Projected augmented reality in DIEP flap breast reconstruction: Projecting perforators on the skin using dynamic infrared thermography.

BACKGROUND: Dynamic infrared thermography (DIRT) is a quick and non-invasive technique for perforator mapping in free flaps that provides real-time information. After a cold challenge, areas best supplied with blood become visible hotspots on color-coded maps, indicating perforators. This study presents a proof of principle for a new and innovative feature of DIRT, where projected augmented reality is used to directly display thermal images on the patient's abdomen prior to the deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. METHODS: A self-aligning projection device prototype (Anatomy Projector) equipped with an integrated thermal camera was used to obtain thermal information and project the color-coded map directly on the patient's abdomen before DIEP flap breast reconstruction. Projected DIRT hotspots were verified using a hand-held Doppler, and compared to the vascularity on computed tomography angiography (CTA), and intraoperative perforator measurements following a Cartesian grid. RESULTS: A total of 514 DIRT hotspots were projected in 50 patients, among them 97.3% could be verified using Doppler. The positive predictive value for CTA was 74.5%. Intraoperative measurements yielded 132 perforators in 71 flaps, among them 75 perforators (56.8%) correlated with projected DIRT hotspots, and half of them (54.7%) appeared within the first 5 emerging hotspots. CONCLUSION: This study showed that real-time display of thermal data in DIEP flap breast reconstruction is feasible via projected augmented reality. Projection facilitates convenient marking of hotspots, and a high resemblance to Doppler and CTA data was observed. Further research should assess the added value of projecting thermal images intraoperatively and in other fields of plastic surgery.

24 Hours Ex-vivo Hypothermic Acellular Perfusion of Porcine Forelimb: A 7-day Follow-up Study.

BACKGROUND: One of the limiting factors for vascularized composite allograft (VCA) storage is the short viable ischemic time (4-6 hours). Hypothermic machine perfusion (MP) enables near-physiological preservation, avoiding the deleterious effects of hypoxia and static cooling. This study aims to compare muscle injury after 24-hour acellular perfusion with static cold storage (SCS) in a porcine limb replantation model, examining outcomes for up to 7 days after reperfusion. METHODS: Sixteen procured porcine forelimbs were perfused hypothermic for 24 hours with Histidine-Tryptophan-Ketoglutarate (HTK, n=8) or preserved on ice for 4 hours (SCS, n=8) before orthotopic replantation. Muscle injury was assessed using biochemical markers and muscle biopsies were analyzed using the Histologic Injury Severity Score (HISS). RESULTS: During preservation, limb weight decreased by 2% in the SCS group and increased by 44% in the perfusion group (p<0.001). Twelve limbs (HTK, n=6; SCS, n=6) survived for 7 days. Three days after replantation, increased creatinine kinase levels were observed in the perfusion group (33781 mmol/liter versus 2163 mmol/liter; p<0.001). Mean endpoint HISS was 3.8 (SD 0.7) in the perfusion group and 1.8 (SD 0.7) in the SCS group (p=0.008), mostly due to increased edema (p=0.004). CONCLUSION: 24 hours of hypothermic MP and 4 hours of SCS of VCA demonstrated both minimal degenerated muscle tissue seven days after replantation.

Microneedling in Abdominal Scarring after DIEP-flap Breast Reconstruction to Improve Scar Quality: A Randomized Controlled Split Scar Trial.

Background: Deep inferior epigastric perforator (DIEP) flap breast reconstruction leads to large scars in the breast and abdominal region. Common symptoms related to abdominal scarring include changes in color, stiffness, thickness, and irregularity of the skin. The aim of this study was to examine whether microneedling improves the abdominal scar quality after DIEP-flap breast reconstruction. Methods: A prospective randomized controlled within subject comparison design (N = 30) was used to study the effect of microneedling treatments on the abdominal scar, versus no treatment. Three electrically powered microneedling sessions were performed every 4 weeks on one side of the abdominal scar. Abdominal scar assessment was performed at baseline and 3-, 6-, and 9-month follow-up using the Patient and Observer Scar Assessment Scale (POSAS). Treated and untreated sides were compared using a t test or Wilcoxon signed-rank test in case the data were not normally distributed. Results: Twenty-seven women completed the study. Microneedling treatment led to lower POSAS scores compared with the untreated scar side after the 3- and 9-month follow-up. At the 9-month follow-up, the POSAS total score (Mdn = 17, interquartile range = 18.3 versus Mdn = 21.4, interquartile range = 17.5) was statistically lower for the treated side compared with the untreated side, implying a better-appraised scar quality. The observer POSAS total score was statistically lower for the treated side compared with the untreated side. Conclusions: Based on patient and observer ratings, overall abdominal scars after DIEP-flap surgery improve significantly after microneedling treatment. Scar symptoms reduce faster under the influence of microneedling treatment compared with no treatment.

