Free Fibula Flap for Congenital Pseudarthrosis of the Tibia: Indications and Challenges.

Background: Congenital pseudoarthrosis of the tibia (CPT) is a rare pathological disease associated with neurofibromatosis type 1 (NF1). It presents with tibial bowing and can progress into a nonhealing fracture. Treatment options include conservative approaches such as serial bracing or various surgical options.Surgically, the aims are to achieve long-term bone union, prevent limb length discrepancies (LLDs), and avoid mechanical axis deviation, soft tissue lesions, nearby joint stiffness, and pathological fracture.The purpose of our study is to highlight our experience with both the conservative approach and the use of vascularized free fibula reconstruction of these deformities, including the challenges encountered with a long-term follow-up until skeletal maturity. Methods: We present a retrospective analysis of a total of nine (9) patients consisting of three (3) girls and six (6) boys. Six (6) children were treated with a vascularized fibula flap, and the other three (3) were treated conservatively. Outcomes measured included fractures, LLD, ankle valgus deformity, donor site morbidity, and number of surgical corrections. Results: All patients had flap survival. Three (3) of six children had a previous failed surgery with intramedullary nail and bone graft prior to performing a vascularized free fibula reconstruction. The follow-up period ranged from 8 months to 200 months. The complications included stress fractures (50%), LLD (66.6%), and ankle valgus (33.3%). During growth phases, these children required multiple corrective surgeries. Conclusions: Fibula free flap is a good treatment option for CPT even in patients with prior surgical failures with variable results.Level of Evidence - Level 4 - Case series Therapeutic Studies-Investigating the Results of Treatment.

Perfusion Dynamics during Secondary Flap Debulking with Liposuction.

BACKGROUND: Lower extremity trauma often necessitates reconstruction with flap transfer. One of the reconstructive goals is a thin soft tissue coverage with appropriate contour. Therefore, a secondary debulking of the flap is usually performed. METHODS: Debulking through conventional lipectomy is compared with liposuction followed by excision of the defatted flap excess. Demographic data, surgical details, and postoperative outcomes are compared and analyzed. The perfusion dynamics of the flaps undergoing liposuction debulking are studied by means of perioperative indocyanine green fluorescence angiography, as well as postoperative laser Doppler imaging. RESULTS: Patients undergoing lipectomy (n = 69; 57.5%) or liposuction (n = 51; 42.5%) debulking had a similar rate of postoperative complications. Partial necrosis was observed in 7.2% (lipectomy) versus 7.8% (liposuction) of flaps. Fluorescence angiography showed a substantial decrease in flap perfusion following the infiltration with an epinephrine-containing tumescent solution (74.3% ± 8.2% prior to infiltration versus 16.8% ± 7.1% after infiltration; p < 0.001), resulting in a dark flap appearance. Laser Doppler imaging confirmed the hypoperfusion on postoperative day 1. CONCLUSION: Secondary debulking of a lower extremity flap can be safely and efficiently performed through liposuction combined with peripheral excision of the defatted flap in a single stage. Perfusion studies may show a misleading hypoperfusion of the defatted flap, which does not accurately predict subsequent necrosis or complications.

Push-Through Filtration of Emulsified Adipose Tissue Over a 500-µm Mesh Significantly Reduces the Amount of Stromal Vascular Fraction and Mesenchymal Stem Cells.

BACKGROUND: Mechanical isolation of the stromal vascular fraction (SVF) separates the stromal component from the parenchymal cells. Emulsification is currently the most commonly used disaggregation method and is effective in disrupting adipocytes and fragmenting the extracellular matrix (ECM). Subsequent push-through filtration of emulsified adipose tissue removes parts of the ECM that are not sufficiently micronized, thereby further liquifying the tissue. OBJECTIVES: The aim of this study was to investigate whether filtration over a 500-µm mesh filter might affect the SVF and adipose-derived mesenchymal stem cell (MSC) quantity in emulsified lipoaspirate samples by removing ECM fragments. METHODS: Eleven lipoaspirate samples from healthy nonobese women were harvested and emulsified in 30 passes. One-half of the sample was filtered through a 500-µm mesh filter and the other half was left unfiltered. Paired samples were processed and analyzed by flow cytometry to identify cellular viability, and SVF and MSC yield. RESULTS: Push-through filtration reduced the number of SVF cells by a mean [standard deviation] of 39.65% [5.67%] (P < .01). It also significantly reduced MSC counts by 48.28% [6.72%] (P < .01). Filtration did not significantly affect viability (P = .118). CONCLUSIONS: Retention of fibrous remnants by push-through filters removed ECM containing the SVF and MSCs from emulsified lipoaspirates. Processing methods should aim either to further micronize the lipoaspirate before filtering or not to filter the samples at all, to preserve both the cellular component carried within the ECM and the inductive properties of the ECM itself.

Is the Systematic Sponge Count an Impediment to Patient Care During Plastic Surgical Procedures?

