Free Flaps in Sternal Osteomyelitis After Median Sternotomy: A Center's 12-Year Experience.

BACKGROUND: Adequate treatment of deep sternal wound infections (DSWIs) after open thoracic surgery still presents a major challenge. This study retrospectively analyzes the results of a single center's 12-year experience in treating DSWI, with special emphasis on free flap reconstruction. METHODS: In this single-center, retrospective study, all patients admitted with the diagnosis of DSWI after open thoracic surgery between 2009 and 2020 were included. A comparative analysis was performed between: (1) pedicled versus free flaps, (2) the center's two workhorse flaps-the pedicled latissimus dorsi (pLD) versus free anterolateral thigh (fALT) flaps, as well as (3) myocutaneous (MC) versus fasciocutaneous (FC) flaps. Primary endpoints were length of hospital stay (LOS) after reconstruction and in-hospital mortality. RESULTS: Of a total of 165 patients included, 152 underwent DSWI defect reconstruction with a total of 12 different reconstruction methods. Although the defect size was larger in patients who underwent free flap coverage, and the risk profile in the fALT and FC flap groups was higher, the LOS after reconstruction (in days) did not differ significantly between the groups (pedicled vs. free flaps: 23 vs. 28, p > 0.05; pLD vs. fALT: 24.5 vs. 26, p > 0.05; MC vs. FC flaps: 23 vs. 26, p > 0.05). Also, no significant differences were found in terms of in-hospital mortality when comparing the groups (pedicled vs. free flaps: 11.2 vs. 17.4%, p > 0.05; pLD vs. fALT: 11.5 vs. 12.5%, p > 0.05; MC vs. FC flaps: 12.9 vs. 12.5%, p > 0.05). CONCLUSION: With proper patient selection, free tissue transfer is a valuable alternative in the treatment of sternal dehiscence after a DSWI. Furthermore, our data demonstrate that MC flaps are not necessarily superior to FC flaps in the reconstruction of sternal osteomyelitis defects.

Long-term Results After Autologous Fat Transfer for Treatment of Chronic Lower Extremity Wounds.

Autologous fat transfer may offer a simple and effective treatment option for chronic wound patients, delivering adipose-derived stem cells, with potent regenerative attributes. Nevertheless, the clinical benefit has not yet been sufficiently demonstrated. A total of 39 wound patients were treated with autologous fat transfer (AFT) and matched with a control group, according to the identified confounding variables "gender" and "method of defect closure." All data were acquired retrospectively. Primary outcome was "wound closure" and "reduction of wound size."After a follow-up of 48 weeks, there was no significant difference in primary outcome (wound closure P = .54) between both groups. The relative wound reduction after fat transfer was 69.9% ± 42.7% compared to 53.4% ± 106.8% in the control group (P = .91). Subgroup analysis of all patients, healed by secondary intention, revealed an increased wound size reduction (P = .03) and wound closure rate (P = .20) in the case group after 12 weeks. No adverse events were recorded. Fat grafting can reduce the wound size if left to secondary healing and may be considered individually for reconstructive purposes. A repeated application of autologous fat might be beneficial due to a temporary effect.

A 10-Year Retrospective before-and-after Study of Lipedema Surgery: Patient-Reported Lipedema-Associated Symptom Improvement after Multistage Liposuction.

BACKGROUND: Despite an increasing demand for surgical treatment of lipedema, the evidence for liposuction is still limited. Little is known about the influence of disease stage, patient age, body mass index, or existing comorbidities on clinical outcomes. It was hypothesized that younger patients with lower body mass index and stage would report better results. METHODS: This retrospective, single-center, noncomparative study included lipedema patients who underwent liposuction between July of 2009 and July of 2019. After a minimum of 6 months since the last surgery, all patients completed a disease-related questionnaire. The primary endpoint was the need for complex decongestive therapy based on a composite score. Secondary endpoints were the severity of disease-related complaints measured on a visual analogue scale. RESULTS: One hundred six patients underwent a total of 298 large-volume liposuctions (mean lipoaspirate, 6355 ± 2797 ml). After a median follow-up of 20 months, a median complex decongestive therapy score reduction of 37.5 percent (interquartile range, 0 to 88.8 percent; p < 0.0001) was observed. An improvement in lipedema-associated symptoms was also observed (p < 0.0001). The percentage reduction in complex decongestive therapy scores was greater in patients with a body mass index less than or equal to 35 kg/m2 (p < 0.0001) and in stage I and II patients (p = 0.0019). CONCLUSION: Liposuction reduces the severity of symptoms and the need for conservative treatment in lipedema patients, especially if it is performed in patients with a body mass index below 35 kg/m2 at an early stage of the disease. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Management of large volume liposuction in lipedema patients with von Willebrand disease: A systematic review and treatment algorithm.

