The long-term intercorrelation between post-burn pain, anxiety, and depression: a post hoc analysis of the "RE-ENERGIZE" double-blind, randomized, multicenter placebo-controlled trial.

BACKGROUND: Despite the growing prevalence of burn survivors, a gap persists in our understanding of the correlation between acute burn trauma and the long-term impact on psychosocial health. This study set out to investigate the prevalence of long-term pain and symptoms of anxiety and depression in survivors of extensive burns, comparing this to the general population, and identify injury and demographic-related factors predisposing individuals to psychosocial compromise. METHODS: RE-ENERGIZE was an international, double-blinded, randomized-controlled trial that enrolled 1200 patients with partial- or full-thickness burns that required surgical treatment. For the post hoc analysis, we excluded participants who did not complete the Short Form Health Survey (SF-36) questionnaire. Normative data were taken from the 2021 National Health Interview Survey dataset. Propensity score matching was performed using the nearest-neighbor 1-to-1 method, and the two cohorts were compared in terms of chronic pain, and symptoms of anxiety and depression. A multivariable analysis was performed on the burns cohort to identify factors predicting post-discharge pain and symptoms of anxiety and depression. RESULTS: A total of 600 burn patients and 26,666 general population adults were included in this study. Following propensity score matching, both groups comprised 478 participants each, who were predominately male, white, overweight and between 20 and 60 years old. Compared to the general population, burn patients were significantly more likely to report the presence of moderate and a lot of pain (p = 0.002). Symptoms of anxiety were significantly higher in the burn population in two of four levels (most of the time; some of the time; p < 0.0001 for both). Responders in the burn population were significantly less likely to report the absence of depressive symptoms (p < 0.0001). Burn patients were also significantly more likely to report that their mental health affects their social life. TBSA, history of depression, and female sex were identified as independently associated factors for pain, anxiety, and depressive symptoms. The presence of chronic pain and anxiety symptoms independently predicted for symptoms of depression. CONCLUSIONS: Analyzing the largest multicenter cohort of patients with extensive burns, we find that burn injury is associated with chronic pain, and symptoms of anxiety and depression. In addition, TBSA-burned and history of depression directly correlate with the prevalence of chronic pain, and symptoms of anxiety and depression. Finally, pain, and symptoms of anxiety and depression are interrelated and may have interactive effects on the process of recovery following burn injury. Burn patients would, therefore, benefit from a multidisciplinary team approach with early mobilization of pain and mental health experts, in order to promptly prevent the development of psychosocial challenges and their consequences.

Patient characteristics and disease spectrum in a German vascular anomalies center.

BACKGROUND: Vascular malformations are rare diseases that should be treated in dedicated vascular anomaly centers (VAC). There is only a small amount of data on the diagnostic and therapeutic handling of these patients, before they are referred to a VAC. PURPOSE: To demonstrate the disease-specific patient characteristics in a German VAC, which are required to determine diagnostic and therapeutic steps. MATERIAL AND METHODS: In a retrospective study, all patients who were treated in the VAC from April 2014 until August 2021 were identified. In total, 593 patients were included in this study. RESULTS: Almost all patients had previously consulted a physician (591/593, 99.7%). A mean of two different physicians had been consulted (range 0-10). Patients with more complex, syndromal vascular malformations had significantly more previous appointments (P = 0.0018). In only 44% (261/593) of patients, the referral diagnosis was made correctly. Most patients had been previously treated for their vascular anomaly: pharmacotherapy (n = 130; 21.9%), compression garments (n = 141; 23.8%), surgical resection (n = 80; 17.3%) and sclerotherapy (n = 68; 11.5%). Fifty-two patients who had been falsely diagnosed had also received therapy prior to their referral to the VAC (8.8%). Most patients received an ultrasound examination in the VAC (n = 464; 78.2%). Most frequently, compression therapy was prescribed (n = 256; 43.2%), followed by sclerotherapy (n = 175, 29.5%) and pharmacotherapy (n = 55; 9.3%). CONCLUSION: Patients suffering from vascular anomalies often go through a complicated scheduling with numerous outpatient appointments and have a high risk of misdiagnosis and mistreatment prolonging the medical condition. Therefore, patients with vascular anomalies should be treated in a dedicated vascular anomaly center.

The combined risk predictive power of frailty and hypoalbuminemia in free tissue flap reconstruction: A cohort study of 34,571 patients from the NSQIP database.

