Subcutaneous mastectomy in female-to-male transsexuals is associated with higher risk of postoperative bleeding complications.

Introduction: Chest contouring or subcutaneous mastectomy (SCM) in female-to-male (FtM) transgender individuals is the primary surgery in the gender reassignment process. Many authors report high rates of postoperative bleeding in these patients and discuss a possible influence of preoperative hormone therapy. However, there is a lack of data on the analysis between different surgical techniques and postoperative bleeding risk. Materials and Methods: In this retrospective study, we included 22 FtM transgender individuals who underwent bilateral SCM using 4 different techniques (44 breasts) between June 2014 and September 2023. Postoperative complications regarding surgical techniques and patient demographics were collected and analyzed. Results: SCM with free nipple grafting was the most commonly used technique (n = 12, 54.5%). The mean operative time was 163.4 ± 49.2 minutes. There were no significant differences in operative time between the surgical techniques (p ≥ 0.20 in all cases). The rate of acute postoperative bleeding was 20.5% (n = 9). Acute postoperative bleeding occurred most frequently in patients who received a semi-circular incision for SCM. There was no significant difference in the rate of acute postoperative bleeding between the different surgical techniques. BMI, breast weight, and duration of surgery were not associated with the rate of acute complications (p > 0.17 in all cases). Conclusions: Less invasive SCM techniques in FtM transgender individuals are associated with higher postoperative bleeding risk.

Evaluation of the predictive value of the body-mass-index choosing perforator flaps from different donor sites.

BACKGROUND: Free flap design must fulfill different criteria to ensure functional and aesthetic reconstruction of different types of defects in different body areas. A four-dimensional planning concept was used including flap length, width, thickness and tissue composition. This study evaluates if body-mass-index (BMI) has a predictive value for flap design. METHODS: A prospective study including hospitalized patients in the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery was conducted. Not taking into account the reason for admission, the patients were examined based on age, weight, height, BMI and sex. The areas of a potential harvest of free fasciocutaneous and perforator flaps were measured using ultrasound examination to determine the thickness of the subcutaneous layers and prove blood perfusion. RESULTS: Over the period of four months, a total of 101 patients (36 females and 65 males) were included in this study and gave written consent. No statistical significance regarding the demographic data such as age, sex and BMI could be identified. An average to high correlation between free flap thickness and BMI was shown for the thoracodorsal artery perforator (TDAP), anterior lateral thigh (ALT) and deep inferior epigastric perforator (DIEP) flap in both, male and female patients. Free flaps of distal body parts such as the interosseous posterior flap, showed a lower correlation. No correlation using the Pearson coefficient could be found for age and volume. CONCLUSION: Our study demonstrated that the BMI is a predictive indicator that can be used in the preoperative planning of reconstructions using free flaps. Depending on the defect location, the BMI can be considered to predict the thickness of the free flap and may influence the surgeon's choice. On the other hand, a lower correlation between BMI and flap thickness encourages the use of standard flaps if more volume is desired, as the DIEP flap might be sufficient even in normal-weight women. Flaps of distal body parts, such as the forearm or lower leg, are not prone to such predictions and require other selection criteria.

Influence of Tamoxifen on Different Biological Pathways in Tumorigenesis and Transformation in Adipose-Derived Stem Cells, Mammary Cells and Mammary Carcinoma Cell Lines-An In Vitro Study.

