Systemic Tranexamic Acid for Reduced Postoperative Blood Loss and Less Bleeding Complications in Fleur-de-lis Abdominoplasty and Apronectomy.

BACKGROUND: Strategies minimizing surgical bleeding, including the antifibrinolytic agent tranexamic acid, play a crucial role in clinical practice to optimize overall surgical outcomes. Despite its proven efficacy in various clinical fields, there is a limited understanding regarding the use of tranexamic acid in plastic and aesthetic procedures. This study is the first investigating the effects of systemically administered tranexamic acid on postoperative blood loss and bleeding complications in fleur-de-lis abdominoplasties and apronectomies. METHODS: Patients who received 1 g tranexamic acid (n = 44) during fleur-de-lis abdominoplasty or apronectomy were retrospectively compared with those who did not (n = 44). In this context, the outcome parameters 24-h and total drain fluid production, drain time, hospital stay, absolute and relative drop in hemoglobin and hematocrit level as well as bleeding complications such as blood transfusion, hematoma puncture and evacuation were evaluated. RESULTS: Tranexamic acid significantly decreased both drainage volume in 24 h (40.5%, p = 0.0046) and total drain fluid production (42.5%, p = 0.0017). Moreover, a shorter drainage time (19.4%, p = 0.0028) and hospital stay (21.4%, p = 0.0009) were observed. The administration of tranexamic acid was also associated with a reduced postoperative decline in hemoglobin and hematocrit levels. Notably, no bleeding complications were observed in patients who received tranexamic acid, while 6 events occurred in patients without (p = 0.0262). CONCLUSION: Systemic administration of tranexamic acid effectively reduced postoperative blood loss and bleeding complications in fleur-de-lis abdominoplasties and apronectomies. 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 .

Outcome After Reconstruction of 43 Digital Nerve Defects With Muscle-in-Vein Conduits.

PURPOSE: Muscle-in-vein conduits provide an alternative for bridging digital nerve defects when tension-free suture is not possible. Low donor site morbidity and absence of additional costs are favorable advantages compared with autografts or conduits. METHODS: We retrospectively reviewed 37 patients with 43 defects of proper palmar digital nerves. Primary repair by muscle-in-vein conduits was performed in 22 cases, whereas 21 cases underwent secondary reconstruction. Recovery of sensibility was assessed using static and moving 2-point discrimination and Semmes-Weinstein monofilament testing. Results were compared with the contralateral side serving as a control. Outcome data were stratified according to international guidelines and evaluated for differences in terms of age, gap length, time of reconstruction, and concomitant injuries. RESULTS: The median gap length was 20 mm (range, 9-60 mm). After a median follow-up of 25.0 months (interquartile range, 29.0 months), the median static and moving 2-point discrimination were 7.0 mm and 5.0 mm (interquartile range, 3.0 mm), respectively. The evaluation with Semmes-Weinstein monofilament revealed a median reduction of sensibility of 2 levels compared with the contralateral side. According to the American Society for Surgery of the Hand guidelines, 81.4% of the results were classified as excellent or good, whereas fair and poor results were noted in 9.3% of the cases each. The modified Highet and Sander's criteria rated complete clinical recovery in 13 cases; 23 results were regarded as S3+. CONCLUSIONS: Muscle-in-vein conduits can be considered for primary and secondary reconstruction of digital nerves. Successful sensory recovery in terms of measurable 2-point discrimination was achieved in 91% of all cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A Single-Center 10-Year Experience of 180 Transmasculine Patients Undergoing Gender-Affirming Mastectomy While Continuing Masculinizing Hormone Replacement Therapy.