BACKGROUND: When performing large volume liposuction, perioperative management of lipedema patients with coagulation disorders remains challenging due to a lack of clinical experience. With a prevalence of 1% of von Willebrand disease (VWD) in the general population, basic knowledge on diagnostic and adapted surgical strategies are essential for patients' safety. OBJECTIVE: Based on a selective literature review, the purpose of this article is to present a standardized algorithm for diagnosis and perioperative treatment of VWD patients undergoing large volume liposuction. METHODS: The databases MEDLINE (via PubMed) and Web of Science were selectively searched with the term "(((liposuction) OR (surgery)) OR (lipectomy)) AND (((VWD) OR (hemostaseology)) OR (von Willebrand disease))". Included were articles published in English or German until November 2020. RESULTS: The evidence for large volume liposuctions in patients with VWD is limited. Experience is largely based on operations with similar bleeding risks. A safe performance requires an adjustment of the surgical technique and a customized perioperative drug substitution plan. According to the current literature, perioperative thromboembolic events appear to be rare with adequate drug treatment. CONCLUSION: The implementation of the developed diagnostic and treatment algorithm may help further reducing bleeding complications and improve the safety for treated patients.

Liposuction for Lipedema: Functional Therapy or Aesthetic Procedure?

Liposuction is one of the most common procedures undertaken in plastic surgery with a steadily increasing trend over the years. Although usually performed as an aesthetic procedure for body contouring, it can also be utilized in specific patient groups for disease symptom reduction. One such disease entity is lipedema. The goal of this video to present the authors' technique in the surgical treatment of lipedema, and to offer the viewer a better understanding of the differences between an aesthetic liposuction and a functional liposuction as performed on a lipedema patient. Between July 2009 and July 2019, 106 lipedema patients have been treated in the authors' specialized lipedema clinic, with a total of 298 liposuction procedures and a median follow-up of 20 months. The mean amount of lipoaspirate was 6354.73 ml (± 2796.72 ml). The patients reported a significant reduction in lipedema-associated complaints and improvement in quality of life. The need for conservative therapy was significantly reduced. No serious complications were reported. The authors also present before and after photographs of three 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 www.springer.com/00266 .

Disease progression and comorbidities in lipedema patients: A 10-year retrospective analysis.

Multiple associated comorbidities have been described for lipedema patients. Disease diagnosis still remains challenging in many cases and is frequently delayed. The purpose of this study was to determine the most common comorbidities in lipedema patients and the impact of surgical treatment onto disease progression. A retrospective assessment of disease-related epidemiologic data was performed for patients who underwent liposuction between July 2009 and July 2019 in a specialized clinic for lipedema surgery. All patients received a standardized questionnaire regarding the clinical history and changes of lipedema-associated symptoms and comorbidities after surgery. 106 patients who underwent a total of 298 liposuction procedures were included in this study after returning the questionnaire fully filled-in. Multiple comorbidities were observed in the assessed collective. The prevalence for obesity, hypothyroidism, migraine, and depression were markedly increased in relation to comparable nonlipedema populations. Despite a median body mass index (BMI) of 31.6 kg/m2 (IQR 26.4-38.8), unexpected low prevalence of diabetes (5%) and dyslipidemia (7%) was found. Diagnosis and initiation of guideline-appropriate treatment were delayed by years in many patients. After surgical treatment (medium follow-up 20 months, IQR 11-42), a significant reduction of lipedema-associated symptoms was demonstrated. Lipedema occurs with a diversity of associated comorbidities. Therefore, on the basis of available data, the authors suggest the necessity of a multimodal therapy concept for a comprehensive and holistic treatment. Despite a commonly increased BMI, lipedema patients appear to have an advantageous metabolic risk profile.

Lipedema-Pathogenesis, Diagnosis, and Treatment Options.

BACKGROUND: Lipedema is often unrecognized or misdiagnosed; despite an estimated prevalence of 10% in the overall female population, its cause is still unknown. There is increasing awareness of this condition, but its differential diagnosis can still be challenging. In this article, we summarize current hypotheses on its pathogenesis and the recommendations of current guidelines for its diagnosis and treatment. METHODS: This review is based on publications about lipedema that were retrieved by a selective search in the MEDLINE, Web of Science, and Cochrane Library databases. RESULTS: The pathophysiology of lipedema remains unclear. The putative causes that have been proposed include altered adipogenesis, microangiopathy, and disturbed lymphatic microcirculation. No specific biomarker has yet been found, and the diagnosis is currently made on clinical grounds alone. Ancillary tests are used only to rule out competing diagnoses. The state of the evidence on treatment is poor. Treatment generally consists of complex decongestive therapy. In observational studies, liposuction for the permanent reduction of adipose tissue has been found to relieve symptoms to a significant extent, with only rare complications. The statutory healthinsurance carriers in Germany do not yet regularly cover the cost of the procedure; studies of high methodological quality will be needed before this is the case. CONCLUSION: The diagnosis of lipedema remains a challenge because of the hetero - geneous presentation of the condition and the current lack of objective measuring instruments to characterize it. This review provides a guide to its diagnosis and treatment in an interdisciplinary setting. Research in this area should focus on the elucidation of the pathophysiology of lipedema and the development of a specific biomarker for it.

Use of a Total Leg Fillet Flap to Cover Multiple Pelvic Pressure Ulcers.

The authors present the surgical strategy in the treatment of a morbidly obese paraplegic patient with a massive sacral pressure ulcer as well as bilateral trochanteric ulcers in a 1-step leg-sacrificing procedure utilizing the "spare-part" concept. It is the intention of the authors to reinforce the use of fillet flaps as a last resort option in paraplegic patients with pressure sores.