Stromal Vascular Fraction Obtained From Subcutaneous Adipose Tissue: Ex-Obese and Older Population as Main Clinical Targets.

INTRODUCTION: Human adipose tissue contains a heterogeneous and synergistic mixture of cells called stromal vascular fraction (SVF) with highly proliferative and angiogenic properties, conferring promising applicability in the field of regenerative medicine. This study aims to investigate if age, body mass index (BMI), history of obesity and massive weight loss, and harvest site are related to SVF cell marker expression. METHODS: A total of 26 samples of subcutaneous adipose tissue were harvested from patients admitted to the Plastic and Reconstructive department in University Hospital Center of São João, Porto, Portugal, for body contouring surgery. The percentage of cells expressing CD31, CD34, CD45, CD73, CD90, and CD105 was assessed and compared with patient's age, BMI, history of obesity and massive weight loss (ex-obese group), and harvest site. RESULTS: In the ex-obese group, a significantly higher number of cells expressing CD90 (P = 0.002) was found. BMI, harvest site, and age appear to have no association with SVF subpopulations. CONCLUSIONS: This study suggests that ex-obese patients have a higher percentage of SVF cells expressing CD90, which correlates with higher proliferative and angiogenic rates. The effect of former obesity and massive weight loss on the expression of CD90 is a new and relevant finding because it makes this population a suitable candidate for reconstructive and aesthetic surgery and other fields of regenerative medicine. The use of SVF appears also promising in older patients because no negative correlation between increasing age and different cell markers expression was found.

Successful Surgical Resection and Reconstruction of a Giant Facial Vascular Malformation in an Elderly Patient.

Venous vascular malformations can be challenging, especially in an elderly patient. As these lesions can present with ulceration, deformity, pain, and swelling resulting from thrombi formed due to low flow (palpable phleboliths), removing them can be important for the well-being of the patient. A 79-year-old patient presented with a giant venous malformations occupying the left hemiface and a deprivation amblyopia in his left eye. Successful surgical resection and reconstruction was achieved and the patient was very pleased with his new appearance. Despite his age and surgical risks, we consider that never is late to improve a disfigured face.

Growth Factor-Free Vascularization of Marine-Origin Collagen Sponges Using Cryopreserved Stromal Vascular Fractions from Human Adipose Tissue.

The successful integration of transplanted three-dimensional tissue engineering (TE) constructs depends greatly on their rapid vascularization. Therefore, it is essential to address this vascularization issue in the initial design of constructs for perfused tissues. Two of the most important variables in this regard are scaffold composition and cell sourcing. Collagens with marine origins overcome some issues associated with mammal-derived collagen while maintaining their advantages in terms of biocompatibility. Concurrently, the freshly isolated stromal vascular fraction (SVF) of adipose tissue has been proposed as an advantageous cell fraction for vascularization purposes due to its highly angiogenic properties, allowing extrinsic angiogenic growth factor-free vascularization strategies for TE applications. In this study, we aimed at understanding whether marine collagen 3D matrices could support cryopreserved human SVF in maintaining intrinsic angiogenic properties observed for fresh SVF. For this, cryopreserved human SVF was seeded on blue shark collagen sponges and cultured up to 7 days in a basal medium. The secretome profile of several angiogenesis-related factors was studied throughout culture times and correlated with the expression pattern of CD31 and CD146, which showed the formation of a prevascular network. Upon in ovo implantation, increased vessel recruitment was observed in prevascularized sponges when compared with sponges without SVF cells. Immunohistochemistry for CD31 demonstrated the improved integration of prevascularized sponges within chick chorioalantoic membrane (CAM) tissues, while in situ hybridization showed human cells lining blood vessels. These results demonstrate the potential of using cryopreserved SVF combined with marine collagen as a streamlined approach to improve the vascularization of TE constructs.

