Effects of Preoperative Extracorporeal Shockwave Therapy on Scar Formation-A Pilot Study on 24 Subjects Undergoing Abdominoplasty Surgery.

OBJECTIVES: Extracorporeal shockwave therapy (ESWT) has been demonstrated as a feasible noninvasive method to improve wound healing. This effect was demonstrated to result from increased perfusion and angiogenesis due to systemic growth factor expression. We, therefore, hypothesized that preoperative ESWT reduces scar formation after surgery. METHODS: A prospective, controlled pilot study on 24 patients undergoing abdominoplasty was conducted and the efficacy of preoperative unfocused, low energy EWST was evaluated. The right and left half of the operative area were randomly allocated to ESWT or placebo treatment in intrapatient control design. At 6 and 12 weeks after surgery, scar formation was evaluated by 19 different scar parameters included in the patient, observer scar assessment, and the Vancouver scar scale. RESULTS: The overall rating of the Vancouver and POSAS scale with Mann-Whitney (MW) analysis revealed a clear trend favoring ESWT. At week 6, 7 of 19 parameters clearly favored ESWT (MW > 0.53). At week 12, 8 of 19 parameters clearly favored ESWT. The largest differences were observed in thickness and overall impression (Vancouver scar scale). CONCLUSIONS: ESWT presumably reduces scar formation and postoperative symptoms after abdominoplasty surgery. Further studies are required to confirm ESWT efficacy with statistical significance. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

The Impact of Age on Perioperative Complications after Extremity Reconstruction with the Free Gracilis Flap: A Retrospective Cohort Study Involving 153 Patients.

BACKGROUND: The need for plastic and reconstructive surgery on elderly patients has been on the rise due to an increase in life expectancy in the past decades. Therefore, a study was conducted on young and elderly patients following microsurgical extremity reconstructions with free gracilis muscle flaps with the primary aim to investigate the influence of age and the American Society of Anesthesiologists (ASA) score on the general outcome, as well as surgical and medical complications. METHODS: A retrospective analysis of 153 patients receiving free gracilis muscle flaps for extremity reconstructions between November 2009 and January 2018 was performed at two partner institutions specialized in microsurgical reconstructions. A logistic regression analysis was performed to correlate age and the ASA score with postoperative complication probability. Patients younger than 70 years were directly compared with elderly patients with respect to age, gender, ASA score, preexisting comorbidities, localization, and postoperative medical and surgical complications. RESULTS: Age turned out to be not significantly associated with major flap complications (p = 0.925) but with higher ASA scores (p = 0.016). However, an age-related significant increase in minor flap complications could be observed in the elderly (p = 0.008). A significant correlation between minor medical complications and age could be observed (p = 0.001) in contrast to ASA score (p = 0.912). CONCLUSION: An increased minor flap, as well as minor and major medical complications, must be expected in extremity reconstructions with free gracilis flaps in elderly patients. Higher ASA scores correlate with a higher incidence of major flap complications. Septuagenarians are more prone to develop perioperative major medical complications than patients younger than 70 years. Age and general medical condition, coupled with the performance of each patient, should be thoroughly assessed individually to facilitate a tailored reconstructive approach using risk assessment tools and established scoring systems.

Minimizing the Short-term Reoperation Rate in Abdominoplasty Procedures by Prolonged Postoperative Immobilization.

BACKGROUND: Abdominoplasty is a common procedure in postbariatric surgery. Over the years, a high number of technical refinements of the procedure have been established to improve safety and reduce associated complications. Nevertheless, the complication rate is high. The purpose of this study was to examine the incidence of postoperative complications in patients undergoing abdominoplasty in association with prolonged postoperative immobilization. METHODS: Retrospective analysis of 82 patients who underwent abdominoplasty was performed. Patients were divided in two study groups regarding their immobilization period. Group 1 included patients with an immobilization period defined as strict bed rest for at least 45 h after surgery. Group 2 included all patients with shorter immobilization time, but earliest mobilization in the evening on the day of surgery. RESULTS: Overall, complication rate was 27%. Major complications were observed in 15% in group 1 and in 23% in group 2. Hematoma requiring surgical revision was observed in 5% in group 1 and in 14% in group 2. Surgical revisions within the first 60 days were necessary in 5% in group 1 and in 20% in group 2. CONCLUSION: Prolonged immobilization after abdominoplasty does not crucially lower the overall complication rate, but influences the severity of complications in a positive way. Increasing the duration of postoperative immobilization up to 45 h after abdominoplasty significantly decreases the reoperation rate in our practice. The risk for a surgical revision is nearly four times higher if the patient leaves bed earlier. Surgeons should consider this option especially in patients with a high risk for complication development.

