Systemic Tranexamic Acid for Reduced Postoperative Blood Loss and Less Bleeding Complications in Fleur-de-lis Abdominoplasty and Apronectomy.

BACKGROUND: Strategies minimizing surgical bleeding, including the antifibrinolytic agent tranexamic acid, play a crucial role in clinical practice to optimize overall surgical outcomes. Despite its proven efficacy in various clinical fields, there is a limited understanding regarding the use of tranexamic acid in plastic and aesthetic procedures. This study is the first investigating the effects of systemically administered tranexamic acid on postoperative blood loss and bleeding complications in fleur-de-lis abdominoplasties and apronectomies. METHODS: Patients who received 1 g tranexamic acid (n = 44) during fleur-de-lis abdominoplasty or apronectomy were retrospectively compared with those who did not (n = 44). In this context, the outcome parameters 24-h and total drain fluid production, drain time, hospital stay, absolute and relative drop in hemoglobin and hematocrit level as well as bleeding complications such as blood transfusion, hematoma puncture and evacuation were evaluated. RESULTS: Tranexamic acid significantly decreased both drainage volume in 24 h (40.5%, p = 0.0046) and total drain fluid production (42.5%, p = 0.0017). Moreover, a shorter drainage time (19.4%, p = 0.0028) and hospital stay (21.4%, p = 0.0009) were observed. The administration of tranexamic acid was also associated with a reduced postoperative decline in hemoglobin and hematocrit levels. Notably, no bleeding complications were observed in patients who received tranexamic acid, while 6 events occurred in patients without (p = 0.0262). CONCLUSION: Systemic administration of tranexamic acid effectively reduced postoperative blood loss and bleeding complications in fleur-de-lis abdominoplasties and apronectomies. 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 .

[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / "Wahl der Lappenplastik zur Phalloplastik ­ was ist zeitgemäßer Standard" ­ Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

A Single-Center 10-Year Experience of 180 Transmasculine Patients Undergoing Gender-Affirming Mastectomy While Continuing Masculinizing Hormone Replacement Therapy.

BACKGROUND: Gender-affirming mastectomy is a fundamental step in the transition process of transmasculine patients following the initiation of hormone replacement therapy. Its perioperative management, however, remains underreported and controversial. In this study, a large series of mastectomies in transmen maintaining hormonal therapy is presented. METHODS: Over a 10-year study period, a consecutive series of 180 transmasculine patients undergoing chest masculinizing surgery was evaluated. Demographical and surgical data were collected and analyzed for potential factors influencing outcome. RESULTS: The overall rate of complications was 15.5%. Patients who underwent periareolar incision mastectomy were significantly more likely to develop any type of complication than patients with a sub-mammary incision (28.6% vs. 13.2%, p = 0.045). Hematoma was the most common reason for surgical revision. It occurred significantly more often among the periareolar group (21.4% vs. 7.9%, p = 0.041). Duration and type of hormonal therapy did not differ between patients with or without complications. In a multivariate regression analysis, smoking and type of incision were identified as significant predictors of the all-cause complication rate, whereas the influence of BMI and resection weight diminished after adjusting for confounding factors. CONCLUSION: There is scarcity of information concerning the influence of perioperative hormonal therapy in patients undergoing chest wall masculinization. The observed complication rates-with special regard to hematoma-were comparable to current reports; yet further research is needed to profoundly evaluate this topic and provide evidence-based recommendations for the perioperative management of HRT of transmasculine patients. 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 .

Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique.

BACKGROUND: Phalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique. AIM: To evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients. METHODS: Between 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients' demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other. RESULTS: Patients' demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision. CLINICAL IMPLICATION: Optimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty. STRENGTHS & LIMITATION: This retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far. CONCLUSION: The Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty. Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661-668.

Air Flow Cooling Improves Anterolateral Thigh Perforator Mapping Using the FLIR ONE Thermal Camera.