Nasal Reconstruction: Reconstruction of a Nasal Tip, Columella and Middle Crura Defect After Human Bite with a Turn Down Flap Associated With Conchal Graft and Interpolated Melolabial Flap.

ABSTRACT: Nasal reconstruction is one of the most difficult procedures in plastic surgery due to its complex anatomy and function. A 31-year male was sent to our evaluation after an acquired nasal defect caused by a human bite 2 years before. The defect encompassed the nasal tip, columella, and both middle crura. After a detailed evaluation, the inner lining was reconstructed with a turndown flap of the released scar. In the same operative time, a shaped conchal cartilage graft was anchored to the remnants of both lateral crura and covered with a melolabial interpolated flap. Division, debulking, and final in setting of the flap was done after 5 weeks. Although simple steps were used, a good aesthetic reconstruction was achieved with minimal donor site morbidity.This case proves that a good planning is a cornerstone of a good reconstruction.

A Ruler for Abdominoplasty Preoperative Markings: The Potential of Best Scar Symmetry.

Background. Scar appearance is an important outcome in abdominoplasty surgery, and its asymmetry can have a significant impact on patient and surgeon satisfaction. Here, we compared the scar symmetry reached with a ruler specially designed for the preoperative marking in abdominoplasty to the classic preoperative incision marking. Methods. In this randomized, uni-blind study, 42 patients were allocated to 2 different groups. Group 1 patients had their preoperative marking made by a group of surgeons that used the classic technique as described by Baroudi (n = 21), and Group 2 patients received their preoperative marking by another group of surgeons, using a ruler specially designed to fit the abdominal contour (n = 21). Patients were evaluated using a standard questionnaire that collected information about general patient's characteristics. On the follow-up period, we evaluated the presence of late surgical complications, need for revision surgery, patient's satisfaction concerning the postoperative scar, and 4 distances were measured in both groups to assess symmetry. Statistical analysis was made. Results. A total of 42 patients underwent abdominoplasty and were evaluated on the follow-up period (mean time: 4 months). The mean difference of corresponding measures on each side (A-B vs. A-B' and A-C vs. A-C') was higher in Group 1 comparing to Group 2. The level of correlation between corresponding measurements was higher in Group 2. Better satisfaction regarding the scar symmetry was achieved in Group 2, being this result statistically significant (P = .004). Conclusions. The use of the specialized ruler may help surgeons achieve a better scar symmetry with higher patient satisfaction.

Functional facial reconstruction in a patient with severe burn sequelae with a prelaminated parascapular free flap based on a three-dimensional model: A case report.

Significant evolution has been made concerning resuscitation and emergency management of severely burned patients, and nowadays most patients will survive and deal with burns sequelae. They constitute a reconstructive challenge, mainly because options and donor areas are frequently compromised, results are often limited, and other options should then be considered. A 27-year-old male patient with 55% total burn surface area, presented with severe facial disfigurement including ectropion, upper/lower lip retraction, and partial loss of the nose. In order to improve the patient's condition, autologous reconstruction was considered. The only unburned area in the body was the left dorsal region, and a three-stage reconstruction was planned using a paraescapular flap. In a first stage, an elective surgery was performed to identify and tag the recipient vessels in the neck. After 3 months, the prelamination process was initiated with the drawing of a facial model, and a nose and lips were opened inside the flap. This was based on a three-dimensional latex model as a print of the patient's face, which allowed us to calculate distances and estimate the length of the vascular pedicles. After 3 months, the flap (18 × 8 cm) was transferred and microvascular anastomoses were performed. No major complications were seen after surgeries, and after 28 months, an extremely important functional gain was obtained. Despite the number of surgeries required and less than optimal aesthetic results, this method may offer a satisfactory solution for complex acquired facial burn sequelae when other local or distant flap options are not available.

Facial Reconstruction Based on Combined Three-Dimensional Printing and Microsurgical Free Transfer.