Thighplasty: improving aesthetics through revival of the medial, horizontal procedure: A safe and scar-saving option.

INTRODUCTION: Thighplasty is a common bodycontouring procedure, but also associated with a high complication rate. The purpose of this study was to access the outcome of the medial horizontal thigh lift as it is a common surgical technique regarding thigh deformity correction performed at the authors' department. Surgical keysteps, clinical applications, advantages and disadvantages of the procedure are shown. Postoperative evaluation took place with special focus on individual patient satisfaction. METHODS: Retrospective analysis of 25 bilateral thigh lifts with single medial horizontal incision line was performed. Evaluated data include patient age, sex, body mass index, combined procedures, additional liposuction, weight loss, former bariatric surgery, comorbidities, smoking status and surgical complications. Follow-up was performed with a standardized protocol and the scar was accessed according to the Vancouver-Scare-Scale. Additionally the patients were asked to complete a questionnaire divided into the sections 'scars', 'postoperative result' and 'sexuality'. RESULTS: Average patient-age was 43 years. Average follow-up was 2 years and 8 months. Average weight loss before surgery was 57 kg. 36% of all patients additionally received a liposuction of the medial thigh. In six cases (24%), we observed complications, which were designated as 'minor complications' in five times (conservative management without problems) and 'major complication' in one time (surgical revision). Postoperative patient-satisfaction was high. DISCUSSION AND CONCLUSION: Compared to the horizontal and vertical combined thigh lift with the classic T-shaped incision lines we observed fewer complications and a reduction of postoperative morbidity. Additionally patient satisfaction was very high. We estimate that the main reason therefore is the avoidance of the vertical scar and its associated short- and longterm problems. The evaluated data confirm the medial horizontal thighplasty as a good and valuablesurgical option for the management of thigh deformities with moderate skin and tissue excess, localized in the upper part of the thigh.

Reconstructive microsurgical approach for the treatment of pyoderma gangrenosum.

INTRODUCTION: Pyoderma gangrenosum (PG) is a rare type of autoimmune disease that results in progressive ulcers with or without previous trauma. However, PG is not well understood to date, and its treatment therefore remains a challenge. Because of the disease's systemic characteristic and the unpredictability of the clinical course, no gold standard treatment is available, especially concerning the surgical procedures to treat pyodermic lesions. Often, PG is not recognized during routine clinical practice, and standard ulcer treatment (conservative wound care, debridement, skin grafting, and local flap coverage) is initiated; this induces an autoinflammatory response, resulting in disastrous ulcers, thereby making free flap coverage necessary. The purpose of this study was to assess the outcome of microvascular free-tissue transfer as a treatment option for extended soft-tissue defects resulting from PG. MATERIALS AND METHODS: We retrospectively evaluated 8 cases in 5 patients suffering from PG of the lower extremity who received defect closure with a microvascular free-tissue transfer under immunosuppressive and corticosteroid therapy. RESULTS: The average patient age was 60 years; three were male, and two were female. Seven defects were covered with free gracilis muscle flap. One patient received an anterolateral thigh flap. The average defect size was 93 cm2. No flap loss was observed during follow-up. All patients received broad-spectrum antibiotic treatment and corticosteroids. Two patients also received infliximab. DISCUSSION AND CONCLUSION: PG once diagnosed is not a contraindication for microvascular free-tissue transfer. Multidisciplinary evaluation of each case is fundamental. All surgical treatments should be performed only with sufficient protective immunosuppression therapy. If the defect requires free flap coverage, it should be considered as a surgical option despite the potential risk of a pathergic response in PG and was a safe treatment option in all our cases. In conclusion, we share our experience regarding preoperative, intraoperative, and postoperative care of patients with PG receiving free flap surgery.

A double-blind randomized prospective study comparing prilocaine versus ropivacaine in upper blepharoplasty.

