Machine Perfusion Enables 24-h Preservation of Vascularized Composite Allografts in a Swine Model of Allotransplantation.

The current gold standard for preserving vascularized composite allografts (VCA) is 4°C static cold storage (SCS), albeit muscle vulnerability to ischemia can be described as early as after 2 h of SCS. Alternatively, machine perfusion (MP) is growing in the world of organ preservation. Herein, we investigated the outcomes of oxygenated acellular subnormothermic machine perfusion (SNMP) for 24-h VCA preservation before allotransplantation in a swine model. Six partial hindlimbs were procured on adult pigs and preserved ex vivo for 24 h with either SNMP (n = 3) or SCS (n = 3) before heterotopic allotransplantation. Recipient animals received immunosuppression and were followed up for 14 days. Clinical monitoring was carried out twice daily, and graft biopsies and blood samples were regularly collected. Two blinded pathologists assessed skin and muscle samples. Overall survival was higher in the SNMP group. Early euthanasia of 2 animals in the SCS group was linked to significant graft degeneration. Analyses of the grafts showed massive muscle degeneration in the SCS group and a normal aspect in the SNMP group 2 weeks after allotransplantation. Therefore, this 24-h SNMP protocol using a modified Steen solution generated better clinical and histological outcomes in allotransplantation when compared to time-matched SCS.

A Two-Step Approach for Breast Augmentation with Chest Wall Deformity?

Breast augmentation in the case of chest wall deformity can be challenging. It is essential to treat the two problematics separately, and not to attempt compensation for asymmetry with vastly different breast implants. With this work, we wish to highlight the approach based on the use of custom-made 3D implants, enabling optimal correction of thoracic deformity. A first case study illustrates a one-step approach to correcting deformity and augmenting the breast. The importance of separate management of these issues lies in the fact that possible normalization of thoracic dysmorphia alone can sometimes lead to withdrawal of the request for breast augmentation. We illustrate this with a second case report with optimal patient satisfaction after isolated correction of a pectus excavatum.Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Ultrasound and Helium Plasma-Assisted Liposuction for Body Contouring: A Single-Retrospective Cohort Study of 639 Patients.

BACKGROUND: Over the past two decades, liposuction techniques have significantly evolved, moving from basic fat removal to sophisticated methods aimed at improving safety, efficiency, and cosmetic outcomes. This study evaluates the efficacy and safety of a combined approach using ultrasound-assisted liposuction (UAL) and helium plasma radiofrequency (HPRF) technology to enhance skin tightening without the need for extensive surgical interventions. METHODS: We conducted a retrospective analysis of 639 patients who underwent the combined UAL and HPRF liposuction technique. The patient cohort had an average age of 31.5 years and a mean BMI of 27.9 kg/m2. The procedure predominantly targeted the abdomen, with an average of 2.4 body areas treated per patient. Surgical duration averaged 118 minutes, with a mean aspirate volume of 1698 mL. RESULTS: Minimal residual skin laxity was observed in 87% of patients, and 91% achieved excellent improvement in body contouring. The complication rates were low, with minor occurrences of seroma (5.6%) and a very low incidence of infection (0.3%). This combined technique demonstrated safety and efficacy, providing significant skin tightening and reducing recovery time compared to more invasive procedures. CONCLUSIONS: The combined use of UAL and HPRF technology offers a safe and effective method for enhancing skin tightening and improving body contouring outcomes. Despite the promising results, this study acknowledges the limitations of its retrospective design. Future prospective, multicenter studies are recommended to further validate these findings. This technique represents a significant advancement in the field of cosmetic surgery, emphasizing minimally invasive solutions with substantial esthetic benefits. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A New Surgical Technique for Female-to-Male Top Surgery: The Posterioinferior Pedicle (PIPe) Approach.

