Marcus Lehnhardt

Major and Lethal Complications of Liposuction: A Review of 72 Cases in Germany between 1998 and 2002

Background: Liposuction is the most frequently performed cosmetic operation in Germany, with approximately 200,000 procedures performed in 2003. The public perception of liposuction as minor surgery fails to consider the potential of major complications or a possibly fatal outcome. Methods: A retrospective analysis of severe or lethal complications related to cosmetic liposuction is presented. To collect pertinent information, the authors sent 3500 questionnaires to departments of pathology and forensic medicine, intensive care units, and others. After the identification of cases with major complications, the second phase of the investigation consisted of interviews with the physicians performing the liposuction. Results: Two thousand two hundred seventy-five questionnaires (65 percent) were returned. The analyzed data showed 72 cases of severe complications, including 23 deaths following cosmetic liposuction in a 5-year period from 1998 to 2002. The most frequent complications were bacterial infections such as necrotizing fasciitis, gas gangrene, and different forms of sepsis. Further causes of lethal outcome were hemorrhages, perforation of abdominal viscera, and pulmonary embolism. Fifty-seven of 72 complications were clinically evident within the first 24 postoperative hours; 41 of these 72 liposuction procedures were performed using tumescent anesthesia and 17 of 72 were performed using true tumescent anesthesia, with four deaths. Conclusions: Major risk factors for the development of severe complications are insufficient standards of hygiene, the infiltration of multiple liters of wetting solution, permissive postoperative discharge, and selection of unfit patients. The lack of surgical experience was a notorious contributing factor, particularly regarding the timely identification of developing complications. This is in fact the first study reporting deaths related to liposuction performed entirely under true tumescent anesthesia.

Inhibition of early steps in the lentiviral replication cycle by cathelicidin host defense peptides.

BackgroundThe antibacterial activity of host defense peptides (HDP) is largely mediated by permeabilization of bacterial membranes. The lipid membrane of enveloped viruses might also be a target of antimicrobial peptides. Therefore, we screened a panel of naturally occurring HDPs representing different classes for inhibition of early, Env-independent steps in the HIV replication cycle. A lentiviral vector-based screening assay was used to determine the inhibitory effect of HDPs on early steps in the replication cycle and on cell metabolism.ResultsHuman LL37 and porcine Protegrin-1 specifically reduced lentiviral vector infectivity, whereas the reduction of luciferase activities observed at high concentrations of the other HDPs is primarily due to modulation of cellular activity and/ or cytotoxicity rather than antiviral activity. A retroviral vector was inhibited by LL37 and Protegrin-1 to similar extent, while no specific inhibition of adenoviral vector mediated gene transfer was observed. Specific inhibitory effects of Protegrin-1 were confirmed for wild type HIV-1.ConclusionAlthough Protegrin-1 apparently inhibits an early step in the HIV-replication cycle, cytotoxic effects might limit its use as an antiviral agent unless the specificity for the virus can be improved.

Regeneration of the entire human epidermis using transgenic stem cells

Junctional epidermolysis bullosa (JEB) is a severe and often lethal genetic disease caused by mutations in genes encoding the basement membrane component laminin-332. Surviving patients with JEB develop chronic wounds to the skin and mucosa, which impair their quality of life and lead to skin cancer. Here we show that autologous transgenic keratinocyte cultures regenerated an entire, fully functional epidermis on a seven-year-old child suffering from a devastating, life-threatening form of JEB. The proviral integration pattern was maintained in vivo and epidermal renewal did not cause any clonal selection. Clonal tracing showed that the human epidermis is sustained not by equipotent progenitors, but by a limited number of long-lived stem cells, detected as holoclones, that can extensively self-renew in vitro and in vivo and produce progenitors that replenish terminally differentiated keratinocytes. This study provides a blueprint that can be applied to other stem cell-mediated combined ex vivo cell and gene therapies.

Skin electroporation of a plasmid encoding hCAP-18/LL-37 host defense peptide promotes wound healing.

Host defense peptides, in particular LL-37, are emerging as potential therapeutics for promoting wound healing and inhibiting bacterial growth. However, effective delivery of the LL-37 peptide remains limiting. We hypothesized that skin-targeted electroporation of a plasmid encoding hCAP-18/LL-37 would promote the healing of wounds. The plasmid was efficiently delivered to full-thickness skin wounds by electroporation and it induced expression of LL-37 in the epithelium. It significantly accelerated reepithelialization of nondiabetic and diabetic wounds and caused a significant VEGFa and interleukin (IL)-6 induction. IL-6 was involved in LL-37-mediated keratinocyte migration in vitro and IL-6 neutralizing antibodies delivered to mice were able to suppress the wound healing activity of the hCAP-18/LL-37 plasmid. In a hindlimb ischemia model, electroporation of the hCAP-18/LL-37 plasmid increased blood perfusion, reduced muscular atrophy, and upregulated the angiogenic chemokines VEGFa and SDF-1a, and their receptors VEGF-R and CXCR-4. These findings demonstrate that a localized gene therapy with LL-37 is a promising approach for the treatment of wounds.

