Reto Wettstein

Efficacy, safety and complications of autologous fat grafting to healthy breast tissue: a systematic review.

BACKGROUNDnFat grafting for primary breast augmentation is growing in popularity due to its autologous properties and its side benefit of removing unwanted fat from other areas, although volume gain is unpredictable and patient safety remains unclear.nnnOBJECTIVEnThe aim of this study was to provide an evidence-based overview of autologous fat grafting to healthy breast tissue with focus on volume gain, safety and complications.nnnDESIGNnA systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.nnnDATA SOURCESnThe MEDLINE, Cochrane Library and EMBASE databases were searched for clinical studies on autologous fat grafting to healthy breast tissue within the last 30 years.nnnDATA EXTRACTIONnClinical articles were evaluated for indication, pre- and postoperative work-up, surgical technique, volume gain (efficacy), complications, radiographic changes and oncological safety. The level of evidence was assessed according to the Oxford Centre for Evidence-based Medicine 2011.nnnRESULTSnA total of 36 articles involving 1453 patients with a mean follow-up period of 16.3 months (1-156 months) were included. No randomised controlled studies were found. Six percent of the patients undergoing fat grafting to healthy breast tissue experienced major complications requiring a surgical intervention or hospitalisation. Two patients with breast cancer (0.1%) after fat grafting for cosmetic purposes were reported. Average breast volume gain ranged from 55% to 82% relative to the grafted fat volume.nnnCONCLUSIONSnThe prevalence of complications and re-operations in fat grafting to healthy breast tissue compared favourably to implant-based breast augmentation. Although no increased incidence of breast cancer was found, long-term breast cancer screening and the implementation of publicly accessible registries are critically important to proving the safety of fat grafting.

A comparative study of two methods of surgical treatment for painful neuroma.

Painful neuromas may follow traumatic nerve injury. We carried out a double-blind controlled trial in which patients with a painful neuroma of the lower limb (n = 20) were randomly assigned to treatment by resection of the neuroma and translocation of the proximal nerve stump into either muscle tissue or an adjacent subcutaneous vein. Translocation into a vein led to reduced intensity of pain as assessed by visual analogue scale (5.8 (SD 2.7) vs 3.8 (SD 2.4); p < 0.01), and improved sensory, affective and evaluative dimensions of pain as assessed by the McGill pain score (33 (SD 18) vs 14 (SD 12); p < 0.01). This was associated with an increased level of activity (p < 0.01) and improved function (p < 0.01). Transposition of the nerve stump into an adjacent vein should be preferred to relocation into muscle.

Laser Surface Scanning Analysis in Reconstructive Rhytidectomy

The implementation of laser surface scanning to assess facial symmetry after unilateral face-lift procedures used to reconstruct defects after skin tumor resection is presented. Six patients who had undergone defect reconstruction with a flap raised from the subcutaneous plane were included in the study. Immediate postoperative photographic evaluation confirmed facial asymmetry because of unilateral skin tension. After a minimum follow-up period of 1 year, photographic and laser surface scanning analysis showed restored facial symmetry. In conclusion, laser surface scanning is a promising technology for objectifying results obtained and could be implemented for evaluation of the immediate and long-term effects from rhytidectomy procedures. Subcutaneous flaps without duplication or resection of the superficial musculoaponeurotic system are ideal for unilateral procedures because facial symmetry is restored after 1 year.

Progenitor cell therapy for sacral pressure sore: a pilot study with a novel human chronic wound model

IntroductionChronic wounds are a major health-care issue, but research is limited by the complexity and heterogeneity in terms of wound etiology as well as patient-related factors. A suitable animal model that replicates the situation in humans is not available. Therefore, the aim of the present work is to present a standardized human wound model and the data of a pilot study of topically applied progenitor cells in a sacral pressure sore.MethodsThree patients underwent cell harvest from the iliac crest at the time of the initial debridement. Forty-eight hours after bone marrow harvest and debridement, the CD34+ selected cell suspension was injected into the wound. With the aid of a laser scanner, three-dimensional analyses of wound morphometry were performed until the defect was reconstructed with a local flap 3 weeks after debridement.ResultsDecreases in volume to 60%u2009±u20096% of baseline on the sham side and to 52%u2009±u20093% of baseline on the cell side were measured. Histologic work-up revealed no signs of metaplastic, dysplastic, or neoplastic proliferation/differentiation after progenitor cell treatment. CD34+ cells were detected in the biopsies of day 0.ConclusionsThe pressure sore wound model allows investigation of the initial 3 weeks after cell-based therapy. Objective outcome analysis in terms of wound volume and histology can be performed without, or with, minimal additional morbidity, and the anatomy of the sacral area allows a control and study side in the same patient. Therefore, this model can serve as a standard for wound-healing studies.Trial registrationClinicalTrials.gov NCT00535548.

Superior epigastric artery perforator flap for sternal osteomyelitis defect reconstruction.

Sternal osteomyelitis after median sternotomy is associated with considerable morbidity and mortality. Combined with radical debridement, muscle and less frequently omentum flaps are used to reconstruct the resulting defects. In this study, we present our experience with the fasciocutaneous superior epigastric artery perforator (SEAP) flap for defect closure. After resection of the entire sternum, including the costochondral arches and the sternoclavicular joints, the repair of the defect was performed with the perforator flap without any re-stabilisation of the thoracic wall. A consecutive series of nine patients with a mean age of 69 ± 6 years were reconstructed with the SEAP flap. The mortality rate was zero. One patient developed a mediastinal haematoma and required five re-interventions by the cardiothoracic surgeons and thereafter a revision to close a small-wound dehiscence at the tip of the flap. Another two patients developed partial necrosis of the flap that could be managed conservatively. One patient had a revision for a seroma on the donor site, resulting in a 100% closure rate of the defect; there were revisions in two out of nine patients. The underlying infection was controlled by debridement, antibiotic therapy and flap closure in all cases. The overall success of the procedure was satisfactory; however, the local complication rate was relatively high with three out of nine patients on the flap side and one of nine on the donor site. Major advantages of the perforator flap in this highly morbid patient cohort are that the operation is relatively quick, muscle tissue is spared and re-education facilitated.