INTRODUCTION: Most of the time, female-to-male (FtoM) chest surgery involves mastectomy techniques and free transplantation of the nipple-areola complex. With the increasing prevalence of gender dysphoria and the demand for female-to-male gender reassignment surgery, the need for FtM top surgery is also rising. To meet this demand, we present a new approach: the PIPe technique, based on a fasciocutaneous flap with a posteroinferior pedicle. MATERIALS AND METHODS: All patients with FtoM gender dysphoria undergoing surgery using the posteroinferior pedicle flap technique in the Plastic Surgery Department at Rennes University Hospital Center were included. The procedure involved extensive liposuction of the lower internal and external mammary quadrants, followed by liposuction of deep tissues in the upper quadrants, except in the pedicle area. After removing skin from the lower quadrants down to the dermis and de-epithelializing the posteroinferior pedicle flap, the thoracic flap was lowered and the areola transposed. RESULTS: From July 2022 to March 2023, fifteen patients underwent surgery, and their results were collected prospectively. The average age was 25 years, the mean weight was 76.6 kg, and the average BMI was 28.1 kg/m2. The average operating time was 102 min, and the mean weight excised was 459.5 g. The average length of hospital stay was 3.3 days, and the drainage duration was 2.4 days. No major complications were reported, and there were no cases of reintervention or recurrence. CONCLUSIONS: Our study presents a novel surgical approach utilizing the posteroinferior pedicle technique. Its key benefit lies in the preservation of neurovascular function, which makes it an attractive option for patients seeking to retain nipple sensitivity. This procedure is reliable, reproducible, and recommended as a first-line treatment for grade II and III gynecomastia due to its low rate of major complications and favorable functional and aesthetic outcomes. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lipo-Bodylift Reconstruction Following Massive Weight Loss: Our Experience with 100 Consecutive Cases.

BACKGROUND: We report our experience using the Lipo-Bodylift technique for circumferential lower trunk reconstruction following massive weight loss. METHODS: The procedure combines extensive circular liposuction with circular skin resection immediately under the dermis. We classify lower trunk deformities using three parameters: (1) excess skin (in the horizontal direction, or both horizontally and vertically); (2) the body mass index (BMI); and, (3) skin quality (hyperlaxity or a normal tone). All patients can be divided into four groups, of whom groups I and II are the best candidates for the Lipo-Bodylift procedure. We also describe our perioperative management and patient outcomes, with a focus on postoperative complications. RESULTS: Between January 2015 and January 2020, 100 patients underwent Lipo-Bodylift treatment. The median patient age was 41 years. The median preoperative BMI was 26.3 kg/m2. The median drainage duration and hospital stay were both 3 days. Of all patients, 30% experienced at least one complication, 2% of which were major. Of the minor complications, 27 patients evidenced wound dehiscence. Only (positive) smoking status was significantly associated with postoperative complications (p < 0.001). CONCLUSION: We developed the Lipo-Bodylift technique after analyzing changes in the skin and subcutaneous fat after massive weight loss. The technique completes the arsenal of body contouring techniques, appears to be less invasive than the undermining that is usually performed during circumferential reconstruction of the lower trunk, and is associated with a lower rate of major complications. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266.

Alternative Flap Options for Upper Extremity Reconstruction.

For major upper limb defects, a wide range of established pedicled and free flap options can be used. These include the latissimus dorsi/thoracodorsal artery perforator, lateral arm, posterior interosseous artery, rectus abdominis, gracilis, and anterolateral thigh flaps. Technical proficiency is essential, and favorable success rates in terms of functional and esthetic outcomes can be achieved. Herein, alternative flap options (both pedicled and free) are introduced and discussed through a few illustrative case examples.

The Naso-Orbito-Frontal (NOF) Complex In Facial Feminization Surgery.

