free flap was adapted to build the inner tube which represents the neourethra. For the last step, a free anterolateral thigh flap is utilized as the outer tube of the neophallus. All patients were evaluated regarding aesthetic and functional outcomes as well as postoperative complications and revision surgeries. RESULTS: Our results showed a 100% flap survival rate with a mean follow-up of 4.4 years (range, 2.7-6). Three radial forearm free flaps and one free anterolateral thigh flap presented with partial flap necrosis. Generally, complications occurred in 11 patients (52.4%). The most common complications were related to urethral reconstruction including fistula formation (n = 8) and stenosis (n = 5). All except one patient obtained the ability to void while standing. CONCLUSION: Despite the complexity, the initial results are very promising for a single-stage phalloplasty with complete functional creation of a neophallus. Further improvements have to be implemented for reduction of postoperative complications particularly regarding urethral reconstruction. LEVEL OF EVIDENCE: IV (Therapeutic).

Autologous Fat Transplantation for Thumb Carpometacarpal Joint Osteoarthritis (Liparthroplasty): A Case Series with Two Years of Follow-UP.

Adipose-derived mesenchymal stem cell (ASC) therapy is currently a focus of regenerative medicine. Lipoaspirate is rich in ASCs and is evolving into a promising, less-invasive tool to treat thumb carpometacarpal osteoarthritis as compared with common surgical techniques, for example, trapeziectomy or prosthesis implantation. The present study aimed to examine the effect of 1 mL intraarticular lipoaspirate injection (liparthroplasty) in 31 thumb carpometacarpal osteoarthritis patients (27 woman and four men) with a median age of 58 (interquartile range (IQR) of 10) years and Eaton-Littler Stage 2 or 3. Median pain levels assessed via visual analogue scale significantly decreased from 7 (IQR 2) to 4 (IQR 6) after six months (p < 0.0001) and 2 (IQR 5) after two years (p < 0.0001). Median pre-interventional Disabilities of the Arm, Shoulder and Hand (DASH) scores of 59 (IQR 26) significantly reduced to a value of 40 (IQR 43) after six months (p = 0.004) and to 35 (IQR 34) after two years (p < 0.0001). Subjective grip strength showed no significant improvement. However, the time until recurrence of symptoms was measured and a cumulative remission rate of 58% was detected after two years. Satisfaction rates were 68% after six months and 51% after two years. In conclusion, liparthroplasty represents a promising option to reduce pain and functional impairment and to postpone surgery for a certain period of time.

Motiva Ergonomix Round SilkSurface Silicone Breast Implants: Outcome Analysis of 100 Primary Breast Augmentations over 3 Years and Technical Considerations.

BACKGROUND: Macrotextured anatomical implants are frequently used in aesthetic breast surgery; however, several safety concerns linked to this implant type have been raised recently. In an attempt to address these shortcomings, Motiva Ergonomix implants have been introduced. Here, the authors describe the current world's largest experience with these novel devices in aesthetic breast surgery and evaluate the postoperative outcome of 100 primary breast augmentations. METHODS: A retrospective assessment of 100 consecutive primary breast augmentation patients over a period of 3 years was conducted. Patients were followed for a minimum of 6 months postoperatively. Demographics, surgical data, and complications were recorded. In addition, a survey regarding the breast augmentation outcome was performed. RESULTS: The reasons for surgery were mainly hypoplasia (52 percent) and ptosis (28 percent). All implants were placed by means of an inframammary approach in a submuscular pocket, and the average implant volume was 370 cc (range, 150 to 700 cc) with mostly full projection (65 percent). The revision rate was 7 percent. The authors observed four cases of implant malpositioning, one implant rupture, one implant exchange for aesthetic reasons, and one hematoma evacuation. Nevertheless, the authors achieved a 100 percent satisfaction rate with the postsurgical outcome among both patients and surgeons. CONCLUSIONS: Motiva Ergonomix implants provide reliable and satisfying results for both patients and surgeons. They can be used safely and effectively for aesthetic breast surgery. However, like all breast prostheses, Motiva Ergonomix implants are not completely free of complications and should be used only with advanced technique to achieve optimal results. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Mechanical irritation by protruding bone: A possible cause of breast implant rupture.

Although breast implants have been in clinical use for almost 6 decades and have undergone considerable development during this time, implant rupture is still a dreaded long-term complication. Some obvious external factors, such as trauma, can lead to implant rupture, but many studies have reported a high rate of "spontaneous" implant rupture. Herein, we present two cases with the aim of raising awareness of a new possible cause of "spontaneous" implant rupture: mechanical irritation by bony protrusions.

Skin Rejuvenation through HIF-1α Modulation.

The constant intrinsic and extrinsic stress the skin is exposed to leads to significant impairments of the regenerative capacity of aging skin. Current skin rejuvenation approaches lack the ability to holistically support the biological processes that exhaust during aging skin degeneration, such as collagen production, cell migration and proliferation, and new vessel formation. Similar to chronic wounds, aged skin is characterized by dysfunction of key cellular regulatory pathways impairing regeneration. Recent evidence suggests that the same mechanisms hindering a physiologic healing response in chronic wounds are the basis of impaired tissue homeostasis in aged skin. Dysfunction of a main response-to-injury pathway, the hypoxia-inducible factor (HIF)-1α regulatory pathway, has been identified as pivotal both in chronic wounds and in aging skin degeneration. HIF-1α signaling is significantly involved in tissue homeostasis and neovascularization, resulting in the production of new collagen, elastin, and nourishing blood vessels. Modulating the functionality of this pathway has been demonstrated to significantly enhance tissue regeneration. In this review, we present an overview of the regenerative effects linked to the up-regulation of HIF-1α functionality, potentially resulting in skin rejuvenation on both the cellular level and the tissue level.

Seasonal Impact on Surgical-Site Infections in Body Contouring Surgery: A Retrospective Cohort Study of 602 Patients over a Period of 6 Years.

BACKGROUND: Postoperative surgical-site infections are severe complications following body contouring surgery. Here, the authors evaluate whether surgical-site infection rates are influenced by higher temperatures during the summer season. METHODS: We enrolled 602 patients who underwent body contouring surgery between 2009 and 2015 in a retrospective cohort study. Data collected included demographics, surgical data, and postoperative outcome. Body contouring surgery procedures included lower and upper body lift, abdominoplasty, breast reduction, mastopexy, brachioplasty, and thigh lift. Infection rates were calculated on a seasonal basis and compared using Fisher's exact test and logistic regression analysis. RESULTS: There were 136 patients (125 women and 11 men) in the warm season [June to August; with an average temperature of 67.622°F (19.79°C)] and 466 patients (438 women and 28 men) in the cold seasons group [September to May, with an average temperature of 45.45 °F (7.47°C)]. The composition of the study cohorts was comparable. The average age was 40 years and the average body mass index was 27 kg/m. From a total of 602 patients, the authors observed 33 surgical-site infections, representing a rate of 5.48 percent. A statistically significant increase of postoperative surgical-site infections could be detected during summer (10.29 percent versus 4.08 percent; p = 0.0071), representing an increase of 150 percent. In addition, a logistic regression analysis determined "season" as the strongest predictor for surgical-site infections, with a risk increase of 2.693 times in the warm season. CONCLUSIONS: Body contouring operations are elective procedures, making careful risk consideration an absolute prerequisite. The authors demonstrate a significantly increased infection risk during summer and establish a causal link between the warm season and surgical-site infection accumulation. Consequently, preoperative patient information and operative planning should be adjusted accordingly. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, II.