BACKGROUND: Due to the variable vascular anatomy preoperative perforator mapping facilitates anterolateral thigh (ALT) free flap harvesting. Dynamic infrared perforator imaging can assist preoperative planning by displaying hot spots that represent angiosomes. This study aims to compare previously described precooling methods to develop a standardized simplified protocol for ALT perforator planning. METHODS: Fifty thighs were examined with a FLIR ONE thermal camera. Four different cold challenges, including alcoholic disinfection, wet laparotomy sponge cooling, fan cooling, and cold pack application, were compared. Hot spot locations within a 250 mm × 80 mm area were compared double-blinded to perforator locations determined by Doppler ultrasonography considered as gold standard. RESULTS: The matching rate of thermographic hot spots and sonographically identified perforators was 34.9 ± 22.2%. An increased matching rate of 62.2 ± 42.2% was noted taking only favored perforators (septocutaneous course, diameter >1 mm, distance <3 cm to the center, and visible concomitant veins) into account. Precooling with a fan followed by alcoholic disinfection provided clearest thermograms and fastest results. CONCLUSION: Thermographic imaging is a reliable method for perforator imaging. Its supplemental use to ultrasound may reduce examination time and yield additional information. Precooling by air flow or alcoholic disinfection can be easily implemented and provide the best thermograms. The matching rate of thermographic hot spots and perforators increases when taking only clinically relevant perforators into account. Thermal perforator mapping therefore reduces distraction by negligible perforators.

Implant Replacement or Removal: What Happens after Capsular Contracture? A German Study Examining Breast Implant Revision Surgery and Patient Choices in 946 Cases.

INTRODUCTION: Capsular contracture most often leads to implant revision surgery for aesthetic or reconstructive purposes. However, little is known about which operation is chosen when revision surgery has to be performed. We performed analysis of revision indications and performed revision surgery considering implant removal or replacement and additional surgical procedures. To our knowledge, this study presents the largest German single-center analysis regarding implant revision surgery after the onset of complications. METHODS: Retrospective 10-year data analysis of a single-center population undergoing breast implant revision surgery. RESULTS: Capsular contracture was the most frequent finding before reoperation, both removal and replacement (p < 0.05). It was linked to longer duration of in situ implant placement (p < 0.05) and more frequently in reconstructive patients (p < 0.05). Implant replacement was performed more often before definite implant removal for reconstructive patients (p < 0.05). Mean duration of in situ implant placement before definite removal was lower for reconstructive patients (p = 0.005). Overall reconstructive patients were older than aesthetic patients (p < 0.05). After implant removal, 61.7% of aesthetic patients chose to undergo mastopexy, 54.7% of reconstructive patients opted for autologous breast reconstruction, and 25.4% did not choose an additional surgical procedure after implant removal. CONCLUSION: Significant differences are observed for reconstructive and aesthetic patients regarding indication leading to revision surgery, time of revision surgery, and the type of performed revision surgery itself. After implant removal, more than 60% of aesthetic patients undergo mastopexy, more than half of reconstructive patients choose autologous breast reconstruction, and over a quarter of patients choose no additional surgical procedures.

Otoplasty through Ventral Skin Incision and Shaping of the Antihelix by Abrasion-A Retrospective Study.

(1) Background: Protruding ears are the most common auricular malformation affecting approximately 5% of the population. One common factor leading to auricular protrusion is a deficiency or total absence of the antihelix. A technique first described by Gottfried Lemperle in 2003 attempts cartilage thinning, folding, and fixation by non-absorbable mattress sutures after ventral skin incision along the ventral helical rim. (2) Methods: Retrospective analysis of patient records was performed for otoplasties according to this technique, performed between 1985 and 2014 at Agaplesion Markus Hospital in Frankfurt, Germany. All recorded complications were examined. (3) Results: A total of 912 single otoplasties were performed according to this technique from 1985 to 2014. Overall complications included 26% minor complications not requiring further surgery and 11% major complications leading to revision surgery. Within those requiring revision surgery, the most common reason was recurrence of auricular protrusion (5%), followed by suture granulomas (5%) and hematomas (2%). (4) Conclusions: Lemperle's otoplasty technique addresses the open thinning and shaping of the antihelix through a ventral incision along the helix to prevent irregularities and possible ridges. Results show a low complication rate comparable to data found in published studies. This technique is easy to perform, safe, and avoids often seen contour irregularities of the antihelix compared to techniques with a posterior approach.

