Stromal Vascular Fraction Cells from Individuals Who Have Previously Undergone Radiotherapy Retain Their Pro-Wound Healing Properties.

Beneficial effects have been observed following the transplant of lipoaspirates containing adipose-derived stem cells into chronic wounds caused by oncologic radiotherapy. It is not yet certain whether adipose-derived stem cells are resistant to radiation exposure. Therefore, the aims of this study were to isolate stromal vascular fraction from human breast tissue exposed to radiotherapy and determine the presence of adipose-derived stem cells. Stromal vascular fraction from irradiated donor tissue was compared to commercially sourced pre-adipocytes. Immunocytochemistry was used to determine the presence of adipose-derived stem cell markers. Conditioned media from stromal vascular fraction isolated from irradiated donors was used as a treatment in a scratch wound assay of dermal fibroblasts also isolated from irradiated donors and compared to pre-adipocyte conditioned media and serum free control. This is the first report of human stromal vascular fraction being cultured from previously irradiated breast tissue. Stromal vascular fraction conditioned media from irradiated donors had a similar effect in increasing the migration of dermal fibroblasts from irradiated skin to pre-adipocyte conditioned media from healthy donors. Therefore, the ability of adipose-derived stem cells in the stromal vascular fraction to stimulate dermal fibroblasts in wound healing appears to be preserved following radiotherapy. This study demonstrates that stromal vascular fraction from irradiated patients is viable, functional and may have potential for regenerative medicine techniques following radiotherapy.

The effect of a known object in a static image of a burn to improve the burn size estimation.

INTRODUCTION: Currently information regarding burn size from referring departments to burn centres varies in accuracy. Inaccurate assessment of burn size can lead to over or under treatment. Photographs of injuries may improve accuracy of assessment. We aimed to assess the accuracy of measuring burn size on a static image by including a standard object in the image. METHODS: Simulated burn areas were drawn on different body parts of the model. Using an iPhone® model 5 s with an 8 megapixel camera we took photos of the marked area, and repeated them with the palm, a standard bank card and a penny in the picture. First the Du Bois formula, was used to calculate body surface area. Members of the Burns team were asked to view the photos (n = 30) and estimate the percentage of the simulated burn. RESULTS: We found an overall overestimation of burn size. Small areas of the forearm were better estimated and within 1.1% of the calculated surface area, however we found no improvement when using a standard object in these images. The back areas were most overestimated ranging from 0.9%-8.9% despite all being the same sized area. CONCLUSIONS: Static images tend to overestimate burn size despite the use of a standard object in the image.

Adipose Tissue: A Source of Stem Cells with Potential for Regenerative Therapies for Wound Healing.

Interest in adipose tissue is fast becoming a focus of research after many years of being considered as a simple connective tissue. It is becoming increasingly apparent that adipose tissue contains a number of diverse cell types, including adipose-derived stem cells (ASCs) with the potential to differentiate into a number of cell lineages, and thus has significant potential for developing therapies for regenerative medicine. Currently, there is no gold standard treatment for scars and impaired wound healing continues to be a challenge faced by clinicians worldwide. This review describes the current understanding of the origin, different types, anatomical location, and genetics of adipose tissue before discussing the properties of ASCs and their promising applications for tissue engineering, scarring, and wound healing.

Management of the Lateral Breast.

Breast asymmetry is a common finding in developing adolescents. In select cases, there is maldevelopment of 1 or both breasts, which persists into adulthood and causes significant negative impact on life. Various surgical techniques (eg, breast augmentation/reduction) and nonsurgical techniques (eg, bras/gel inserts) are currently in practice to achieve breast symmetry. We describe a unique case of a young lady with Poland's syndrome, who presented with a lateralized right breast. We have used a V-Y advancement flap, along with a breast implant, to medialize the breast and achieve symmetry in contour and volume, followed by medialization of the nipple areolar complex. Using this technique produced an excellent result on our patient. We, therefore, feel that using the V-Y advancement flap is a novel and good option for dealing with difficult cases of lateralized breast.

Bipedicled DIEAP flaps for reconstruction of limb soft tissue defects in male patients.