Nurses and surgeons collaborate to conduct safe surgery. We follow time-consuming and labor-intensive protocols, such as the systematic counting and verifying of surgical sponges. However, the counting process may be distracting from other patient-centered tasks. To understand the perception of plastic surgery professionals about the intraoperative sponge count, we designed an online questionnaire. One hundred plastic surgeons and residents from 32 different countries completed the survey. The results showed that most often (70%) the scrub person determines when sponges will be counted, and 34.3% of the time, a sponge count is incorrect at the first count and then corrected. The main reason for an incorrect sponge count appears to be a change in personnel (53%). Radiological imaging is required during an average of 8.7% of surgeries to rule out a retained sponge in the patient. Notably, missing sponges are most frequently found elsewhere in the operating room. Younger surgeons prefer to pause during the surgical procedure until the sponge count is completed and noted to be correct. This approach appears to be associated with fewer counting errors, a shorter counting time, and a significant reduction in distraction of the whole surgical team. Performing a cavity sweep before beginning wound closure and using large surgical sponges are also suggested as alternatives to counting sponges. A sponge count can become an impediment to patient care because it has limited reliability and causes distraction among the team. A surgical pause can be implemented until the sponge count is completed or until any discrepancy is resolved.

Improving the Female Silhouette and Gluteal Projection: An Anatomy-Based, Safe, and Harmonious Approach Through Liposuction, Suspension Loops, and Moderate Lipofilling.

BACKGROUND: Liposuction is the main technique to improve body contour, emphasize appealing curves, and highlight one's muscular definition. The number of procedures in which the harvested fat is utilized for gluteal augmentation has greatly increased. OBJECTIVES: The authors aim to demonstrate their technique in order to obtain a sculpted harmonious body through a safe procedure, as well as review their 101 consecutive cases between 2014 and 2018. METHODS: Anatomical guidelines and preoperative markings were provided to guide the 3-step procedure: zones of maximal and mild liposuction, barbed wire suspension, and moderate fat grafting. Novel concepts are introduced as the anterior body diagonal, posterior body diagonal as well as other specific axes the pubic unit, and a vertical ratio for the buttock, which are the basic foundations for sculpting the female body into a pleasing hourglass shape with a well projected buttock. Recommendations for location of sacral diamond, sacral dimples, and the maximally projected point of the buttock are given. The authors explain their philosophy through 4 principles: knowledge of anatomy, the relationship between specific body areas and surrounding zones, a balanced gluteal augmentation is not achieved through large volume fat grafting alone, and grafting in the subcutaneous layer. RESULTS: A total of 101 patients were treated following the described technique and examples are shown. The complication rate was low. No serious adverse effects were recorded apart from 1 ruptured suspension loop. CONCLUSIONS: The described anatomy-based approach, including liposuction, suspension loops, and fat grafting, is a novel and safe technique leading to a desirable, long-lasting outcome.

Quality and Quantity-Cultured Human Mononuclear Cells Improve Human Fat Graft Vascularization and Survival in an In Vivo Murine Experimental Model.

BACKGROUND: Fat graft ischemia impedes us from having satisfying long-term results. The quality and quantity culture is a 1-week cell culture that increases the vasculogenic potential of peripheral blood mononuclear cells (PBMNC). This in vivo murine model investigates whether enrichment with quality and quantity-cultured human mononuclear cells (MNC-QQ) improves the vascularization in the human fat graft and whether this decreases the tissue loss. METHODS: Human adipose tissue, PBMNC, MNC-QQ, and stromal vascular fraction were prepared. First, PBMNC, MNC-QQ, and stromal vascular fraction were compared in vitro for vasculogenic potential by endothelial progenitor cell colony-forming and culture assays. Second, 0.25-g fat grafts were created with 1 × 106 PBMNC (n = 16), 1 × 106 MNC-QQ (n = 16), 1 × 106 stromal vascular fraction (n = 16), or phosphate-buffered saline as control (n = 16) before grafting in BALB/c nude mice. Grafts were analyzed for weight persistence, vessel formation by CD31 immunohistochemistry, and angiogenic markers by quantitative polymerase chain reaction. RESULTS: MNC-QQ develop more definitive endothelial progenitor cell colonies and more functional endothelial progenitor cells compared to PBMNC and stromal vascular fraction. Weight persistence after 7 weeks was significantly higher in grafts with MNC-QQ (89.8 ± 3.5 percent) or stromal vascular fraction (90.1 ± 4.2 percent) compared with control (70.4 ± 6.3 percent; p < 0.05). MNC-QQ-enriched grafts had the highest vessel density (96.6 ± 6.5 vessels/mm2; control, 70.4 ± 5.6 vessels/mm2; p < 0.05). MNC-QQ exerted a direct vasculogenic effect through vascular integration and a potential paracrine vascular endothelial growth factor-mediated effect. CONCLUSION: Quality and quantity-cultured human mononuclear cells containing endothelial progenitor cells stimulate fat graft vascularization and enhance graft survival in a rodent recipient.

The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications.

