Evi M. Morandi

Differentiation between acute skin rejection in allotransplantation and T-cell mediated skin inflammation based on gene expression analysis.

Advances in microsurgical techniques and immunosuppressive medication have rendered transplantation of vascularized composite allografts possible, when autologous tissue is neither available nor sufficient for reconstruction. However, skin rejection and side effects of long-term immunosuppression still remain a major hurdle for wide adoption of this excellent reconstructive technique. Histopathologic changes during acute skin rejection in vascular composite allotransplantation often mimic inflammatory skin disorders and are hard to distinguish. Hence, the identification of diagnostic and therapeutic markers specific for skin rejection is of particular clinical need. Here we present novel markers allowing for early differentiation between rejection in hind limb allotransplantation and contact hypersensitivity. Assessment of Ccl7, Il18, and Il1b expression is most indicative of distinguishing skin rejection from skin inflammatory disorders. Gene expression levels varied significantly across skin types and regions, indicating localization specific mechanism of leukocyte migration and infiltration. Expression of Il12b, Il17a, and Il1b gene expression levels differed significantly between rejection and inflammation, independent of the skin type. In synopsis of the RNA expression profile and previously assessed protein expression, the Il1 family appears as a promising option for accurate skin rejection diagnosis and, as a following step, for development of novel rejection treatments.

Use of Underarm Cosmetic Products in Relation to Risk of Breast Cancer: A Case-Control Study

Background Previous studies on breast cancer (BC), underarm cosmetic products (UCP) and aluminum salts have shown conflicting results. We conducted a 1:1 age-matched case-control study to investigate the risk for BC in relation to self-reported UCP application. Methods Self-reported history of UCP use was compared between 209 female BC patients (cases) and 209 healthy controls. Aluminum concentration in breast tissue was measured in 100 cases and 52 controls. Multivariable conditional logistic regression analysis was performed to estimate odds ratios (ORs) with 95% confidence intervals (CIs), adjusting for established BC risk factors. Findings Use of UCP was significantly associated with risk of BC (p = 0.036). The risk for BC increased by an OR of 3.88 (95% CI 1.03–14.66) in women who reported using UCPs several times daily starting at an age earlier than 30 years. Aluminum in breast tissue was found in both cases and controls and was significantly associated to self-reported UCP use (p = 0.009). Median (interquartile) aluminum concentrations were significantly higher (p = 0.001) in cases than in controls (5.8, 2.3–12.9 versus 3.8, 2.5–5.8 nmol/g). Interpretation Frequent use of UCPs may lead to an accumulation of aluminum in breast tissue. More than daily use of UCPs at younger ages may increase the risk of BC.

Comparison of fasciocutaneous V-Y and rotational flaps for defect coverage of sacral pressure sores: a critical single-centre appraisal

Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V‐Y flap. All primary sacral pressure sores of grades III–IV that were being covered with gluteal fasciocutaneous rotational or V‐Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V‐Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V‐Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature.

Safety of long-term subcutaneous free flap skin banking after skin-sparing mastectomy

Background A persistent problem in autologous breast reconstruction in skin-sparing mastectomies is skin restoration after skin necrosis or secondary oncological resection. As a solution to facilitate reconstruction, skin banking of free-flap skin has been proposed in cases where the overlying skin envelope must be resected, as this technique spares the patient an additional donor site. Herein, we present the largest series to date in which this method was used. We investigated its safety and the possibility of skin banking for prolonged periods of time. Methods All skin-sparing mastectomies and immediate autologous breast reconstructions from December 2009 until June 2013 at our institution were analysed. Results We identified 31 patients who underwent 33 free flap reconstructions in which skin banking was performed. Our median skin banking period was 7 days, with a maximum duration of 171 days. In 22.5% of cases, the banked skin was used to reconstruct overlying skin defects, and in 9.6% of cases to reconstruct the nipple-areolar complex. Microbiological and histological investigations of the banked skin revealed neither clinical infections nor malignancies. Conclusions In situ skin banking, even for prolonged periods of time, is a safe and cost-effective method to ensure that skin defects due to necrosis or secondary oncological resection can be easily reconstructed.

