Vincenzo Penna

Negative pressure wound therapy reduces the ischaemia/reperfusion-associated inflammatory response in free muscle flaps☆

BACKGROUNDnWe recently established negative pressure wound therapy (NPWT) as a safe postoperative care concept for free muscle flaps; however, the molecular effects of NPWT on free muscle flaps remain elusive. Here we investigated the effects of NPWT on pathological changes associated with ischaemia/reperfusion injury in free flap tissue.nnnMETHODSnFrom July 2008 to September 2010, 30 patients receiving skin-grafted free muscle transfer for defect coverage were randomly assigned to two treatment groups: In one group the skin-grafted free flap was covered by a vacuum dressing (NPWT); in the second group, flaps were covered by conventional petroleum gauze dressings (conv). Biopsies were taken intra-operatively prior to clipping of the pedicle and on postoperative day 5. Samples were analysed by immunohistochemistry for infiltration of inflammatory cells, real-time polymerase chain reaction (RT-PCR) for the analysis of expression levels of interleukin-1β (IL-1β) and tumour necrosis factor (TNF)-alpha as markers of inflammation. Histological samples were also examined for interstitial oedema formation, and apoptosis was detected by a terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay.nnnRESULTSnNPWT leads to a significantly reduced tissue infiltration of CD68 + macrophages and reduced expression of the inflammatory cytokines IL-1β and TNFα. None of these parameters was significantly elevated in the pre-ischaemic biopsies. Furthermore, NPWT reduced the interstitial oedema formation and the number of apoptotic cells in free flap tissue.nnnCONCLUSIONnNPWT of skin-grafted free muscle flaps leads to a reduced inflammatory response following ischaemia/reperfusion, resulting in reduced oedema formation improving the microcirculation and ultimately reduced tissue damage. We thereby deliver new insight into the effects of NPWT.

Changes in the aging upper lip – a photomorphometric and MRI-based study (on a quest to find the right rejuvenation approach)

BACKGROUNDnA lack of scientific data about the complex three dimensional changes in relation to the rest of the face is the reason for the multitude of rejuvenation approaches to the aging upper lip. In this study the underlying anatomic changes and facial proportions of the senile upper lip are scientifically evaluated for the first time.nnnMETHODSn(1) In 182 standardized subject photographs proportions of the upper lip were measured, compared to facial dimensions and correlated to age. (2) In cranial MRI scans of 30 women aged 20-35 and 30 women aged 65-80 relevant anatomical dimensions were measured.nnnRESULTSnBoth studies showed a statistically significant lengthening of the aging upper lip. The photomorphometric study further shows an increase of prolabium skin at the cost of a decreasing visible upper lip vermilion. The MRI scans showed a decrease in thickness. A loss of volume could not be shown.nnnCONCLUSIONnIsolated volume augmentation is not a causal method of upper lip rejuvenation and it may therefore rather lead to an unnatural blown up look.

The aging perioral region — do we really know what is happening

ObjectivesThe perioral region is subject to a myriad of different treatments for rejuvenation, many of which are applied without a clear understanding of the underlying physiological processes of perioral aging. The results of these procedures are therefore sometimes not optimal and do not achieve a natural youthful appearance. The aim of this study was to put the results of three investigations into the perioral aging process into relation to clinical application in aesthetic medicine.DesignThree different investigations were performed to evaluate the complex 3-dimensional changes during the perioral aging process. Perioral proportions of 182 standardized subject photographs were measured in a photomorphometric study and correlated to age. In cranial MRI scans of 30 women aged 20–35 and 30 women aged 65–80 relevant anatomical dimensions were measured. Histological cross cuts of the upper lip complex of 20 individuals in two age groups, young (< 40 years, n = 10) and old (> 80 years, n = 10), were analysed. The results were then set into relation to today’s lip rejuvenation procedures.ResultsAll studies showed a statistically significant lengthening of the aging upper lip. The photomorphometric study further showed an increase of prolabium skin at the cost of a decreasing visible upper lip vermilion. The MRI scans showed a decrease in thickness and redistribution towards a length increase but no total volume loss. Histomorphometric analysis revealed statistically significant thinning of the cutis, thickening of the subcutis and a degeneration of elastic and collagen fibers. The orbicularis oris muscle becomes thinner and shows a decrease of the forward curve defining the vermilion border. The results show that the main processes of lip aging are redistribution from thickness to length without total volume loss and a decrease of structural components of the lip, which leads to the decrease of pouting, an inversion of the vermilion and a ptosis of the lip.ConclusionA new and better understanding of the underlying physiological changes of perioral aging is essential and will lead to a better and more specific implementation of perioral rejuvenation procedures which will lead to more natural results.