BACKGROUND: Gender-affirming mastectomy is a fundamental step in the transition process of transmasculine patients following the initiation of hormone replacement therapy. Its perioperative management, however, remains underreported and controversial. In this study, a large series of mastectomies in transmen maintaining hormonal therapy is presented. METHODS: Over a 10-year study period, a consecutive series of 180 transmasculine patients undergoing chest masculinizing surgery was evaluated. Demographical and surgical data were collected and analyzed for potential factors influencing outcome. RESULTS: The overall rate of complications was 15.5%. Patients who underwent periareolar incision mastectomy were significantly more likely to develop any type of complication than patients with a sub-mammary incision (28.6% vs. 13.2%, p = 0.045). Hematoma was the most common reason for surgical revision. It occurred significantly more often among the periareolar group (21.4% vs. 7.9%, p = 0.041). Duration and type of hormonal therapy did not differ between patients with or without complications. In a multivariate regression analysis, smoking and type of incision were identified as significant predictors of the all-cause complication rate, whereas the influence of BMI and resection weight diminished after adjusting for confounding factors. CONCLUSION: There is scarcity of information concerning the influence of perioperative hormonal therapy in patients undergoing chest wall masculinization. The observed complication rates-with special regard to hematoma-were comparable to current reports; yet further research is needed to profoundly evaluate this topic and provide evidence-based recommendations for the perioperative management of HRT of transmasculine patients. 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 http://www.springer.com/00266 .

Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique.

BACKGROUND: Phalloplasty is a crucial part of female-to-male genital gender-affirming surgery, however, up to date, there is still no standardized phalloplasty technique. AIM: To evaluate the outcome of a single-center series of phalloplasties using the free radial forearm flap variations by Chang and Hwang vs by Gottlieb and Levine on a similar number of transgender patients. METHODS: Between 2018 and 2020, 45 female to male transgender patients underwent phalloplasty using a neuro-microvascular free radial forearm flap in our department. Twenty patients underwent phalloplasty by the use of the Chang and Hwang design, whereas 25 patients were subjects to a phalloplasty according to Gottlieb and Levine technique. Patients' demographics, procedural characteristics, postoperative complications, and outcome of both groups were retrospectively evaluated and compared with each other. RESULTS: Patients' demographics were similar in both groups. We did not observe relevant differences concerning postoperative complications comparing the two groups, except for the statistically significant lower rate of partial flap necrosis in the Gottlieb and Levine group. No statistically significant risk factors for an increase in complication rate could be identified. Urethral fistulas were the leading cause of revision. CLINICAL IMPLICATION: Optimizing a phalloplasty surgical technique and contributing to establish the gold standard in phalloplasty. STRENGTHS & LIMITATION: This retrospective study presents the first comparison between the free radial forearm flap phalloplasty by Chang and Hwang and by Gottlieb and Levine performed at the same department on a similar number of transgender patients published so far. CONCLUSION: The Chang and Hwang design is associated with a lower rate of urologic complications (fistulas, stenosis) while the Gottlieb and Levine design has a statistically significant lower incidence of partial flap necrosis. Future prospective trials are needed to establish the gold standard in phalloplasty. Spennato S, Ederer IA., Borisov K et al. Radial Forearm Free Flap Phalloplasty in Female-to-Male Transsexuals - A Comparison Between Gottlieb and Levine's and Chang and Hwang's Technique. J Sex Med 2022;19:661-668.

A Training Model for Local Flaps Using Fresh Human Skin Excised During Body Contouring Procedures.

BACKGROUND: The safe execution of local flaps tends to be challenging for surgical residents. Thus, the purpose of the study was to evaluate a training model of local flaps based on fresh human skin excised from body contouring procedures. MATERIALS AND METHODS: A questionnaire and surgical skills evaluation-analyzing the theoretical and procedural knowledge about local flaps-were held both before and after the surgical skills training. All surgical procedures were executed on a simulation model based on fresh human skin. Skills evaluation was done according to a modified version of the Objective Structured Assessment of Technical Skills Score. Results before and after the training were compared using SPSS, version 21. RESULTS: In pretraining evaluation, residents showed great difficulty regarding the accuracy of flap design and sufficiency of wound coverage indicating the need for surgical training outside the operating theater. After training, the procedural skills significantly improved as depicted by the modified Objective Structured Assessment of Technical Skills score with a mean cumulative pretraining score of 26.81 ± 5.41 and posttraining score of 43.59 ± 5.72 (P = 0.008). Also, theoretical knowledge significantly improved in the posttraining evaluation with exception to the indication of a Z-plasty (P = 0.257). The training model itself was generally regarded as highly useful and thus recommendable to others. CONCLUSIONS: Surgical handling and the understanding of tissue rotation clearly improved by the presented model which mimics very realistic conditions. The simulation model based on fresh human skin shows cost-effectiveness and allows a broad range for flap procedures wherefore its use should be further promoted.