Breast carcinoma is one of the most common malignant tumors in women. In cases of hormone-sensitive cells, tamoxifen as an anti-estrogenic substance is a first line medication in the adjuvant setting. The spectrum of autologous breast reconstructions ranges from fat infiltrations to complex microsurgical procedures. The influence of adipose-derived stem cells (ASC) on the tumor bed and a possibly increased recurrence rate as a result are critically discussed. In addition, there is currently no conclusive recommendation regarding tamoxifen-treated patients and autologous fat infiltrations. The aim of the present study was to investigate the effect of tamoxifen on the gene expression of a variety of genes involved in tumorigenesis, cell growth and transformation. Mammary epithelial cell line and mammary carcinoma cell lines were treated with tamoxifen in vitro as well as co-cultured with ASC. Gene expression was quantified by PCR arrays and showed increased expression in the mammary carcinoma cell lines with increasing time of treatment and concentration of tamoxifen. The data presented can be considered as an addition to the controversial discussion on the relationship between ASC and breast carcinoma cells. Further studies are needed to quantify the in vivo interaction of ASC and mammary carcinoma cells and to conclusively assess the impact of tamoxifen in reconstructive cases with fat grafting.

Complications and Disasters After Minimally Invasive Tissue Augmentation with Different Types of Fillers: A Retrospective Analysis.

BACKGROUND: The interest in youthful appearance and rejuvenating procedures is unbroken in our society. Besides surgical procedures, permanent fillers are utilized. The incorrect and unprofessional use of these substances, auto-injections in particular, have devastating results for patients and are challenging for the plastic surgeon. The aim of this retrospective study was to delineate the differences between permanent and non-permanent filler complications and appropriate treatment options. METHODS: We conducted a retrospective study and researched the hospital information system in the time period from 2001 to 2020. Patients with unprofessional use of permanent fillers, auto-injections and injections of unformulated substances were determined. Age, gender, localization, complications, length of hospital stay, comorbidities, histopathological workups and surgical salvage procedures were noted. Descriptive statistics were calculated. RESULTS: Seventeen patients were identified from 2001 till 2020. In four cases, auto-injections by the patients were the cause, whereas in the other patients the injections were performed by medical staff. Ages range from 18 to 57 years. Fourteen patients were female and three were male. The injected substances could be recognized as synthol, silicone, vaseline, fat tissue, hyaluronic acid as well as non-medical substances. Surgical procedures were necessary in eleven cases. One patient died because of the underlying diseases. CONCLUSION: Our results indicate different sequels of filler materials injected in an unprofessional way, possible complications, conservative and surgical techniques to resolve these rare complications. We suggest a staged therapy adjusted to the clinical symptoms. Milder symptoms can be handled conservatively, whereas severe infections, skin breakdowns or persistent granuloma are justifying indications for surgical treatment. LEVEL OF EVIDENCE V: 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 surgical approach to Pyoderma gangrenosum: A retrospective monocenter study.

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

Application of Critical Care Scores in Severely Burned Patients.

Early detection of sepsis is of crucial importance in patients with severe burn injuries. However, according to the S1-guideline, based on systemic inflammatory response syndrome (SIRS) criteria, the early diagnosis of sepsis in severely burned patients is difficult. The value of the new definition of sepsis based on sequential organ failure assessment (SOFA) according to S3-guidelines for patients with severe burn injuries is not described in detail in the literature. We analyzed retrospectively all data during the period 2014 to 2018 from the electronic patient information system. Using the receiver operating characteristic curve, the area under the curve was calculated for the diagnostic value of procalcitonin, SIRS, and SOFA score according to the burned total body surface area. Six hundred fifty-one patients with burn injuries were admitted to our burn unit, 315 of them had burn injuries affecting more than 10% body surface area with partial- to full-thickness burns (grade 2-4). In this group, 59 patients showed one or more septic events in the course of the intensive care treatment, defined by positive bloodstream infection. Both S1- and S3-guidelines were inappropriate to diagnose sepsis in patients with severe burn injuries. Due to pathophysiological changes of the body function in severely burned patients, which show features of both SIRS and pathological SOFA scores (>2 points) at the outset of burn injury, the diagnosis of sepsis associated with burns is intricate in this patient group. Assessing data for potential hallmarks of sepsis in burn patients we found procalcitonin to show a significant correlation with sepsis.

Hot Bathtub, Cold Consequences-Misleading Wounds After Scald Injuries: A Retrospective Analysis.

