The Vascularized Fibula as Salvage Procedure in Extremity Reconstruction: A Retrospective Analysis of Time to Heal and Possible Confounders.

The vascularized fibula transfer is a well-established technique for extremity reconstruction, but operative planning and patient selection remains crucial. Although recently developed techniques for bone reconstruction, such as bone segment transfer, are becoming increasingly popular, bone defects may still require vascularized bone grafts under certain circumstances. In this study, 41 cases, 28 (68%) men and 13 (32%) women (median age: 40 years), were retrospectively analyzed. Therapy-specific data (flap vascularity [free vs. pedicled] size in cm and configuration [single- vs. double-barrel], mode of fixation [internal/external]) and potential risk factors were ascertained. Indications for reconstruction were osteomyelitis at host site (n = 23, 55%), pseudarthrosis (n = 8, 20%), congenital deformity (n = 6, 15%), traumatic defect, and giant cell tumor of the bone (n = 2, 5% each). Complete healing occurred in 34 (83%) patients after a median time of 6 months. Confounders for prolonged healing were female gender (p = 0.002), reconstruction in the lower limb (p = 0.011), smoking (p = 0.049), and the use of an external fixator (p = 0.009). Six (15%) patients required secondary limb amputation due to reconstruction failure, and one patient had persistent pseudarthrosis at last follow-up. The only risk factor for amputation assessed via logistic regression analysis was preexisting PAOD (peripheral artery occlusive disease; p = 0.008) The free fibula is a reliable tool for extremity reconstruction in various cases, but time to full osseous integration may exceed six months. Patients should be encouraged to cease smoking as it is a modifiable risk factor.

Modeling Wound Chronicity In Vivo: The Translational Challenge to Capture the Complexity of Chronic Wounds.

In an aging society with common lifestyle-associated health issues such as obesity and diabetes, chronic wounds pose a frequent challenge that physicians face in everyday clinical practice. Therefore, nonhealing wounds have attracted much scientific attention. Several in vitro and in vivo models have been introduced to deepen our understanding of chronic wound pathogenesis and amplify therapeutic strategies. Understanding how wounds become chronic will provide insights to reverse or avoid chronicity. Although choosing a suitable model is of utmost importance to receive valuable outcomes, an ideal in vivo model capturing the complexity of chronic wounds is still missing and remains a translational challenge. This review discusses the most relevant mammalian models for wound healing studies and provides guidance on how to implement the hallmarks of chronic wounds. It highlights the benefits and pitfalls of established models and maps out future avenues for research.

Unlocking longevity: the role of telomeres and its targeting interventions.

Average life expectancy has been steadily increasing in developed countries worldwide. These demographic changes are associated with an ever-growing social and economic strain to healthcare systems as well as society. The aging process typically manifests as a decline in physiological and cognitive functions, accompanied by a rise in chronic diseases. Consequently, strategies that both mitigate age-related diseases and promote healthy aging are urgently needed. Telomere attrition, characterized by the shortening of telomeres with each cell division, paradoxically serves as both a protective mechanism and a contributor to tissue degeneration and age-related ailments. Based on the essential role of telomere biology in aging, research efforts aim to develop approaches designed to counteract telomere attrition, aiming to delay or reduce age-related diseases. In this review, telomere biology and its role in aging and age-related diseases is summarized along with recent approaches to interfere with telomere shortening aiming at well- and healthy-aging as well as longevity. As aging research enters a new era, this review emphasizes telomere-targeting therapeutics, including telomerase activators and tankyrase inhibitors, while also exploring the effects of antioxidative and anti-inflammatory agents, along with indirectly related approaches like statins.

Tattoo Pigment Biokinetics in vivo in a 28-Day Porcine Model: Elements Undergo Fast Distribution to Lymph Nodes and Reach Steady State after 7 Days.