BACKGROUND: Upper blepharoplasties are a common procedure in plastic surgery. This procedure can be performed effectively under local anesthesia with or without sedation. The ideal local anesthetic should cause less intraoperative bleeding and less postoperative edema. Our study aimed to show the difference between the two local anesthetics 1% prilocaine (Xylonaest) in combination with epinephrine 1:100,000 and ropivacaine (Naropin) in combination with epinephrine 1:100,000 including sodium chloride, particularly in regard to swelling and bleeding in patients undergoing upper blepharoplasties. MATERIAL AND METHODS: In this double-blind, prospective, randomized study, 31 patients between March 2014 and September 2014 were included. The anesthetic agents used in all cases were 1% prilocaine (Xylonaest) in combination with epinephrine 1:100,000 for one side and ropivacaine consisting of 10-mg Naropin, 5-ml sodium chloride, and 1-ml epinephrine for the other side. The data presented in this study were collected by one of the surgeons performing the surgery. Intraoperative bleeding and postoperative edema were both calculated using a score of five points for each. RESULTS: The average bleeding tendency was 3.39 for prilocaine and 1.71 for local ropivacaine, showing a significant difference (p < 0.0001) between both local anesthetics in bleeding tendency. There was also a significant minor swelling at all times on the side on which ropivacaine was used. DISCUSSION: In our study, we demonstrated that ropivacaine (Naropin) has less intra- and postoperative side effects including swelling and bleeding compared with prilocaine (Xylonaest).

Trigger Finger Caused by Extraskeletal Chondroma.

Chondroma is a relatively rare, but well-reported benign neoplasm. This lesion normally occurs attached to bone; however, they may be rarely found without association to bone and embedded in soft tissue. The authors describe the case of a 76-year-old man in whom flexor tendon triggering was associated with an extraskeletal chondroma between the annular ligament and the flexor tendon.

Treatment of Eyelid Ptosis due to Kearns-Sayre Syndrome Using Frontalis Suspension.

Blepharoptosis is a common indication for surgery in plastic surgery units, yet its possible underlying pathology frequently remains unidentified. A 52-year-old man with a 20-year history of progressive bilateral ptosis (right>left) presented with recurrent ptosis of both eyes; he had undergone an operation on the levator aponeurosis 12 years prior. Due to the suspicion of an underlying disease, he was evaluated further. Chronic progressive external ophthalmoplegia in transition to the more severe syndromic variant Kearns-Sayre syndrome, a mitochondrial disorder causing myopathy, was diagnosed. The patient was treated with coenzyme Q10, and he underwent ptosis surgery on both eyes. This case illustrates a potentially multi-systemic disease that was diagnosed by a further evaluation of a common symptom, in this case worsening blepharoptosis. Awareness of myopathic symptoms is necessary to prevent overlooking serious yet improvable conditions.

Redefining the vascular anatomy of the peroneus brevis muscle flap.

The peroneus brevis flap can be used as either proximally or distally based flap for coverage of small to medium-sized defects in the lower leg. The purpose of this study was to clarify the vascular anatomy of the peroneus brevis muscle. An anatomical dissection was performed on 17 fixed adult cadaver lower legs. Altogether, 87 segmental branches (mean 5.1 ± 1.6 per leg) either from the fibular or anterior tibial artery to the muscle were identified. Sixty-two were branches from the fibular artery (mean 3.4 ± 1.1 per fibular artery), whereas 25 (mean 1.4 ± 0.9 per anterior tibial artery) originated from the anterior tibial artery. The distance between the most distal vascular branch and the malleolar tip averaged 4.3 ± 0.6 cm. An axial vascular bundle to the muscle could be identified in all cadavers; in one leg two axial supplying vessels were found. Their average length was 5.5 ± 2.4 cm and the average arterial diameter was 1.1 ± 0.5 mm, the average venous diameter was 1.54 ± 0.7 mm. The constant blood supply to the peroneus brevis muscle by segmental branches from the fibular and tibial artery make this muscle a viable option for proximally or distally pedicled flap transfer. The location of the most proximal and distal branches to the muscle and conclusively the pivot points for flap transfer could be determined. Furthermore, a constant proximal axial vascular pedicle to the muscle may enlarge the clinical applications. Perfusion studies should be conducted to confirm these findings.

The distally based peroneus brevis muscle flap-clinical series and review of the literature.

The distally pedicled peroneus brevis muscle flap is rarely used for defect coverage in the distal lower leg. The purpose of this article was to present our clinical series and provide a review of the literature to analyze the overall complication rates and safety of this flap. In our clinical series of 10 patients undergoing reconstruction with the flap, one necrosis of the distal half of the flap and one necrosis of a skin graft occurred. Our review of the literature identified 192 patients undergoing reconstruction with distally pedicled peroneus brevis flaps. The overall complication rate was 41.6%. Typical indications, complications, advantages and disadvantages to alternatives are discussed. The distally pedicled peroneus brevis flap is an interesting option for soft tissue coverage in the distal lower leg. The donor site can always be closed primarily, the anatomy is constant and complication rates are comparable to alternatives in this region like the distally based sural fasciocutaneous flap.

