Decreasing Time Intervals in Recurring Capsular Contracture? A Single Center Retrospective Study over 6 Years.

Although breast implants of the current generation can, in principle, remain in the body for life, follow-up operations of the augmented or reconstructed breasts are regularly necessary. Capsular contracture is the leading cause for revisional surgery. The aim of this study was to evaluate indications and changes in time intervals between consecutive implant replacements with a focus on capsular contracture. Methods: In the period from 2012 to 2017, all patients with breast implant replacements or removals at our institution were identified. From the medical file, the time of the first implantation and earlier replacements were analyzed for indication and timing of surgery. Results: A total of 498 operations for implant replacement or removal were analyzed in 323 patients. Including prior operations, 717 procedures could be evaluated. If capsular contracture was the indication, revision surgery was performed on average 14.3 years or 8.4 years in aesthetic or reconstructive cases, respectively. In patients with more than one implant removal or replacement, we saw a reduction in the time interval between the first, second, and third follow-up operation. Conclusions: The main indication to perform implant replacements or removals was capsular contracture recurring at increasingly shorter intervals. Patients must be informed about this possible progression when changing implants, but also before the first operation. If capsular contracture occurs after a rather short time period in reconstructive cases, the opportunity of an alternative approach (eg, autologous reconstruction) instead of a renewed implant change should be discussed with the patient.

Corrigendum to "Do your surgical glove characteristics and wearing habits affect your tactile sensibility?" [Ann. Med. Surg. Volume 57, September 2020, Pages 281-286].

[This corrects the article DOI: 10.1016/j.amsu.2020.08.002.].

Overall Complication Rates of DIEP Flap Breast Reconstructions in Germany-A Multi-Center Analysis Based on the DGPRÄC Prospective National Online Registry for Microsurgical Breast Reconstructions.

While autologous breast reconstruction has gained momentum over recent years, there is limited data on the structure and quality of care of microsurgical breast reconstruction in Germany. Using the breast reconstruction database established by the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), the presented study investigated the overall outcomes of deep inferior epigastric perforator (DIEP) flap reconstructions in Germany. Data of 3926 patients and 4577 DIEP flaps performed by 22 centers were included in this study. Demographics, patient characteristics, perioperative details and postoperative outcomes were accounted for. Centers performing < Ø 40 (low-volume (LV)) vs. ≥ Ø 40 (high-volume (HV)) annual DIEP flaps were analyzed separately. Overall, total and partial flap loss rates were as low as 2.0% and 1.1% respectively, and emergent vascular revision surgery was performed in 4.3% of cases. Revision surgery due to wound complications was conducted in 8.3% of all cases. Mean operative time and length of hospital stay was significantly shorter in the HV group (LV: 385.82 min vs. HV: 287.14 min; LV: 9.04 (18.87) days vs. HV: 8.21 (5.04) days; both p < 0.05). The outcome and complication rates deduced from the national registry underline the high standard of microsurgical breast reconstruction on a national level in Germany.

Do your surgical glove characteristics and wearing habits affect your tactile sensibility?

BACKROUND: Tactile sensibility plays a critical role in medicine, especially in surgical practice. In order to prevent surgical site infections and protect the surgeon, the use of surgical gloves is standard practice. However, wearing these might affect the sensibility of the hand disadvantageously, especially in disciplines that require precision work. METHODS: We evaluated the influence of six different glove types, as well as gloves wearing habits (double gloving, over- and undersized gloves) on tactile sensibility using two-point-discrimination and Semmes-Weinstein monofilament testing in 27 non-surgeons. RESULTS: There were significant differences regarding tactile sensibility of gloved compared to bare hands and between different types of gloves. While undersized gloves and double gloving did not affect tactile sensibility, oversized gloves were associated with a significant deterioration of the sensibility of the hand in the Semmes-Weinstein monofilament test. CONCLUSION: This study demonstrates that surgical gloves negatively affect the sensibility of the hand and show significant differences between different types of gloves.

Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas.