Microsurgical reconstruction of oncological scalp defects in the elderly

The incidence of scalp tumors requiring radical excision increases with age. Free flap surgery is the standard reconstructive option for large defects; however, there is an ongoing uncertainty about its safety in the elderly. We conducted a review of data and report on 19 patients aged ≥75 years and 13xa0<xa075 years. Data regarding patient demographics, types of tumors, surgery, size of defect, flaps used, and prevalence of complications were analyzed. The patients in the elderly group had more accompanying medical conditions and a higher ASA score. Squamous cell carcinoma was the predominant tumor in the elderly and sarcoma in the younger patients. The defect size was similar in both groups. The latissimus dorsi (LD) and the anterolateral thigh (ALT) flaps were flaps of first choice, with temporal vessels most commonly used for anastomosis. Surgery lasted longer in the younger patients. There was no difference in the duration of hospital stay. No significant correlation was found between age and the flap-related or medical complications. Revision surgery was more often required in the younger patients. We conclude that free flap surgery is safe and reliable in the elderly population. The LD and the ALT are the most commonly used flaps. Advanced age should not be considered a risk factor for free flap surgery in these patients.

Classification of the Aging Lips: A Foundation for an Integrated Approach to Perioral Rejuvenation

AbstractBackgroundnAlthough perioral aging is highly individual with several distinct processes taking part simultaneously, there is scarce systematic information which helps to indicate the right rejuvenation approach among the multitude of proposed procedures. Existing data about perioral aging has not yet been transformed into a consistent therapeutic concept. The intention of this study was to provide a simple, yet reproducible classification and to offer appropriate rejuvenation approaches.MethodsTo identify reliable and constant landmarks of the ongoing process of perioral aging, 462 perioral photo documentations were morphometrically analyzed. Based upon the identified landmarks a two-dimensional classification was developed. The classification was validated by three plastic surgeons. Inter- and intra-rater reliability was calculated using Cohen’s kappa coefficient.ResultsPerioral aging can be broken down into changes of the lip shape and changes of the lip surface. Both processes can be classified into three stages each: Lip shape according to the shape in profile view, the lip length in relation to the frontal incisors, and the degree of vermilion inversion. Lip surface according to the presence and degree of radial wrinkles and the visibility of the structural elements Cupid’s bow, philtrum, and white roll. Inter-observer reliability was rated very good (kappa values between 0.819 and 0.963) and perfect for intra-observer reliability (1.0).ConclusionA better understanding of perioral aging leads to a simple classification for the aging lips. Using the classification helps to tailor an appropriate treatment to the individual patient and aids to achieve a natural rejuvenation result.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Refinements in reconstruction of penile skin loss using intra-operative prostaglandin injections, postoperative tadalafil application and negative pressure dressings