BACKGROUND: With the increasing demand for facial feminization surgery, there is a growing need for reliable and reproducible techniques to enhance outcomes. OBJECTIVE: This study aimed to evaluate the effectiveness of single-stage Naso-Orbito-Frontal (NOF) complex reshaping in facial feminization surgery. Effectiveness was gauged by CT scan assessments and an unvalidated patient satisfaction survey at 6 months post-operative. METHODS: The study included 155 transfeminine patients undergoing surgery of the upper third of the face. Outcomes were compared in patients receiving either Orbito-Frontal (OF) surgery or combined Naso-Orbito-Frontal (NOF) surgery. A comparative analysis of pre- and postoperative standardized CT scan sections was performed, focusing on multiple anatomic angles in two dimensions. A self-administered satisfaction questionnaire based on six FACE-Q items was completed at 6 months. RESULTS: Among the 155 patients, 65 underwent OF surgery, and 90 underwent NOF surgery. The follow-up period ranged from 6 to 36 months, with an average of 18 months. Significant changes in craniometric measurements were observed: in the OF group, average changes in nasofrontal, frontal tilt, and metopion angles were +12.3±0.2°, -8.5±2.2°, and +20.0±0.1° respectively (p<0.001); in the NOF group, same metrics were +28.5±0.3°, -9.3±2.4°, and +23.9±0.1° (p<0.001). The NOF group demonstrated higher overall satisfaction (Median: 4/5) compared to the OF group (Median: 3/5). No early complications were reported. CONCLUSION: The NOF complex surgery is an effective approach in gender-affirming surgery of the upper third of the face, yielding predictable results and higher patient satisfaction.Level of Evidence 3.

Breast Reconstruction in a Postbariatric Patient Using a Fleur-de-lis Free Deep Inferior Epigastric Artery Perforator Flap: A Mini-review.

Breast reconstruction in postbariatric patients presents unique challenges due to substantial weight loss-induced body deformities. We present the case of a 51-year-old woman with massive lower abdominal deformities who underwent a mastectomy treatment followed by a temporary expander-based reconstruction. A year later, a fleur-de-lis-shaped free deep inferior epigastric artery perforator flap and abdominoplasty were performed for autologous reconstruction and abdominal contouring. This design addressed both purposes while allowing a voluminous flap to be harvested on periumbilical perforators. No postoperative complications were found, and the outcomes were favorable. Although deep inferior epigastric artery perforator flaps are standard in autologous breast reconstruction, our case demonstrates the utility of the fleur-de-lis design in massive weight loss patients for vascular safety and volume enhancement. Finally, we discuss this rarely described approach and compare it with other variants, showcasing versatility in addressing complex reconstruction needs in this particular patient population.

Update/Refinement of Targeted Muscle Reinnervation Indication: A Scoping Review of Applications for Non-Amputees.

Background: Targeted muscle reinnervation (TMR) was originally developed to enhance prosthetic control in amputees. However, it has also serendipitously demonstrated benefits in reducing phantom pain and neuromas. As a result, it has emerged as a secondary treatment for chronic neuromas in amputees and holds promise for managing neuropathic pain in non-amputee patients, particularly those with neuromas. This review synthesizes the current literature on TMR indications for non-amputee patients, highlighting its potential to address chronic peripheral nerve pain and neuromas beyond its original application in amputation. Methods: A thorough search of the PubMed and Cochrane databases up to January 2024 was conducted following the PRISMA guidelines. Inclusion criteria comprised case series, cohort studies, and randomized controlled trials reporting TMR outcomes in non-amputees. Results: Of 263 articles initially identified, 8 met the inclusion criteria after screening and full-text assessment. The articles were all case series with varied sample sizes and mainly focused on neuroma treatment (n = 6) and neuropathic pain management (n = 2) for both upper and lower extremities. Clinical studies included TMR efficacy for sural nerve neuromas in the lower extremities and hand neuromas, showing pain relief and improved function. Key findings were encouraging, showing successful pain relief, patient satisfaction, and psychosocial improvement, with only rare occurrences of complications such as motor deficits. Conclusions: In non-amputee patients, TMR appears to be a promising option for the surgical management of neuropathic pain, demonstrating favorable patient satisfaction and psychosocial outcomes along with low morbidity rates. Although functional improvements in gait recovery and range of motion are encouraging, further research will be important to confirm and expand upon these findings.

Nonsurgical Treatment of Postburn Hypopigmentation: A Literature Review.