BACKGROUND: Urogenital fistulas are devastating complications occurring after tumors or trauma. Surgical treatment is challenging. Thus, further surgical repair options are needed for treatment of complex fistulas within the pelvic region. METHODS: Twelve patients with urogenital fistulas were surgically treated in our department from 2004 to 2012. These selected cases fulfilled eligibility criteria for continence-preserving surgery - a history of fistula recurrences with ongoing incontinence after receiving at least two surgical attempts. Five VRAM and eight gracilis flaps were used to cover up given tissue defects and to perform functional continence-preserving reconstruction with mean follow-up of 6.3 years. Data were retrospectively reviewed, and standardized survey was performed to evaluate quality of life of all living patients (n = 10). RESULTS: In all cases, final surgical treatment of the given fistulae by VRAM or gracilis flaps could be achieved, with mean operating time of 5:31 h (range: 4:50-6:48 h) for VRAM flap and 3:11 h (range: 2:04-4:42 h) for gracilis flap. Outcome measures were primarily to avoid fistula recurrence after plastic surgical treatment, and secondary quality of life and survival. All patients had their continence preserved, but two patients died during follow-up period. Postoperative assessment revealed the following: VRAM flap patients (n = 3) showed slight incontinence during the follow-up period, whereas continence was restored in all patients with gracilis flap reconstruction (n = 7). Quality-of-life assessment indicated restoration of quality of life in comparison to general population (women > men). Furthermore, key points of the two presented surgical techniques are demonstrated in detail. CONCLUSION: With preformed VRAM or gracilis flaps, complex urogenital fistulas can be successfully eradicated and continence is restored. The main focus should be the recovery of quality of life, which could be successfully regained. Nevertheless, the continence success rate has to be defined on an individual, case-by-case basis. LEVEL OF EVIDENCE: Original work, cohort study level III.

Squamous-cell Carcinoma Arises in Red Parts of Multicolored Tattoo within Months.

SUMMARY: Skin cancer formation is on the rise. Only a few case reports, which focus on skin cancer being caused by tattoos, have been published so far. Our aim is to determine whether skin cancer occurrence can be triggered by tattoos. In our presented case, a squamous-cell carcinoma developed inside of the red areas of a multicolored tattoo within months. Furthermore, surgical removal of the cancerously mutated skin area without mutilating the design of the tattoo was challenging. Due to widespread skin alterations in other red areas of the tattoo, those affected skin regions were surgically removed and split-skin grafting was performed. After 1-year follow-up period, the patient has been tumor free. Squamous-cell carcinoma is an unusual reaction that can occur in tattoos. Nevertheless, this skin cancer should be included in the list of cutaneous complications related to tattooing.

The effect of a bacterial contamination on the formation of capsular contracture with polyurethane breast implants in comparison with textured silicone implants: an animal study.

INTRODUCTION: One of the most common complications following breast augmentation is capsular contracture. The subclinical infection of the implant is often considered to be one of the main risk factors. It is believed that polyurethane (PU) implants, because of their larger foam-like surface, have lower capsular contracture rates due to better tissue integration. It remains unclear if bacterial contamination and biofilm formation result in higher capsular contracture rates under the condition of the increased surface of PU implants compared to textured silicone-gel implants. The effect of this bacterial contamination was examined in an animal-based study. METHODS: A total of 80 mini implants (40 textured silicone-gel implants and 40 PU implants) were implanted in the dorsum of female Wistar rats. In each group, 20 implants were inoculated before implantation with a standard amount of Staphylococcus epidermidis. Capsules and implants were explanted after 60 days, followed by double-blind histological, immunohistochemical, and microbiological examinations. RESULTS: Macroscopic separation of the total capsule in the textured implant group was possible whereas the growth of surrounding tissue into the foam structure of PU implants made separation in that group difficult. After contamination, a thicker capsule could be observed in both groups without significant differences. Histologically, capsules around PU implants showed significantly lower expression of parallel myofibrils. We were able to describe a significant higher infiltration with inflammatory cells in capsules around PU implants both with and without contamination. Microbiological investigations revealed positive growth of S. epidermidis around one PU implant without related signs of capsular contracture. DISCUSSION: This study demonstrates that aside from the surface of silicone implants, bacterial contamination has major impact on the architecture of capsule formation. In our study, we were able to demonstrate that bacterial contamination leads to a thicker capsule and an increased tissue reaction with a higher amount of inflammatory cells. However, a resulting bacterial infection was only demonstrated in one case and had an insignificant influence on capsule architecture. The observed inflammatory reaction around PU implants was observed as a nonbacterial, granulomatose foreign body reaction. EBM RATING: Level I: Evidence obtained from at least one properly designed randomized controlled trial.