The role of near-infrared fluorescence imaging with indocyanine green dye in pedicle division with the paramedian forehead flap.

The paramedian forehead flap is considered the gold standard for nasal reconstruction following oncologic surgery. During the 21-day delay in two-stage surgery protocols, many patients report considerably reduced quality of life because of the pedicle. This prospective case series study examined the usefulness of near-infrared (NIR) fluorescence with indocyanine green (ICG) for flap perfusion assessment and identified variables associated with time to flap perfusion. Ten patients (mean age 75.3 ± 11.6 years) with diagnosis of basal cell carcinoma (n = 9) or squamous cell carcinoma (n = 1) underwent intravenous indocyanine injection and NIR fluorescence imaging for assessment of flap vascularisation 2 to 3 weeks after stage 1 surgery. NIR fluorescence imaging showed 90% to 100% perfusion areas in all patients after 14 to 21 days. Early pedicle division occurred in two patients on postoperative days 14 and 16. One minor complication (wound healing disorder) was seen following flap takedown after 14 days. There were no associations between time to flap perfusion and defect size or flap area. NIR fluorescence imaging with ICG dye is a useful method for non-invasive perfusion assessment when used in conjunction with clinical assessment criteria. However, a decision for early pedicle division may raise risk of complications in specific patient groups and must therefore be made with great care.

A Training Model for Local Flaps Using Fresh Human Skin Excised During Body Contouring Procedures.

BACKGROUND: The safe execution of local flaps tends to be challenging for surgical residents. Thus, the purpose of the study was to evaluate a training model of local flaps based on fresh human skin excised from body contouring procedures. MATERIALS AND METHODS: A questionnaire and surgical skills evaluation-analyzing the theoretical and procedural knowledge about local flaps-were held both before and after the surgical skills training. All surgical procedures were executed on a simulation model based on fresh human skin. Skills evaluation was done according to a modified version of the Objective Structured Assessment of Technical Skills Score. Results before and after the training were compared using SPSS, version 21. RESULTS: In pretraining evaluation, residents showed great difficulty regarding the accuracy of flap design and sufficiency of wound coverage indicating the need for surgical training outside the operating theater. After training, the procedural skills significantly improved as depicted by the modified Objective Structured Assessment of Technical Skills score with a mean cumulative pretraining score of 26.81 ± 5.41 and posttraining score of 43.59 ± 5.72 (P = 0.008). Also, theoretical knowledge significantly improved in the posttraining evaluation with exception to the indication of a Z-plasty (P = 0.257). The training model itself was generally regarded as highly useful and thus recommendable to others. CONCLUSIONS: Surgical handling and the understanding of tissue rotation clearly improved by the presented model which mimics very realistic conditions. The simulation model based on fresh human skin shows cost-effectiveness and allows a broad range for flap procedures wherefore its use should be further promoted.

Bilateral reduction mammaplasty with pulsed electron avalanche knife PlasmaBlade™ and conventional electrosurgical surgery: A retrospective, randomised controlled clinical trial.

Wound-healing disorders are common complications in bilateral reduction mammaplasty. Traditional electrosurgical devices generate large amounts of thermal energy, often causing extensive thermal-related collateral tissue damage. This study aimed to retrospectively analyse the operative performance of a novel low-thermal plasma dissection device (pulsed electron avalanche knife-PEAK PlasmaBlade™) compared with traditional electrosurgery. Twenty patients with breast hypertrophy were randomly treated with PEAK PlasmaBlade™ on one breast and conventional electrosurgery on the other. Primary outcome measures were resection weight, drain duration, total drainage volume, and drain output on the first postoperative day. Breasts treated with PEAK PlasmaBlade™ had significantly higher resection weights (728.0 ± 460.1 g vs 661.6 ± 463.4 g; P = .038), significantly lower drain output on the first postoperative day (15.9 ± 15.2 mL vs 27.6 ± 23.5 mL; P = .023), and significantly lower drain durations (2.8 ± 1.0 days vs 3.3 ± 1.0 days; P = .030). Mean total drainage volume was lower where breast reduction was performed with PEAK PlasmaBlade™, but this difference was not significant. No major complications occurred, but wound-healing disorders were documented in almost one-third of the patients (35.0%, n = 7). The PEAK PlasmaBlade™ seems to be superior to conventional electrosurgery for bilateral reduction mammaplasty in terms of tissue damage and wound healing.