Comparison of anterolateral thigh, lateral arm, and parascapular free flaps with regard to donor-site morbidity and aesthetic and functional outcomes.

Background: The purpose of this study was to compare the morbidity and the aesthetic and functional outcomes of primarily closed donor sites of three commonly used free flaps. Methods: Sixty patients who had undergone free flap reconstruction (20 anterolateral thigh, 20 parascapular, and 20 lateral arm flaps) were included in this study. The average follow-up time was 50 months (range, 6 to 135 months). Patients assessed subjective donor-site morbidity and satisfaction with the aesthetic and overall functional result using a self-report questionnaire. Outcome measures were the Disabilities of the Arm, Shoulder and Hand questionnaire; the Lower Extremity Functional Scale; and the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire. Results: No significant differences in range of motion or in questionnaire, scale, or survey scores were detected. Sensory disorders were present in 100 percent (lateral arm), 90 percent (anterolateral thigh), and 45 percent (parascapular). No correlation to flap size was detected (187 cm2 for parascapular and anterolateral thigh, and 70 cm2 for lateral arm flaps). Postoperative complications were seromas (parascapular, n = 2), hematomas (parascapular, n = 1; lateral arm, n = 2), and dehiscence (n = 4 for each flap). Patient satisfaction with the donor site was rated 2.9 for lateral arm and anterolateral thigh flaps and 2.5 for parascapular flaps (1 = excellent, 6 = poor). Seventy percent of anterolateral thigh, 85 percent of lateral arm, and 100 percent of parascapular flap patients would choose their flap again. Conclusion: In terms of reducing donor-site morbidity, the parascapular flap represents a valuable alternative to the anterolateral thigh and lateral arm flaps, but side positioning and increased seroma are drawbacks.

Patterns of expression and secretion of vascular endothelial growth factor in malignant soft-tissue tumours

Abstract Vascular endothelial growth factor (VEGF) is an important cytokine especially in the process of tumour angiogenesis. A total of 46 soft-tissue sarcomas were analysed for the expression and possible secretion of VEGF by immunohistochemistry, in-situ hybridisation, and enzyme-linked immunosorbent assays (ELISA). VEGF was demonstrated immunohistochemically in tumour tissue in 45 of 46 cases. The detection of mRNA transcripts yielded evidence of synthesis of VEGF in these sarcomas. ELISA could be performed in 21 cases. Higher concentrations of VEGF were found in tumour-related intraoperatively sampled venous blood in 16 out of 21 patients (76%) than in systemic concentrations taken preoperatively. The results indicated the secretion of VEGF by tumour cells although these raised concentrations were not statistically significant. In 12 out of these 16 patients (75%) a concurrent moderate to strong immunoexpression of VEGF was detected. The relevance of VEGF blood concentrations as a potential “progress parameter” for the course of disease remains questionable. This is mainly due to the lack of statistical significance in the difference between systemic VEGF concentrations in patients and those of a control group. Further long-term follow-up studies are needed, which should include patients with tumour recurrences.

Synergistic apoptotic effects of taurolidine and TRAIL on squamous carcinoma cells of the esophagus

The treatment of choice for esophageal cancer is considered surgical resection, but a median survival of around 20 months after treatment is still discouraging. The value of adjuvant or neoadjuvant radiation or chemotherapy is limited and to date, benefits have only been described for certain tumor stages. Therefore, new therapeutic options are required. As alternative chemotherapeutics, we tested the antibiotic taurolidine (TRD) on KYSE 270 human esophageal carcinoma cells alone and in combination with rhTRAIL (TNF related apoptosis-inducing ligand). Viability, apoptosis and necrosis were visualized by TUNEL assay and quantitated by FACS analysis. Gene expression was analysed by RNA microarray. The most effective concentration of TRD as single substance (250 micromol/l) induced apoptosis to a maximum of 40% after 12-h dose dependently, leaving 4% viable cells after 48 h; by comparison, rhTRAIL did not have a significant effect. The combination of both substances doubled the effect of TRD alone. Gene expression profiling revealed that TRD downregulated endogenous TRAIL, TNFRSF1A, TRADD, TNFRSF1B, TNFRSF21, FADD, as well as MAP2K4, JAK2 and Bcl2, Bcl2l1, APAF1 and caspase-3. TNFRSF25, cytochrome-c, caspase-1, -8, -9, JUN, GADD45A and NFKBIA were upregulated. TRAIL reduced endogenous TRAIL, Bcl2l1 and caspase-1 expression. BIRC2, BIRC3, TNFAIP3, and NFKBIA were upregulated. The combined substances upregulated endogenous TRAIL, NFKBIA and JUN, whereas DFFA and TRAF3 were downregulated compared to TRD as single substance. We conclude that TRD overcomes TRAIL resistance in KYSE 270 cells. Synergistic effects are dependent on the same and on distinct apoptotic pathways which, jointly triggered, result in an amplified response. Several apoptotic pathways, including the TNF-receptor associated and the mitochondrial pathway, were differentially regulated by the substances on gene expression level. Additionally transcription factors seem to be influenced, NFKB in particular. Endogenous TRAIL expression is increased by the combination of substances, whereas it is reduced by each single substance. Taking into consideration that the non-toxic TRD was able to reduce rhTRAIL toxicity and dose, combined therapy with TRD and rhTRAIL may offer new options for treatment in esophageal cancer.

