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Zusammenfassung Ziel Diese Studie untersucht, ob das vaskularisierte Knochentransplantat aus der medialen Femurkondyle (MFC) auch erfolgreich bei kleinen (< 4 cm) Knochendefekten an der oberen Extremität eingesetzt werden kann, die nicht das Skaphoid betreffen. Patienten und Methoden Achtmal wurde bei 7 Patienten mit einem Alter zwischen 28 und 66 Jahren ein vaskularisiertes Knochentransplantat aus der MFC zur Rekonstruktion von Knochendefekten, die nicht das Kahnbein betrafen, an der oberen Extremität eingesetzt. Knochenheilung, Komplikationen, Hebemorbidität und die Patientenzufriedenheit wurden erfasst. Die Nachuntersuchungszeit betrug 3 bis 40 Monate. Die Indikationen für die Rekonstruktion mittels freier MFC waren 2 trotz mehrerer Voroperationen nicht geheilte distale Radiusfrakturen, ein ossärer Defekt am distalen Radius nach Fraktur mit radioskaphoidaler Arthrose, ein akutes, komplexes Trauma mit Verlust von Anteilen des Karpus und des distalen Radius bei Explosionsverletzung, eine Rekonstruktion des ersten Mittelhandknochens (MHK) nach Resektion eines Riesenzelltumors und 3 Arthrodesen zwischen dem 1. und 2. MHK als Rettungsoperation nach mehrfachen Operationen bei Daumensattelgelenksarthrose. Ergebnisse Vier der 8 Knochentransplantate zeigten eine regelrechte Heilung; 3-mal war sie mit 7, 8 und 9 Monaten verzögert. Einmal zeigte sich nur eine partielle Knochenheilung. Zweimal kam es zu einem revisionsbedürftigen Hämatom an der Entnahmestelle. Die Patientenzufriedenheit war mit Schmerzfreiheit in 7 der 8 Fälle in Anbetracht der Komplexität der Fälle zufriedenstellend. Schlussfolgerung Das freie vaskularisierte Knochentransplantat aus der MFC kann erfolgreich ohne Längenverlust zur Rekonstruktion bei Knochendefekten an der oberen Extremität eingesetzt werden, die nicht das Kahnbein betreffen und kleiner als 4 cm sind.

To evaluate whether a vascularized bone graft from the medial femur condyle (MFC) can successfully be used to reconstruct small bone defects (4 cm) on the upper extremity other than the scaphoid.In 7 patients at the age of 28 to 66 years 8 vascularized bone grafts from the MFC were used to reconstruct bone defects on the upper extremity other than the scaphoid. Bone healing, complications, donor side morbidity, and patient´s satisfaction were evaluated. Follow-up was 3 to 40 months. Indications were: two nonunion of the distal radius in spite of several surgical procedures, one defect of the distal radius following a radius fracture with osteoarthritis of the radiocarpal joint, one acute trauma with partial loss of the carpus and radius due to an explosion injury, reconstruction of the first metacarpal (MC) following resection of a giant cell tumour, and three fusions between the 1There was a regular bony healing in 4 of the 8 cases; delayed bony healing was seen in three cases after 7, 8, and 9 months. In one case there was only a partial bony healing. Two donor side haematomas required surgical revision. Patient's satisfaction was high with 7 painless cases.Free vascularized bone grafts from the medial femur condyle can successfully be used to reconstruct bone defects up to 4 cm of the upper extremity other than the scaphoid.ZIEL: Diese Studie untersucht, ob das vaskularisierte Knochentransplantat aus der medialen Femurkondyle (MFC) auch erfolgreich bei kleinen (4 cm) Knochendefekten an der oberen Extremität eingesetzt werden kann, die nicht das Skaphoid betreffen.Achtmal wurde bei 7 Patienten mit einem Alter zwischen 28 und 66 Jahren ein vaskularisiertes Knochentransplantat aus der MFC zur Rekonstruktion von Knochendefekten, die nicht das Kahnbein betrafen, an der oberen Extremität eingesetzt. Knochenheilung, Komplikationen, Hebemorbidität und die Patientenzufriedenheit wurden erfasst. Die Nachuntersuchungszeit betrug 3 bis 40 Monate. Die Indikationen für die Rekonstruktion mittels freier MFC waren 2 trotz mehrerer Voroperationen nicht geheilte distale Radiusfrakturen, ein ossärer Defekt am distalen Radius nach Fraktur mit radioskaphoidaler Arthrose, ein akutes, komplexes Trauma mit Verlust von Anteilen des Karpus und des distalen Radius bei Explosionsverletzung, eine Rekonstruktion des ersten Mittelhandknochens (MHK) nach Resektion eines Riesenzelltumors und 3 Arthrodesen zwischen dem 1. und 2. MHK als Rettungsoperation nach mehrfachen Operationen bei Daumensattelgelenksarthrose.Vier der 8 Knochentransplantate zeigten eine regelrechte Heilung; 3-mal war sie mit 7, 8 und 9 Monaten verzögert. Einmal zeigte sich nur eine partielle Knochenheilung. Zweimal kam es zu einem revisionsbedürftigen Hämatom an der Entnahmestelle. Die Patientenzufriedenheit war mit Schmerzfreiheit in 7 der 8 Fälle in Anbetracht der Komplexität der Fälle zufriedenstellend.Das freie vaskularisierte Knochentransplantat aus der MFC kann erfolgreich ohne Längenverlust zur Rekonstruktion bei Knochendefekten an der oberen Extremität eingesetzt werden, die nicht das Kahnbein betreffen und kleiner als 4 cm sind.