INTRODUCTION: Pigments of tattoo inks may over time migrate to other parts of the body. Inks kinetics are still poorly understood and little studied. The aim of this first study was to investigate the kinetics of tattoo inks pigment in tattooed porcine skin, which is closer to human skin than mouse skin studied in the past. METHODS: Three animals were tattooed on the inner thigh and one animal served as untreated control. Skin biopsies were taken on days 7, 14, and 28 after tattooing. Animals were sacrificed on day 28 and homogenate samples of the liver, spleen, kidney, and brain, as well the local lymph nodes were prepared. All samples were analyzed for ink components using inductively coupled plasma-mass spectrometry. The ink itself was characterized by dynamic light scattering and matrix-assisted laser desorption-ionization mass analysis. RESULTS: Titanium (212 g/kg), copper (6 mg/kg), aluminum (1 mg/kg), zirconium (1 mg/kg), and chromium (3 mg/kg) were found in the ink. Significant deposits of ink elements were detected in the tattooed skin when compared to non-tattooed skin from the same animal (mean ± standard deviation: titanium 240 ± 81 mg/kg, copper 95 ± 39 mg/kg, aluminum 115 ± 63 mg/kg, zirconium 23 ± 12 mg/kg, and chromium 1.0 ± 0.2 mg/kg; p < 0.05). Lymph node concentrations of titanium, copper, aluminum, zirconium, and chromium were 42 ± 2 mg/kg, 69 ± 25 mg/kg, 49 ± 18 mg/kg, 0.3 ± 0.2 mg/kg, 0.5 ± 0.2 mg/kg, respectively. CONCLUSION: Deposits in skin were unchanged from days 7-28 indicating no redistribution or elimination. No significant deposits of ink elements were found in the liver, spleen, kidney, and brain. In conclusion, our findings confirmed distribution of elements from tattoos to regional lymph nodes, but neither to excretory organs, e.g., liver and kidney, nor to spleen and brain. Thus systemic internal organ exposure was not found.

Risks in the analogue and digitally-supported medication process and potential solutions to increase patient safety in the hospital: A mixed methods study.

BACKGROUND: In hospital medication errors are common. Our aim was to investigate risks of the analogue and digitally-supported medication process and any potential solutions. METHODS: A mixed methods study including a structured literature search and online questionnaires based on the Delphi method was conducted. First, all risks were structured into main and sub-risks and second, risks were grouped into risk clusters. Third, healthcare experts assessed risk clusters regarding their likelihood of occurrence their possible impact on patient safety. Experts were also asked to estimate the potential for digital solutions and solutions that strengthen the competence of healthcare professionals. RESULTS: Overall, 160 main risks and 542 sub-risks were identified. Main risks were grouped into 43 risk clusters. 33 healthcare experts (56% female, 50% with >20 years professional-experience) ranked the likelihood of occurrence and the impact on patient safety in the top 15 risk clusters regarding the process steps: admission (n = 4), prescribing (n = 3), verifying (n = 1), preparing/dispensing (n = 3), administering (n = 1), discharge (n = 1), healthcare professional competence (n = 1), and patient adherence (n = 1). 28 healthcare experts (64% female, 43% with >20 years professional-experience) mostly suggested awareness building and training, strengthened networking, and involvement of pharmacists at point-of-care as likely solutions to strengthen healthcare professional competence. For digital solutions they primarily suggested a digital medication list, digital warning systems, barcode-technology, and digital support in integrated care. CONCLUSIONS: The medication process holds a multitude of potential risks, in both the analogue and the digital medication process. Different solutions to strengthen healthcare professional competence and in the area of digitalization were identified that could help increase patient safety and minimize possible errors.

The efficacy of adipose-derived stem cells in burn injuries: a systematic review.

BACKGROUND: Burn injuries can be associated with prolonged healing, infection, a substantial inflammatory response, extensive scarring, and eventually death. In recent decades, both the mortality rates and long-term survival of severe burn victims have improved significantly, and burn care research has increasingly focused on a better quality of life post-trauma. However, delayed healing, infection, pain and extensive scar formation remain a major challenge in the treatment of burns. ADSCs, a distinct type of mesenchymal stem cells, have been shown to improve the healing process. The aim of this review is to evaluate the efficacy of ADSCs in the treatment of burn injuries. METHODS: A systematic review of the literature was conducted using the electronic databases PubMed, Web of Science and Embase. The basic research question was formulated with the PICO framework, whereby the usage of ADSCs in the treatment of burns in vivo was determined as the fundamental inclusion criterion. Additionally, pertinent journals focusing on burns and their treatment were screened manually for eligible studies. The review was registered in PROSPERO and reported according to the PRISMA statement. RESULTS: Of the 599 publications screened, 21 were considered relevant to the key question and were included in the present review. The included studies were almost all conducted on rodents, with one exception, where pigs were investigated. 13 of the studies examined the treatment of full-thickness and eight of deep partial-thickness burn injuries. 57,1 percent of the relevant studies have demonstrated that ADSCs exhibit immunomodulatory effects during the inflammatory response. 16 studies have shown improved neovascularisation with the use of ADSCs. 14 studies report positive influences of ADSCs on granulation tissue formation, while 11 studies highlight their efficacy in promoting re-epithelialisation. 11 trials demonstrated an improvement in outcomes during the remodelling phase. CONCLUSION: In conclusion, it appears that adipose-derived stem cells demonstrate remarkable efficacy in the field of regenerative medicine. However, the usage of ADSCs in the treatment of burns is still at an early experimental stage, and further investigations are required in order to examine the potential usage of ADSCs in future clinical burn care.