Factors Associated with Treatment Outcome Satisfaction Six Months after Upper Blepharoplasty: A Large Cohort Study.

Background: Upper blepharoplasty is the most popular facial cosmetic surgery. Although there are a variety of reasons to undergo this procedure, all patients expect an optimal cosmetic result. However, little is known about the factors that influence satisfaction with treatment outcome. Objectives: We assessed to what extent patient characteristics, clinician-rated and postsurgical outcome measures, and patient-reported satisfaction with facial appearance and quality-of-life are associated with patient-reported satisfaction with treatment outcome after a primary upper blepharoplasty. Methods: This study was performed in 583 patients with an upper blepharoplasty between 2016 and 2021. The primary outcome was satisfaction with treatment outcome 6 months postoperatively using the FACE-Q. Determinants were baseline patient characteristics (demographics), preoperative and postoperative clinician-rated and surgical outcome measures, and preoperative and postoperative FACE-Q appearance and quality-of-life scales. Hierarchical linear regression analysis was used to determine how much of the variance in satisfaction with outcome could be explained by these groups of determinants. Results: A total of 63% of the variance could be explained by the five groups of determinants of which 8% was explained by the baseline patient characteristics and clinician-rated and patient-reported outcomes together, another 8% by the postoperative clinician-rated outcomes, and the remaining 47% by the postoperative patient-reported outcomes. Conclusions: Patient characteristics, clinician-rated outcome measures, and baseline FACE-Q appearance and quality-of-life scores were of limited value in explaining satisfaction with treatment outcome. However, the postoperative FACE-Q appearance scale and the decision to undergo a blepharoplasty were strongly associated with satisfaction with treatment outcome.

"Patient-Reported Satisfaction and Health-Related Quality of Life in Patients with Breast Augmentation: A follow-up of six months".

BACKGROUND: To evaluate the success of a breast augmentation, it is essential to measure outcomes from the patient perspective since a successful aesthetic result is especially determined by the patient. This study aimed to evaluate patient-reported satisfaction with their breasts, psychosocial, physical, and sexual well-being in patients undergoing breast augmentation using validated questionnaires. METHODS: This is a multicenter cohort study based on ongoing routinely-collected data. Patient-reported satisfaction and health-related quality of life were assessed with the BREAST-Q Augmentation Module at intake and six months postoperatively. RESULTS: A total of 1405 patients were included. Large changes in BREAST-Q scores (range, 0-100) between intake and six months postoperatively were seen: satisfaction with their breasts (mean, effect size: +57, 3.8), psychosocial well-being (+38, 2.1), physical well-being (-14, -1.2), and sexual well-being (+44, 2.4). Moreover, improvements in all four scales were not dependent on their intake scores and all postoperative scores reached similar levels. A decreased physical well-being of the chest was measured post-surgery. The satisfaction with the breasts scale correlated moderately to strongly with the psychosocial and sexual well-being scale 6 months post-surgery. Subgroup analysis based on patient characteristics found no differences in outcomes, except for BMI. CONCLUSION: Significant improvement in patient-reported satisfaction with their breasts, psychosocial, and sexual well-being can be seen six months after breast augmentation despite a declined physical well-being after treatment. Postoperative satisfaction levels do not depend on preoperative scores. These insights can contribute to improve preoperative communication between surgeon and patient regarding the expected outcomes.

Computerized adaptive testing for the patient evaluation measure (PEM) in patients undergoing cubital tunnel syndrome surgery.