INTRODUCTION: Significant morbidity and mortality are hallmarks of the functional decline seen in physically frail patients. The modified frailty index 5 (mFI-5) represents a risk predictor score that has been validated as a comorbidity-based scale in surgery. Serum albumin levels of <3.5 g/dL (hypoalbuminemia) have also been implicated with poor postoperative outcomes. However, the association between these two parameters remains to be investigated. We aimed to elucidate the interdependence of preoperative albumin levels and frailty, as evaluated by the mFI-5 score, and its reliability to prognosticate postoperative results in free flap reconstruction (FFR). METHODS: We conducted a multicenter, retrospective cohort study and accessed the ACS National Surgical Quality Improvement Program (ACS-NSQIP) from 2008 to 2021. We identified all adult patients (≥18 years of age) who underwent a FFR. We extracted perioperative data and lab values including albumin. Multivariable linear and logistic regression analyses were performed to identify independent risk predictors. Main outcomes involved mortality, length of hospital stay, reoperation, medical and surgical complications, and discharge destination within the 30-day postoperative period. RESULTS: A total of 34,571 patients were included in the study, with an average age of 53.9 years (standard deviation [SD] 12.2) and an average body mass index (BMI) of 28.8 (SD 6.1). Of these patients, 7484 were male (21.6%), whereas 22,363 (64.7%) had no frailty (mFI = 0). Additionally, 9466 patients had a frailty score of 1 (27.4%), 2505 had a score of 2 (7.2%), 226 had a score of 3 (0.7%), and 11 had a score of 4 or higher (0.0%). Albumin levels were available for 16,250 patients (47.0%), and among them, 1334 (8.2%) had hypoalbuminemia. Regression analyses showed that higher mFI scores were independent predictors of any, surgical, and medical complications, as well as increased rates of reoperations, unplanned readmissions, and prolonged hospital stays. Hypoalbuminemia independently predicted any, surgical, and medical complications, and higher mortality, reoperation, and longer hospital stay. When both frailty and albumin levels (mFI-5 and albumin) were considered together, this combined assessment was found to be a more accurate predictor of all major outcomes (any, medical and surgical complications, mortality, and reoperation). Further, our analysis identified a weak negative correlation between serum albumin levels and mFI scores (Spearman R: -.1; p < .0001). CONCLUSION: In conclusion, this cohort study highlights the association of hypoalbuminemia with adverse postoperative outcomes, including those not directly related to frailty. Simultaneously, higher mFI scores independently predicted outcomes not associated with hypoalbuminemia. Stemming from these findings, we recommend considering both serum albumin levels and frailty in patients receiving FFR. This perioperative algorithm may help provide more individualized planning including multidisciplinary care and pre and posthabilitation.

Fibrin Glue Coating Limits Scar Tissue Formation around Peripheral Nerves.

Scar tissue formation presents a significant barrier to peripheral nerve recovery in clinical practice. While different experimental methods have been described, there is no clinically available gold standard for its prevention. This study aims to determine the potential of fibrin glue (FG) to limit scarring around peripheral nerves. Thirty rats were divided into three groups: glutaraldehyde-induced sciatic nerve injury treated with FG (GA + FG), sciatic nerve injury with no treatment (GA), and no sciatic nerve injury (Sham). Neural regeneration was assessed with weekly measurements of the visual static sciatic index as a parameter for sciatic nerve function across a 12-week period. After 12 weeks, qualitative and quantitative histological analysis of scar tissue formation was performed. Furthermore, histomorphometric analysis and wet muscle weight analysis were performed after the postoperative observation period. The GA + FG group showed a faster functional recovery (6 versus 9 weeks) compared to the GA group. The FG-treated group showed significantly lower perineural scar tissue formation and significantly higher fiber density, myelin thickness, axon thickness, and myelinated fiber thickness than the GA group. A significantly higher wet muscle weight ratio of the tibialis anterior muscle was found in the GA + FG group compared to the GA group. Our results suggest that applying FG to injured nerves is a promising scar tissue prevention strategy associated with improved regeneration both at the microscopic and at the functional level. Our results can serve as a platform for innovation in the field of perineural regeneration with immense clinical potential.

Patient-reported Outcomes Utilizing the Breast-Q Questionnaire After Breast Conserving Surgery With and Without Oncoplastic Breast Surgery: A Systematic Review and Meta-analysis.