Management of Severe Burn Wounds Colonized With Multi-resistant Pseudomonas aeruginosa and Fusarium Using Marine Omega3 Wound Matrix in a Female Victim of War.

War-related burns are common injuries, also among the civilian population. Additional trauma such as fractures or shrapnel wounds may add significant morbidity. Burn injuries in war zones are furthermore frequently undertreated and hence prone to complications. We report a case of a young female victim of war, whose severely infected burn wounds could be successfully healed using a combination of targeted antimicrobial therapy, wound conditioning using decellularized fish skin, and subsequent skin grafting.

Testing the effects of photobiomodulation on angiogenesis in a newly established CAM burn wound model.

Burn wounds are a common challenge for medical professionals. Current burn wound models hold several limitations, including a lack of comparability due to the heterogeneity of wounds and differences in individual wound healing. Hence, there is a need for reproducible in vivo models. In this study, we established a new burn wound model using the chorioallantoic membrane assay (CAM) as a surrogate model for animal experiments. The new experimental setup was tested by investigating the effects of the auspicious biophysical therapy, photobiomodulation (PBM), on the wound healing of an induced CAM burn wound with a metal stamp. PBM has been shown to positively influence wound healing through vascular proliferative effects and the increased secretion of chemotactic substances. The easily accessible burn wounds can be treated with various therapies. The model enables the analysis of ingrowing blood vessels (angiogenesis) and diameter and area of the wounds. The established model was used to test the effects of PBM on burn wound healing. PBM promoted angiogenesis in burn wounds on day 4 (p = 0.005). Furthermore, there was a not significant trend toward a higher number of vessels for day 6 (p = 0.065) in the irradiated group. Changes in diameter (p = 0.129) and the burn area (p = 0.131) were not significant. Our results suggest that CAM can be a suitable model for studying burn wounds. The novel experimental design enables reproducible and comparable studies on burn wound treatment.

Metacarpophalangeal Joint Reconstruction of a Complex Hand Injury with a Vascularized Lateral Femoral Condyle Flap Using an Individualized 3D Printed Model-A Case Report.

This case report describes the surgical management of a patient with a complex hand trauma. This injury included tendon, vascular, and nerve injuries, a partial amputation of the index finger, fractures of the third proximal phalanx, and destruction of the metacarpophalangeal joint of the fifth finger. Firstly, the acute treatment of a complex hand injury is described. Secondly, the planning and execution of a joint reconstruction using a vascularized lateral femoral condylar flap, assisted by an individual 3D model, is illustrated. Precise reconstruction of the affected structures resulted in good revascularization as well as an anatomical bone consolidation. Intensive physical therapy, including autonomous proprioceptive range-of-motion exercises by the patient, resulted in significant functional improvement of the hand in daily life. Overall, we report on the successful reconstruction of a metacarpophalangeal joint by using a vascularized flap from the lateral femoral condyle. Furthermore, this case report highlights the efficacy of integrating individualized 3D printing technology to plan complex reconstructions, opening up promising opportunities for personalized and optimized interventions.

Do Sex-Specific Factors Influence the Surgical Treatment of Facial Skin Cancer?