There are patients with craniofacial deformity that can lead to extensive bone loss and severe disfigurement. Autologous reconstruction may be challenging in these patients, and it is usually associated with flap donor area morbidity and unfavorable aesthetic and functional results. A 51-year-old patient with human immunodeficiency virus infection, developed in the context of immunosuppression a fulminant fungal rhino-sinusitis with the need for surgical debridement, and in consequence extensive destruction of the nasal cavity and upper jaw, resulting in severe disfigurement due to nasal deformity and maxillary collapse. Human immunodeficiency virus disease was controlled and the complex craniofacial defect was posteriorly reconstructed with direct 3-dimensional (3D) printing combined with microsurgical free tissue transfer. The 3D facial implant, in titanium, was individualized and fabricated based on computed tomography images of the patient. A radial forearm free flap was used since a soft-tissue defect was anticipated after scar release and implant placement. It allowed simultaneous coverage of the palate, the anterior surface of maxilla and intranasal lining. The flap survived despite flap venous congestion in the postoperative period probably facilitated because of the complex 3D flap configuration and pedicle tunneling into the neck. After 9 months, the patient showed a tremendous aesthetic and functional improvement. The 3D printing was useful in our patient with craniofacial reconstruction. Its combination with free tissue transfer may improve the surgeon's armamentarium when dealing with complex patients.

Necrotic Loxoscelism of the Scalp.

A 15 month old boy was referred to our department after he and his mother moved to our country. He had been bitten by a brown recluse spider (Loxosceles reclusa) at the age of 7 months, in Brazil. Initially, he presented to the emergency department of his local hospital with rash in the scalp, near the bite. After a few days, he developed systemic disease with multiorgan failure and was admitted on intensive care unit, where he has been treated for 2 months. During this hospital stay he developed skin necrosis of the scalp, right preauricular, mandibular, and neck regions. He also developed right foot ischemia, which resulted in amputation. At the discharge time, he was under topical treatment with silver sulfadiazine, which was maintained until our observation, 8 months after being bitten. The child was successfully treated, and is now stable and awaiting lower limb prosthetic replacement.Loxoscelism (bites by spiders of the genus Loxosceles) is the only proven arachnological cause of dermonecrosis. The brown recluse spider, Loxosceles reclusa, is the best known and can cause necrotic dermatologic injury throw an enzyme, sphingomyelinase D, that has been shown to be cytotoxic to endothelial and red blood cells. Although the majority of persons bitten by a brown recluse spider probably will not seek medical attention, some patients may develop systemic loxoscelism, especially children.

Giant Tongue in a Patient With Chiari Malformation and Neuroleptic-Induced Tardive Dyskinesia.

A 68-year-old woman, presented with a squamous cell carcinoma of the malar region, and underwent wide local excision. During her clinical examination, repetitive protrusion and intrusion of the tongue as well as stereotypic, abnormal movements of the mouth and lips were observed, in a pattern that resembled chewing, sucking or lip pursing; dyskinesias ceased when she was speaking or bringing food to the mouth. She was unaware of the movements and the tongue was observed to move similar to choreiform movements, while revealing a giant "snake-like" macroglossia. She had history of mental retardation and alcohol abuse, and was under classic antipsychotic medications for several years. During a previous neurological investigation, type I Chiari malformation was diagnosed. In this case, concomitant Chiari malformation and neuroleptic-induced tardive dyskinesia, may together have been responsible for giant macroglossia, and to our best knowledege no similar observation has been reported in the literature.

The Facial Artery Perforator Flap as a New Option for Reconstruction of Intraoral Defects: Surgical Tips and Clinical Series.

