The secretome of stressed peripheral blood mononuclear cells increases tissue survival in a rodent epigastric flap model.

Reconstructive surgery transfers viable tissue to cover defects and to restore aesthetic and functional properties. Failure rates after free flap surgery range from 3 to 7%. Co-morbidities such as diabetes mellitus or peripheral vascular disease increase the risk of flap failure up to 4.5-fold. Experimental therapeutic concepts commonly use a monocausal approach by applying single growth factors. The secretome of γ-irradiated, stressed peripheral blood mononuclear cells (PBMCsec) resembles the physiological environment necessary for tissue regeneration. Its application led to improved wound healing rates and a two-fold increase in blood vessel counts in previous animal models. We hypothesized that PBMCsec has beneficial effects on the survival of compromised flap tissue by reducing the necrosis rate and increasing angiogenesis. Surgery was performed on 39 male Sprague-Dawley rats (control, N = 13; fibrin sealant, N = 14; PBMCsec, N = 12). PBMCsec was produced according to good manufacturing practices (GMP) guidelines and 2 ml were administered intraoperatively at a concentration of 2.5 × 107 cells/ml using fibrin sealant as carrier substance. Flap perfusion and necrosis (as percentage of the total flap area) were analyzed using Laser Doppler Imaging and digital image planimetry on postoperative days 3 and 7. Immunohistochemical stainings for von Willebrand factor (vWF) and Vascular Endothelial Growth Factor-receptor-3 (Flt-4) were performed on postoperative day 7 to evaluate formation of blood vessels and lymphatic vessels. Seroma formation was quantified using a syringe and flap adhesion and tissue edema were evaluated clinically through a cranial incision by a blinded observer according to previously described criteria on postoperative day 7. We found a significantly reduced tissue necrosis rate (control: 27.8% ± 8.6; fibrin: 22.0% ± 6.2; 20.9% reduction, p = .053 vs. control; PBMCsec: 19.1% ± 7.2; 31.1% reduction, p = .012 vs. control; 12.9% reduction, 0.293 vs. fibrin) together with increased vWF+ vessel counts (control: 70.3 ± 16.3 vessels/4 fields at 200× magnification; fibrin: 67.8 ± 12.1; 3.6% reduction, p = .651, vs. control; PBMCsec: 85.9 ± 20.4; 22.2% increase, p = .045 vs. control; 26.7% increase, p = .010 vs. fibrin) on postoperative day 7 after treatment with PBMCsec. Seroma formation was decreased after treatment with fibrin sealant with or without the addition of PBMCsec. (control: 11.9 ± 9.7 ml; fibrin: 1.7 ± 5.3, 86.0% reduction, 0.004 vs. control; PBMCsec: 0.6 ± 2.0; 94.8% reduction, p = .001 vs. control; 62.8% reduction, p = .523 vs. fibrin). We describe the beneficial effects of a secretome derived from γ-irradiated PBMCs on tissue survival, angiogenesis, and clinical parameters after flap surgery in a rodent epigastric flap model.

Local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction: a new technique in cancer surgery.

INTRODUCTION: Soft tissue reconstruction after vulvar, vaginal, or anal cancer resection poses a formidable task for reconstructive surgeons because of the functional, locational, and cosmetic importance of this region. Although numerous flaps have been designed for vulvar reconstruction, each has its disadvantages. METHODS: The authors introduce the local fasciocutaneous infragluteal (FCI) flap for vulvar and vaginal reconstruction after tumor resection, vaginal scar obliteration, and vulvar ulceration in 15 patients operated on between 1999 and 2007. The FCI flap is supplied by the cutaneous branch of the descending branch of the inferior gluteal artery. The sensory supply of this flap comes from side branches of the posterior cutaneous nerve of the thigh. A total of 17 flaps were performed in 15 patients. RESULTS: Except for one, all flaps survived. One flap necrosis occurred because of false postoperative position with compression and tension to the vascular pedicle. In the remaining patients, we found one local cancer recurrence with necessity of a second flap from the contralateral side. The patients report satisfaction with reconstruction, without one having pain at donor site and recurrent vaginal ulceration. CONCLUSIONS: This article discusses the expanding indications of this versatile flap and the operative technique of the local FCI flap for reconstruction of vulvar and partial vaginal defects. It can be raised in different volume and dimension out of possible irradiated area with an inconspicuous scar.