Oncoplastic breast surgery (OBS) arose to decrease the deformity following breast conserving surgery (BCS) for breast cancer. In this meta-analysis (MA), we pool Breast-Q™ questionnaire data to compare quality of life (QOL) in breast cancer patients who received BCS alone or in combination with Level I or II oncoplastic breast surgery (BCS+OBS). All relevant databases were searched following the PRISMA and QUOROM guidelines. All prospective or retrospective studies with a BCS or BCS+OBS cohort that reported QOL as assessed with the Breast-Q™ questionnaire were eligible. Fifty-five studies (75 distinct patient cohorts; 11,186 patients) were included in the MA, with 12 studies reporting both pre- and postoperative values and eligible for a pairwise MA. The pairwise MA showed a significant postoperative improvement in the overall satisfaction with the breast (MD +8.0%, p=0.003) and in the psychosocial well-being (MD +9.2%, 3.5-14.8, p=0.001) of the entire cohort (BCS and BCS+OBS). A subgroup MA of proportions highlighted a superiority of BCS+OBS to BCS in terms of overall satisfaction with the breast (72.0%, 68.0-76.1, versus 62.9%, 58.3-67.5; p=0.02) and psychosocial well-being (78.9%, 71.5-86.4, versus 73.3%, 67.3-76.5, p=0.0001). A leave-one-out sensitivity analysis confirmed the results of the pairwise MA and the MA of proportions. Oncoplastic breast surgery effectively improves QoL based on the patient-reported outcomes assessed using the Breast-Q™ questionnaire. The improvements were associated with acceptable complication rates, further supporting the use of BCS followed by OBS where mastectomy would otherwise be necessary.

Soft Tissue Reconstruction of Complex Infrainguinal Wounds Following Revisionary Vascular Surgery.

BACKGROUND: Large, full-thickness infrainguinal wounds following revision revascularization procedures of the lower extremity are a challenging complication for reconstructive surgery. Frequently, these patients present with various comorbidities and after several previous reconstructive attempts. Therefore no straightforward soft tissue reconstruction is likely. METHODS: Patients who presented with large, complex inguinal wounds for soft tissue reconstruction were analyzed retrospectively in terms of flap choice, outcome, and complication rates. A focus was set on the reconstructive technique and a subgroup analysis was assessed. RESULTS: Nineteen patients (11 men, 8 women) who received 19 flaps (17 pedicled, 2 free flaps) were included in this retrospective study. Average patient age was 73.3 years (range: 53-88). Ten fasciocutaneous flaps (anterolateral thigh [ALT], 52.6%) and 9 muscle flaps (47.4%) were applied. Among muscle flaps, 3 pedicled gracilis flaps, 4 pedicled rectus abdominis flaps, and 2 free latissimus dorsi flaps were used. No flap losses were observed except 1 case of limited distal flap necrosis (gracilis group). Body mass index ranged from 19 to 37, mean 26.8. Mean surgery time in all patients was 165.9 min (range: 105-373). Revision surgery due to local wound healing problems averaged 1.6 in all patients. In all cases sufficient soft tissue reconstruction was achieved and bypasses were preserved. Lengths of stay averaged 27.2 days (range: 14-59). Mortality was considerably (10.5%) due to systemic complications (one patient died due to a heart attack 4 weeks postoperatively, another patient died due to an extensive pulmonary embolism 2 weeks postoperatively). CONCLUSIONS: Soft tissue reconstruction of complex inguinal wounds after revision vascular surgery is challenging and wound healing problems are expectable. In addition to the rectus abdominis flap the pedicled ALT flap is feasible in a broad variety of medium to large wounds. Free flap reconstruction is recommended for very large defects. A structured interdisciplinary approach is required for the management of complex wounds after vascular surgery to prevent and to deal with complications and perioperative morbidity.

Performance of a vascular anomaly center: a retrospective analysis of 461 cases over seven years.

BACKGROUND: Vascular malformations are rare diseases that are best managed in multidisciplinary vascular anomaly centers (VAC). So far, there are few published data on the logistic structure, patient allotment, and internal workflow in an interdisciplinary VAC. PURPOSE: To demonstrate the referral structure and patient allotment in a European VAC. MATERIAL AND METHODS: A retrospective cohort study was conducted. All patients treated in the VAC since its establishment in April 2014 until June 2020 were identified. A total of 461 patients were included in this study. RESULTS: Most often, a venous malformation was diagnosed (49.9%), followed by arteriovenous malformations (8.7%) and syndromal vascular malformations (8.2%). Only 45.1% of referral diagnoses were correct. Of referrals, 35.1% were internal on-campus references, 28.0% were external references through physicians in private practice, and 19.7% came via external cooperating hospitals. Of the patients, 17.1% were self-admissions without a referral. CONCLUSION: The most important referring clinics are internal medicine, pediatric, and vascular surgery. A substantial proportion of referrals came from private practices. Recruiting these cooperation partners should be considered a high priority when establishing a new VAC. The rate of misdiagnosis is high, and more education of fellow clinicians is urgently needed. Therefore, patients with vascular malformations should be referred to and treated in dedicated centers for vascular anomalies.

Advancing Nerve Regeneration: Translational Perspectives of Tacrolimus (FK506).