Does obesity impact the outcome of severely burned patients?

Although obesity appears to be an important predictor of mortality and morbidity, little data about the impact of body mass index (BMI) on the outcome of severely burned patients are available. Patients admitted to the General Hospital Vienna between 1994 and 2014, who underwent surgery because of burn injuries, were enrolled in this study. BMI was used to divide patients into five groups: BMI 18.5 to 24.9, 25 to 29.9, 30 to 34.9, 35 to 39.9, and > 40. The groups were compared in terms of difference of mortality and morbidity. Of 460 patients, 34.3% (n = 158) died. Mortality rates were the lowest in patients with obesity class III and the highest in patients with BMI 35 to 39.9 (BMI 18.5-24.9: 30.5%, BMI 25-29.9: 31.5%, BMI 30-34.9: 41.3%, BMI 35-39.9: 55.5%, BMI > 40: 30%; P = .031). BMI was not found to be an independent risk factor when corrected with age, percent total body surface area burned, full-thickness burns, and inhalation injury. No significant differences in length of stay, inhalation trauma, pneumonia, wound infection, sepsis, and invasive ventilation were observed. BMI as an independent risk factor for severely burned patients could not be confirmed via multivariate analysis.

Dynamic Prognostication Using Conditional Recurrence and Progression Estimates for Patients with Nonmuscle Invasive Bladder Cancer.

PURPOSE: Conditional estimates provide a dynamic prediction of outcomes but to our knowledge there are no data on nonmuscle invasive bladder cancer. We assessed changes in conditional recurrence and progression rates after transurethral resection of the bladder and explored the prognostic impact of established factors and risk groups with time. MATERIALS AND METHODS: We retrospectively analyzed data on 1,292 consecutive patients with newly diagnosed Ta/T1 bladder cancer who underwent transurethral resection of the bladder. Study end points were time to first recurrence and time to progression. RESULTS: The 2-year recurrence rate at baseline was 36%, which improved as a function of the time that patients were free of disease recurrence. After 6, 12, 24, 36 and 48 months the 2-year conditional recurrence rate improved to 31% (14% improvement vs baseline), 22% (39% improvement), 16% (56% improvement), 13% (64% improvement) and 11% (69% improvement), respectively. Comparably, conditional progression rates improved with increasing followup, although relative differences were less distinct. The prognostic impact of established factors and nonmuscle invasive bladder cancer risk groups progressively decreased with time and finally disappeared. However, bacillus Calmette-Guérin had a protective effect on progression even after 3 years. We provide tables with dynamic prognostic information at all analyzed time points. CONCLUSIONS: In patients with primary Ta/T1 bladder cancer recurrence and progression rates improve with time. The prognostic impact of established factors and risk groups decreases and finally disappears. The effect of bacillus Calmette-Guérin on progression is long-lasting. Conditional outcome estimates may improve patient counseling and individualize surveillance planning.

Histopathology and prognosis of de novo bladder tumors following solid organ transplantation.

BACKGROUND: Patients following solid organ transplantation have an increased risk of developing de novo bladder tumors, but their biology is poorly characterized. METHODS: We studied 1743 patients who underwent a transurethral resection of a newly diagnosed bladder tumor at a single institution. The histopathology, treatment, recurrence-free survival and overall survival were evaluated and compared between transplant and non-transplant patients. RESULTS: We identified 74 transplant patients who developed a de novo bladder tumor after a median post-transplantation interval of 62 months. The tumor was malignant in 29 patients (39 %). The most common benign lesion was nephrogenic adenoma (84 %), which neither coexisted with nor developed into malignant tumors during follow-up. Compared with non-transplant patients (n = 1669), transplant patients were significantly younger (median 55 vs 69 years, P < 0.001) and had a 9.0-fold higher odds of benign tumors (P < 0.001), while there were no differences in pathology among patients with urothelial carcinoma of the bladder (UCB). In a multivariable analysis for non-muscle-invasive UCB that was adjusted for the risk group, patients with a transplant had a 1.8-fold increased risk of recurrence (P = 0.048). Four of five transplant patients did not respond to Bacillus Calmette-Guérin instillations. There were no differences in overall survival after radical cystectomy (P = 0.87). CONCLUSIONS: The majority of bladder tumors in transplant patients are benign, and they neither coexist with nor develop into malignant tumors. Transplant patients with non-muscle-invasive UCB show an increased risk of disease recurrence, while those treated with radical cystectomy have similar outcomes to patients without a transplant.