In outcome measures, item response theory (IRT) validation can deliver interval-scaled high-quality measurement that can be harnessed using computerized adaptive tests (CATs) to pose fewer questions to patients. We aimed to develop a CAT by developing an IRT model for the Patient Evaluation Measure (PEM) for patients undergoing cubital tunnel syndrome (CuTS) surgery. Nine hundred and seventy-nine completed PEM responses of patients with CuTS in the United Kingdom Hand Registry were used to develop and calibrate the CAT. Its performance was then evaluated in a simulated cohort of 1000 patients. The CAT reduced the original PEM length from ten to a median of two questions (range two to four), while preserving a high level of precision (median standard error of measurement of 0.27). The mean error between the CAT score and full-length score was 0.08%. A Bland-Altman analysis showed good agreement with no signs of bias. The CAT version of the PEM can substantially reduce patient burden while enhancing construct validity by harnessing IRT for patients undergoing CuTS surgery.

Alternative imaging technologies for perforator mapping in free flap breast reconstructive surgery - A comprehensive overview of the current literature.

BACKGROUND: The use of perforator mapping has become routine for many microsurgeons in the planning and performing of free flaps in breast reconstructions. Within this field, the number of available technologies and their quality has rapidly evolved over time. This study presents an up-to-date review on the spectrum of alternative perforator mapping modalities and the efficiency and utilization in the practice of free flap breast reconstructive surgery. METHODS: Extensive searches of the PubMed and Embase databases were performed. Articles containing free flap tissue transfer in breast reconstruction and a perforator imaging modality were included. Qualitative and descriptive analyses of the outcomes were performed, and the quality of the evidence was appraised. RESULTS: One hundred and sixty-eight articles were included. Besides the routinely used handheld Doppler, CT angiography, and MR angiography, seven alternative technologies (38 studies) have been found; color Doppler fluorescent angiography, dynamic infrared thermography, image-guided stereotaxy, template, 3D printed model, and augmented reality. The modalities were classified based on their concept of imaging as volumetric perforator imaging, real-time perforator imaging, and complementary techniques. A poor level of evidence for each alternative modality was found. CONCLUSION: An overview of alternative imaging techniques available to pre- and intraoperatively map perforator locations have been given. Several novel promising techniques have been identified, all to be used in conjunction with volumetric imaging. This overview provides a perspective on the future field of imaging in reconstructive surgery.

Closed-Incision Negative-Pressure Therapy Reduces Donor-Site Surgical Wound Dehiscence in DIEP Flap Breast Reconstructions: A Randomized Clinical Trial.

BACKGROUND: In breast reconstruction operations, surgical wound dehiscence is a serious complication that generates a significant burden on patients and health care systems. There are indications that postoperative treatment with closed-incision negative-pressure therapy has been associated with reduced wound dehiscence rates. This randomized clinical trial examines the effect of closed-incision negative-pressure application on abdominal donor-site surgical wound dehiscence in low- and high-risk patients undergoing breast reconstruction with a deep inferior epigastric perforator flap. METHODS: Eighty eligible women, stratified as low- or high-risk patients, were included and were randomized for treatment with either closed-incision negative-pressure or adhesive strips by drawing sealed, opaque envelopes. All surgeons were kept blinded for allocation. Primary outcomes were surgical wound dehiscence and surgical-site infection at the abdominal donor site on follow-up after 12 weeks. Secondary outcomes were seroma and hematoma formation. Five patients were excluded from the study because of insufficient exposure to the study treatment ( n = 4) or major protocol deviation ( n = 1). RESULTS: A total of 75 women, low-risk ( n = 38) and high-risk ( n = 37), received either closed-incision negative-pressure ( n = 36) or adhesive strips ( n = 39). Patients' demographics did not differ significantly. Donor-site surgical wound dehiscence occurred in 23 patients; the absolute risk reduction was statistically significant (21.6 percent; 95 percent CI, 1.5 to 41.7 percent). No statistically significant differences were found in surgical-site infection or secondary outcomes. CONCLUSION: In this randomized clinical trial, postoperative treatment with closed-incision negative-pressure therapy decreased the incidence of surgical wound dehiscence at the abdominal donor site in low- and high-risk deep inferior epigastric perforator flap breast reconstruction patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Ex Vivo Thrombolysis to Salvage Free Flaps Using Machine Perfusion: A Pilot Study in a Porcine Model.