BACKGROUND: Extensive soft tissue deficiencies involving the limbs can be difficult to reconstruct and may require more than one microsurgical flap transfer to cover the defect. This can be particularly challenging in male patients, where the sacrifice of a donor muscle could result in considerable comorbidity. This paper describes the use of the bipedicled deep inferior epigastric artery perforator (DIEAP) flap to perform a one-stage reconstruction of extensive soft tissue defects in male patients. METHODS: By using preoperative multidetector computed tomographic (MDCT) angiography, the dominant perforators of the abdominal wall were identified and the bipedicled DIEAP flap was used for a one-stage reconstruction of complicated tissue loss in 12 male patients. In seven of these flaps, a microsurgical anastomosis between the two epigastric pedicles of the DIEAP flap was carried out. The feasibility of the procedure, clinical outcome, and possible associated comorbidities were evaluated. RESULTS: Successful large tissue reconstructions were performed using all four traditional zones of the DIEAP flap, with dimensions of flaps ranging from 20 × 8 to 50 × 17 cm. Venous congestion was seen to develop in two flaps, one of which was salvaged by performing an additional venous anastomosis, but the other flap failed to survive. Apart from this, complications were minimal. CONCLUSIONS: Soft tissue coverage of extensive wounds in male patients without sacrificing muscle flaps can be challenging. This extended utilization of the entire DIEAP flap has helped us to address this issue.

DIEAP flap for safe definitive autologous breast reconstruction.

BACKGROUND: Breast cancer is the commonest form of cancer in women affecting almost a quarter of a million patients in the US annually. 30 percent of these patients and patients with genetic mutations undergo removal of the breast, as highlighted in a high profile celebrity patient. Although breast reconstruction with free microvascular transfer of a DIEAP flap from the abdomen is an ideal form of reconstruction, there have been misgivings about the complexity and potential complications. This study was aimed at clearing these misunderstandings and establishing the value of this form of breast reconstruction. METHODS: 1036 DIEAP flap breast reconstructions carried out at the University Hospital, Gent (five year period) and at the Sana Kliniken, Düsseldorf (three year period) were included prospectively. Comorbid factors like chemotherapy, radiotherapy, patient age >65 years, BMI >30 and smoking were recorded. Outcomes were evaluated over a mean follow up of 2 years. RESULTS: Overall complication rate related to the reconstructed breast and donor abdominal area was 6.8 percent. Total flap loss was seen in only 0.8 percent. The mean operating time was less than five hours. Older age, higher BMI, chemotherapy and radiotherapy did not have a significant influence on complication rates, however smoking resulted in significant delay in wound healing in the breast (p = 0.025) and abdominal wounds (p = 0.019). CONCLUSION: The DIEAP flap is an excellent option for breast reconstruction, with a low level of donor site morbidity and complications. It is an autologous reconstruction that provides a stable long term result.

Maintaining ear aesthetics in helical rim reconstruction.

BACKGROUND: Wedge resections of the helical rim may result in a significant deformity of the ear with the ear not only smaller but cupped and prominent too. Our technique involves resection of the wedge in the scaphal area without extending into the concha followed by advancement of the helical rim into the defect. This technique is most suitable for peripheral defects of the helical rim, in the middle third. METHODS: Our modified surgical technique was applied to reconstruction of the pinna after resection of the tumor in 12 patients. Free cartilaginous helical rim, length of helical rim to be resected, and projection of the ear from the mastoid was measured. This was then compared with measurements after the operation, and the patient satisfaction assessed with a visual analog scale. RESULTS: The free cartilaginous rim was 91.67 ± 5.61 mm. Of this, 21.92 ± 3.78 mm was resected, which amounted to 23.84% ± 3.35% of the rim. Although this resulted in a mean increase in ear projection of 6.42 ± 1.68 mm, the aesthetic outcome was good (visual analog scale, 9.08 ± 0.9). CONCLUSIONS: This technique reduces cupping and does not make the ear as prominent as it may do after a conventional wedge resection and results in high patient satisfaction.

Are Pfannenstiel scars a boon or a curse for DIEP flap breast reconstructions?