BACKGROUND: The authors have recently 1st described the use of the facial artery perforator flap (FAP) for intraoral reconstruction. In this study, they discuss technical notes and surgical tips associated with the procedure and the application of this flap in 4 patients with intraoral defects resulting from cancer or osteoradionecrosis. METHODS: A retrospective study of 4 consecutive patients was performed on all patients who underwent reconstruction of an intraoral defect with a FAP flap, over a 12-month period from March 2017 to March 2018.The flap was designed according to the size of the defect centered on the perforator and was tunneled intraorally by means of a 90° rotation or advanced medially. The most constantly encountered perforator 1.5 cm lateral to the oral commissure was used in 3 cases; a cranial perforator was selected in 1 patient. RESULTS: Four FAP flaps were used in 4 patients with intraoral defects. Follow-up was 6 to 12 months. Median defect size was 9.15 cm (range, 3.4-21.5 cm). All reconstructions were successful, without major flap loss or infections. One patient with severe osteoradionecrosis and fungal infection developed minor flap loss and dehiscence, which was treated conservatively. There were no signs of local recurrence and functional outcomes were satisfactory. CONCLUSIONS: The FAP flap is an effective and versatile solution for reconstruction of intraoral defects until 5 cm × 4 cm (20 cm) without significant donor-site morbidity. It may be considered a new reconstructive option for intraoral defects, which warrants further study in a larger series or patients.

The facial artery perforator flap for intraoral reconstruction of a mouth floor defect.

Facial artery perforator flaps have been recently reported by different authors for perioral, nasal alar and cheek defects, but not for intraoral reconstruction. We have extended the use of the facial artery perforator flap in a 56-year-old man with a squamous cell carcinoma of left mouth floor, who was submitted to tumor resection with marginal mandibulectomy and left supraomohyoid neck dissection. The flap was designed according to the size of the defect (5 × 3 cm), centered on the perforator to create a symmetric flap and was tunnelled intraorally by means of a 90° rotation. The postoperative period was uneventful, allowing timely initiation of adjuvant radiotherapy. After 8 months, there were no signs of local recurrence or wound dehiscence, and functional outcomes were satisfactory. The main advantages of this flap in this case were the reduction in morbidity at the donor site with preservation of nerves, muscles and facial artery, and it allowed greater freedom. To the best of the authors' knowledge, this technique has not been reported before. It may constitute an important reconstructive option when dealing with similar defects, if our results are confirmed in larger series.

Reconstruction of a near total ear amputation with a neurosensorial radial forearm free flap prelaminated with porous polyethylene implant and delay procedure.

When an auricular defect is caused by high-energy trauma that causes damage to the surrounding tissues, the patient may be not a candidate for reconstruction with local flaps and free tissue transfer may be necessary. Here we present a case of total auricular reconstruction in a 27 year-old man who had total loss of the left ear and traumatized temporal skin and fascia. A radial forearm flap prelaminated by a porous polyethylene implant was employed. A "printed" ear made of silicone, based on the patient's CT-scan of the contralateral ear, was used for intraoperative molding of the future reconstruction. Prolonged prelamination time and surgical delay (three months) were performed to reduce edema, distortion and loss of definition of the framework after revascularization. After subsequent integration and neovascularization of the added tissue, the prelaminated flap was transferred. Flap reinnervation was also performed by direct coaption of the great auricular nerve to the lateral antebrachial cutaneous nerve. The flap fully survived and there were no complications in the early postoperative period. Between 3 and 6 months, the patient returned to normal ranges in terms of warmth and cold, and recovered the discriminative facial sensibility. After one year the auricular reconstruction was intact and satisfactory aesthetic results were achieved. This method may offer a satisfactory solution for a difficult problem and may be considered for acquired total ear defects.

Nine years of a single referral center management of Stevens-Johnson syndrome and toxic epidermal necrolysis (Lyell's syndrome).