Treatment of segmental bone and soft-tissue defects of the forearm with the free osteocutaneous lateral arm flap.

BACKGROUND: Complex defects of the forearm often require microvascular reconstruction with osteocutaneous free flaps to salvage the limb. In this review, we report our experience with the use of the free osteocutaneous lateral arm flap to reconstruct such defects in four patients. METHODS: Three male patients with osseous defects of the ulna and one defect of the radius with associated soft-tissue defects were treated with a free osteocutaneous lateral arm flap between 2004 and 2007. The indications for the procedure included posttraumatic osteitis (3) and bone with soft-tissue defects after trauma (1). We evaluated the patients with respect to postoperative results by evaluating the range of motion, pain, strength, and score on the disabilities of the arm, shoulder, and hand questionnaire. Donor-site morbidity was also documented. RESULTS: The average length of segmental bone defects was 5.75 cm. The average dimension of the skin paddle was 99.5 cm. The average duration of follow-up was 43.3 months. All bone flaps healed without nonunion; the fasciocutaneous flaps healed without complications. No problems related to microanastomoses were found. Functional results were very satisfactory; disabilities of the arm, shoulder, and hand questionnaire scores showed a median of 5.8 (0-10.8). All patients had returned to their preinjury occupations. CONCLUSION: This analysis demonstrates that the free osteocutaneous lateral arm flap is an effective treatment for combined segmental osseous and soft-tissue defects of the forearm that are caused by osteitis and trauma.

Autologous breast augmentation with the deepithelialized fasciocutaneous infragluteal free flap: a 10-year experience.

INTRODUCTION: Breast augmentation with silicone implants is frequently performed, a daily procedure in plastic surgery. Nevertheless, there are well-known risks of capsular formation and contraction leading to pain, displacement, and rupture after breast augmentation. Thus, the frequency of augmentation with autologous tissue is increasing. Most frequently used are the transverse rectus abdominis muscle flap, the deep inferior epigastric artery perforator flap, and the gracilis free flap, but in some cases, these flaps are not the first choice. Therefore, we present our experience with the free fasciocutaneous infragluteal (FCI) flap. METHODS: The FCI flap is based on a constant end artery of the inferior gluteal artery and has frequently been used for various indications at our department for many years. Since 1998, 17 patients suffering from breast hypoplasia, congenital breast asymmetry, or consecutive capsular fibrosis were treated with 25 FCI flaps. RESULTS: In this series, no complete or partial flap loss was clinically detected. The only complaint was a discomfort at the donor site in the early postoperative period. As revealed by a final questionnaire, all patients were satisfied with the result. CONCLUSION: Our results suggest that the FCI flap should be considered as a worthy alternative for autologous breast augmentation, especially in thin patients suffering from breast hypoplasia, congenital asymmetry, or consecutive capsular formations.

Perineal reconstruction after rectal and anal disease using the local fascio-cutaneous-infragluteal flap: A new and reliable technique.