Peripheral nerve injuries have far-reaching implications for individuals and society, leading to functional impairments, prolonged rehabilitation, and substantial socioeconomic burdens. Tacrolimus, a potent immunosuppressive drug known for its neuroregenerative properties, has emerged in experimental studies as a promising candidate to accelerate nerve fiber regeneration. This review investigates the therapeutic potential of tacrolimus by exploring the postulated mechanisms of action in relation to biological barriers to nerve injury recovery. By mapping both the preclinical and clinical evidence, the benefits and drawbacks of systemic tacrolimus administration and novel delivery systems for localized tacrolimus delivery after nerve injury are elucidated. Through synthesizing the current evidence, identifying practical barriers for clinical translation, and discussing potential strategies to overcome the translational gap, this review provides insights into the translational perspectives of tacrolimus as an adjunct therapy for nerve regeneration.

Microporous Polylactic Acid Scaffolds Enable Fluorescence-Based Perfusion Imaging of Intrinsic In Vivo Vascularization.

In vivo tissue engineering (TE) techniques like the AV loop model provide an isolated and well-defined microenvironment to study angiogenesis-related cell interactions. Functional visualization of the microvascular network within these artificial tissue constructs is crucial for the fundamental understanding of vessel network formation and to identify the underlying key regulatory mechanisms. To facilitate microvascular tracking advanced fluorescence imaging techniques are required. We studied the suitability of microporous polylactic acid (PLA) scaffolds with known low autofluorescence to form axial vascularized tissue constructs in the AV loop model and to validate these scaffolds for fluorescence-based perfusion imaging. Compared to commonly used collagen elastin (CE) scaffolds, the total number of vessels and cells in PLA scaffolds was lower. In detail, CE-based constructs exhibited significantly higher vessel numbers on day 14 and 28 (d14: 316 ± 53; d28: 610 ± 74) compared to the respective time points in PLA-based constructs (d14: 144 ± 18; d28: 327 ± 34; each p < 0.05). Analogously, cell counts in CE scaffolds were higher compared to corresponding PLA constructs (d14: 7661.25 ± 505.93 and 5804.04 ± 716.59; d28: 11211.75 + 1278.97 and 6045.71 ± 572.72, p < 0.05). CE scaffolds showed significantly higher vessel densities in proximity to the main vessel axis compared to PLA scaffolds (200-400 µm and 600-800 µm on day 14; 400-1000 µm and 1400-1600 µm on day 28). CE scaffolds had significantly higher cell counts on day 14 at distances from 800 to 2000 µm and at distances from 400 to 1600 µm on day 28. While the total number of vessels and cells in PLA scaffolds were lower, both scaffold types were ideally suited for axial vascularization techniques. The intravascular perfusion of PLA-based constructs with fluorescence dye MHI148-PEI demonstrated dye specificity against vascular walls of low- and high-order branches as well as capillaries and facilitated the fluorescence-based visualization of microcirculatory networks. Fluorophore tracking may contribute to the development of automated quantification methods after 3D reconstruction and image segmentation. These technologies may facilitate the characterization of key regulators within specific subdomains and add to the current understanding of vessel formation in axially vascularized tissue constructs.

Effective or Harmful-Evaluation of Locally Applied Antibiotics on Adipose Tissue during Lipofilling to the Breast-An In Vitro Study.

Lipofilling is a frequently used and safe procedure for breast reconstruction. One of the most feared complications is soft tissue infection following lipofilling. Because of this, some surgeons propose the practice of rinsing fat grafts with antibiotics. This study investigates the effect of antibiotic rinses on fat grafts in an in vitro model. Adipocytes and stem cells were isolated from fat tissue harvested during 24 lipofilling procedures and incubated with different doses of clindamycin or cefazolin. Cell viability, metabolism, proliferation, and differentiation capacities were analyzed by gross morphology, fluorescence staining, -(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromid (MTT-), and Glyceraldehyde 3 Phosphate Dehydrogenase (G3PD)-assay as well as reactive oxygen species (ROS)-assay. Cefazolin and clindamycin led to significant reduction of cell viability of adipocytes. High doses of both antibiotics led to a rupture of adipocytes with visible free lipid droplets. Cell metabolism was significantly decreased after incubation with both antibiotics. There was a significant increase in ROS production. Exposure to clindamycin and cefazolin led to morphological changes in stem cells in a dose- and time-dependent manner. Furthermore, differentiation potential was significantly reduced. Antibiotic susceptibility testing, however, showed that low concentrations of antibiotics effectively inhibited bacterial growth in contaminated fat grafts. This study confirms that rinsing fat grafts with clindamycin or cefazolin not only overly prevents infection but also has cytotoxic and metabolic effects on adipocytes. Therefore, based on these results, the routine clinical application in high doses cannot be recommended.

Multicenter consensus statements on the use of low-intensity pulsed ultrasound (LIPUS) in Hand Surgery.