Human Macrophages Preferentially Infiltrate the Superficial Adipose Tissue

Human abdominal subcutaneous adipose tissue consists of two individual layers—the superficial adipose tissue (SAT) and deep adipose tissue (DAT)—separated by the Scarpa’s fascia. The present study focuses on the analysis of morphological and immunological differences of primary adipocytes, adipose-derived stem cells (ASC), and tissue-infiltrating immune cells found in SAT and DAT. Adipocytes and stromal vascular fraction (SVF) cells were isolated from human SAT and DAT specimens and phenotypically characterized by in vitro assays. Ex vivo analysis of infiltrating immune cells was performed by flow cytometry. Primary adipocytes from SAT are larger in size but did not significantly differ in cytokine levels of LEPTIN, ADIPOQ, RBP4, CHEMERIN, DEFB1, VISFATIN, MCP1, or MSCF. ASC isolated from SAT proliferated faster and exhibited a higher differentiation potential than those isolated from DAT. Flow cytometry analysis indicated no specific differences in the relative numbers of ASC, epithelial progenitor cells (EPC), or CD3+ T-cells, but showed higher numbers of tissue-infiltrating macrophages in SAT compared to DAT. Our findings suggest that ASC isolated from SAT have a higher regenerative potential than DAT-ASC. Moreover, spatial proximity to skin microbiota might promote macrophage infiltration in SAT.

Contributing effect of lymphatic disruption in trapdoor deformity in nasolabial flaps—superiorly based vs. inferiorly based flap: A case report

The nasolabial flap is well suited for reconstruction of the lower third of the nose. In one-stage reconstruction used as transposition flap, complications can be caused by blunting of the normal concavity of the nasofacial sulcus, but also by trapdoor formation. Various theories have attempted to explain this phenomenon of bulging tissue occurring in transposition flaps. The contributing effect of lymphatic dysfunction is not clear. In our case performed after excision of basal cell carcinoma, both lower thirds of the nose of a 77-year-old patient were reconstructed with a nasolabial transposition flap using an inferior base on one and a superior base on the other side. A follow-up showed greater trapdoor deformity on the superiorly based transposition flap. Assuming that the inferiorly based flap has better drainage than the superiorly based due to intact vertical lymphatics, our case suggests that lymphatic disruption may significantly contribute to the development of trapdoor deformity.Level of Evidence: Level V, risk/prognostic study.

An old problem with a new solution: Cost-effective, easy correction of rhinophyma using a disposable razor

Fig. 1. Preoperative lateral (A) and frontal (B) standardized photographs of the patient. treatment of rosacea includes rigorous avoidance of triggers, antibiotics, and retinoids. The mainstay of the treatment of rhinophyma consists of surgery, using a CO2 laser, hydrosurgery, or simple excision. We report the case of a 55-year-old female patient who presented with a case of distorting rhinophyma (Fig. 1) after undergoing conservative treatment with oral isotretinoin and ivermectin without any improvement. Tangential excision was performed using a commercially available, sterile single-blade razor (Fig. 2). Wound dressings using Mepithel (Mölnlycke Health Care, Goeteborg, Sweden) were applied postoperatively. The final aesthetic outcome 10 months postoperatively was pleasing, and the patient’s postoperative course was uneventful. No further corrections were needed. The nose regained a natural contour (Fig. 3). Despite the manifold technologies available for the treatment of rhinophyma, there is no consensus on the best technique. The feasibility of obtaining appropriate histopathological samples is the main advantage of tangential excisional techniques. In such techniques, it is crucial to leave the lower part of the pilosebaceous units intact by careful, step-by-step shaving to guarantee total excision along with undisturbed healing by secondary intention. A sterile, disposable razor is a valuable tool in rhinophyma surgery that is inexpensive, commercially available, and easy to use. This method has been described before [3], but it has largely been forgotten and is not in routine clinical use. Thus, we herein re-describe and recommend this cost-effective technique that

