Lorenz Larcher

Indications, outcomes, and complications of pedicled propeller perforator flaps for upper body defects: a systematic review.

Background The aim of this investigation was to systematically review the current literature to provide the best data for indications, outcomes, survival, and complication rates of pedicled propeller perforator flaps for upper body defects. Methods A comprehensive literature review for articles published from January 1991 to December 2011 was performed using the PubMed, Medline, and Cochrane Databases. Articles without available full-text, single case reports or papers with excessive missing data were excluded. Papers reporting pedicle-perforator (propeller) flaps used for lower extremity reconstruction were excluded from meta-analysis. Results From the initial 1,736 studies our search yielded, 343 studies qualified for the second stage of selection. Of 117 full-text reports screened, 41 studies, met the definitive inclusion and exclusion criteria. Of the selected 41 articles, 26 were case series, original papers or retrospective reviews and were included, whereas 15 were case report papers and therefore were excluded. Two hundred ninety-five propeller flaps were reported to have been used in a total of 283 patients. Indications include repair of trauma-induced injuries, post-trauma revision surgery, cancer resection, chronic infection, pressure sores, and chronic ulcers with a major complication rate (3.3%) comparable to that of free flaps. No specific exclusion criteria for the procedure were presented in the studies reviewed. Conclusions Pedicled propeller flaps are a versatile and safe reconstructive option that are easy and quick to raise and that provide unlimited clinical solutions because of the theoretical possibility of harvesting them based on any perforator chosen among those classified in the body.

Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience.

PURPOSE Rhinophyma is characterized by slowly progressive tumour-like enlargement of the nasal skin that will not resolve spontaneously. Though its treatment consists of surgical removal of the hyperplastic alterations, in the literature there is not general agreement about the best method. We presented our experience with two different treatment modalities such as decortication by scalpel and CO2 laser treatment. METHODS The authors reviewed the long-term results of 67 patients affected by rhinophyma treated with two different methods between 1996 and 2011. Outcomes were determined by case notes, clinical review and patient satisfaction questionnaire. RESULTS Forty-five cases were treated with tangential excision and 22 with a CO2 laser. Minor complications, including scarring and hypopigmentation, were seen in 6 patients. All patients were satisfied with their outcomes at the follow-up visit, and no major complications were detected during follow-up. CONCLUSION Both tangential excision and carbon dioxide laser are well-established, reliable procedures for rhinophymaplasty that preserve the underlying sebaceous gland fundi allowing spontaneous re-epithelialization without scarring with similar outcomes and high patient satisfaction. The original nose shape and nearly normal skin surface texture are preserved by quickly removal of the hypertrophic tissue sparing the pilosebaceous tissue. The CO2 laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs.

Propionibacterium avidum infection following breast reduction: high morbidity from a low-virulence pathogen

Propionibacterium avidum is a common inhabitant of sebaceous glands, traditionally considered to be of low virulence and generally found on implanted foreign material. We report a rare case of P. avidum breast abscess, causing severe morbidity following breast reduction surgery. A 36-year-old woman presented with a non-painful wound discharge 3 weeks postoperatively, and was treated conservatively. She was readmitted 7 weeks postoperatively with a red and tender breast. A purulent discharging abscess was drained under ultrasound guidance. A 2-week intravenous course of amoxicillin–clavulanic acid, followed by oral replacement for a month resulted effective. Serial ultrasound imaging was useful in treatment decision-making. The infective potential of P. avidum may be underappreciated. Proximity of sutures to the axilla, tobacco smoking and the potential for resorbable sutures to host bacteria may predispose to infection, and should raise the clinicians awareness.

Complete excision of nonmelanotic skin cancer: a matter of surgical experience.

AbstractNonmelanotic skin cancer is the most common human neoplasia and its incidence is rising. The completeness of resection is the most important quality feature of surgical treatment of nonmelanotic skin cancer, as a complete resection distinctly reduces local recurrence. In this trial, we analyze the incomplete resection rate of nonmelanotic skin cancer (N = 524) through plastic surgery assistant doctors in the first 3 years of surgical training. We find that the incomplete resection rate of nonmelanotic skin cancer decreases significantly (P = 0.026) from mean 12.1% in the first year of training to mean 5.7% in the third year of training, despite a gain in difficulty level concerning tumor localization. Moreover, we identify the following tumor features as a risk factor for incomplete resection: facial tumors (P = 0.034), recurrent lesions (P = 0.032), and the tumor class of the superficial basal cell carcinoma (P = 0.010). We prove that complete excision of nonmelanotic skin cancer distinctly depends on the surgeon’s experience level.