OBJECTIVE: The purpose of this agreement was to establish consensus statements on the use of low-intensity pulsed ultrasound (LIPUS) in hand surgery. METHODS: Based on Delphi consensus methodology, a preliminary list of questions on the use of LIPUS in hand surgery was developed by an interdisciplinary team of hand and plastic surgeons as well as psychologists and experts from communications science. Based on these, questionnaires were invented and a total of three Delphi rounds have been conducted. Delphi panelists consisted of 11 German hand surgeons with a mean experience in hand surgery of 15 years (7-23 years). Questions and statements were revised during this process, resulting in a consensus at the end of round three. RESULTS: After three Delphi rounds, the following recommendations could be derived. LIPUS can be applied for impaired fracture healing of the digits, metacarpals, carpal bones as well as a prophylactic procedure in order to avoid further revision surgery. LIPUS therapy can be useful in addition to revision surgery for delayed union and non-unions. In the case of certain risk factors (replantation, revascularization, osteoporosis, smoking), it can be applied directly postoperatively in order to prevent impaired fracture healing. It should be applied for 90-120 days. CONCLUSION: There is a consensus among German hand surgeons, when and how LIPUS can be applied for improving fracture healing of the hand. Randomized controlled trials with direct comparison of fracture treatment with and without LIPUS are needed to support these statements with objective data.

Perfusion of the proximal scaphoid pole: correlation between preoperative ge-MRI and intraoperative findings.

BACKGROUND: Gadolinium enhanced MRI (ge-MRI) is considered as gold standard for perfusion evaluation in case of scaphoid nonunion (SNU). However, its clinical value and specificity is still not clearly evaluated. This study compares preoperative ge-MRI-based perfusion assessment and intraoperative proximal pole (PP) perfusion after scaphoid reconstruction by vascularized bone grafts. In addition, the postoperative osseous consolidation (OC) was correlated to intraoperative perfusion findings. METHODS: Between 08/2010 and 01/2020, 60 of 271 patients with scaphoid nonunion received a vascularized radius bone graft for reconstruction. Medical reports were checked for intra-op perfusion findings. Consolidation rate was assessed at mean follow-up of 3 months by CT evaluation. In 50 cases (83.2%), complete medical and radiological history could be obtained. Preoperative ge-MRI was reevaluated by a blinded radiologist for advanced analysis of sensitivity and specificity. RESULTS: Preoperative ge-MRI (initial finding, IF) showed 23 avascular, 20 malperfused, and seven vital PP. Blinded radiological follow-up (second finding, SF) revealed 14 avascular, 28 malperfused, and 8 vital PP, with a concordance of 65.3% (n = 35). After correlation with the intra-op findings, a specificity of preoperative ge-MRI of 76.5% (IF) and 88.2 (SF), respectively, was revealed for exclusion of avitality. For detection of malperfusion, there was a sensitivity of 92.7% (IF) and 85.4% (SF), respectively. Complete OC was seen 12 weeks postoperatively in 37 (73.5%), partial OC in 9 (18.3%), and nonunion in 4 cases (8.2%) on CT-scans. Of the 41 malperfused/avascular PP, 31 (75.6%) progressed to complete and 6 (14.6%) to partial (at least 2 adjacent CT-layers of 2 mm) OC, with 4 nonunions. CONCLUSION: The sensitivity and specificity of ge-MRI for detection/ exclusion of malperfusion/avitality of the PP was lower than expected. Therewith, the intraoperative assessment of PP perfusion regains a high value in decision-making for the appropriate graft. We recommend preservation of the dorsal radial vascular plexus initially until the vascularity of the proximal pole has been estimated. Patient education for all contingencies and retraction options should be obtained.

Intraoperative Heparin Bolus and Postoperative Anticoagulation with Low Molecular Weight Heparin Increase Reliability of Microsurgical Free Flaps for Upper Extremity Reconstruction.