BACKGROUND: Significant morbidity can result from perineal wounds, particularly if the tissue has been partially devitalized after radiotherapy and extensive resection for cancer or chronic inflammation which may occur in Crohn's disease. Many different types of flaps have been used to improve healing of perineal tissue defects. The purpose of this study was to evaluate the morbidity and outcomes of reconstruction using the local fasciocutaneous infragluteal (FCI) flap. METHODS: Fourteen consecutive patients undergoing local FCI flap reconstruction for perineal wounds and defects were included in the study. In 5 female patients, the defect included the dorsal wall of the vagina, which was reconstructed in 1 step. Ten patients underwent operations for anal or low rectal cancer, 3 suffered from Crohn's disease and extensive local fistula formation, and 1 young girl presented with a defect after resection of a perineal synovial sarcoma. Eleven of these patients underwent preoperative chemotherapy and either pre- or intra-operative radiotherapy. RESULTS: Complete healing of perineal wounds occurred in 13 of the 14 patients. There were 4 flap-related complications, including 3 patients with delayed wound healing and wound dehiscence and 1 patient with partial flap necrosis. The last patient required a second local flap for wound closure. In 2 patients, a second FCI flap was necessary because of a second tumor and a local tumor recurrence. Ambulation and normal mobility were possible after the flap procedure in all patients without restriction of activity. Four patients died during the follow-up period (median, 42.5 months) from tumor metastasis. CONCLUSION: Local FCI flap for reconstruction of large perineal defects achieves good wound healing with only moderate morbidity in most patients after extensive resection owing to cancer or Crohn's disease.

Pectus excavatum and free fasciocutaneous infragluteal flap: a new technique for the correction of congenital asymptomatic chest wall deformities in adults.

BACKGROUND: Pectus excavatum is typically a cosmetic congenital chest wall deformity. In most cases, it does not affect heart and lung function; therefore, because of their high rate of complications, extensive procedures need not be performed. Various alternative techniques (e.g., reconstruction with silicone prosthesis or the transverse rectus abdominis musculocutaneous flap) were introduced in asymptomatic pectus excavatum. All of these methods have their advantages but also limitations. Thus, the authors used a free fasciocutaneous infragluteal flap for reconstruction of asymptomatic pectus excavatum in selected patients. METHODS: Between 2001 and 2007, six patients suffering from asymptomatic pectus excavatum underwent correction with the free fasciocutaneous infragluteal flap. The fasciocutaneous infragluteal flap is based on a constant end artery of the inferior gluteal artery. After raising of the flap and wound closure in the buttock region, the flap was adjusted to the defect using a small skin incision in the inframammary fold, and the vessels were anastomosed. RESULTS: There were no flap losses and no major complications. One patient suffered from a sensory change at the posterior thigh in the early postoperative period that resolved completely within 2 weeks. In four cases, flap shaping or liposuction was performed to improve the aesthetic result. In the authors' final evaluation, all patients were very satisfied with the result and would undergo the procedure again. CONCLUSIONS: The authors have demonstrated for the first time the reconstruction of asymptomatic pectus excavatum with the free fasciocutaneous infragluteal flap. It is the authors' opinion that, in selected patients, this flap offers an excellent alternative to established techniques for this problem.

Reconstruction of soft tissue defects overlying the Achilles tendon using the super extended abductor hallucis muscle flap.

BACKGROUND: Soft tissue defects overlying the Achilles tendon often occur after traumatic ruptures of the Achilles tendon or because of pressure ulcers in patients suffering from circulatory problems. Ideally, reconstruction should be achieved in as few stages as possible. Currently, there are different methods used to treat these defects. Here, we examined whether reconstruction of this region could benefit from the super extended abductor hallucis muscle flap. METHODS: In 12 cadaver feet, the vascular supply and mobilization radius of the abductor hallucis muscle were studied to clarify the possible clinical utilization of this flap. A technique for Achilles defect reconstruction using this flap, along with the functional and cosmetic results in six patients are presented. RESULTS: Our anatomic findings agree with those available in the literature and the adaptation in pedicle preparation allowed an increase in rotation of the flap for successful coverage of defects overlying the Achilles tendon. Using the super extended abductor hallucis muscle flap, the functionality and the anatomic shape were successfully reconstructed. Six weeks after surgery all patients were fully mobile, unless they suffered from Achilles tendon ruptures then they were mobile after 12 weeks. CONCLUSIONS: The super extended abductor hallucis muscle flap might represent an alternative to established methods because of ease of handling and a shorter anesthesia compared with a free flap procedure.