Lipografting as a novel therapeutic option in secondary tarsal tunnel release

Reasons for recurrent or persisting symptoms of tarsal tunnel syndrome after surgical treatment include incomplete release, pre-existing intrinsic axonal damage, and excessive scarring. Recently, fat grafting has been described for secondary surgical carpal tunnel therapy with beneficial effects in all patients in whom abundant scarring was found. We describe a case of secondary tarsal tunnel release applying this novel technique. A 65-year-old woman presented with symptoms of tarsal tunnel syndrome, including neuropathic pain, paresthesia, and sleeplessness, due to worsening of symptoms at night and chronic analgesic use. Nine years previously she had undergone surgery on the left ankle joint due to traumatic rupture of the medial collateral ligaments. Soon afterwards, she suffered from distal tibial nerve compression without major motor impairment. Symptoms included severe neuropathic pain located on the plantar aspect of the foot, paresthesia with Tinel sign posterior to the medial malleolus, and a burning sensation on the medial border of the foot. After surgical release the symptoms worsened, and revision surgery and conservative treatment employing corticosteroid injections, orthopedic shoe inserts, and intense physical therapy, including scar treatment, failed. An electromyogram demonstrated chronic denervation of the abductor hallucis muscle and abductor digiti minimi muscles, and nerve conduction studies showed severe axonal sensorimotor damage of the tibial nerve. Sonography revealed preserved continuity, but there was hypoechogenic swelling of the tibial nerve with excessive scarring (Fig. 1A). Revision tarsal tunnel release was performed uneventfully, and excessive scar tissue and a long section of nerve compression were found. After open neurolysis, the wound was closed using monofile interrupted sutures, and fat harvested from the abdomen by means of liposuction was injected directly into the underlying surgical area. Except for a small amount of fat discharging from the wound, the patient’s course was uneventful. Pain evaluation using a visual analog scale improved substantially from 8/10 preoperatively to 1/10 postoperatively, and symptoms were absent at night. Sonography 6 months postoperatively showed the fat graft within rarefied, loosened scar tissue and continuity of the tibial nerve (Fig. 1B). The electromyogram showed persistent axonal sensorimotor impairment despite dramatic clinical improvement reported by the patient, but there were signs of reinnervation in the abductor digiti minimi muscle and persistent mild signs of neurogenic damage of the abductor hallucis muscle. Conservative and operative treatment options are disappointing in recurrent tarsal tunnel syndrome. In a series of 51 patients, the novel method of vein-wrapping was used to protect the nerve from scarring and improve gliding with good results. Nerve-wrapping in bioscaffolds or autologous vein grafts is thought to provide a FIGURE 1. (A) Gray-scale transverse scan depicting a hypoechogenic, thickened tibial nerve (dotted line), with a cross-sectional area of 0.23 cm and adjacent excessive scar formation (arrowheads). (B) Postoperative gray-scale longitudinal scan depicting the tibial nerve (dotted line) and the fat graft (arrowheads) within the scar tissue. Ultrasonography (US) of the tibial nerve was performed on a Philips iU22 device (Philips, Bothell, Washington) using a 12–5and a 17–5-MHZ broadband linear-array transducer.

The posterior thigh flap for defect coverage of ischial pressure sores – a critical single-centre analysis

The development of pressure sores is still not only an enormous economical but also a medical burden. Especially in the ischial region, the local defect coverage remains demanding as it is the main weight‐bearing area in wheelchair‐mobilised patients and is prone to high mobility. The purpose of our study was to report our long‐time experience with the reconstruction of ischial pressure ulcers with the medially based posterior thigh flap.

A small ‘lick’ will sink a great ship: fulminant septicaemia after dog saliva wound treatment in an asplenic patient

Capnocytophaga canimorsus is a bacterium transmitted through the saliva of dogs. An infection can cause severe sepsis with acral necrosis and is potentially fatal. Here, we report the case of a 41‐year‐old man who was infected through a wound that was licked by his dog. He went into septic shock with disseminated intravascular coagulation and subsequently lost both lower legs, his nose and all the fingers on both hands.