The pedicled gastrocnemius muscle flap: a review of 218 cases.

Background: Data regarding donor-site morbidity, postoperative clinical course, and functional and aesthetic outcome after gastrocnemius muscle flaps are rare. Methods: Data regarding 218 consecutive patients treated with gastrocnemius muscle flaps were acquired from patients’ charts and from contact with patients, with special reference to treatment and clinical course. Eighty-two were interviewed with a standardized questionnaire, 40 were examined physically, and 34 underwent dynamometric muscle function tests. Results: The authors observed wound-healing difficulties in 7 percent, wound infections in 4 percent, and one flap loss; 4.5 percent of the lateral gastrocnemius patients suffered from postoperative palsy of the peroneal nerve. Eighty-seven percent were not significantly limited walking on even ground, but only 42 percent could run, and 40 percent complained about pain when walking more than 200 m. The average range-of-motion deficit in the ankle joint for flexion and extension was 11 percent and 10 percent, respectively. The maximal plantar flexion force in the ankle joint of the operated leg was 76.2 percent. Strength endurance was reduced approximately 24.4 percent in the operated leg compared with the nonaffected side. Conclusions: Gastrocnemius muscle transfer represents a safe and simple procedure in the treatment of lower leg defects and in limb preservation. The strength loss and functional impairment (and sensation disorders) are considerable but may not be exclusively attributable to the muscle transfer but rather the result of the preceding trauma, infection, or tumor resection. The donor-site morbidity is well tolerated by the majority of the patients.

Nucleofection: A New Method for Cutaneous Gene Transfer?

Background. Transfection efficacy after nonviral gene transfer in primary epithelial cells is limited. The aim of this study was to compare transfection efficacy of the recently available method of nucleofection with the established transfection reagent FuGENE6. Methods. Primary human keratinocytes (HKC), primary human fibroblasts (HFB), and a human keratinocyte cell line (HaCaT) were transfected with reporter gene construct by FuGENE6 or Amaxa Nucleofector device. At corresponding time points, β-galactosidase expression, cell proliferation (MTT-Test), transduction efficiency (X-gal staining), cell morphology, and cytotoxicity (CASY) were determined. Results. Transgene expression after nucleofection was significantly higher in HKC and HFB and detected earlier (3 h vs. 24 h) than in FuGENE6. After lipofection 80%–90% of the cells remained proliferative without any influence on cell morphology. In contrast, nucleofection led to a decrease in keratinocyte cell size, with only 20%–42% proliferative cells. Conclusion. Related to the method-dependent increase of cytotoxicity, transgene expression after nucleofection was earlier and higher than after lipofection.

TRAIL and Taurolidine induce apoptosis and decrease proliferation in human fibrosarcoma

BackgroundDisseminated soft tissue sarcoma still represents a therapeutic dilemma because effective cytostatics are missing. Therefore we tested TRAIL and Tarolidine (TRD), two substances with apoptogenic properties on human fibrosarcoma (HT1080).MethodsViability, apoptosis and necrosis were visualized by TUNEL-Assay and quantitated by FACS analysis (Propidiumiodide/AnnexinV staining). Gene expression was analysed by RNA-Microarray and the results validated for selected genes by rtPCR. Protein level changes were documented by Western Blot analysis. NFKB activity was analysed by ELISA and proliferation assays (BrdU) were performed.Results and discussionThe single substances TRAIL and TRD induced apoptotic cell death and decreased proliferation in HT1080 cells significantly. Gene expression of several genes related to apoptotic pathways (TRAIL: ARHGDIA, NFKBIA, TNFAIP3; TRD: HSPA1A/B, NFKBIA, GADD45A, SGK, JUN, MAP3K14) was changed. The combination of TRD and TRAIL significantly increased apoptotic cell death compared to the single substances and lead to expression changes in a variety of genes (HSPA1A/B, NFKBIA, PPP1R15A, GADD45A, AXL, SGK, DUSP1, JUN, IRF1, MYC, BAG5, BIRC3). NFKB activity assay revealed an antipodal regulation of the several subunits of NFKB by TRD and TRD+TRAIL compared to TRAIL alone.ConclusionTRD and TRAIL are effective to induce apoptosis and decrease proliferation in human fibrosarcoma. A variety of genes seems to be involved, pointing to the NFKB pathway as key regulator in TRD/TRAIL-mediated apoptosis.