CONTEXT: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) corresponds to a rare and acute life-threatening mucocutaneous reactions characterized by extensive necrosis and epidermal detachment. There are no efficacious pharmaceutical interventions proven through large clinical trials. OBJECTIVE: We sought to study clinical cases admitted in our institution in order to determine which drugs and medical comorbidities or treatments impacted the mortality. MATERIAL AND METHODS: In a retrospective study over 9 years we evaluated all patients presenting biopsy-proven SJS or TEN for age, gender, total body surface area involved, causing agents, SCORTEN score, blood transfusion, steroid administration, intubation, length of intensive care stay and death rate. Statistical analysis was done using SPSS statistical software. RESULTS: The highest incidence of SJS and TEN was in age group of 71-80 years. Of the 30 patients, 30% died from SJS/TEN, mainly due sepsis. For each subgroup SJS/TEN overlap had the highest mortality. The highest mortality was from antibiotic treatment as causing agent. Step-wise regression analysis identified mechanical ventilation requirement and age over 65 years as mortality high-risk factors. DISCUSSION: The most crucial interventions are discontinuation of the offending drug and prompt referral to a burn unit, which helps in early diagnosis and decrease mortality in these diseases. CONCLUSION: When SJS/TEN is caused by antibiotics suspicion of developing fatal sepsis should be high, independently of patients' medical condition.

Facegram - Objective quantitative analysis in facial reconstructive surgery.

Evaluation of effectiveness in reconstructive plastic surgery has become an increasingly important asset in comparing and choosing the most suitable medical procedure to handle facial disfigurement. Unfortunately, traditional methods to assess the results of surgical interventions are mostly qualitative and lack information about movement dynamics. Along with this, the few existing methodologies tailored to objectively quantify surgery results are not practical in the medical field due to constraints in terms of cost, complexity and poor suitability to clinical environment. These limitations enforce an urgent need for the creation of a new system to quantify facial movement and allow for an easy interpretation by medical experts. With this in mind, we present here a novel method capable of quantitatively and objectively assess complex facial movements, using a set of morphological, static and dynamic measurements. For this purpose, RGB-D cameras are used to acquire both color and depth images, and a modified block matching algorithm, combining depth and color information, was developed to track the position of anatomical landmarks of interest. The algorithms are integrated into a user-friendly graphical interface and the analysis outcomes are organized into an innovative medical tool, named facegram. This system was developed in close collaboration with plastic surgeons and the methods were validated using control subjects and patients with facial paralysis. The system was shown to provide useful and detailed quantitative information (static and dynamic) making it an appropriate solution for objective quantitative characterization of facial movement in a clinical environment.

Reconstruction of a postraumatic radial club hand with a free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure-A case report.

Radial club hand may be congenital or acquired; radial deviation of the hand is usually found, associated with palmar flexion-pronation and treatment of severe forms of radial club hand is often difficult. Here we present a case of reconstruction of a severe postraumatic radial club hand with a free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure in a 28-year-old man. The patient had a radial deviation of the wrist and right upper limb shortening as a result of an infected pseudarthrosis of the radius. This deformity was reconstructed with a free fibular osteoseptocutaneous flap associated to arthrodesis of the distal radioulnar joint and an ulnar resection osteotomy proximal to the arthrodesis in order to restore rotation of the forearm (Sauvé-Kapandji procedure). The flap fully survived and no complications were seen in the early postoperative period at both recipient and donor sites. Radius alignment was restored. At 5-month follow-up, the skeleton was healed. There was minimal osteopenia at the distal radial segment. Wrist extension was 48 degrees, flexion 24 degrees, and pronation-supination was 58-0-48 degrees, with full finger flexion. The patient could hold a 4 kg dumbbell with the elbow flexed without discomfort. His DASH score-Disabilities of the Arm, Shoulder, and Hand Questionnaire was 15.83. Combined free fibular osteoseptocutaneous flap and Sauve-Kapandji procedure may be considered in severe forms of postraumatic radial club hand, however, further data are necessary. © 2016 Wiley Periodicals, Inc. Microsurgery 36:593-597, 2016.

The Retromolar Trigone: Anatomy, Cancer Treatment Modalities, Reconstruction, and a Classification System.