Scalds in the elderly are frequently associated with the use of a bathtub and a disturbed consciousness. Therefore, the total burn surface area is often high. The initial clinical presentation displays a stark erythema of the skin, which frequently does not represent the true depth. The aim of this study was to characterize and assess medical features and outcome of scalds sustained in the bathtub. We conducted a retrospective study at a burn intensive care unit (BICU) between 2011 and 2018. Medical features as well as the treatment in these patients were statistically analyzed. We identified 16 patients and divided them into two groups regarding survival and lethality. The mean total burn surface area was 37.50 ± 19.47%. In 81.25% of the patients, we found a previous history of neurological or psychiatric disorders. Dementia and alcohol abuse were the most common triggers for the trauma. The statistical analysis showed a significant difference for the ABSI-score and the presence of multi organ failure (P-value .0462, respectively, .0004). Erythematous skin areas tended to progress into full thickness burns. We, therefore, coined the term "lobster redness" for these regions. Scalds sustained in the bathtub are devastating injuries. Initial assessment can be misleading and might delay early necrectomy. The wounds request even more attention, if the injuries occurred due to unconsciousness because of the longer exposure to heat. Early necrectomy should be considered. A biopsy with histological workup can be useful. Furthermore, we recommend special safety precautions for neurologically and psychiatrically affected patients.

Reconstruction of Basic Hand Function by a Free Osteocutaneous Spare-Part Flap From the Lower Leg After Septicemia: A Case Report.

Background: Spare-part surgery is widely accepted and offers an option in extremely traumatized patients for reconstructive maneuvers. Standardized techniques are lacking, and the therapy needs to fit the patient's clinic. Materials and Methods: In a woman with necrosis of almost all extremities due to septic infection, we used the lower leg as a free osteocutaneous flap to reconstruct a basic hand function after amputation. The fibula segment was buried alongside the remaining first metacarpal bone. On the hand stump, 2 short metacarpals were lengthened using the remaining 2 metacarpals as osteovascular on-top plasties. The flap was microsurgically anastomosed end-to-side to the ulnar artery. After 3 months, the buried fibula was trimmed to the necessary thumb length and fixed to the local metacarpal I stump. Secondary procedures were performed to deepen the first web space. Results: The patient is now able to manage her daily life. Also, she is able to put on her prosthesis on both legs and walk without aids. Conclusions: To our knowledge, this is the first description of successful microvascular transfer of an osteocutaneous free flap from an amputated lower leg of this size and could present a valuable technique for other cases.

Expected Reduction of The Nipple-Areolar Complex Over Time After Treatment of Gynecomastia with Ultrasound-Assisted Liposuction Mastectomy Compared to Subcutaneous Mastectomy Alone.

BACKGROUND: The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia. OBJECTIVE: The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL). MATERIALS AND METHODS: A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed. RESULTS: The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=<0.001) in the SCM+UAL compared to the SCM only cohort. The mean reduction of the area in the SCM cohort was 1.60cm2 (SD 1.48) or 23.37% (SD 9.78) after 5.82 years and in the SCM+UAL cohort 2.60cm2 (SD 1.60) or 35.85% (SD 6,86) after 7.43 years. As independent significant factors for reduction of the NAC, the resection weight and SCM+UAL combination were identified. There were no significant differences regarding the patients' satisfaction measured with the BODY-Q (p=0.222) and the ordinal scale (p=0.445) between the two cohorts. CONCLUSIONS: The SCM with UAL showed a larger reduction over time of the NAC compared to the SCM independent from the stage of gynecomastia. When planning the surgical treatment of gynecomastia, a technique and resection weight dependent reduction of the NAC over time must be considered. 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 .

Epidemiologic and Molecular Investigation of a MRSA Outbreak Caused by a Contaminated Bathtub for Carbon Dioxide Hydrotherapy and Review of the Literature.