The treatment of postburn hypopigmentation was primarily surgical before the advent of new technologies. Medical devices and therapies are emerging to manage scar sequelae that can be disfiguring and associated with severe psychosocial impact. These innovations have been poorly investigated for hypopigmentation, but they represent a real hope. We reviewed all articles published on Pubmed up to June 2022. Included studies had to specifically focus on treating postburn hypopigmented scars. All articles evaluating transient solutions such as make-up, and articles describing inflammation-linked hypopigmentation with no etiological details or no burn injury history were excluded. Through this review, we have highlighted 6 different types of nonsurgical treatments reported in postburn leukoderma potentially allowing definitive results. Electrophoto-biomodulation or E light (combining intensive pulsed light, radiofrequency, and cooling), topical daylight psoralen UVA therapy, and lasers (fractional lasers using pulse energies or CO2FL devices, lasers-assisted drug delivery as local bimatoprost and tretinoin or pimecrolimus) have been explored with encouraging results in hypopigmented burns. Finally, other promising medical strategies include using FK506, a nonsteroidal anti-inflammatory drug, to induce melanogenesis or using melanocyte-stimulating hormones with fractional laser-assisted drug deliveries, which are expected to emerge soon.

Continuous oxygen monitoring to enhance ex-vivo organ machine perfusion and reconstructive surgery.

Continuous oxygenation monitoring of machine-perfused organs or transposed autologous tissue is not currently implemented in clinical practice. Oxygenation is a critical parameter that could be used to verify tissue viability and guide corrective interventions, such as perfusion machine parameters or surgical revision. This work presents an innovative technology based on oxygen-sensitive, phosphorescent metalloporphyrin allowing continuous and non-invasive oxygen monitoring of ex-vivo perfused vascularized fasciocutaneous flaps. The method comprises a small, low-energy optical transcutaneous oxygen sensor applied on the flap's skin paddle as well as oxygen sensing devices placed into the tubing. An intermittent perfusion setting was designed to study the response time and accuracy of this technology over a total of 54 perfusion cycles. We further evaluated correlation between the continuous oxygen measurements and gold-standard perfusion viability metrics such as vascular resistance, with good agreement suggesting potential to monitor graft viability at high frequency, opening the possibility to employ feedback control algorithms in the future. This proof-of-concept study opens a range of research and clinical applications in reconstructive surgery and transplantation at a time when perfusion machines undergo rapid clinical adoption with potential to improve outcomes across a variety of surgical procedures and dramatically increase access to transplant medicine.

A Swine Burn Model for Investigating the Healing Process in Multiple Depth Burn Wounds.

Burn wound healing is a complex and long process. Despite extensive experience, plastic surgeons and specialized teams in burn centers still face significant challenges. Among these challenges, the extent of the burned soft tissue can evolve in the early phase, creating a delicate balance between conservative treatments and necrosing tissue removal. Thermal burns are the most common type, and burn depth varies depending on multiple parameters, such as temperature and exposure time. Burn depth also varies in time, and the secondary aggravation of the "shadow zone" remains a poorly understood phenomenon. In response to these challenges, several innovative treatments have been studied, and more are in the early development phase. Nanoparticles in modern wound dressings and artificial skin are examples of these modern therapies still under evaluation. Taken together, both burn diagnosis and burn treatments need substantial advancements, and research teams need a reliable and relevant model to test new tools and therapies. Among animal models, swine are the most relevant because of their strong similarities in skin structure with humans. More specifically, Yucatan minipigs show interesting features such as melanin pigmentation and slow growth, allowing for studying high phototypes and long-term healing. This article aims to describe a reliable and reproducible protocol to study multi-depth burn wounds in Yucatan minipigs, enabling long-term follow-up and providing a relevant model for diagnosis and therapeutic studies.

Smartphone-based thermography in flap surgery: A systematic review and meta-analysis of perforator identification.