BACKGROUND: Abdominal incisions and their subsequent scarring alter the vascular architecture of the abdominal pannus. This is of significance when reconstructing the breast with the deep inferior epigastric perforator (DIEP) flap. This study aimed to objectively investigate the impact of the lower abdominal Pfannenstiel scar in utilizing the DIEP flap. METHODS: A retrospective study of breast reconstruction with DIEP flaps was conducted on patients who had a Pfannenstiel scar (n = 36) compared with patients who did not (n = 36). Computed tomography angiograms were analyzed for the numbers, positions, and dimensions of perforator vessels. Influence of the scar on the reconstructive outcome was assessed. RESULTS: The number of perforators was greater in the control group (mean, 9.14) compared with the study group (mean, 8.3) but was not significant, with marginal significance (p = 0.09). The percentage of found perforators with 4 mm or greater was significantly higher in the study group than in the control group (21.7 percent compared with 14.3 percent, respectively; p = 0.04). The position of perforators was more or less the same, and complications were also comparable in both groups. CONCLUSIONS: Pfannenstiel incisions result in undermining of the lower abdominal apron and, in most cases, division of the superficial epigastric vessels. This results in "ischemic preconditioning" of the flap, as has been evidenced by the increased dimensions of the perforators. Hence, flaps raised from these abdomens are not only safe but may even be better vascularized. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Morbidity of microsurgical breast reconstruction in patients with comorbid conditions.

BACKGROUND: Although free tissue-transfer with the deep inferior epigastric perforator (DIEP) flap is one of the best forms of autologous breast reconstruction, surgeons have remained guarded over selecting patients for the procedure in the presence of comorbid conditions. This study has investigated the relevance of these conditions. METHODS: A prospective review of all free flap breast reconstructions (n = 624) was performed over a 2-year period at the Department of Plastic Surgery at the Sana Kliniken Düsseldorf. Patients were placed into three groups based on comorbid conditions such as age 65 years or older, active smoking, and body mass index greater than or equal to 30. Flap and donor-site complications were analyzed. RESULTS: Six hundred twenty-four breast reconstructions with DIEP or muscle-sparing transverse rectus abdominis musculocutaneous (TRAM) flaps were performed in 558 patients (66 bilateral reconstructions). There were 36 patients older than 65 years at the time of surgery, 94 active smokers, and 79 patients with a body mass index of greater than or equal to 30. Flap complications such as venous congestion (n = 5), partial flap loss (n = 10), marginal necrosis (n = 15), and total flap loss (n = 5) occurred in 35 cases (5.6 percent). Donor-site complications such as delayed abdominal wound healing (n = 9), seroma (n = 8), abdominal hernia (n = 3), and bulging (n = 11) occurred in 31 cases (5 percent). CONCLUSIONS: Despite having significantly higher complications in the form of delayed donor-site wound healing in active smokers and higher total flap loss in obese patients, the overall complication rates compared with other reconstructive procedures are low. Microsurgical reconstruction with DIEP and muscle-sparing TRAM flaps is associated with low complication rates, excellent aesthetic outcome, and high patient satisfaction, even in patients with known risk factors.

Locating perforator vessels by dynamic infrared imaging and flow Doppler with no thermal cold challenge.

BACKGROUND: Dynamic Infrared Imaging (DIRI) is a noninvasive technique that precisely analyzes the infrared radiation of any object. We used this technique to locate the dominant perforator vessels in flap surgery in conjunction with conventional Doppler. METHODS: Ten patients scheduled for deep inferior epigastric artery perforator flap and 6 for free-fibular flaps were selected. Perforator vessels were localized in the donor area, using Doppler and DIRI. The ability to locate the dominant perforators was compared between both techniques. RESULTS: DIRI produced a precise map showing the location of the perforators and their area of perfusion at the skin level. Their dominance can be determined by their size. Flow Doppler located the perforators at the aponeurotic level without size and perfusion information. CONCLUSIONS: DIRI produces a skin thermographic map of perforator vessels and their perfusion area. Handheld Doppler locates perforators at the aponeurotic level. Their combination increases safety in the planning of perforator flap surgery.

What should define a "perforator flap"?

In spite of the Gent consensus on perforator flap terminology, widespread confusion still exists regarding the true description of these flaps, making it hard to understand these surgical procedures in comparison with conventional flap techniques. The value of perforator flaps can be better understood by further clarifying certain aspects of previous descriptions. The authors would like to propose enriching the standard Gent nomenclature with optional terms that specify additional aspects of the perforator flap such as including the vessel of origin, the type of vascular dissection, the muscle involved, and the type of perforator vessel. When describing a new flap, these terms will help clarify the anatomical aspects and the surgical approach. Lastly, a better understanding will help in the ongoing debates on this type of surgery and will aid in its dissemination and adoption into reconstructive practice.