BACKGROUND: Mechanical evacuation of capillary thrombi in free flaps is difficult, and often requires thrombolytic therapy. Utilizing machine perfusion systems, the possibility rises to salvage free flaps ex vivo by administering high doses of thrombolytic agents. The primary aim of this pilot study in a porcine model is to investigate the feasibility of ex vivo thrombolysis using an extracorporeal perfusion machine. METHODS: A model of stasis-induced thrombosis was used in 12 free rectus abdominis flaps harvested from six Dutch Landrace pigs. Compromised flaps were ex vivo perfused with University of Wisconsin preservation solution and treated according to the following study groups: (1) 1 mg of tissue plasminogen activator (t-PA) as additive, (2) 3 mg of t-PA as an additive, and (3) no thrombolytic additive. Microcirculation was assessed using near-infrared fluorescence angiography. RESULTS: Pedicled abdominal flaps were created and thrombus formation was successfully induced. Eleven abdominal flaps were perfused using the modified heart-lung machine setup. Near-infrared fluorescence angiography showed delayed or no filling was noted in the control group. In comparison, the flaps which were perfused with 1 mg t-PA or 3 mg t-PA as additive showed increased fluorescence intensity curves. CONCLUSION: This pilot study in a porcine model presents a reliable and reproductive stasis-induced thrombosis model in free flaps. By adding t-PA to a custom-made extracorporeal perfusion system, the indocyanine green fluorescence intensity curves increased of all flaps that were perfused with different dosages of t-PA as additives, indicating restoration of capillary pressure and microcirculatory inflow.

Ex Vivo Machine Thrombolysis Reduces Rethrombosis Rates in Salvaged Thrombosed Myocutaneous Flaps in Swine.

BACKGROUND: There is a risk for thrombotic complications (2 to 5 percent) associated with microsurgical reconstruction. Current thrombolytic therapy has a salvage rate between 60 and 70 percent, but it is afflicted by bleeding complications (2 to 6 percent). The use of machine perfusion for delivering thrombolytic agents is a new method that could potentially reduce these complications. In this article, the authors compared flap salvage outcomes comparing machine thrombolysis versus a manual flush with tissue plasminogen activator. METHODS: Sixteen bilateral flaps (12 × 9 cm) were dissected from eight female Dutch Landrace pigs (70 kg). Thrombosis was induced in free rectus abdominis flaps by clamping the pedicle's veins for 2 hours. Flaps were either thrombolysed with 2 mg tissue plasminogen activator (1 mg/ml) during 2 hours of machine perfusion (perfusion group; n = 8) or injected intraarterially (manual group; n = 8) before replantation. Near-infrared fluorescence angiography was used to confirm thrombus formation and to assess tissue perfusion; muscle biopsy specimens were analyzed for ischemia/reperfusion injury directly after thrombolysis and 15 hours after replantation. RESULTS: A higher incidence of secondary thrombosis was seen in the manual group compared to the perfusion group ( n = 6 versus n = 0, respectively; p < 0.001), resulting in two complete flap failures. Fifteen hours after replantation, mean fluorescence intensities were 13.0 (95 percent CI, 10.1 to 15.8) and 24.6 (95 percent CI, 22.0 to 27.2) in the perfusion and manual group, respectively ( p < 0.001), and mean muscle injury scores were comparable, measuring 7.5 ± 1.5. CONCLUSION: Two hours of machine thrombolysis of compromised flaps in a porcine model showed higher salvage rates compared to a manual injection with tissue plasminogen activator and reduced the incidence of secondary thrombosis. CLINICAL RELEVANCE STATEMENT: Using machine perfusion systems for ex vivo thrombolysis provides the benefits of local treatment of a composite tissue without the risk of systemic complications and may improve salvage rates and reduce the incidence of secondary thrombosis.

Long-term outcomes after ulna shortening osteotomy: a mean follow-up of six years.