Background: Thermography can be used in pre-operative planning of free perforator flap surgeries. Thermography assesses skin temperature by measuring the quantity of infrared radiation observed. In this meta-analysis, authors assess the sensitivity of smartphone-based thermal imaging (SBTI) in the detection of perforators and analyze the difference between static and dynamic imaging. Materials and methods: Authors followed the PRISMA guidelines for systematic reviews and meta-analyses. The meta package in R was used to conduct the meta-analysis. The "metaprop" function was used to calculate the overall sensitivity estimate and 95% confidence interval. The "metaprop.one" function was used to calculate subgroup estimates for static and dynamic study types. The "metareg" function was used to conduct meta-regression analyses to explore sources of heterogeneity. Results: This study includes seven articles with 1429 perforators being evaluated. The overall proportion of the sensitivities was estimated to be 0.8754 (95% CI: 0.7542; 0.9414) using a random effects model. The heterogeneity of the studies was high, as indicated by the tau^2 value of 1.2500 (95% CI: 0.4497; 8.4060) and the I^2 value of 92.6% (95% CI: 88.1%; 95.4%). The pooled sensitivity for static imaging was 0.8636 (95%CI: 0.6238-0.9603) with a tau^2 of 2.0661 and a tau of 1.4374, while the pooled sensitivity for dynamic imaging was slightly higher (p = 0.7016) at 0.8993 (95%CI: 0.7412-0.9653) with a smaller tau^2 of 0.8403 and a tau of 0.9167. Conclusion: Further studies need to confirm that SBTI is a reliable and convenient technique for detecting perforators for the pre-operative planning of free perforator flap surgeries.

Effect of Subnormothermic Machine Perfusion on the Preservation of Vascularized Composite Allografts After Prolonged Warm Ischemia.

BACKGROUND: Warm ischemia time (WIT) and ischemia-reperfusion injury are limiting factors for vascularized composite allograft (VCA) transplantation. Subnormothermic machine perfusion (SNMP) has demonstrated the potential to extend WIT in organ transplantation. This study evaluates the effect of SNMP on VCA viability after prolonged WIT. METHODS: Rat hindlimbs underwent WIT for 30, 45, 60, 120, 150, or 210 min, followed by 3-h SNMP. Monitoring of perfusion parameters and outflow determined the maximum WIT compatible with limb viability after SNMP. Thereafter, 2 groups were assessed: a control group with inbred transplantation (Txp) after 120 min of WIT and an experimental group that underwent WIT + SNMP + Txp. Graft appearance, blood gas, cytokine levels, and histology were assessed for 21 d. RESULTS: Based on potassium levels, the limit of WIT compatible with limb viability after SNMP is 120 min. Before this limit, SNMP reduces potassium and lactate levels of WIT grafts to the same level as fresh grafts. In vivo, the control group presented 80% graft necrosis, whereas the experimental group showed no necrosis, had better healing ( P  = 0.0004), and reduced histological muscle injury ( P  = 0.012). Results of blood analysis revealed lower lactate, potassium levels, and calcium levels ( P  = 0.048) in the experimental group. Both groups presented an increase in interleukin (IL)-10 and IL-1b/IL-1F2 with a return to baseline after 7 to 14 d. CONCLUSIONS: Our study establishes the limit of WIT compatible with VCA viability and demonstrates the effectiveness of SNMP in restoring a graft after WIT ex vivo and in vivo, locally and systemically.

Exploring Iodide and Hydrogen Sulfide as ROS Scavengers to Delay Acute Rejection in MHC-Defined Vascularized Composite Allografts.

Vascularized composite allografts (VCA) face ischemic challenges due to their limited availability. Reperfusion following ischemia triggers oxidative stress and immune reactions, and scavenger molecules could mitigate ischemia-reperfusion injuries and, therefore, immune rejection. We compared two scavengers in a myocutaneous flap VCA model. In total, 18 myocutaneous flap transplants were performed in Major histocompatibility complex (MHC)-defined miniature swine. In the MATCH group (n = 9), donors and recipients had minor antigen mismatch, while the animals were fully mismatched in the MISMATCH group (n = 9). Grafts were pretreated with saline, sodium iodide (NaI), or hydrogen sulfide (H2S), stored at 4 °C for 3 h, and then transplanted. Flaps were monitored until clinical rejection without immunosuppression. In the MATCH group, flap survival did not significantly differ between the saline and hydrogen sulfide treatments (p = 0.483) but was reduced with the sodium iodide treatment (p = 0.007). In the MISMATCH group, survival was similar between the saline and hydrogen sulfide treatments (p = 0.483) but decreased with the sodium iodide treatment (p = 0.007). Rhabdomyolysis markers showed lower but non-significant levels in the experimental subgroups for both the MATCH and MISMATCH animals. This study provides insightful data for the field of antioxidant-based approaches in VCA and transplantation.