The transverse musculocutaneous gracilis flap for chest wall reconstruction in male patients with Poland's syndrome.

Poland's syndrome represents a congenital unilateral deformity of the breast, chest wall, and upper limb with extremely variable manifestations. In most cases, the problem is mainly cosmetic, and the reconstruction of the chest wall should use a method designed to be performed easily and to achieve minimal scarring and donor site morbidity. We describe using a transverse musculocutaneous gracilis (TMG) flap for chest wall and anterior maxillary fold reconstruction in three male patients. In two patients, only the pectoralis major muscle was missing. In the third case, the ipsilateral latissimus dorsi muscle was also absent. The indication for surgical treatment was purely cosmetic. In all patients, a free TMG flap was performed to reconstruct the anterior axillary fold and the soft tissue defect. There was no flap loss, and all three patients had a clearly improved appearance of the chest wall. In this article, we demonstrate our experience with the use of a TMG flap for chest wall reconstruction in male patients with Poland's syndrome.

Colorimetric examination of typical free flap donor sites and comparison to recipient sites in the extremities.

Results after free flap reconstruction in the extremities are often impaired by missing color match of the transferred flap and the recipient site. But pre-existing color match is the precondition for satisfying aesthetic results. To obtain suitable free flap donor sites in terms of color for extremity reconstruction and to understand frequent color mismatch, we performed a colorimetric study including 60 healthy volunteers. Ten free flap donor sites were compared with ten recipient sites in the extremities. The results of our study showed that lower extremity sites are markedly lighter than upper extremity sites with the exception of the palmar forearm. We encountered an excellent color match of the radial forearm flap to the back of the hand (4.10 ± 1.91) and the palm of the hand (5.62 ± 2.21), and significantly relevant color match to the palmar aspect of the forearm (2.52 ± 1.23). Additionally, the lateral arm flap showed a remarkable color match to the dorsal aspect of the forearm (3.13 ± 2.06). Furthermore we encountered significantly relevant color match of the fibula flap to the anterior aspect of the lower leg (2.01 ± 1.08) and excellent color match of the anterolateral thigh flap (ALT) to the palmar aspect of the forearm (3.66 ± 2.10). No further significantly relevant color differences between the other donor sites and recipient regions were found. Colorimetric measurements are a helpful tool in reconstructive surgery to compare skin color of different anatomic sites.

Lower limb salvage in a 7-month-old infant using free tissue transfer.

Free flap reconstruction in infants is extremely rare. A seven-and-a-half-month-old male infant sustained an extensive soft tissue defect on his left knee caused by extravasation of an intraosseous arterenol infusion. A free latissimus dorsi flap was successfully performed for soft tissue reconstruction. Indications, advantages, and outcome of the procedure are discussed.

Idiopathic granulomatous mastitis: successful treatment by mastectomy and immediate breast reconstruction.

We describe three women with idiopathic granulomatous mastitis (IGM), a rare, benign breast disease. It is a chronic inflammatory lesion of the breast and presents with the clinical symptoms of inflammation, breast mass and tumorous indurations and ulcerations of the skin. Clinical and radiological findings often mimic breast cancer. Histopathologic examination remains the gold standard for the diagnosis. It is a non-malignant entity but it may be both locally aggressive and recurrent. The treatment of choice is unclear, but surgical excision and adjunctive treatment with glucocorticoids or antibiotics is described most frequently. We present three patients with a long history of recurrences that was successfully treated by mastectomy and immediate breast reconstruction.

Skin banking: treatment option for native skin necrosis following skin-sparing mastectomy and previous breast irradiation.

Skin flap necrosis, as well as positive resection margins in the context of skin-sparing mastectomy and immediate breast reconstruction, may require reoperation, potentially associated with tissue loss, and thereby impair the aesthetic result. Skin banking has recently been described as a method for handling skin flaps of uncertain viability. Here, we describe the advantages of skin banking in previously irradiated patients with breast cancer recurrence, which underwent skin-sparing mastectomy and immediate breast reconstruction. Aside from its utility in the management of skin necrosis, we present this method as an option to conserve the native breast shape in patients with questionable total resection during surgery.