AIMS: The primary aim of this study was to describe long-term patient-reported outcomes after ulna shortening osteotomy for ulna impaction syndrome. METHODS: Overall, 89 patients treated between July 2011 and November 2017 who had previously taken part in a routine outcome evaluation up to 12 months postoperatively were sent an additional questionnaire in February 2021. The primary outcome was the Patient-Rated Wrist and Hand Evaluation (PRWHE) total score. Secondary outcomes included patient satisfaction with treatment results, complications, and subsequent treatment for ulnar-sided wrist pain. Linear mixed models were used to compare preoperative, 12 months, and late follow-up (ranging from four to nine years) PRWHE scores. RESULTS: Long-term outcomes were available in 66 patients (74%) after a mean follow-up of six years (SD 1). The mean PRWHE total score improved from 63 before surgery to 19 at late follow-up (difference in means (Δ) 44; 95% confidence interval (CI) 39 to 50; p = <0.001). Between 12 months and late follow-up, the PRWHE total score also improved (Δ 12; 95% CI 6 to 18; p = < 0.001). At late follow-up, 14/66 of patients (21%) reported a PRWHE total score of zero, whereas this was 3/51 patients (6%) at 12 months (p = 0.039). In all, 58/66 patients (88%) would undergo the same treatment again under similar circumstances. Subsequent treatment (total n = 66; surgical n = 57) for complications or recurrent symptoms were performed in 50/66 patients (76%). The most prevalent type of reoperation was hardware removal in 42/66 (64%), and nonunion occurred in 8/66 (12%). CONCLUSION: Ulna shortening osteotomy improves patient-reported pain and function that seems to sustain at late follow-up. While satisfaction levels are generally high, reoperations such as hardware removal are common. Cite this article: Bone Jt Open 2022;3(5):375-382.

24-hour Perfusion of Porcine Myocutaneous Flaps Mitigates Reperfusion Injury: A 7-day Follow-up Study.

BACKGROUND: Static cold storage is the gold standard of preservation in vascularized composite allotransplantation and allows a preservation time of 4-6 hours. Machine preservation is a promising technique for prolonged preservation; however, studies on extended preservation that compare different preservatives are scarce. This study aims to assess the feasibility of 24-hour acellular perfusion and compares different preservation solutions in a porcine myocutaneous flap replantation model. METHODS: Six harvested bilateral myocutaneous flaps of three Dutch Landrace pigs were perfused hypothermically for 24 hours with University of Wisconsin machine perfusion solution (UW-MPS; n = 2) or histidine-tryptophan-ketoglutarate solution (HTK; n = 2) or preserved on ice for 4 hours (n = 2) before orthotopic replantation. Animals were observed for 7 days after replantation. Skeletal muscle injury was assessed by biochemical markers during perfusion, and muscle biopsies were analyzed for ischemia reperfusion injury directly after preservation and at 1, 3, and 7 days after replantation. RESULTS: Markers of muscle damage varied during perfusion, but decreased overall in both perfusion groups. Flap weight increased 60% and 97% in the HTK-perfused flaps, compared with -6% and -7% in the UW-MPS-perfused flaps after 24 hours. Histopathologic evaluation demonstrated decreased muscle damage in flaps perfused with HTK compared with the UW-MPS-perfused flaps at 1 week after replantation. CONCLUSIONS: Machine perfusion of myocutaneous flaps for 24 hours with subsequent replantation is feasible, but warrants further research. Perfusion with HTK solution seemed to result in better histological outcomes 7 days after reperfusion compared with UW-MPS.

Development and Evaluation of a Remote Patient Monitoring System in Autologous Breast Reconstruction.

Flap monitoring after a deep inferior epigastric perforator flap breast reconstruction is crucial to detect complications in time. A novel and innovative wireless device has been developed and tested in a feasibility study. This study describes our experience with remote patient monitoring via this device in postoperative monitoring of deep inferior epigastric perforator flaps. METHODS: Following a deep inferior epigastric perforator breast reconstruction, the "Free Flap Patch" was adhered to the flap, continuously measuring temperature and tissue saturation. Data were stored locally on the patch and analyzed in a retrospective manner. Raw analog-digital-conversion values from the red- and infrared sensors, delta muscle saturation (dSmO2), and estimated tissue oxygenation (StO2) were assessed and compared with clinical records. RESULTS: No adverse events related to the device were recorded. One patient suffered flap loss; a decrease in estimated tissue oxygenation was measured with the device in situ. No deviations in clinical variables were recorded in the uncompromised flaps. CONCLUSIONS: A wearable patient monitoring device was successfully utilized in clinical practice. In one patient, a flap failure was recorded where the PPG-derived StO2 parameter was indicatory for this event. The Free Flap Patch has the potential of automatically predicting blood supply issues in an early stage. More data are needed for clinical validation.

Breast and abdominal scarring after DIEP flap breast reconstruction: An exploration of patient-reported scar quality.