BACKGROUND: Microsurgery is an indispensable tool of upper extremity reconstruction addressing defect coverage and the restoration of function. Perioperative anticoagulation and antiplatelet therapy are controversially discussed with impact on microsurgical outcome, but without clear evidence. This study aims to evaluate the impact of perioperative anticoagulation and antiplatelet therapy in microsurgical upper extremity reconstruction. METHODS: All eligible patients treated with microsurgical upper extremity reconstruction between January 2000 and July 2014 were included in a comparative analysis to define a superior anticoagulation and antiplatelet regime in a retrospective study. Endpoints were all major complications (e.g., total flap loss, arterial and venous thrombosis) as well as minor complication. RESULTS: A total of 183 eligible free flaps to the upper extremity were transferred in 169 patients. Altogether, 11 arterial (6.0%) and 9 venous (4.9%) thromboses, 11 total flap losses (6.0%), and 16 cases with hematoma (8.7%) were detected. In the subgroup analysis, patients who did not receive any heparin intraoperatively (n = 21; 11.5%) had a higher rate of major complications (p = 0.001), with total flap loss being the most frequent event (p = 0.004). A trend was shown for intraoperative bolus administration of 501 to 1,000 units unfractionated heparin (UFH) intravenously to have the lowest rate of major complications (p = 0.058). Intraoperative administration of acetylsalicylic acid (n = 13; 8.1%) did not have any influence on the rate of major complications. Postoperative anticoagulation with continuous UFH intravenously (n = 68; 37.2%) resulted in more frequent complications (p = 0.012), for example, an increased rate of total flap loss (p = 0.02) and arterial thrombosis (p = 0.02). CONCLUSION: The results of the present study favor administration of 501 to 1,000 units UFH intravenously as an intraoperative bolus (e.g., 750 units UFH intravenously). Postoperative low molecular weight heparin subcutaneous application in a prophylactic dose given once or twice a day was associated with less complications compared with continuous infusion of UFH, although continuously applied UFH may reflect an increased risk profile.

A Retrospective Matched-Pair Analysis of Long-term Outcomes after Successful Lower Extremity Free Flap Salvage.

BACKGROUND: Pedicle occlusion with total free flap loss after microvascular lower extremity reconstruction is a considerably rare yet devastating complication. Fortunately, in the majority of cases, emergency salvage takebacks of compromised free flaps are initiated in a timely manner. In this report, we present our analysis of long-term outcomes following transient vascular compromise mitigated through successful free flap salvage in the lower extremity. METHODS: We performed a single-center retrospective matched-pair analysis of 46 patients with lower extremity free flap reconstructions. Cases underwent successful revisions of microvascular compromise (n = 23), whereas controls had uneventful postoperative courses (n = 23). Patient-reported outcome questionnaires and physical evaluations were used to assess general quality of life, functional outcomes, and cosmesis (Lower Extremity Functional Scale [LEFS], Lower Limb Outcomes Questionnaire [LLOQ], Short Form 36 (SF-36), Vancouver Scar Scale [VSS]). The mean follow-up time was 4.4 years. RESULTS: The health-related quality of life assessed by the SF-36 did not differ significantly between both groups in any of the subscales (p ≥ 0.15 for all subscales). Functional outcomes did not show significant differences between both groups according to the LEFS (p = 0.78) and LLOQ (p = 0.45). The overall scar appearance assessed by the VSS showed significantly poorer cosmesis in the re-exploration group (p = 0.014). CONCLUSION: Salvage of compromised free flaps in the lower extremity yields similar long-term outcomes compared to noncompromised free flaps with regard to function and quality of life. However, free flap revisions may lead to impaired scar formation. This study provides further evidence that the opportunity for urgent re-exploration is indispensable.

From Esthetic Medicine to Optimizing Reconstructive Outcome: A Feasibility Trial on Secondary Refinement of Fasciocutaneous Anterolateral Thigh Flaps with Cryolipolysis.

BACKGROUND: Free adipocutaneous anterolateral thigh (ALT) flaps have evolved as workhorse flaps to reconstruct complex, multicompound defects. While coverage is safely achieved, flaps may remain bulky. As a standard of care, flaps are refined with liposuction, partial excision, or combination of both. Cryolipolysis is widely used for fat reduction in esthetic medicine. This pilot comparative study analyses whether cryolipolysis may serve as a safe alternative method to effectively reduce volume in fasciocutaneous flaps. Moreover, patients' satisfaction with the procedure is evaluated. METHODS: In this single-center, retrospective, interventional comparative cohort study, 10 patients with free subfascial ALT flaps for distal extremity reconstruction underwent cryolipolysis (60 minutes, -9°C). Circumference of the extremities and subcutaneous fat thickness were determined before (T1) and 12 weeks (T2) after cryolipolysis. Patient satisfaction was evaluated with a questionnaire of Likert's scale questions. Duration of hospital stay, intervention time, costs, and possible complications were analyzed and compared with surgical flap contouring (n = 12). RESULTS: All patients undergoing cryolipolysis were male, with a median age of 52 years without arterial disease-like state or deep vein thrombosis (DVT). At T2, a significant reduction of circumference of 1.8 ± 0.9 cm (p < 0.001) and subcutaneous fat layer of 7.7 ± 3.0 mm (p < 0.0001) was recorded. Overall, 90% of the patients were satisfied with the result. Cryolipolysis was well tolerated. One patient developed a second-degree frostbite which healed without further intervention. Cryolipolysis proofed to be as safe as surgical flap contouring. Hospital stay was significantly shorter (p < 0.01) and personal resources were spared when flap contouring was performed with cryolipolysis. CONCLUSION: This is a novel application of evolving body-contouring cryolipolysis from esthetic medicine into optimizing outcomes in reconstructive surgery. Cryolipolysis has been shown to be relatively safe and effective to reduce ALT's volume with high patients' satisfaction. This successful pilot study encourages further investigation with a prospective randomized control trial.