Impact of diabetes on clinical outcome in severely burned patients.

INTRODUCTION: According to the International Diabetes Federation, approximately 425 million people worldwide suffer from diabetes mellitus, a figure that will double in the next 20 years. Data on the ratio of treated diabetics in burn intensive care units remain scarce and the effects on the mortality rate are poorly defined. METHODS: Our retrospective, single-centre study aimed to evaluate differences in the risk factors due to diabetes mellitus, the clinical outcome and the patient population of diabetic patients after severe burn injuries over a time period of 21 years. RESULTS: Despite increasing numbers of diabetic patients, the ratio of burn patients suffering from diabetes remained stable during the study period. The risk factors for mortality were higher age (OR 1.03, 95% confidence interval (CI), 1.02-1.04, p < 0.0001), female sex (OR 1.56, 95% CI, 1.06-2.29, p = 0.025), higher % total body surface area (TBSA) (OR 3.88, 95% CI, 2.81-5.46, p < 0.0001), full thickness burns (OR 8.58, 95% CI, 3.84 - 23.60, p < 0.0001) and the presence of inhalation injuries (OR 4.68, 95% CI, 3.15-7.02, p < 0.0001) Patients with diabetes had a smaller extent of burned areas with a median TBSA of 30% (quartiles: 22-50%, p = 0.036) compared to non-diabetic patients (35% (25-55%)) but had a similar length of stay with a median of 29 (quartiles: 13-44) days vs. 23 (10-48) days. Outcome analysis showed an overall mortality of 35.6%. Diabetes was not associated with higher mortality rate after burn injury in a univariate model (OR 1.80, 95% CI 0.92-3.51). After correction for %TBSA, the effect of diabetes on mortality was significant (OR 2.80, 95% CI, 1.33-5.90). CONCLUSION: Our data indicate higher mortality rates (50-100%) of diabetic patients with TBSA greater than 40% in severely burned patients compared to non-diabetic patients without a significant outcome due to the low number of cases in the subgroup analyses.

Muscle-in-Vein Conduits for the Treatment of Symptomatic Neuroma of Sensory Digital Nerves.

BACKGROUND: Considering the debilitating burden of neuroma resulting in a significant loss of function and excruciating pain, the use of muscle-in-vein conduits (MVCs) for the reconstruction of painful neuroma of sensory nerves of the fingers was assessed. METHODS: We retrospectively analyzed 10 patients who underwent secondary digital nerve repair by MVCs. The recovery of sensibility was evaluated by static and moving two-point discrimination (2PDs, 2PDm) and Semmes-Weinstein monofilament testing (SWM). The minimum follow-up was set 12 months after the operation. RESULTS: The median period between trauma and nerve repair was 13.4 weeks (IQR 53.5). After neuroma resection, defects ranged from 10-35 mm (mean 17.7 mm, SD 0.75). The successful recovery of sensibility was achieved in 90% of patients after a median follow-up of 27.0 months (IQR 31.00). The mean 2PDs and 2PDm was 8.1 mm (SD 3.52) and 5.2 mm (SD 2.27), respectively. Assessment by SWM resulted in a mean value of 3.54 (SD 0.69). Reduction in pain was achieved among all patients; eight patients reported the complete relief of neuropathic pain. There was no recurrence of neuroma in any patient. CONCLUSIONS: Muscle-in-vein conduits provide an effective treatment for painful neuroma of digital nerves, resulting in satisfactory restoration of sensory function and relief of pain.

BMI Specific Complications Following Implant-Based Breast Reconstruction after Mastectomy.