PURPOSEnPenile shaft skin defects represent demanding reconstructive tasks because a high degree of flexibility and stability of the skin grafts are essential to allow regular erections and sexual intercourse.nnnMETHODSnA new concept of tailoring skin grafts to the erect penis by intra-operative application of prostaglandin E1 and postoperative stabilisation by negative-pressure wound therapy and pharmacological expansion by tadalafil was tested on four patients with penile shaft skin defects. Graft take, stability, pliability, softness and aesthetic results were evaluated up to at least 12 months postoperatively. The ratio of the skin transplanted area in the non-erect compared to the erect penis (non-erect/erect ratio) and the ratio of the skin transplanted area in the erect penis at 12 months compared to intra-operatively (Post/Pre ratio) was determined to define the amount of graft contraction and flexibility. International Index of Erectile Function (IIEF)-5 scores were evaluated postoperatively.nnnRESULTSnThere were no complications. Graft take was 97, 100, 100 and 100%. Stable skin grafts were achieved after 2 weeks. Sexual intercourse was possible at 2-3 months. The Post/Pre ratio was between 81 and 87% and proves comparably mild contracture rates. The non-erect/erect ratio of 50-72% shows how significantly undersized penile shaft skin grafts are when adjusted to the non-erect penis and that an adequate flexibility for erections can be reconstructed. IIEF-5 scores proved regular potency in three patients; one patient was no longer sexually active.nnnCONCLUSIONSnWith the new concept of tailoring the skin graft to the erect penis, pharmacological expansion and external stabilisation by vacuum-assisted closure (VAC) dressing the difficult task of penile skin reconstruction can be facilitated, accelerated and the functional and aesthetic outcome improved compared to earlier efforts or to results presented in the literature.

Simultaneous pectoralis major myocutaneous flap combined with breast reduction for sternal defect coverage

BACKGROUNDnThe pectoralis myocutaneous island flap is a well established technique for tissue reconstruction. In female patients with concomitant breast hypertrophy there may be a simultaneous indication for breast reduction mammoplasty. The inferior pole of the breast and the inframammary fold coincide with the skin island territory of myocutaneous flaps supplied by the thoracoacromial artery.nnnMETHODSnA technique is described where this tissue is preserved as the flap skin island in combination with a superior pedicle reduction mammoplasty. The technique is illustrated with two exemplary cases.nnnRESULTS AND CONCLUSIONnThe technique is suitable in women with relative unilateral or absolute bilateral large breasts with a combined sternal defect and should be taken into consideration for respective cases.

Long-Term Follow-up of Recurrence and Patient Satisfaction After Surgical Treatment of Gynecomastia

Background“Gynecomastia” is an enlargement of the male breast. Our study aims to assess patient satisfaction as well as evaluate differences in recurrence rates in lipomatous and glandular gynecomastia 10–19xa0years postoperatively.MethodsForty-one gynecomastia patients undergoing surgical treatment from 1997 to 2005 were invited for a follow-up examination 10–19xa0years postoperatively. Of these, 16 patients presented for a clinical examination. Patient satisfaction was measured with a validated questionnaire [consultation satisfaction questionnaire (CSQ)-9]. Furthermore, photo-material and patient charts were evaluated concerning preoperative macroscopical type of gynecomastia, BMI, and operative technique.ResultsMean follow-up time was 13.8xa0years (range: 10.5–19xa0years). Eight patients (50%) had presented with lipomatous and eight patients (50%) with glandular gynecomastia prior to surgery. One of the patients with glandular gynecomastia (12.5%) presented with recurrence at the time of follow-up, while five of the eight patients showing lipomatous gynecomastia (62.5%) presented with recurrence. Interestingly, younger patient groups tend to be more satisfied with the operative treatment of gynecomastia than older patient groups, especially regarding the improvement of self-esteem.ConclusionsLong-term follow-up results showed that recurrence rates are significantly higher in patients with lipomatous gynecomastia than in patients with glandular gynecomastia, with BMI increase in patients with glandular and lipomatous gynecomastia showing no statistically significant differences. Furthermore, general patient satisfaction and improvement of self-esteem was higher in younger patient groups than older patient groups.Level of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.Clinical Trial Registration Number: DRKS00009630.