Facial skin cancer (FSC) is prone to incomplete excision due to the sophisticated anatomy and the aesthetic importance of the face. In this study, we sought to investigate to what extent sex-specific differences and other operation-, patient-, and cancer-specific factors influence the re-resection rate in FSC surgery, in order to provide personalized treatment strategies to patients. In this retrospective study, patients (>18 years) undergoing surgical excision of an FSC were enrolled. Each patient's demographic data, cancer location, the surgical team, primary and secondary surgeries were analyzed. Overall, 469 patients (819 surgeries) were included. The mean age was 69 ± 15 years. No significant association between sex-specific factors (surgeon's sex (OR: 1.09, 95% CI: 0.76-1.56) or patient's sex (OR: 0.85, 95% CI: 0.62-1.17), surgeon-patient sex concordance and discordance) and the likelihood of secondary surgery were found. However, healing by secondary intention (OR: 4.28; 95% CI: 1.94-9.45) and cancer location showed an increased re-resection rate. In conclusion, FSC surgery is a safe method unaffected by sex-specific factors, which had no impact on the re-resection rate. However, in further analysis, the likelihood of a re-resection was influenced by other factors such as healing by secondary intention and cancer location. This knowledge might be useful to provide an algorithm for personalized treatment strategies in the future.

Simultaneous Free Fibula and Anterolateral Thigh Flap in Lower Extremity Reconstruction Following Osteomyelitis in a Trauma Patient: A Case Report.

This case report focuses on a 17-year-old polytrauma patient who suffered a septic wound infection after an open reduction and internal fixation (ORIF) and soft tissue reconstruction with a pedicled flap, which led to a substantial bone and soft tissue defect of the lower leg. After thorough antibiotic treatment and after ensuring a non-septic wound, the defect was reconstructed using a contralateral free fibula flap designed as a flow through flap in a double loop manner to accommodate two fibular fragments and an ipsilateral ALT flap. Early weight bearing was initiated 11 days after the free flap transfer under external fixation, with full weight bearing achieved in 36 days with external fixation. After the removal of external fixation, full weight bearing was able to be reinitiated after 13 days, leading to the patient's return to normal activity 6 months after the bony reconstruction. This case presents an innovative approach to treating a complex defect, with the final decision on using two separate free flaps instead of a single osteofasciocutaneous free flap resulting in a good bony reconstruction and soft tissue coverage, and with the use of external fixation enabling early rehabilitation.

Persistent Pain as an Early Indicator for Operative Carpal Tunnel Revision after Primary Release: A Retrospective Analysis of Recurrent and Persistent Carpal Tunnel Syndrome.

BACKGROUND: Prolonged symptoms of carpal tunnel syndrome (CTS) after primary carpal tunnel release (CTR) can reduce the quality of life and lead to multiple referrals across specialties. The following study aimed to identify differences in symptoms, signs, and intraoperative findings between recurrent and persistent CTS cases to avoid undesired outcomes after primary CTR. METHODS: A retrospective analysis was conducted on revision CTRs performed between 2005 and 2015 using literature-based definitions for recurrent (a relapse of symptoms occurs following a symptom-free period of ≥3 months) and persistent (symptoms persisting longer than three months after surgical release) CTS. The parameters assessed were symptoms, clinical signs, and intraoperative findings. RESULTS: Out of 53 cases, 85% (n = 45) were external referrals, whereby our own revision rate was 0.67% (n = 8/1199). Paresthesia and numbness were frequent in both groups; however, abnormal postoperative pain was reported more often in persistent cases (86%; n = 30/35) in comparison to recurrent cases (50%; n = 9/18; p = 0.009). Scarring around the median nerve was observed in almost all recurrent cases (94%; n = 17/18) and in 40% (n = 14/35) of persistent cases (p < 0.001). Incomplete division of the palmar ligament was the primary cause for revision in the persistent cohort (49%; n = 17/35). CONCLUSIONS: For patients experiencing symptoms for more than three months after CTR, primarily presenting as pain, it is advisable to consider referring the patient to a certified hand clinic for additional evaluation.

The Efficacy of Regeneration Oil and Almond Oil on Split-Thickness Skin Graft Donor Sites: A Single-Blinded Randomized Controlled Trial.