[Successful free microvascular radial artery flap for phalloplasty in case of a persistent median artery - Retrospective analysis of 48 patients and review of the literature]. / Erfolgreiche freie mikrovaskuläre A. radialis-Lappenplastik zur Phalluskonstruktion bei persistierender A. mediana (PMA).

BACKGROUND: Anomalies of the radial arterial system can be of importance during harvesting of a radial forearm flap. In particular when using the forearm flap for phalloplasty due to the required dimensions of the flap, sufficient arterial supply is of fundamental importance. In case of a persistent median artery perfusion conditions in the supply area of ​​the A. radialis and the A. ulnaris may have been altered or even completely regressed. METHODS: A retrospective evaluation of all phalloplasties performed in our institution was carried out from January 2016 to December 2018. In all patients technique according to Gottlieb and Levine or Chang was applied. RESULTS: In the retrospectively evaluated population of 48 patients, a persistent arteria mediana was found intraoperatively in two patients, corresponding to an incidence of 4.2 %. In both patients, the phalloplasty was accomplished without restriction of flap perfusion or hand perfusion. A review of the literature provides an overview of the incidence of aberrant vascularization of the forearm and the consequences that can be derived for the planning of a radial artery flap. CONCLUSION: Variations in the arterial anatomy of the forearm, as the presence of a persistent median artery, are sufficiently common to warrant careful preoperative evaluation when planning a free vascularized forearm flap for reconstructive surgery. The preoperative performed Allen-test provides no clear inference possibility and therefore often requires intraoperative random findings. The reconstructive surgeon should be aware of these possible variations because it can affect the harvest and the survival of the forearm flap as well as causing ischaemia of the hand.

Effect of low-thermal dissection device versus conventional electrocautery in mastectomy for female-to-male transgender patients.

Subcutaneous mastectomy, the first step in sexual reassignment surgery of female-to-male transsexuals, is associated with high rates of complication and revision surgery. Also, conventional electrosurgery and the associated thermal tissue damage may compromise outcome. This retrospective randomised clinical study evaluated the effect of low-thermal plasma dissection device (PEAK PlasmaBlade, Medtronic, Minneapolis, Minnesota) in comparison with conventional electrosurgery. A total of 17 female-to-male transsexuals undergoing mastectomy were randomised to PEAK PlasmaBlade on one breast side and to monopolar electrosurgery on the other side of the same patient. Wounds of 17 patients were examined histologically for acute thermal injury. Significantly less total volume of drain output (58.8 ± 37.4 mL vs 98.5 ± 76.4 mL; P = .012) was found on the PEAK PlasmaBlade side compared with the electrosurgery side. Duration of drain was significantly shorter on the PEAK PlasmaBlade side (2.5 ± 0.7 days vs 3.2 ± 0.6 days; P = .010). Furthermore, the PEAK PlasmaBlade side showed fewer thermal damages (41.2% vs 82.4%; P = .039) and thermal injury depth from PEAK PlasmaBlade side was less (3170 vs 4060 µm). PEAK PlasmaBlade appears to be superior to monopolar electrosurgery for mastectomy in female-to-male transsexuals, because it demonstrated less thermal tissue damage, less total volume of drain output, and shorter duration of drain, resulting in faster wound healing.

Microsurgical Phalloplasty in Nontranssexual Patients - Considerations After a Retrospective Single-center Analysis of 23 Cases.