Sensory recovery outcome after digital nerve repair in relation to different reconstructive techniques: meta-analysis and systematic review.

Good clinical outcome after digital nerve repair is highly relevant for proper hand function and has a significant socioeconomic impact. However, level of evidence for competing surgical techniques is low. The aim is to summarize and compare the outcomes of digital nerve repair with different methods (end-to-end and end-to-side coaptations, nerve grafts, artificial conduit-, vein-, muscle, and muscle-in-vein reconstructions, and replantations) to provide an aid for choosing an individual technique of nerve reconstruction and to create reference values of standard repair for nonrandomized clinical studies. 87 publications including 2,997 nerve repairs were suitable for a precise evaluation. For digital nerve repairs there was practically no particular technique superior to another. Only end-to-side coaptation had an inferior two-point discrimination in comparison to end-to-end coaptation or nerve grafting. Furthermore, this meta-analysis showed that youth was associated with an improved sensory recovery outcome in patients who underwent digital replantation. For end-to-end coaptations, recent publications had significantly better sensory recovery outcomes than older ones. Given minor differences in outcome, the main criteria in choosing an adequate surgical technique should be gap length and donor site morbidity caused by graft material harvesting. Our clinical experience was used to provide a decision tree for digital nerve repair.

Cell-based resorption assays for bone graft substitutes.

The clinical utilization of resorbable bone substitutes has been growing rapidly during the last decade, creating a rising demand for new resorbable biomaterials. An ideal resorbable bone substitute should not only function as a load-bearing material but also integrate into the local bone remodeling process. This means that these bone substitutes need to undergo controlled resorption and then be replaced by newly formed bone structures. Thus the assessment of resorbability is an important first step in predicting the in vivo clinical function of bone substitute biomaterials. Compared with in vivo assays, cell-based assays are relatively easy, reproducible, inexpensive and do not involve the suffering of animals. Moreover, the discovery of RANKL and M-CSF for osteoclastic differentiation has made the differentiation and cultivation of human osteoclasts possible and, as a result, human cell-based bone substitute resorption assays have been developed. In addition, the evolution of microscopy technology allows advanced analyses of the resorption pits on biomaterials. The aim of the current review is to give a concise update on in vitro cell-based resorption assays for analyzing bone substitute resorption. For this purpose models using different cells from different species are compared. Several popular two-dimensional and three-dimensional optical methods used for resorption assays are described. The limitations and advantages of the current ISO degradation assay in comparison with cell-based assays are discussed.

Enhanced collateral growth by double transplantation of gene-nucleofected fibroblasts in ischemic hindlimb of rats.

BACKGROUND: Induction of neovascularization by releasing therapeutic growth factors is a promising application of cell-based gene therapy to treat ischemia-related problems. In the present study, we have developed a new strategy based on nucleofection with alternative solution and cuvette to promote collateral growth and re-establishment of circulation in ischemic limbs using double transplantation of gene nucleofected primary cultures of fibroblasts, which were isolated from rat receiving such therapy. METHODS AND RESULTS: Rat dermal fibroblasts were nucleofected ex vivo to release bFGF or VEGF165 in a hindlimb ischemia model in vivo. After femoral artery ligation, gene-modified cells were injected intramuscularly. One week post injection, local confined plasmid expression and transient distributions of the plasmids in other organs were detected by quantitative PCR. Quantitative micro-CT analyses showed improvements of vascularization in the ischemic zone (No. of collateral vessels via micro CT: 6.8±2.3 vs. 10.1±2.6; p<0.05). Moreover, improved collateral proliferation (BrdU incorporation: 0.48±0.05 vs. 0.57±0.05; p<0.05) and increase in blood perfusion (microspheres ratio: gastrocnemius: 0.41±0.10 vs. 0.50±0.11; p<0.05; soleus ratio: soleus: 0.42±0.08 vs. 0.60±0.08; p<0.01) in the lower hindlimb were also observed. CONCLUSIONS: These results demonstrate the feasibility and effectiveness of double transplantation of gene nucleofected primary fibroblasts in producing growth factors and promoting the formation of collateral circulation in ischemic hindlimb, suggesting that isolation and preparation of gene nucleofected cells from individual accepting gene therapy may be an alternative strategy for treating limb ischemia related diseases.