BACKGROUND AND OBJECTIVES: Essential oils are a complementary treatment and can play an important role in scar care. The aim of this study was to evaluate and compare the efficacy of a new essential oil (regeneration oil) with a control group on scar quality in healed split-thickness skin graft donor sites. MATERIALS AND METHODS: A single-center blinded randomized controlled study was performed on 30 patients with healed split-thickness skin graft donor site. The patients were randomly allocated into blended regeneration oil (n = 14) and pure almond oil (n = 16) groups. Application of the assigned oil occurred twice a day for 6 months. Scarring (Patient and Observer Scar Assessment Scale), itching (ITCH Assessment Scale) and scar discoloration (colorimetry) of the donor sites were assessed after 1, 3 and 6 months. RESULTS: We found no statistically significant differences between the groups in any applied parameter. We observed comparable outcomes (scar quality, itchiness, colorit) in healed split-thickness skin graft donor sites for both oils. CONCLUSIONS: Regeneration oil and control oil presented comparable results regarding scar quality, itchiness and colorit in healed split-thickness skin graft donor sites after 6 months of application. Both oils are suitable for skin/scar care in split-thickness skin graft donor sites.

Human In Vitro Skin Models for Wound Healing and Wound Healing Disorders.

Skin wound healing is essential to health and survival. Consequently, high amounts of research effort have been put into investigating the cellular and molecular components involved in the wound healing process. The use of animal experiments has contributed greatly to the knowledge of wound healing, skin diseases, and the exploration of treatment options. However, in addition to ethical concerns, anatomical and physiological inter-species differences often influence the translatability of animal-based studies. Human in vitro skin models, which include essential cellular and structural components for wound healing analyses, would improve the translatability of results and reduce animal experiments during the preclinical evaluation of novel therapy approaches. In this review, we summarize in vitro approaches, which are used to study wound healing as well as wound healing-pathologies such as chronic wounds, keloids, and hypertrophic scars in a human setting.

Molecular Mechanisms Related to Burns, Burn Wound Healing and Scarring.

The process of burn injury is multifaceted and involves a whole spectrum of inflammatory responses that can have significant implications for burn patients, including local, regional, and systemic effects [...].

Textured vs. Smooth Breast Implants Using the Jones Criteria-What Is the Currently Available Evidence for BIA-ALCL?: A Systematic Review.

Breast-Implant-Associated Anaplastic Large-Cell Lymphoma (BIA-ALCL) is a rare low-incidence type of T-cell non-Hodgkin lymphoma, arising in the capsule around breast implants, and predominantly associated with the use of macro-textured breast implants. The purpose of this study was to use an evidence-based approach to systematically identify clinical studies comparing smooth and textured breast implants in women with regard to the risk of developing BIA-ALCL. METHODS: A literature search in PubMed in April 2023 and the article reference list of the French National Agency of Medicine and Health Products decision from 2019 were screened for applicable studies. Only clinical studies where the Jones surface classification could be applied (required information: breast implant manufacturer) for comparison of smooth and textured breast implants were considered. RESULTS: From a total of 224 studies, no articles were included due to the lack of fit to the strict inclusion criteria. CONCLUSIONS: Based on the scanned and included literature, implant surface types in relation to the incidence of BIA-ALCL were not evaluated in clinical studies and data from evidence-based clinical sources plays a minor to no role in this context. An international database that combines breast implant-related data from (national, opt-out) medical device registries is, therefore, the best available option to obtain relevant long-term breast implant surveillance data on BIA-ALCL.

Workflow assessment of an augmented reality application for planning of perforator flaps in plastic reconstructive surgery: Game or game changer?

Objective: In contrast to the rising amount of financial investments for research and development in medical technology worldwide is the lack of usability and clinical readiness of the produced systems. We evaluated an augmented reality (AR) setup under development for preoperative perforator vessel mapping for elective autologous breast reconstruction. Methods: In this grant-supported research pilot, we used magnetic resonance angiography data (MR-A) of the trunk to superimpose the scans on the corresponding patients with hands-free AR goggles to identify regions-of-interest for surgical planning. Perforator location was assessed using MR-A imaging (MR-A projection) and Doppler ultrasound data (3D distance) and confirmed intraoperatively in all cases. We evaluated usability (System Usability Scale, SUS), data transfer load and documented personnel hours for software development, correlation of image data, as well as processing duration to clinical readiness (time from MR-A to AR projections per scan). Results: All perforator locations were confirmed intraoperatively, and we found a strong correlation between MR-A projection and 3D distance measurements (Spearman r = 0.894). The overall usability (SUS) was 67 ± 10 (=moderate to good). The presented setup for AR projections took 173 min to clinical readiness (=availability on AR device per patient). Conclusion: In this pilot, we calculated development investments based on project-approved grant-funded personnel hours with a moderate to good usability outcome resulting from some limitations: assessment was based on one-time testing with no previous training, a time lag of AR visualizations on the body and difficulties in spatial AR orientation. The use of AR systems can provide new opportunities for future surgical planning, but has more potential for educational (e.g., patient information) or training purposes of medical under- and postgraduates (spatial recognition of imaging data associated with anatomical structures and operative planning). We expect future usability improvements with refined user interfaces, faster AR hardware and artificial intelligence-enhanced visualization techniques.