Local flap therapy for the treatment of pressure sore wounds

The aim of this study was to analyse the effectiveness of an interdisciplinary cooperation between conservative and surgical disciplines for the treatment of pressure sores (PS). From January 2004 to December 2005, a single‐centre study was performed with paraplegic and tetraplegic patients presenting with PS grades III–V. Outcome measures were defect size, grade, method of reconstruction, complication and recurrence rate as well as average length of hospitalisation. A total of 119 patients aged 22–84u2009years with totally 170 PS were included. The most common PS were located in the ischial region (47%), followed by the sacral (18%), trochanteric (11%), foot (9%) and the malleolar (8%) regions. Defect sizes ranged between 4 and 255u2009cm2. Grade IV was the most common PS (68%), followed by grade III (30%) and grade V (2%) PS. For wound closure, fasciocutaneous flaps were used most frequently (71%), followed by skin grafts (10%) and myocutaneous flaps (7%). Postoperative follow‐up ranged between 6 and 38u2009months. The overall complication and recurrence rate was 26% and 11%, respectively. If no complication occurred, the average duration of hospitalisation stay after the first debridement was 98u2009±u200962u2009days. In conclusion, our treatment concept is reliable, effective and results in a low recurrence rate. The complication rate, even though favourable when compared with the literature, still needs to be improved.

Defect reconstruction over the olecranon with the distally extended lateral arm flap

Defect reconstruction over the olecranon should be reliable, quick, relatively simple and with minimal complications. More recently, perforator flaps have been described with the benefit of minimal donor site morbidity when compared with muscle flaps or flaps relying on the major arteries of the upper extremity. So far, most of these flaps were harvested on the upper arm and rotated 180° into the defect. The aim of the present study was to analyse the results with the proximally based, distally extended lateral arm flap for soft-tissue reconstruction over the olecranon. The subcutaneous tissue layer in this area is thinner than in the upper arm, and less rotation of the pedicle is necessary. The location of the perforator just proximal to the lateral epicondyle and the precise territory of the flap are well known. Nine consecutive male patients with a mean age of 57±27 years presenting with soft-tissue defects after surgical treatment of bursitis (eight cases) or a pressure sore (one case) were operated on. The mean operation time was 60±15 min. In eight of the nine cases, the flap healed uneventfully or with a minor complication (fistula). One patient underwent revision surgery due to marginal flap necrosis. The defect was closed with a local advancement flap. In conclusion, the flap was reliable, relatively simple and quick to harvest, and yielded acceptable aesthetic results with minimal bulging over the olecranon. Postoperative recovery was relatively painless and short.

Treatment of basal cell carcinoma with surgical excision and perilesional interferon-α.

UNLABELLEDnThe classical treatment of basal cell carcinoma (BCC) is surgical removal. Recent scientific interest has shifted towards alternative, non-surgical interventions in order to decrease the morbidity associated with surgical excision.nnnAIMnThis study aims to evaluate a novel approach that combines surgical excision with perilesional interferon injection in a pilot study.nnnMETHODnA total of 23 patients with facial nodular/solid BCC were enrolled and randomised to receive surgical removal with frozen-section control followed by a single perilesional infiltration of either interferon-α or Ringers lactate. Patients were evaluated for signs of local complications and recurrence after a minimal follow-up of 1 year.nnnRESULTS AND CONCLUSIONnNo major complications occurred after infiltration of interferon. One patient required oral antibiotics in the interferon group and two patients showed a small wound dehiscence. At the 1-year follow-up, one patient suffered from a recurrence in the control group. No recurrence was observed in the interferon group. A single perilesional infiltration of interferon-α was safe and did not increase the local complication rate. No recurrence was observed. A larger study is required to analyse the potential of this combination approach in order to minimise the safety margin and thereby decrease the morbidity associated with surgery while improving the cure rate.

Neurocutaneous sural flap in paraplegic patients

Neurocutaneous flaps have been demonstrated to be a reliable option in different groups of patients but it remains unclear if distally-based sural flaps can be safely used in paraplegic patients because they suffer from significant nervous system alterations. The aim of this proof-of-concept study is to demonstrate that these flaps are reliable in paraplegic patients. We prospectively analysed a group (n=6) of paraplegic patients who underwent reversed sural flap surgery for ulcers on the lateral malleolus. Measurement of area and photographic documentation techniques have been employed to quantify the defect area. Sural nerve biopsies have been analysed histologically with several different staining techniques to assess the neurovascular network and the myelinisation of the nerve. The patients showed uneventful wound healing, except one case that suffered a partial flap necrosis that healed by secondary intention. Histologic analysis revealed an intact neurovascular network and myelinated nerve fibres. In this small series of paraplegic patients that underwent a distally-based sural flap, the complication rate was low, with only one case of superficial partial necrosis demonstrating the reliability and safety of the flap in this subset of patients. Histologic evaluation of sural nerve biopsies revealed an almost normal morphology. A possible explanation of this phenomenon is that the dorsal root ganglia remain intact in paraplegic patients and can preserve neural characteristics in the peripheral sensory nerve system.