OBJECTIVE: To evaluate the outcome of a single-center series of penile reconstruction using the radial free forearm flap in rare indications. MATERIALS AND METHODS: From April 1993 until September 2016, 23 nontranssexual patients underwent phallic reconstruction by the use of a neuromicrovascular free radial forearm flap in our clinic. Patient-specific characteristics, surgical techniques, complications, and outcomes were retrospectively evaluated and interpreted. RESULTS: The indications for surgery were: disorders of sex development (34.8%), reconstruction after oncologic surgery (34.8%), automutilation (8.7%), iatrogenic (8.7%), microphallus (8.7%), and 1 case of priapism (4.3%). Two patients (8.7%) had a total flap necrosis and 2 patients (8.7%) had a partial flap necrosis; 3 out of these 4 patients were heavy smokers. Urinary fistulae and strictures were frequent but were successfully managed by urologists in all cases. There was no statistically significant correlation between smoking, comorbidities, number of venous anastomoses, and complications. CONCLUSION: In departments experienced in microsurgery, the goals of penile reconstruction could also be achieved in patients with rare indications by the use of the neuromicrovascular free radial forearm flap. Despite the high rate of postoperative complications, penile reconstruction with the free radial forearm flap yields satisfying results. An intensive cooperation between the plastic-reconstructive team and the urological team is a prerequisite to achieve the best surgical result.

The acute impact of local cooling versus local heating on human skin microcirculation using laser Doppler flowmetry and tissue spectrophotometry.

INTRODUCTION: Knowledge of thermally induced skin injury has increased, but its pathophysiology remains unclear. Although it is assumed that local cooling may protect tissue, little is known about the impact of local heating on human skin. This study aimed to evaluate acute skin perfusion dynamics following thermal stimuli in healthy human volunteers. MATERIAL AND METHODS: In 54 subjects, a TSA-II-NeuroSensory Analyzer was used to induce local hypothermia (15 °C and 5 °C) and local hyperthermia (40 °C and 45 °C) at the palmar forearm of healthy volunteers. Changes in tissue microcirculation were assessed using an O2C device before and after each temperature change. RESULTS: Blood flow and velocity values showed a continuous decrease with decreasing skin temperature, whereas haemoglobin oxygen saturation (SO2) showed a continuous increase in superficial (2 mm) and deep layers (8 mm). With increasing skin temperature, flow, SO2 and velocity increased in the superficial and deep layers. The relative amount of haemoglobin (rHB) did not show a continuous alteration. DISCUSSION: Local cooling may protect damaged tissue due to increased SO2 (lower oxygen consumption). However, reduced blood flow and velocity in response to local cooling limit nutrient requirements and the transport of metabolites. Despite higher oxygen consumption of tissue at higher temperatures, both blood flow and SO2 increase. Thus, we hypothesize that not only hypothermia but also hyperthermia may provide tissue protection.

A quantitative study of hydration level of the skin surface and erythema on conventional and microclimate management capable mattresses and hospital beds.

BACKGROUND: In addition to pressure itself, microclimate factors are gaining more attention in the understanding of the development of pressure ulcers. While there are already various products to reduce pressure on sore-prone areas to prevent pressure ulcers, there are only a few mattresses/hospital beds that actively influence skin microclimate. In this study, we investigated if microclimate management capable mattresses/hospital beds can influence skin hydration and skin redness/erythema. METHODS: We included 25 healthy subjects in our study. Measurements were made using Courage & Khazaka Multi Probe Adapter MPA with Corneometer CM825 and Mexameter MX18 to determine skin hydration of the stratum corneum and skin redness/erythema before and after the subjects were lying in conventional (Viskolastic® Plus, Wulff Med Tec GmbH, Fedderingen, Germany and Duo™ 2 mattress, Hill-Rom GmbH Essen, Germany) or microclimate management capable mattresses/hospital beds (ClinActiv + MCM™ and PEARLS AFT, Hill-Rom GmbH Essen, Germany). RESULTS: While there was no difference in skin redness/erythema on the different mattresses/hospital beds, skin hydration of the stratum corneum decreased significantly in an air fluidized bed compared to baseline values and values measured on standard mattress/Viskolastic® Plus. CONCLUSION: Air-fluidized therapy reduces skin hydration and therefore could contribute to prevent moisture associated ulcers. Changes in skin hydration as one important factor of skin microclimate can be detected after a short time of incubation and even before an erythema appears.