The use of glandular-derived stem cells to improve vascularization in scaffold-mediated dermal regeneration.

Clinical success in tissue regeneration requires improvements in vascularization capacity of scaffolds. Several efforts have been made in this field including cellular and acellular technologies. In this work we combined the use of stem cells derived from pancreas or submandibular glands expressing green fluorescent protein (GFP(+)) with a commercially available scaffold for dermal regeneration. Cells were isolated, characterized and seeded in a scaffold for dermal regeneration. Scaffolds containing cells were used to induce dermal regeneration in a full skin defect model. After 3 weeks of in vivo regeneration, tissues were harvested and vascularization was analyzed. Results showed that gland-derived stem cells displayed stem cell features and presented multipotential differentiation capacity because they were able to differentiate in cell types representing the 3 different germ layers. After seeding, cells were homogeneously distributed and formed focal adhesions with the scaffold. Metabolic assays showed that cells can be cultured for at least 3 weeks in the scaffold. In vivo, the presence of pancreatic or submandibular stem cells significantly enhanced the vascularization compared to empty scaffolds. Presence of gland-derived stem cells in the regenerating tissue was confirmed by the detection of GFP expression in the wound area. In order to explore the possible mechanisms behind the improvement in vascular regeneration, in vitro experiments were performed, showing that gland-derived stem cells could contribute by angiogenic and vasculogenic mechanisms to this process. Our results suggest that the combined use of stem cells derived from glands and scaffold for dermal regeneration could be a rational alternative to improve vascularization in scaffold-mediated dermal regeneration.

Nerve injuries of the upper extremity-expected outcome and clinical examination.

Nerve injuries are common in trauma surgery and appear more frequently if the upper extremity is affected. The aim of this study is to estimate possible predictors of the outcome after nerve injury of the upper extremity and to demonstrate feasible tools to follow up postoperative nerve regeneration for the daily clinical practice. During January 2000 until December 2004, a total of 372 nerve lesions of the upper extremity have been treated in our clinic. Patient's age, site of nerve lesion, concomitant injuries, and the timing of surgical repair could be outlined to be significant predictors for clinical outcome. Digital nerve lesions showed the best regenerative capacity. Most predictors of clinical outcome such as patient's age, concomitant injuries, and site of lesion cannot be influenced. But knowing the predictors helps specify the prognosis of nerve regeneration. For the daily clinical practice, static two-point discrimination, location of Tinel's sign, and grip strength measurement seem to be fast and reproducible tools to follow up nerve regeneration at the upper extremity.

The clinical use of artificial nerve conduits for digital nerve repair: a prospective cohort study and literature review.

Tubulization as an alternative to autologous nerve grafting successfully bridges relatively short nerve gaps. Digital nerve lesions are ideal for clinical outcome studies, but only a few data have been published so far. We are presenting our clinical experiences based on a review of the outcome and techniques in the current literature. Fifteen digital nerve lesions in 14 patients have been overcome by interpositional grafting of a hollow collagen I conduit. A follow-up of 12 months could be guaranteed in 12 cases. The mean nerve gap was 12.5 +/- 3.7 mm. Four out of 12 patients, assessed 12 months postoperatively, showed excellent sensibility (S4). Five patients achieved good sensibility, one poor, and two no sensibility. Our results confirm tubulization as one possible technique in nerve reconstruction. However, the indication has to be set carefully, and the operation still requires solid microsurgical skills, especially for proper handling and debridement of the severed nerve endings.