PURPOSE: This research aimed to explore factors associated with patient-reported breast and abdominal scar quality after deep inferior epigastric perforator (DIEP) flap breast reconstruction (BR). MATERIAL AND METHODS: This study was designed as a descriptive cross-sectional survey in which women after DIEP flap BR were invited to complete an online survey on breast and abdominal scarring. The online survey was distributed in the Netherlands in several ways in order to reach a diverse population of women. Outcomes were assessed with the Patient Scale of the Patient and Observer Scar Assessment Scale (POSAS). Additional items were assessed with a numeric rating scale (NRS). RESULTS: A total of 248 women completed the survey. There was a statistically significant worse POSAS scar appraisal for the abdominal scar compared with the breast scar. The vast majority of women reported high scores on at least one scar characteristic of their breast scar or abdominal scar. Overall, color, stiffness, thickness, and irregularity scored higher than pain and itching. Women were only moderately positive about the size, noticeability, location, and the information provided regarding scarring. CONCLUSION: It is crucial to address the inevitability of scars in patient education before a DIEP flap BR, with a particular focus on the abdominal scar, as women experience abdominal scars significantly worse than their breast scars. Providing more information on the experience of other women and the expected appearance will contribute to having realistic expectations while allowing them to make well-informed decisions.

Assessment of Patient Satisfaction With Appearance, Psychological Well-being, and Aging Appraisal After Upper Blepharoplasty: A Multicenter Prospective Cohort Study.

BACKGROUND: To determine the success of an upper blepharoplasty, a popular cosmetic procedure, it is essential to measure outcomes from the patient perspective because these often outweigh objective outcomes. OBJECTIVES: This study aimed to assess patient-reported satisfaction with facial appearance, psychological well-being, and aging appraisal after upper blepharoplasty with validated questionnaires. METHODS: This prospective cohort study included upper blepharoplasty patients from 8 outpatient clinics. Patient-reported satisfaction was assessed with the FACE-Q at intake, and 6 and 12 months postoperatively. RESULTS: In total, 2134 patients were included. High satisfaction with outcome and decision to undergo treatment were measured 6 months postoperatively. Large improvements in FACE-Q scores (range, 0-100) between intake and 6 months postoperatively were seen for satisfaction with appearance (mean, effect size: eyes +48, 2.6; upper eyelids +48, 3.1; facial appearance overall +26, 1.4), psychological well-being (+11, 0.56), and aging appraisal (+22, 1.0). Patients reported they appeared a mean [standard deviation] 3.3 [5.2] years younger postblepharoplasty. No clinically relevant changes were seen between 6 and 12 months. Additionally, improvements in appearance were not dependent on their intake scores, whereas improvements in psychological well-being and aging appraisal were smaller in patients with higher intake scores. Satisfaction with treatment outcome was strongly correlated with appearance satisfaction but not with aging appraisal. CONCLUSIONS: Significant improvements in patient satisfaction regarding appearance, psychological well-being, and aging appraisal can be seen 6 months after blepharoplasty, and outcomes remain stable up to 12 months postoperatively. These data may be used to inform patients and clinicians and improve the overall quality of care.

A systematic review and meta-analysis of vascularized lymph node transfer for breast cancer-related lymphedema.

BACKGROUND: Vascularized lymph node transfer (VLNT) has become an increasingly popular technique for treating lymphedema. However, although many studies have been performed, its efficacy in increasing patients' quality of life (QoL) and reducing lymphedema in the affected body part has remained controversial. In the present systematic review, we summarized the evidence for VLNT for treating breast cancer-related lymphedema. METHODS: The MEDLINE, Embase, and Cochrane Central databases were searched for studies of patients with breast cancer-related lymphedema who had received VLNT. The study methods were assessed using the MINORS (methodologic index for nonrandomized studies) tool. The primary outcomes were the change in volume difference between the arms and QoL. The secondary outcomes were skin infection, complications, and discontinuation of compression garment use. RESULTS: A total of 17 studies were included for qualitative synthesis and 8 for meta-analysis. The average reduction rate between the healthy and affected arms in the studies included in the meta-analysis was 40.31%. Five studies had evaluated QoL, and all five studies had reported that QoL was significantly increased. Eight studies had evaluated skin infections, of which three had reported the annual infection rates before and after surgery. In these studies, infection rate had decreased significantly. Three studies had described usage of compression garments. When the patients were pooled, 27 of 60 were able to discontinue use of the compression garment. The donor and recipient complication rates were 12.1% and 7.3%, respectively. CONCLUSIONS: The current evidence indicates that VLNT can improve the volume differences between the arms in patients with unilateral lymphedema by ∼40%. In addition, although determined from a few studies, it is likely that VLNT has a positive effect on patients' QoL, the number of skin infections, and compression garment usage and coincided with a low complication rate.