BACKGROUND: Hyaluronic acid (HA) fillers are frequently used for cosmetic purposes as volumizers or as wrinkle fillers. One of the major advantages of hyaluronic acid use is the possibility to neutralize it by using hyaluronidase should complications occur. PATIENT: A case of a 21-year-old female patient is presented, in whom a hyaluronic acid injection-induced vascular occlusion was seen four days after the initial injection, with increasing pain and severe signs of ischemia. METHOD: Treatment consisted of an immediate hyaluronidase injection, supplemented with administration of acetylsalicylic acid, piracetam, low molecular weight heparin (LMWH), corticosteroids, analgesics, prophylactic antibiotics, application of topical nitroglycerin and warmth, smoking cessation, and hyperbaric oxygen therapy. RESULTS: The initial progress and evolution of the deformity with possible therapeutic options are being discussed. CONCLUSION: The "ART" (avoid, recognize, and treat) in handling filler complications is presented, as a new universal guideline for clinical aesthetic practitioners and injectors.

Quality and Quantity-Cultured Murine Endothelial Progenitor Cells Increase Vascularization and Decrease Fibrosis in the Fat Graft.

BACKGROUND: Fat grafting has become a valuable technique for soft-tissue reconstruction; however, long-lasting success depends on several determinants. An early blood supply to the transplanted adipocytes is important to prevent ischemia. The recently developed quality and quantity (QQ) culture increases the vasculogenic potential of endothelial progenitor cells. The authors used a murine fat grafting model to address the hypothesis that QQ-cultured endothelial progenitor cells stimulate the establishment of a blood vessel network and increase graft success. METHODS: c-KitSca-1Lin (KSL) cells were isolated as endothelial progenitor cell precursors from C57BL/6 mice. Adipose tissue was grafted with QQ-cultured KSL cells (QQKSL group), uncultured KSL cells (KSL group), adipose-derived stem cells (ASC group), and a combination (QQKSL+ASC group), and compared to a control group. Five and 10 weeks later, grafts were weighed, histologic and immunohistochemical parameters were evaluated, and gene expression was quantified by quantitative polymerase chain reaction. RESULTS: The highest vessel density was observed in the combined QQKSL+ASC group (68.0 ± 4.3/mm; p < 0.001) and the QQKSL group (53.9 ± 3.0/mm; p < 0.001). QQKSL cells were engrafted in proximity to the graft vasculature. QQKSL cells decreased the fibrosis percentage (13.8 ± 1.8 percent; p < 0.05). The combined QQKSL+ASC group (22.4 ± 1.8/mm; p < 0.001) showed the fewest local inflammation units. A significant up-regulation of platelet-derived growth factor and adiponectin expression was observed in the QQKSL group and QQKSL+ASC group. Graft weight persistence was not significantly different between groups. CONCLUSIONS: Supplementing fat grafts with quality and quantity-cultured endothelial progenitor cells improves graft quality by stimulating vascularization. The increased vessel density is associated with less fibrosis, less inflammation, and better adipose tissue integrity. Enriching fat grafts with QQ-cultured endothelial progenitor cells is a potential solution to their clinical shortcomings.

Fast-Track in Bariatric and Metabolic Surgery: Feasibility and Cost Analysis Through a Matched-Cohort Study in a Single Centre.

BACKGROUND: Due to the rise in severe obesity in Western countries and the increase in bariatric surgery, enhanced recovery (ER) pathways should be developed and promoted. METHODS: A monocentric prospective series of 103 bariatric surgery patients managed with the ER pathway (group ER) was compared with a retrospective and immediately previous series of 103 patients managed with standard care (group CS). The aim of the present study was to assess and compare the differences in terms of mean postoperative length of stay (LOS), costs for surgery and recovery, and the differences in terms of complications, readmission, and reoperation rate in the short term between the ER and CS groups. RESULTS: The mean LOS was 4.18 days in group CS and 1.79 days in group ER (p < 0.0001). The mean operative time (OT) per patient was 190.20 min in the group CS and 133.54 min in the group ER, resulting in an average cost of 7272.57€ per patient in group CS and 5424.09€ per patient in group ER. The average recovery cost was 1809.94€ for the group CS series and 775.07 for the group ER one. Overall complications (Clavien-Dindo up to II) occurred in 6 patients (5.8 %) in group CS and in 2 patients (1.9 %) in group ER (p = 0.149) and specific complications (Clavien-Dindo IIIb) occurred for 9 patients (8.7 %) in Group CS and for 14 patients (13.5 %) in group ER (p = 0.268) after hospital discharge within 1-month of follow-up. Twelve patients (11.5 %) in group CS and 13 (12.5 %) in group ER were readmitted after discharge (p = 0.831) within 1-month of follow-up; 8 patients (7.7 %) in group CS versus 9 patients (8.8 %) in group ER needed to be reoperated (p = 0.800) within 1-month follow-up. CONCLUSIONS: Enhanced recovery pathway reduces significantly LOS in bariatric surgical patients and shortens the mean OT of the procedure, with no significant differences in terms of surgical outcomes. Furthermore, recovery charges were lower and operative time was shorter allowing for procedural cost reduction.