Patient-Reported Outcomes After Reduction Mammoplasty Using BREAST-Q: A Systematic Review and Meta-Analysis.

BACKGROUND: The BREAST-Q questionnaire reduction module is an established tool for outcomes after reduction mammoplasty. OBJECTIVES: This systematic review and meta-analysis assess key parameters affecting pre- and postoperative scores, with specific foci on patient characteristics and tissue resection weights. METHODS: This study was conducted per PRISMA guidelines. PUBMED (National Institutes of Health; Bethesda, MD), Google Scholar (Google; Mountain View, CA), and Web of Science (Clarivate Analytics; Philadelphia, PA) were searched. All studies published before August 1, 2021, were assessed for eligibility by 2 independent reviewers. Inclusion criteria were prospective or retrospective studies in 6 languages that reported quality of life after reduction mammoplasty employing the BREAST-Q questionnaire reduction module. Quality of included studies was assessed employing the Newcastle-Ottawa-Scale. Analysis was performed per Cochrane Collaboration and the Quality of Reporting of Meta-analyses guidelines. RESULTS: A total of 28 papers were included in the systematic review, 13 for preoperative meta-analysis, and 17 for postoperative meta-analysis. Postoperative scores in all 3 quality of life domains (psychosocial, physical, and sexual well-being) and satisfaction with breasts increased significantly after reduction mammoplasty compared with preoperative scores. Satisfaction with breasts showed the greatest improvement, from 22.9 to 73.0. Preoperative scores were lower than normative data, with improvement to comparable scores as the healthy population postoperatively. Improvements in BREAST-Q scores did not correlate with patient comorbidities, complication rates, or amount of breast tissue resected. CONCLUSIONS: Reduction mammoplasty provides marked improvement in BREAST-Q patient-reported quality of life as well established in literature. However, these improvements do not correlate with tissue resection weights, warranting further inquiry of insurance-defined resection requirements.

The prognostic role of extended preoperative hypercoagulability work-up in high-risk microsurgical free flaps: a single-center retrospective case series of patients with heterozygotic factor V Leiden thrombophilia.

INTRODUCTION: Hypercoagulability is associated with an increased risk of microvascular complications and free flap failures. The authors present their experience and approach to diagnosing and treating patients with heterozygotic factor V Leiden (hFVL) thrombophilia undergoing free flap reconstruction. METHODS: Between November 2009 and June 2018, 23 free flap surgeries were performed in 15 hypercoagulable patients with hFVL. According to the timing of perioperative hypercoagulability work-up, they were grouped into flaps with established diagnoses prior to surgery (Group A) versus flaps with unknown diagnoses prior to surgery (Group B). Baseline characteristics and perioperative complications were compared between both groups, including revision surgeries due to microvascular thromboses, acute bleedings, hematomas, flap necroses, and reconstructive failures. RESULTS: HFVL mutations had been confirmed preoperatively in 14 free flap surgeries (61%, Group A), whereas in 9 free flap surgeries (39%, Group B), mutations were only diagnosed postoperatively after the occurrence of microvascular thromboses had warranted extended hypercoagulability work-up. The overall rate of intraoperative flap thromboses was 9% (n = 2), whereas the overall rate of postoperative flap thromboses was 43% (n = 10). The corresponding salvage rates were 100% (n = 2/2) for intraoperative and 40% (n = 4/10) for postoperative pedicle thromboses. A total of five free flaps were lost (22%). Upon comparison, flaps with an unconfirmed diagnosis prior to surgery were at ten times higher risk for developing total necroses (flaps lost in Group B = 4/9 versus Group A = 1/14; OR: 10.4; 95% CI 1.0, 134.7; p = 0.03). CONCLUSION: Meticulous preoperative work-up of patients with any history of hypercoagulability can help reduce free flap loss rates, thus improving surgical outcomes and increasing patient safety.

Influence of closed incision negative-pressure therapy on abdominal donor-site morbidity in microsurgical breast reconstruction.