METHODS: We conducted an outbreak investigation and performed a molecular typing of the outbreak strains with pulsed-field gel electrophoresis (PFGE). In addition, we reviewed PubMed and the Outbreak Database for MRSA outbreaks related to hydrotherapy or other bathing activities. RESULTS: Four patients acquired nosocomial MRSA during the 4-week outbreak period. Environmental sampling revealed the presence of MRSA in the bathtub used for hydrotherapy. The environmental and the patients' isolates showed an indistinguishable restriction pattern in the PFGE. Subsequent discontinuation of bathing stopped the outbreak. The literature search found 9 MRSA outbreak reports related to bathing activities or hydrotherapy. CONCLUSION: The epidemiologic outbreak investigation together with the molecular findings suggests monoclonal spread of MRSA due to surface contamination of the bathtub. After enhancing the disinfection and cleaning process accompanied by staff training with respect to hand hygiene, no further cases occurred. Standardized and best practice cleaning and disinfection protocols are crucial, especially in critical facilities such as hydrotherapy units. Regular environmental sampling is helpful to monitor these processes and to detect potential contamination.

Lymphostasis and Hemostasis in Body-Contouring Surgery Using a Polysaccharide Based Hemostat (4DryField PH).

BACKGROUND: Following liposuction, abdominoplasty is the most frequent body-contouring intervention in the world. The transection of small blood vessels in large areas and subsequent bleeding is a viable risk during this procedure. The resulting microvascular bleedings should be stopped thoroughly to reduce the probability of related complications. In this prospective, monocentric, randomized study, the efficacy of the polysaccharide-based hemostat 4DryField PH (4DF) (PlanTec Medical, Lueneburg, Germany) is examined in classic abdominoplasty and lower body lift after Lockwood. METHODS: For this prospective, monocentric, randomized study, 40 patients underwent surgery for both interventions. Twenty patients received an abdominoplasty, and 20 patients underwent a body lift. In each group, 10 patients have been treated with 4DF, whereas 10 have been served as the untreated control group. RESULTS: 4DF had neither a beneficial nor a negative effect on necessity of drainages, drainage volume and duration, length of hospital stay or frequency of postoperative seromas, wound healing disturbances, and infections, independent of surgical intervention. Patients in the 4DF group, however, had more individual risk factors, and required extended surgical interventions that might mask primary outcome results. CONCLUSIONS: This is the first prospective, monocentric, randomized study on 4DF in body-contouring surgery. The use of 4DF did not lead to a better postoperative outcome regarding hemostasis and lymphostasis. Potential benefits need further evaluation in high-volume studies.

Optimal Positioning of the Nipple-Areola Complex in Men Using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line): An Intuitive Approach.

INTRODUCTION: The reconstruction of the body shape after post-bariatric surgery or high-grade gynecomastia involves, besides skin tightening, the repositioning of anatomical, apparent landmarks. The surgeon usually defines these during the preoperative planning. In particular, the positions of the nipple-areola complexes (NAC) should contribute to the gender-appropriate appearance. While in the female breast numerous methods have been developed to determine the optimal position of the NACs, there are only a few, metric and often impractical algorithms for positioning the nipples and areoles in the male. With this study, we show the accuracy of the intuitive positioning of the nipple-areola complex in men. MATERIAL AND METHODS: From a pre-examined and measured quantity of 10 young and healthy men, six subjects were selected, which corresponded, on the basis of their chest and trunk dimensions, to the average of known data from the literature. The photographed frontal views were retouched in two steps. Initially, only the NACs were removed and the chest contours were left. In a second step, all contours and the navel were blurred. These pictures were submitted to resident and consultant plastic surgeons, who were asked to draw the missing NACs without any tools. The original positions of the nipples were compared with the inscriptions. Furthermore, the results were compared between the contoured and completely retouched pictures and between the residents and consultants. RESULTS: A total of 8 consultants and 7 residents were included. In the contoured and completely retouched images, a significant deviation of the marked positions of the missing features was found. The height of the NAC was determined somewhat more precisely than the vertical position. There was no significant difference between the contoured and completely retouched images, with a discretely more accurate tendency on the contoured images. In comparison with the professional experience, the consultants were tangentially more precise, but without a statistically significant impact. DISCUSSION: The intuitive determination of the NACs is a challenge for the plastic surgeon. In this study, a statistically significant deviation was seen in almost all dimensions, although the clinical relevance cannot be conclusively assessed. We found a positional relationship of the NAC to the infraclavicular groove ("Mohrenheim pit") in the vertical and 4-4.5 cm above the submammary fold. The position of the NAC can be satisfactorily determined by a combination of plastic surgical intuition, patient wishes and practical metric methods using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line). LEVEL OF EVIDENCE V: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Biobrane versus topical agents in the treatment of adult scald burns.