Colony-stimulating factor-1 transfection of myoblasts improves the repair of failing myocardium following autologous myoblast transplantation.

AIMS: Skeletal myoblasts are used in repair of ischaemic myocardium. However, a large fraction of grafted myoblasts degenerate upon engraftment. Colony-stimulating factor-1 (CSF-1) accelerates myoblast proliferation and angiogenesis. We hypothesized that CSF-1 overexpression improves myoblast survival and cardiac function in ischaemia-induced heart failure. METHODS AND RESULTS: Three weeks following myocardial infarction, rats developed heart failure and received intramyocardial injections of mouse CSF-1-transfected or untransfected primary autologous rat myoblasts, recombinant human CSF-1, mouse CSF-1 expressing plasmids, or culture medium. Tissue gene and protein expression was measured by quantitative RT-PCR (reverse transcription-polymerase chain reaction) and western blotting. Fluorescence imaging and immunocytochemistry were used to analyse myoblasts, endothelial cells, macrophages, and infarct wall thickening. Electrocardiograms were recorded online using a telemetry system. Left ventricular function was assessed by echocardiography over time, and improved significantly only in the CSF-1-overexpressing myoblast group. CSF-1-overexpression enhanced myoblast numbers and was associated with an increased infarct wall thickness, enhanced angiogenesis, increased macrophage recruitment and upregulated matrix metalloproteases (MMP)-2 and -12 in the zone bordering the infarction. Transplantation of CSF-1-overexpressing myoblasts did not result in major arrhythmias. CONCLUSION: Autologous intramyocardial transplantation of CSF-1 overexpressing myoblasts might be a novel strategy in the treatment of ischaemia-induced heart failure.

The new distal soleus adiposal pull-through composite flap for reconstruction of defects overlying the Achilles tendon: the anatomy and clinical experience.

INTRODUCTION: Defects overlying the Achilles tendon are common in patients after immobilization, particularly in those with vascular disease. Conservative wound management and local or free flaps are well-known treatments. Rapid recovery is important, especially in elderly patients; therefore, we looked for an alternative local surgical technique. We introduced for the first time the distal soleus adiposal pull-through flap for covering limited defects over the Achilles tendon. METHODS: In 10 cadaveric feet, the vascular supply of the sub-Achilles adiposal tissue was studied to clarify the possible clinical utilization. We introduced this novel technique in 6 clinical cases. First, debridement was carried out and the Achilles tendon was divided in the midline. Next, the underlying soleus muscle and sub-Achilles adiposal tissue were carefully dissected. After detaching the flap distally, it was pulled through the Achilles tendon and fixed into the defect. Forty-eight hours later, the flap was covered with meshed split-thickness skin graft. RESULTS: Our anatomic findings showed a sufficient blood supply of the sub-Achilles adiposal tissue by perforators from the soleus muscle, even after ligation of all perforators from the posterior tibial artery and fibular artery. This novel technique allowed a successful defect reconstruction with good functional and cosmetic outcome in all our cases. Two weeks after operation, all patients were fully mobile. DISCUSSION: The distal soleus adiposal pull-through flap is a reliable flap for coverage of defects overlying the Achilles tendon, especially in patients with vascular problems and/or elderly patients. The ease of handling, short operative time, and the early mobilization are of great benefit to patients. Therefore, this novel technique should be considered for limited defect reconstructions overlying the Achilles tendon.

Fibrin-embedded administration of VEGF plasmid enhances skin flap survival.