The perception of plastic surgery during the COVID-19 pandemic-an analysis of online search patterns on a medical information platform.

In 2020, the COVID-19 pandemic impacted global life and transitioned economies and societal perceptions of life as we knew it. Professional and social life mostly ground to a nadir during the first lockdown in Europe in March. As a consequence, measures aimed at preventing the spread of the virus were established in medical facilities also and elective plastic surgery procedures were temporarily suspended in our clinic and others. A majority of the population, including those potentially contemplating plastic surgery procedures, spent most of their time at home with ample time available to research information about surgical procedures and other topics online. This investigation analyzes the relevance of plastic surgery during the pandemic on the basis of online search behavior patterns. Online traffic data from the online platform http://www.mooci.org were extracted using Google Analytics over a period of 6 months. The parameters analyzed were: pageviews, session duration, and bounce rate. Additionally, differentiation by areas of interest has been obtained. The data were compared and analyzed before and after the beginning of the first hard lockdown in Austria, Germany, and Switzerland. There were no significant differences in regard to pageviews and session duration when comparing time points before and after the beginning of the hard lockdown. The bounce rate exhibited a significant decrease after the beginning of the lockdown, implying a more conscious search for information and greater absorption and retention. There was no difference that could conclusively be attributed to the pandemic in terms of specific areas of interest researched. Society's demand for information about plastic-surgical procedures continues to be steadily prevalent-despite, or even in particular, during a global pandemic. Providing reliable and readily available information about plastic surgery procedures is an important component of a functioning doctor-patient relationship and informed consent. This information may reflect society's increased interest in plastic surgery during the pandemic, or be simply reflective of more spare time at hand to allow for such research. Further studies should investigate the relevance of elective procedures over the entire course of the pandemic.

Modelling the Complexity of Human Skin In Vitro.

The skin serves as an important barrier protecting the body from physical, chemical and pathogenic hazards as well as regulating the bi-directional transport of water, ions and nutrients. In order to improve the knowledge on skin structure and function as well as on skin diseases, animal experiments are often employed, but anatomical as well as physiological interspecies differences may result in poor translatability of animal-based data to the clinical situation. In vitro models, such as human reconstructed epidermis or full skin equivalents, are valuable alternatives to animal experiments. Enormous advances have been achieved in establishing skin models of increasing complexity in the past. In this review, human skin structures are described as well as the fast evolving technologies developed to reconstruct the complexity of human skin structures in vitro.

Clinical Applications of Three-Dimensional Printing in Upper Extremity Surgery: A Systematic Review.

Three-dimensional printing for medical applications in surgery of the upper extremity has gained in popularity as reflected by the increasing number of publications. This systematic review aims to provide an overview of the clinical use of 3D printing in upper extremity surgery. METHODS: We searched the databases PubMed and Web of Science for clinical studies that described clinical application of 3D printing for upper extremity surgery including trauma and malformations. We evaluated study characteristics, clinical entity, type of clinical application, concerned anatomical structures, reported outcomes, and evidence level. RESULTS: We finally included 51 publications with a total of 355 patients, of which 12 were clinical studies (evidence level II/III) and 39 case series (evidence level IV/V). The types of clinical applications were for intraoperative templates (33% of a total of 51 studies), body implants (29%), preoperative planning (27%), prostheses (15%), and orthoses (1%). Over two third of studies were linked to trauma-related injuries (67%). CONCLUSION: The clinical application of 3D printing in upper extremity surgery offers great potential for personalized approaches to aid in individualized perioperative management, improvement of function, and ultimately help to benefit certain aspects in the quality of life.