INTRODUCTION: Closed incision negative-pressure therapy (CINPT) has been shown to shorten the time to heal in post-bariatric abdominoplasty and to lower seroma rates in cosmetic abdominoplasty. The objective of this study was to assess the effect of CINPT on donor-site morbidity following abdominal-based free-flap breast reconstruction. PATIENTS AND METHODS: We reviewed medical records from 225 women who had undergone 300 microsurgical free-flap breast reconstructions from the abdomen from November 1, 2007 to March 31, 2019. Patients were grouped according to wound therapy, including 127 patients in the standard of care group and 98 patients in the CINPT group. Primary outcomes were minor (non-operative) and major (operative) surgical site complications. Secondary outcomes were time to drain removal, in-hospital length, and scar quality. RESULTS: Analysis of patient demographics showed an equal distribution with regard to the age, smoking status, prevalence of diabetes mellitus, preoperative chemotherapy, and previous abdominal surgery in both groups. Significantly more patients with obesity (29.6 vs. 15.8%; p = .01) and bilateral breast reconstruction (40.8 vs. 27.6%; p = .04) were included in the CINPT group. Compared to standard of care, the CINPT group had a lower incidence of major surgical site complications (26.0 vs. 11.2%; p = .001). There was no difference in minor surgical site complications and secondary outcomes between groups. CONCLUSION: The CINPT represents a reliable tool to reduce surgical site complications on the abdominal donor-site in abdominal-based free-flap breast reconstruction.

Evaluation of MR-neurography in diagnosis and treatment in peripheral nerve surgery of the upper extremity: A matched cohort study.

INTRODUCTION: "Watch and wait"-strategies from 3 to 6 months for peripheral nerve injuries are standard of care in specialized centers. However, this contradiction between delayed decision-making and the demand for fast reinnervation, especially of the motoric endplate, has not yet been overcome. Therefore, this study aimed to investigate the time-sparing effects by accelerated decision-making due to the complementary MR-neurography application combined with established diagnostics like electroneurography and neurosonography from the first admission to the determination of the treatment plan. PATIENTS AND METHODS: A retrospective matched-pair chart review analysis with Supplementary MR-neurography in the period between 2014 and 2017 was designed. Matching was performed by the parameters of nerve type, localization of the nerve injury, patient age, and treatment of the injury. Twenty-nine patients were included and matched in the study. MR-neurography imaging was performed by a 3T magnetic resonance imaging with a sampling perfection with application optimized contrasts using different flip angle evolution short tau inversion recovery sequence for the brachial plexus and gradient echo accurate fast imaging with steady-state free precession sequence for the upper extremity. Time to decision-making was investigated for or against a surgical intervention for patients with or without a Supplementary MR-neurography. RESULTS: In general, MR-neurography accelerated decision-making for 28 days, with results of 37.5 + 5.4 days with Supplementary MR-neurography and 65.3 + 9.7 days without Supplementary MR-neurography (p = .05). Within the first 90 days following trauma, patients with MR-neurography (38.2 ± 7.7 days) benefit under a significant faster decision-making (p = .05) than patients without MR-neurography (79.0 + 14.2 days). After 90 days, no evidence of accelerated decision-making was found with the addition of MR-neurography (p = .6). In 10 of the 29 patients, despite additional electroneurography and neurosonography, no decision could be made and the MR-neurography has been used primarily as a diagnostic tool. CONCLUSION: MR-neurography has significant time-sparing effects on the decision-making for approximately 4 weeks within the first 90 days after the trauma. This may help overcome the paradigm of "watch and wait"-strategies during the first 3-6 months after the peripheral nerve injury.

A single-center retrospective comparison of Duplex ultrasonography versus audible Doppler regarding anterolateral thigh perforator flap harvest and operative times.

INTRODUCTION: We reported on the superiority of preoperative Duplex mapping ("Duplex") over audible Dopplers ("Doppler") in anterolateral thigh perforator (ALT) free flaps for upper extremity reconstruction. To corroborate our findings on a larger cohort, we conducted this present study focusing on surgical efficiency and patient safety. METHODS: 150 consecutive ALT free flaps were divided into 65 cases of preoperative Duplex versus 85 Doppler controls. We first compared patient demographics, operative details, and defect and flap characteristics. We then assessed group differences in the number and course of perforators pursued intraoperatively, flap harvest and operative times, and donor-site complications. Additionally, the impact of the training level of the primary microsurgeon was evaluated. RESULTS: Cases and controls were comparable regarding age (p = .48), sex (p = .81), ASA class (p = .48), and BMI (p = .90). Duplex was associated with an increased likelihood of raising flaps on one single dominant perforator of purely septal course and significant reductions of flap harvest (68 ± 10 min, p < .0001) and operative times (74 ± 16 min, p < .0001), regardless of the experience of the primary microsurgeon. There were strong negative linear correlations between preoperative Duplex and both the flap harvest and operative times (p < .0001). Additionally, while there was no effect on the emergency take-back rate (OR = 1.3, p = .60), revisions were significantly less likely among duplexed patients (OR = 0.15, p = .04). CONCLUSIONS: Preoperative Duplex is associated with a significant reduction in ALT free flap harvest and overall operative times, as well as donor-site revisions as opposed to Doppler planning, regardless of the training level of the primary microsurgeon.