Rectus Abdominis Flap Replantation after 18 h Hypothermic Extracorporeal Perfusion-A Porcine Model.

Cold storage remains the clinical standard for composite tissue preservation but is time-limited. A long ischemia time during surgery will adversely affect postoperative outcomes due to ischemia-reperfusion injury. Extracorporeal perfusion (ECP) seems to be a promising alternative for prolonged preservation, but more evidence is needed to support its use and to identify optimal perfusion fluids. This article assessed musculocutaneous flap vitality after prolonged ECP and compared outcomes after replantation to short static cold storage (SCS). Unilateral musculocutaneous rectus abdominis flaps were raised from 15 pigs and preserved by 4 h SCS (n = 5), 18 h mid-thermic ECP with Histidine-Tryptophan-Ketoglutarate (HTK, n = 5) or University of Wisconsin solution (UW, n = 5). Flaps were replanted and observed for 12 h. Skeletal muscle histology was assessed (score 0-12; high scores equal more damage), blood and perfusate samples were collected and weight was recorded as a marker for oedema. Mean histological scores were 4.0 after HTK preservation, 5.6 after UW perfusion and 5.0 after SCS (p = 0.366). Creatinine kinase (CK) was higher after ECP compared to SCS (p < 0.001). No weight increase was observed during UW perfusion, but increased 56% during HTK perfusion. Following 12 h reperfusion, mean weight gain reduced 39% in the HTK group and increased 24% in the UW group and 17% in the SCS group. To conclude, skeletal muscle seemed well preserved after 18 h ECP with HTK or UW perfusion, with comparable histological results to 4 h SCS upon short reperfusion. The high oedema rate during HTK perfusion remains a challenge that needs to be further addressed.

Regenerating Critical Size Rat Segmental Bone Defects with a Self-Healing Hybrid Nanocomposite Hydrogel: Effect of Bone Condition and BMP-2 Incorporation.

The aim of the current study is to assess the biological performance of self-healing hydrogels based on calcium phosphate (CaP) nanoparticles and bisphosphonate (BP) conjugated hyaluronan (HA) in a critical size segmental femoral bone defect model in rats. Additionally, these hydrogels are loaded with bone morphogenetic protein 2 (BMP-2) and their performance is compared in healthy and osteoporotic bone conditions. Treatment groups comprise internal plate fixation and placement of a PTFE tube containing hydrogel (HABP -CaP) or hydrogel loaded with BMP-2 in two dosages (HABP -CaP-lowBMP2 or HABP -CaP-highBMP2). Twelve weeks after bone defect surgery, bone formation is analyzed by X-ray examination, micro-CT analysis, and histomorphometry. The data show that critical size, segmental femoral bone defects cannot be healed with HABP -CaP gel alone. Loading of the HABP -CaP gel with low dose BMP-2 significantly improve bone formation and resulted in defect bridging in 100% of the defects. Alternatively, high dose BMP-2 loading of the HABP -CaP gel does not improve bone formation within the defect area, but leads to excessive bone formation outside the defect area. Bone defect healing is not affected by osteoporotic bone conditions.

[The first bilateral hand transplantation in the Netherlands: results after 1 year]. / De eerste dubbelzijdige handtransplantatie in Nederland.

BACKGROUND: Although more than 130 hand-arm transplantations have been performed worldwide, the first Dutch hand transplantation has been performed only recently. This bilateral hand-arm transplantation was performed in June 2019 in the Radboud University Medical Centre, Nijmegen. This report describes the preparation, procedure and 1-year follow-up results. CASE DESCRIPTION: This 44 years-old female patient had an amputation of both lower legs and hands in 2014, following a severe sepsis with peripheral tissue necrosis. The patient was mobile with her leg prostheses at the time of presentation. The loss of hand function, however, formed a continuous invalidation and could not be improved adequately with prosthesis due to the distal amputation level of her hands. CONCLUSION: The total procedure took 24 hours and was successful. Both the aesthetical and functional results were good and are still improving. The patient considered the transplanted hands immediately as her own.