The aim of the present study was to experimentally evaluate whether topical fibrin-mediated administration of a vascular endothelial growth factor (VEGF)-A plasmid to the wound bed can protect skin flaps from necrosis. A plasmid expression vector containing the VEGF-A cDNA was constructed. The plasmid was then administered to the wound bed of rat abdominal skin flaps in a fibrin sealant. The percentage of viable, ischemic and necrotic tissue was assessed postoperatively as a baseline and after 3 and 7 days using digital surface area morphometry. Laser Doppler imaging of the flaps and VEGF-A Western blot analysis of flap tissue were performed to assess angiogenesis and VEGF-A tissue levels. Flaps treated with VEGF plasmids in the presence of uptake enhancing Lipofectamine transfection reagent increased flap survival 7 days postoperatively significantly associated with markedly elevated tissue perfusion and enhanced tissue VEGF-A protein expression. Our results indicate that topical fibrin-mediated administration of a VEGF-A plasmid may serve as an alternative to previous strategies in treating ischemic skin flaps. The suggested therapeutic approach is easily applicable and inexpensive in preparation. Thus, this protocol may also enhance wound healing in posttrauma skin lacerations or in skin grafts.

Venous sphincters in the choroidea of spontaneously hypertensive rats.

Ocular vasculopathy resulting from severe systemic hypertension affects retina, choroidea, and the optic nerve. While the pathologic changes of the arterial system, including luminal narrowing, are well documented, little is known about the ocular venous vessels in hypertension. Adult 18-week-old spontaneously hypertensive rats (SHRs) were untreated (control) or treated with lisinopril for 4 weeks; normotensive Wistar-Kyoto (WKY) rats were additional controls. The mean systemic blood pressure (MSP) was monitored chronically using telemetry. The ocular microvasculature was examined using scanning electron microscopy (SEM) of corrosion casts, histology of serial sections, and computer-based 3D reconstruction. The MSP in control SHRs (145 +/- 11.9 mmHg) was decreased to 68.1 +/- 4.9 mmHg (P < 0.001) following treatment, which was even below the baseline level of WKY (96.7 +/- 5.8) rats (P < 0.05). In addition to media thickening in arteries, the venous plexus of the choroidea in control SHRs revealed multiple tufts of smooth muscle cells (sphincters) that narrowed the lumen. Correlating to histology, SEM of casts and 3D reconstruction showed numerous constrictions and muscular tufts in veins of the choroidea, narrowing the vascular lumen up to 47%. Following antihypertensive treatment, the percentage of sphincter constriction was decreased to 6% (P < 0.001). The depth of venous sphincter contraction correlated significantly with MSP (r = 0.87). To our knowledge, these results indicate for the first time that venous sphincters occur in the choroidea of the SHRs, and that their muscularity correlates with MSP. Venous sphincters might be involved in the pathophysiology of hypertension-related ocular changes.

Nose reconstruction by chondrocutaneous preauricular free flaps: anatomical basis and clinical results.

Full-thickness defects of the nose result in considerable and distressing disfigurements. Ideally, reconstruction of such defects must be achieved in as few stages as possible and secondary, disfigurement kept to a minimum. In this study, the authors aimed to learn whether nose reconstruction could benefit from chondrocutaneous free flaps taken from the auricular tragus. In 72 ears, the vascular blood supply of the tragus was studied following injection of colored latex. Color-coded Duplex sonography served as a noninvasive method for demonstrating the blood supply of the target area. The procedure of nose reconstruction using the free chondrocutaneous tragus flap and the cosmetic results of this procedure in six patients are presented. Except for 2.8 percent of the anatomical specimens, the superficial temporal artery gave rise to the tragus and its overlying skin. The diameter of these branches ranged from 0.65 to 0.82 mm. Using the tragus composite free flap, the anatomical shape of the nose could be reconstructed successfully, and 6 months after surgery, the color and texture of the flap were very similar to those of the remaining nose. Using deeper parts of the tragus cartilage resulted in minimal scars and maintenance of the tragus anatomical shape. Free tragus flaps could be an alternative approach for nose reconstruction.