A quantitative study of transepidermal water loss (TEWL) on conventional and microclimate management capable mattresses and hospital beds.

BACKGROUND: Transepidermal water loss (TEWL) is regarded as one of the most important parameters characterizing skin barrier integrity and has found to be higher in impaired skin barrier function. Reduced or low TEWL instead indicates skin barrier integrity or improvement. We evaluated if different mattresses/hospital beds can influence this skin barrier function by measuring TEWL before and after subjects lying in conventional and microclimate management capable mattresses/hospital beds. METHODS: We included 25 healthy subjects in our study. Measurements were made using Courage & Khazaka Multi Probe Adapter MPA with Tewameter TM300 to determine TEWL before and after the subjects were lying in conventional (Viskolastic® Plus, Wulff Med Tec GmbH, Fedderingen, Germany and Duo™ 2 mattress, Hill-Rom GmbH Essen, Germany) or microclimate management capable mattresses/hospital beds (ClinActiv + MCM™ and PEARLS AFT, Hill-Rom GmbH Essen, Germany). RESULTS: While there was no statistically significant difference in standard mattresses/hospital beds (22.19 ±â€¯12.99 and 19.80 ±â€¯11.48 g/hm2), the decrease of TEWL was statistically significant in both microclimate management capable mattresses/hospital beds we investigated (16.89 ±â€¯8.586 g/hm2 and 17.41 ±â€¯7.203 g/hm2) compared to baseline values (35.85 ±â€¯24.51 g/hm2). CONCLUSION: As higher TEWL announces impaired skin barrier function these findings indicate that the choice of the mattress/hospital bed is important for skin barrier function and microclimate management systems improve skin barrier function of the skin.

Elastic Wrapping of Lower Extremity Free Flaps during Dangling Improves Microcirculation and Reduces Pain as well as Edema.

BACKGROUND: Free tissue transfer has become a common and safe reconstructive procedure. However, total or partial flap losses remain a looming threat, especially for lower extremity free flaps due to the gravitational challenge associated with dependency. Thus, the majority of microsurgical centers apply some kind of structured flap training. However, due to the lack of evidence, these differ greatly, for example, in the application of an elastic wrapping during dangling. Therefore, the aim of this study was to assess the impact of an elastic wrapping on free flap microcirculation, edema, and pain during dangling. METHODS: Standardized dangling was performed from postoperative day (POD) 6 to 9 in 30 patients with microvascular reconstruction of the lower extremity. The first dangling per day was performed without elastic wrapping, followed by another session with 30 mm Hg of elastic wrapping. Tissue oxygen saturation (StO2), regional hemoglobin content (rHb), and blood flow (BF) were continuously measured in the free flap; the circumference of the flap as well as pain was assessed. RESULTS: During wrapped dangling, BF as well as StO2 was significantly increased, while rHb was significantly lower on all PODs. Wrapped dangling was rated significantly more comfortable and the girth of the free flaps was significantly less after wrapped dependency when compared with unwrapped dangling. CONCLUSION: Dangling with an elastic wrapping with 30 mm Hg pressure improved flap microcirculation and reduced pain and edema formation.

A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity.