VCA supercooling in a swine partial hindlimb model.

Vascularized composite allotransplantations are complex procedures with substantial functional impact on patients. Extended preservation of VCAs is of major importance in advancing this field. It would result in improved donor-recipient matching as well as the potential for ex vivo manipulation with gene and cell therapies. Moreover, it would make logistically feasible immune tolerance induction protocols through mixed chimerism. Supercooling techniques have shown promising results in multi-day liver preservation. It consists of reaching sub-zero temperatures while preventing ice formation within the graft by using various cryoprotective agents. By drastically decreasing the cell metabolism and need for oxygen and nutrients, supercooling allows extended preservation and recovery with lower ischemia-reperfusion injuries. This study is the first to demonstrate the supercooling of a large animal model of VCA. Porcine hindlimbs underwent 48 h of preservation at - 5 °C followed by recovery and normothermic machine perfusion assessment, with no issues in ice formation and favorable levels of injury markers. Our findings provide valuable preliminary results, suggesting a promising future for extended VCA preservation.

Tissue engineering strategies for breast reconstruction: a literature review of current advances and future directions.

Background and Objective: Mastectomy is a primary treatment for breast cancer patients, and both autologous and implant-based reconstructive techniques have shown excellent results. In recent years, advancements in bioengineering have led to a proliferation of innovative approaches to breast reconstruction. This article comprehensively explores the promising perspectives offered by bioengineering and tissue engineering in the field of breast reconstruction. Methods: A literature review was conducted between April and June 2023 on PubMed and Google Scholar Databases. All English and French articles related to bioengineering applied to the field of breast reconstruction were included. We used the Evidence-Based Veterinary Medicine Association (EBVM) Toolkit 14 checklist for narrative reviews as a quality assurance measure and the Scale for the Assessment of Narrative Review Articles (SANRA) tool to self-assess our methodology. Key Content and Findings: Over 130 references related to breast bioengineering were included. The analysis revealed four key applications: enhancing the quality of the skin envelope, improving the viability of fat grafting, creating breast shape and volume via bio-printing, and optimizing nipple reconstruction through engineering techniques. The primary identified approaches revolved around establishing structural support and enhancing cellular viability. Structural techniques predominantly involved the implementation of 3D printed, decellularized, or biocompatible material scaffolds. Meanwhile, promoting cellular content trophicity primarily focused on harnessing the regenerative potential of adipose-derived stem cells (ADSCs) and increasing the tissue's survivability and cell trophicity. Conclusions: Tissue and bioengineering hold immense promise in the field of breast reconstruction, offering a diverse array of approaches. By combining existing techniques with novel advancements, they have the potential to significantly enhance the therapeutic options available to plastic and reconstructive surgeons.

Superior pedicle reduction mammoplasty: A multivariable analysis of 1306 patients. Risk factors for complications and development of a predictive score.

INTRODUCTION: Breast reduction surgery for hypertrophy is one of the most commonly performed procedures in plastic surgery. This surgery exposes patients to complications well documented in the literature. The objective of this study is therefore to identify the risk factors in order to establish an estimate of the risk of developing complications. We propose the first predictive score of postoperative complications including continuous preoperative variables like Body Mass Index (BMI) and Supra Sternal Notch - Nipple Distance (SSN:N). RESULTS: 1306 patients were analyzed. Multivariable logistic regression showed three independent risk factors : active smoking (OR 6.10 [4.23; 8.78] p < 0.0001), BMI (OR 1.16 [1.11; 1.22] p < 0.0001), SSN:N (OR 1.14 [1.08; 1.21] p < 0.0001). The Rennes Plastic Surgery Score estimating occurrence of postoperative complications was determined, integrating regression coefficient of each risk factor. CONCLUSION: Active smoking, BMI and SSN:N distance are independent preoperative risk factors for the occurrence of breast reduction complications. The Rennes Plastic Surgery Score including the continuous values of BMI and SSN:N allows us to provide to our patients a reliable estimate of the risk of occurrence of these complications. EVIDENCE BASED MEDICINE LEVEL II: Lesser-quality prospective cohort or comparative study; retrospective cohort or comparative study; or untreated controls from a randomized controlled trial.