Capsular contracture as a further presenting symptom of implant-related anaplastic large cell lymphoma.

To the Editor: We read with great interest the article by Aladily et al entitled “Anaplastic large cell lymphoma associated with breast implants: a report of 13 cases”. We commend the authors for the excellent description of their cases. Here, we discuss some more key points about this malignancy involving breast-implanted women who have received attention increasingly because of the relative rarity with which anaplastic large cell lymphoma (ALCL) otherwise occurs in this region.2–4 In their paper, Aladily et al1 stressed the need to differentiate the presentation of ALCL associated with breast implants in 2 clinicopathologic subgroups and distinguish a “Seromaor effusion-associated” type without a mass, which seems to have a good prognosis with the proper treatment, and an “aggressive variant with a distinct mass” close to the implant requiring multiple combined therapies. An accurate review of the literature showed that capsular contracture5–7 would be added as a separate and independent presenting symptom that needs further discussion. Nevertheless, in 3 cases, a recalcitrant capsular contracture with multiple recurrences even beyond the immediate postoperative period requiring breast implant revisions has been described as the first clinical sign of disease without an initial evidence of effusion-related enlargement of the breast or a palpable mass. A patient presented with the recurrence of a painful right breast capsular contracture 19 years after the primary placement of implants and 3 years after a previous revision, without evidence of breast mass, seroma-related enlargement of the breast, or lymphadenopathy.5 After a combined surgical (implant removal and capsulectomy) and chemotherapeutic approach, the patient was disease-free at 21 months. Carty et al6 reported the case of a patient with an 8-year history of multiple revision procedures after cosmetic breast implantation for capsular contracture and implant rupture, only after which a painful mass developed in the left breast adjacent to her cosmetic implant. The implant-related ALCL involved both breasts and was refractory to both standard and aggressive therapies, ultimately resulting in the death of the patient secondary to disease progression. In the third case, an implantrelated ALCL developed 19 years after implantation with a painful capsular contracture and asymmetry of the breast without enlargement. No followup information was found. Capsular contracture represents the most common local complication of breast implant placement that clinically manifests as breast induration, which eventually evolves into a painful contracture, causing distortion of breast with respect to shape and volume.8 The severity of contracture is classified on the basis of the Baker 4grade scale, which takes into account a peculiar mixture of breast symptoms and signs. Accordingly, the only cure for grades III (moderate contracture; the patient feels some firmness) and IV (severe contracture; obvious just from observation) is surgical revision. Even if it is confirmed that a cumulative risk of capsular contracture is directly correlated to the increasing interval time between the placement of implant and the occurrence of the contracture,9 almost 92% of contractures develop within the first year after surgery. The most effective treatment of capsular contracture is provided by a revision surgery yielding capsulectomy combined with either implant exchange (change of features of the shell including texture and foam-covered material) or change of plane of implant placement (from subglandular to subfascial or submuscular). Ultimately, only the implants are removed. Five important points should be borne in mind. First, a capsular contracture occurring years after the implantation should alarm surgeons, and ALCL should be included by pathologists in the differential diagnosis. Second, a contracture that behaves as refractory to several surgical revisions during which the prosthesis is reimplanted should be further investigated. Especially when the fibrous capsule appears contracted and

Split-thickness skin grafting for reconstruction of auricular skin defects: a statistical analysis

Surgical reconstruction following the removal of large malignant auricular lesions is challenging. While many options for defect closure have been described, in the elderly population usually affected flap surgery, long anesthesia times, patient compliance, and anticoagulant therapy pose additional risks. An alternative quick, simple, and effective method of defect closure is therefore highly desirable. The objective of the present study was to assess the aesthetic outcome, healing process, complications, and recurrence rates associated with unmeshed split‐thickness skin grafts (STSGs) used for covering large auricular skin defects following cartilage‐sparing skin cancer removal.