BACKGROUND: Breast reconstruction has a positive impact on body image and quality of life for women after experiencing the physically and psychologically demanding process of mastectomy. Previous studies have presented body mass index (BMI) as a predictor for postoperative complications after breast reconstruction, however, study results vary. This retrospective study aimed to investigate the impact of patients' BMI on postoperative complications following implant-based breast reconstruction. METHODS: All implant-based breast reconstructions performed at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Vienna from January 2001 to March 2018 were evaluated. A total of 196 reconstructed breasts among 134 patients met eligibility criteria. Demographic data, surgical techniques, as well as major and minor complications within a one-year follow-up period were analyzed. RESULTS: Patients' BMI did not show a significant impact on complication rates. The overall incidence of postoperative complications was 30.5% (40/131) of which 17.6% required reoperation. Impaired wound healing (18.3%), seroma (6.1%), hematoma (4.6%), capsular contraction (4.6%) and infection (3.8%) were the most common complications. CONCLUSION: In our study cohort, BMI was not associated with a significantly higher risk of complications. However, postoperative complications significantly increased with a longer operative time and resulted in an extended length of hospital stay.

[Percutaneous, antegrade Pinning of proximal phalangeal Fractures: Comparison of Early Active Motion vs. Immobilization by Splinting]. / Perkutane, antegrade K-Draht-Osteosynthese bei Fingergrundgliedfrakturen: Vergleich zwischen frühfunktioneller und statischer Nachbehandlung.

PURPOSE: This retrospective study compares the functional outcome after early active postoperative motion with the outcome after 6 weeks of immobilization by splinting in patients with proximal phalangeal fractures treated by percutaneous, antegrade pinning. PATIENTS AND METHODS: 46 out of 90 patients treated by closed reduction and percutaneous antegrade pinning of isolated fractures of the proximal phalanges were re-evaluated on average after 18.5 months. There were 17 women and 29 men with a mean age of 42.8 years. 28 patients underwent early active postoperative motion and 18 patients were immobilized by splinting for 6 weeks postoperatively. The two groups were statistically comparable with respect to age, gender, fracture localisation and morphology, mechanism of injury and operative time. Follow-up examination included measurement of active and passive range of motion (TAM; TPM) of the injured finger and the uninjured finger of the opposite side as well as grip strength of both hands. In addition, postoperative complications, the DASH-score and time interval between surgery and return to work were registered. RESULTS: There were no significant differences between the two groups regarding rate of complication, number or required revisions, finger motion and grip strenght. Patients with early active motion returned earlier back to work than patients treated by postoperative splinting (2.5 vs. 9.0 weeks; p = 0.035). With 1.7 the DASH-score in the group with early active motion was better than in the splinting group with 2.5 (p = .269). CONCLUSION: Patients with early active postoperative motion returned earlier back to work. There was no significant difference between both groups respecting global finger function.Compliant patients with a fracture of the proximal phalanx treated by closed reduction and percutaneous pinning can be treated with early active motion postoperatively.

Gender has no influence on mortality after burn injuries: A 20-year single center study with 839 patients.

BACKGROUND: According to the ABSI - Abbreviated Burn Severity Index - women exhibit an increased risk of succumbing to burn injuries. In contrast, following non-thermal trauma, increased mortality has been shown for the male gender. Therefore, the purpose of this study was to evaluate gender-specific differences among burn patients with special regard to burn mortality. METHODS: We retrospectively studied 839 patients who were admitted to the Burn Intensive Care Unit (BICU) and underwent surgical treatment between June 1994 and December 2014. In-hospital mortality was the main clinical endpoint. Odds ratios (ORs) were calculated using univariate and multivariate logistic regression models for the association between sex and mortality. RESULTS: In total, we included 530 male and 309 female burn patients. All patients had at least partial-thickness burns and underwent one or more operative procedures. Women were significantly older than men (mean 60.0 years vs 46.2 years; p<0.001). Despite having smaller injuries (24.6% vs 30.3% total body surface area (TBSA); p<0.001), burn mortality among women significantly differed from that of men (27.8% vs 21.7%; OR 1.39, p=0.045, 95% CI 1.01-1.92). This association, however, did not persist after adjusting for age, %TBSA, inhalation injury and full-thickness burns (OR 1.07, p=0.77, 95% CI 0.68-1.70). CONCLUSIONS: Despite increasing research directed at women's health, the assoziation between gender and burn mortality has yielded conflicting results. This study does not support a gender-specific difference in burn mortality in our study population.