BACKGROUND: Retromolar trigone (RMT) tumors are rare and aggressive malignancies, spreading rapidly into surrounding structures. In reviewing the literature, there is lack of information and quality evidence pertaining to their management and high heterogeneity in treatment modalities. METHODS: A systematic Medline search was performed to gather all reports of articles related to retromolar trigone in tle last 10 years (2005-2015). Papers were excluded if they were related to oral cavity cancer but not specific for the RMT. RESULTS: Results were divided into 5 sections: anatomy and lymphatic drainage; etiology and diagnosis; cancer treatment modalities; reconstructive options; proposal of a classifications system. A clinical patient exemplification was also included. Various treatment modalities have been tried in the past including surgery, radiotherapy, and combination therapy using chemoradiation. All these modalities have intrinsic risks. There is also controversy regarding the extent of surgery. Reconstructive options differ with the size of the defects. The ability of the propeller lingual flap to rotate any angle up to 180 degrees allows it to reconstruct small-to-medium sized defects. If bulkier reconstructions are needed to separate oral and nasal cavities, a free flap (radial forearm, anterolateral thigh, medial sural) should be planned. CONCLUSIONS: In view of the rarity of the tumor and heterogeneity of treatment, there is limited information available pertaining to retromolar trigone tumors. A better understanding of RMT amatomy, cancer treatment modalities, and reconstructive options can improve the surgeon decision capacity and clinical results, when dealing with such uncommon and challenging tumors.

The Freestyle Facial Artery Perforator Flap for Reconstruction of Simultaneous Periorbital and Cheek Defects.

The reconstruction of defects involving the nasolabial, paranasal, and periorbital regions may be challenging, because they often involve more than one facial aesthetic unit, and can lead to functional problems. An average of 5 facial artery perforators of caliber >0.5 mm can be found above the mandible. A reference point for the location of the most constantly encountered perforator was suggested as being 1.5 cm lateral to the oral commissure, and at its same level in height or slightly inferior to the commissure. Based on injection studies, it is known that these perforators can supply an average area of 8 cm. The authors have extended the use of the freestyle perforator flap in a 87-year-old woman presented with an advanced melanoma of the paranasal area and nasolabial region (Breslow depth: 9 mm; Clark level V). Complete resection of the lesion with 3 cm oncological margins was performed. One-stage reconstruction with superior cosmetic results was achieved. The need for a perforator dissection is not necessarily a drawback, and classic concerns should be abandoned. The face is highly vascularized, and flap congestion is a rare event, usually a consequence of excessive pedicle trimming. Although technically more demanding, it should become one of the first reconstructive options when dealing with similar defects, if our results are confirmed in larger series.

Correction of Residual Static and Dynamic Labial Deviations in a Paralyzed Face After Free Gracilis Muscle Transplantation.

Free muscle flap transfer is currently the procedure of choice for longstanding facial paralysis to restore symmetry both at rest and when smiling. However, movements obtained are generally localized, unidirectional, and philtrum centralization and lower lip movement is not proportionally achieved. The stability of free flap insertion at the lips also interferes with the results, as gradual disinsertion and shifting of the nasolabial fold can be caused by repetitive movements. Asymmetry of smile can also be caused by lip depressor inactivity due to marginal mandibular paralysis, and both dynamic and static procedures are often required after dynamic reanimation. Here, the authors report a technical refinement that can be used even years after facial reanimation, using concealed scars and with minimal morbidity for correction of static and dynamic labial deviations from the midline. Placement of a transfixed tendon graft in C-fashion tendon graft between the gracilis free flap and the orbicularis oris of the upper and lower lip on the nonparalyzed side allows the forces from muscle contraction to be transferred to the philtrum and lower lip. It allows correction of static and dynamic labial deviations from the midline, reducing rates of inadequate fixation and partial or total disinsertion of the muscle flap in the buccal region.