The current preferred female lip ratio

BACKGROUND Perception of beauty is influenced by the individuals demographic background and characteristics. However, objective measurements and ratios remain the foundation for aesthetic evaluations. This study aimed to elucidate if there exists a universally applicable ideal upper to lower lip ratio. METHODS An interactive online survey was designed. Modifiable ranges of lip ratios were achieved via digital alteration, enabling participants to change the ratio of a single female models lips. The questionnaire was translated into multiple languages and sent to more than 9000 plastic surgeons and the general public worldwide. Demographic data were collected and analysis of variance was used to investigate respective lip ratio preferences. RESULTS A total of 1011 responses from 35 different countries (response rate of 14%) was gathered. The majority of survey takers (60%) chose the 1.0:1.0 lip ratio as most attractive. No differences were found in respect to lip ratio preference and the self-reported ethnicity. However, interesting preferences prevailed when analyzing the subgroups regarding lower lip size. CONCLUSION Age, gender, country of residence, and profession significantly impact individual upper to lower lip ratio preferences. However, a 1.0:1.0 lip ratio can apparently be considered most pleasing in females.

Clinical Applications of the Transverse Musculocutaneous Gracilis Flap for Secondary Breast Reconstruction after Simple Mastectomy.

Background: In secondary autologous breast reconstruction, the current standard is a flap derived from the lower abdomen or the back. If these donor sites are not available because of lack of tissue, prior operations, or simply the patient’s desire to avoid these donor sites, the authors use the transverse musculocutaneous gracilis flap if feasible. Methods: The authors retrospectively evaluated only patients where secondary autologous breast reconstruction was performed with a transverse musculocutaneous gracilis flap because of the prior mentioned reasons. Indications, limitations, advantages, and technique are discussed by sharing the authors’ experience in 23 patients using 26 transverse musculocutaneous gracilis flaps. Results: No flap loss could be observed in this series. In four patients, minimal lateral skin necrosis could easily be managed by débridement and primary wound closure. In 12 cases, subsequent lipofilling was performed for a better breast shape. On average, patient satisfaction was high. Conclusions: Secondary reconstruction after simple mastectomy using the transverse musculocutaneous gracilis flap requires a little more experience than after skin-sparing mastectomy but, especially combined with later lipofilling, can lead to an optimally shaped breast in selected patients with substantial skin laxity and fat distribution at the inner thigh. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Regeneration patterns influence hindlimb automutilation after sciatic nerve repair using stem cells in rats

INTRODUCTION Hindlimb autophagy is common after rat sciatic total axotomy and is considered as a sign of neuropathic pain. We applied adult stem cells in a fibrin conduit in a total sciatic axotomy model to improve nerve regeneration, investigating whether a correlation could be detected between stem cells effects on regeneration and limb autophagy. MATERIAL AND METHODS After sciatic nerve section, a 1-cm sciatic gap was crossed using fibrin conduits. Experimental groups included empty fibrin conduits, fibrin conduits seeded with primary Schwann cells, and fibrin conduits seeded with Schwann cell-like differentiated mesenchymal or adipose-derived stem cells (dMSCs and dASCs). Controls were represented by autografts and by sham rats (tot n=34). At 16 weeks post-implantation, regeneration pattern was analysed on histological sections and related to eventual autophagy. Hindlimbs were evaluated and scored according to autophagy Walls scale and X-Rays radiological evaluation. RESULTS All regenerative cell lines significantly improved myelination at the mid conduit level, compared to the empty tubes. However, dMSC could not significantly improve myelination at the distal stump, showing a more chaotic regeneration compared to both other cells groups and controls. Autophagy was correlated to this regeneration patterns, with higher autophagy scores in the empty and dMSC group. CONCLUSION Hindlimb autophagy can be used as index of neuropathic pain due to nerve lesion or on-going immature regeneration. dMSC group was characterized by a less targeted regeneration comparing to dASC and primary Schwann cells, which confirmed their effectiveness in regeneration and potential in future clinical applications.

Management of complications following aesthetic procedures can lead to significant additional cost

Liposuction is one of the most common surgical interventions in aesthetic surgery, technically easy to perform and is also carried out by many non-plastic surgeons. However, this operation can have severe complications, and dealing with them can impose a great financial burden on the tax payer-supported national health-care systems. We report here about a patient, who was hospitalised for complications after a failed office-based liposuction. The ensuing costs of treatment are also discussed.