BACKGROUND: Lower extremity reconstruction has always been a challenge. Some of the published articles had a major impact on the field but are often not considered as classics because they have fewer citations. We therefore conducted a scientometric analysis of the most cited articles with a focus solely on the lower limb. METHODS: A search was conducted on Medline, the Web of Science database, Google Scholar, and Scopus identifying articles relevant to reconstructive surgery of the lower limb. All journals were included with no time frames. Articles relating solely to orthopedics or vascular reconstruction were excluded. The number of citations obtained were then plotted and compared between the different search engines. The mean citation number was calculated by taking into consideration the total number of years since the article's first year of publication. Articles were then ranked and classified according to their authors, their years of publications, and their countries. They were furthermore categorized and analyzed. RESULTS: Highly cited articles were easily retrieved with Google Scholar, mostly published in Plastic and Reconstructive Surgery (n = 37) and were mainly authored by American Medical Centers (n = 22). Fifty-four percent (54%) of these classic articles discussed the design of new flaps or were anatomical studies. CONCLUSIONS: We were not able to find a correlation between the year of citation and the number of citations. The citation pattern of a paper cannot be predicted, but a majority of highly cited article allowed the design of new reconstructive techniques.

Quantitative Analysis of Heel Skin Microcirculation Using Laser Doppler Flowmetry and Tissue Spectrophotometry.

OBJECTIVE: To examine perfusion changes in the heel skin of individuals with and without diabetes mellitus to understand how skin is pathologically affected by diabetes mellitus. METHODS: This case-control study was conducted at an academic hospital in Tuebingen, Germany. A total of 30 subjects were enrolled in the study: 15 with known type 2 diabetes mellitus and 15 without. Each subject was asked to lie in a supine position on a hard lateral transfer mat for 10 minutes. MAIN OUTCOME MEASURES: Heel perfusion was quantitatively assessed directly after relief of pressure and after 3 and 6 minutes after relief of pressure using laser Doppler flowmetry and tissue spectrophotometry. MAIN RESULTS: Directly after relief of pressure, blood flow increased in the superficial skin layers (2 mm below the surface of the skin) in both groups. However, in deep skin layers (8 mm below the surface of the skin), blood flow increased in patients with diabetes mellitus and decreased in healthy patients. Oxygen saturation (SO2) was higher in healthy subjects directly after pressure relief. CONCLUSIONS: The increase in blood flow in superficial skin layers indicates reactive hyperemia after exposure in both groups. The prolonged hyperemia in deep skin layers in patients with diabetes indicates increased tissue vulnerability. Despite the increase in blood flow in deep skin layers, the SO2 and thus supply of tissue in patients with diabetes were reduced.

Quantitative impact analysis of remote ischemic conditioning and capsaicin application on human skin microcirculation.

BACKGROUND: Improvement of skin microcirculation would be beneficial in transplanted tissues and thus, there is a demand for effective, reliable and harmless angiogenic treatments. The aim of this study was to assess the effect of capsaicin application (CA), the remote effect of capsaicin application (REC), the impact of remote ischemic conditioning (RIC), and the impact of combined remote ischemic conditioning with capsaicin application (Comb) on human skin microcirculation. METHODS: Perfusion changes were assessed using a laser Doppler device (easyLDI, Aimago Lausanne). 30 healthy volunteers were enrolled and divided into two groups: 1) CA and REC: perfusion was assessed on both forearms after application of capsaicin cream on one forearm with an exposure time of 40 minutes. 2) RIC and Comb: perfusion of one forearm was assessed after four cycles of 5 min blood occlusion and 5 min reperfusion using a tourniquet on the contralateral upper arm and application of capsaicin on the ipsilateral forearm. Baseline skin perfusion measurements of both forearms were carried out initially and were used as intra-individual reference. RESULTS: 1) Skin perfusion significantly increased after capsaicin application (CA = +328.3% , p > 0.05). There was no remote skin perfusion change due to capsaicin (REC). 2) RIC significantly improves skin perfusion (RIC = +20.0% , p < 0.05). The combination of RIC and CA does not improve skin perfusion compared to CA alone (Comb). CONCLUSIONS: The conditioning techniques RIC and CA showed a significant increase in human skin perfusion, CA being superior to RIC. However, the combination of CA and RIC showed no additional improvement potential as compared to CA alone. Furthermore, a remote effect of capsaicin application could not be demonstrated. These results encourage to analyze if the conditioning treatments are also beneficial for transplanted tissue survival.