Comparison of the Rubin Dermal Suspension Sutures and Total Parenchymal Reshaping Technique With a Traditional Inverted T-Scar Reduction Mammaplasty Technique Using a Superior Pedicle

AbstractAdipose patients, especially after massive weight loss, pose a challenge to the breast surgeon due to the major loss of volume and the inelasticity of the skin. Rubin described a suitable mammaplasty technique for these patients involving dermal suspension sutures and total parenchymal reshaping. With this technique, the tissue of the prominent axillary skin fold typically found in patients with massive weight loss is used to increase the upper pole volume of the breast. To prove the effectiveness of this technique, the current study compared it with a traditional inverted T-scar technique using a superior pedicle, as described by Höhler. This technique usually is used for a different patient clientele that requires reduction mammaplasty. However, because none of the difficult aforementioned preconditions are found in this clientele, it leads to the best possible outcome and represents the authors’ internal “gold standard” for mammaplasty against which all other techniques must be compared. This study retrospectively analyzed the complication rate, lift effect, and upper pole fullness by chart analysis and photometric analysis of 21 Höhler and 24 Rubin mammaplasties. Despite the more challenging patient clientele in the Rubin groups, both therapies achieved a similar lift effect without significant differences (Höhler 4.8xa0±xa03.3xa0cm vs Rubin 6xa0±xa04xa0cm). In both groups, the upper pole area increased significantly. The ratio of upper pole-to-lower pole area increased from 1.31 preoperatively to 2.1 postoperatively in the Rubin group, suggesting a redistribution of tissue in favor of the upper pole, and it increased from 1.18 to 1.69 in the Höhler group, indicating an even greater increase in upper pole volume in the Rubin group. In conclusion, the technique described by Rubin, despite the dramatically more difficult soft tissue condition of the patients with massive weight loss, results in an outcome similar to that of a traditional reduction mammaplasty technique in terms of increased upper pole volume. It is suitable and preferable for patients who have a lateral axillary roll deformity and can be applied safely for these patients without increasing the complication rate.nLevel of Evidence IVThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Vergleich der Ergebnisse der Resektions-Suspensionsarthroplastik nach Lundborg und Sirotakova zur Behandlung der Rhizarthrose

BACKGROUND AND AIMSnThe aim of this prospective randomised study was to compare Sirotakovas and Lundborgs methods of resection-suspension arthroplasty using the abductor pollicis longus tendon in the surgical treatment of osteoarthritis of the trapeziometacarpal joint.nnnPATIENTS AND METHODSnBetween 2009 and 2012, 38 patients (29 female, 9 male) with symptomatic trapeziometacarpal osteoarthritis (34% stage II, 58% stage III and 8% stage IV according to the Eaton-Littler classification) were randomly allocated to one of the surgical methods (mean age 62.7 years, range 43-85). Preoperatively, the following data were collected: pain intensity (Visual Analogue Scale, VAS; at rest: Lundborg 4.4±1.7; Sirotakova 4.6±2.1), strength (key pinch force Lundborg 8.1u2009kPa±6.6; Sirotakova 10.4u2009kPa±10.8), range of motion in the trapeziometacarpal joint (Lundborg 61.64±26.4; Sirotakova 46.67±25.6), Kapandji index (Lundborg 9.42±1.4; Sirotakova 9.33±1.5), distance between the base of the first metacarpal bone and the scaphoid bone as measured by standardised x-ray images (Lundborg 12u2009mm±1.5; Sirotakova 11.4u2009mm±3), DASH questionnaire (Lundborg 40.4±13.9; Sirotakova 49.9±23.5). A significant difference between the 2 groups was not found. Patients were examined 3 and 9 months postoperatively.nnnRESULTSnBoth resection-suspension arthroplasty procedures led to a statistically significant postoperative reduction of pain, a significant improvement in radial and palmar abduction, a significant gain in quality of life and significant asymptomatic proximalisation of the first metacarpal bone. There was no significant difference in postoperative strength.nnnCONCLUSIONnBoth methods lead to reliable and satisfying results. Given our findings we cannot generally recommend one method over the other.