BACKGROUND: Limited data is available for treatment of scald lesions in adults. The use of the biosynthetic matrix Biobrane® has been suggested as treatment option with more benefits over topical dressings. Application of Biobrane® in scalds in our center led to a perceived increase of infection, secondary deepening, surgery and length of stay. We therefore assessed the effect of different treatment options in adult scalds in our center. METHODS: We performed a retrospective cohort study of adult patients that have been admitted with scalds in our center between 2011 and 2014. We assessed two groups, group 1 with Biobrane® as initial treatment and group 2 with topical treatment using polyhexanid hydrogel and fatty gauze. Primary outcome variables were rate of secondary deepening, surgery, infection (defined as positive microbiological swabs and antibiotic treatment) and length of stay. Total body surface area (TBSA) as well as diabetes mellitus (DM), hypertension, smoking and alcohol consumption as potential confounders were included. RESULTS: A total of 52 patients were included in this study. 36 patients received treatment with Biobrane® and 16 with ointment and fatty gauze. No significant differences were found for age and TBSA whereas gender ratio was different (25/11 male/female in group 1 vs 4/12 in group 2, p=0.003). Rate of secondary deepening, surgery, infection as well as days of hospital stay (DOHS) were comparable. Logistic and multilinear regression showed TBSA to be a predictive factor for infection (p=0.041), and TBSA and age for length of stay (age p=0.036; TBSA p=0.042) in group 1. CONCLUSION: The use of Biobrane® in adult scald lesions is safe and non-inferior to topical treatment options. In elder patients and larger TBSA Biobrane® may increase the risk of infection or a prolonged stay in hospital. LEVEL OF EVIDENCE: Level 3 - retrospective cohort study.

Ten Years' Follow-Up on Combined Palmar and Dorsal Internal Fixation of Complex Distal Radius Fractures.

Complex distal intra-articular radial fractures (AO Type C3) are rare, but are life-changing injuries. They are usually related to high-velocity trauma mechanisms in a working male population.We surveyed a cohort of these fractures treated in our institution to assess the functional long-term outcome.Twelve consecutive patients with comminuted intra-articular distal radial fractures were treated at our institution. Osteosynthesis was performed by a single senior surgeon with volar and dorsal extended approaches. The intermediate and final control included conventional X-ray, range of motion (ROM), grip strength, and the Disabilities of the Arm, Shoulder, and Hand index (DASH), as well as the Patient-rated Wrist Evaluation (PRWE) score for functional outcome at 1 and 10 years' of follow-up.At 10 years' follow-up, anatomic reconstruction with a step or gap of <1 mm was achieved in 10 of the 12 above-mentioned patients, whereas 2 patients were lost to follow-up. ROM was good to excellent in 8 patients. Median grip strength was 107% of the contralateral side. Median DASH-Index and PRWE were 2.3 and 6 respectively, at 10 years. Eight patients returned to premorbid heavy labor. One patient was retired at the time of injury.Combined volar and dorsal approaches allow achieving anatomical reconstruction in comminuted intra-articular distal radius fractures and reveal good functional outcomes at intermediate and long-time follow-up.