The aims of the Oncoplastic Breast Consortium initiative were to identify important knowledge gaps in the field of oncoplastic breast-conserving surgery and nipple-sparing or skin-sparing mastectomy with immediate breast reconstruction, and to recommend appropriate research strategies to address these gaps. A total of 212 surgeons and 26 patient advocates from 55 countries prioritised the 15 most important knowledge gaps from a list of 38 in two electronic Delphi rounds. An interdisciplinary panel of the Oncoplastic Breast Consortium consisting of 63 stakeholders from 20 countries obtained consensus during an in-person meeting to select seven of these 15 knowledge gaps as research priorities. Three key recommendations emerged from the meeting. First, the effect of oncoplastic breast-conserving surgery on quality of life and the optimal type and timing of reconstruction after nipple-sparing or skin-sparing mastectomy with planned radiotherapy should be addressed by prospective cohort studies at an international level. Second, the role of adjunctive mesh and the positioning of implants during implant-based breast reconstruction should ideally be investigated by randomised controlled trials of pragmatic design. Finally, the BREAST-Q questionnaire is a suitable tool to assess primary outcomes in these studies, but other metrics to measure patient-reported outcomes should be systematically evaluated and quality indicators of surgical morbidity should be further assessed.

Background/aim Free flap reconstruction with damaged or diseased vessels is a challenging problem. We describe our case series using an arteriovenous loop or bypass surgery with free flaps for complex defect reconstructions at the lower extremity and the pelvic region. Patients and methods In this single-center retrospective cohort study 11 consecutive patients (mean age=73 years, range=53-88 years) were operated on, between June 2016 and August 2018. Patients were reconstructed with free gracilis flaps (n=8), free latissimus dorsi flap (n=1) and chimeric scapular flap (n=1), respectively. Results The mean loop length was 30 cm (range=12-40 cm). The loop/bypass revision rate was 27% (3/11), and the overall flap loss rate was 20% (2/10). After a mean follow-up time of 17 months (range=12-24 months), the limb salvage rate was 75% (6/8). Conclusion We successfully reconstructed complex defects with poor recipient vessels using arteriovenous loops or bypass surgery and free flaps.

Objectives. Bone ischemia and necrosis are challenging to treat, requiring investigation of native and engineered bone revascularisation processes through advanced imaging techniques. This study demonstrates an experimental two-step method for precise bone and vessel analysis in native bones or vascularised bone grafts using X-ray microtomography (μCT), without interfering with further histological processing. Methods. Distally ligated epigastric arteries or veins of 6 nude rats were inserted in central channels of porous hydroxyapatite cylinders and these pedicled grafts were implanted subcutaneously. One week later, the rats were perfused with ink-gelatin and euthanised and the femurs, tibias, and grafts were explanted. Samples were scanned using μCT, decalcified, incubated with phosphotungstic acid (PTA) for contrast enhancement, rescanned, and processed histologically. Results. Contrast-enhanced μCT displayed the course and branching of native bone vessels. Histologically, both central (−17%) and epiphyseal vessels (−58%) appeared smaller than in μCT scans. Hydroxyapatite cylinders were thoroughly vascularised but did not display bone formation. Grafts with a central artery had more (+58%) and smaller (−52%) vessel branches compared to grafts with a vein. Conclusions. We present a relatively inexpensive and easy-to-perform two-step method to analyse bone and vessels by μCT, suitable to assess a variety of bone-regenerative strategies.

Background The emphasis on aesthetic outcomes and quality of life (QoL) has motivated surgeons to develop skin- and nipple-sparing mastectomy (SSM/NSM) for breast cancer (BC) treatment or prevention. Immediate breast reconstruction is based on implants or autologous tissue. The optimal positioning of the implant is not clear: While pre-pectoral positioning respects the anatomic position of the mammary gland and avoids surgery-induced alterations of the pectoralis major muscle, the lack of muscle coverage may increase the risk of additional surgical interventions due to major complications. The Oncoplastic Breast Consortium (OPBC) identified this knowledge gap as research priority in 2019. Trial design International, multicenter study with a superiority trial design and two parallel groups with 1:1 random allocation to pre- or sub-pectoral implant-based breast reconstruction (IBBR). Following a pragmatic approach, randomly assigned IBBR will be performed according to the surgeons’ usual care by use of a one- or two-stage approach with or without adjunctive mesh. Follow-up visits are performed within routine care (visits at 10 days and at 1, 6, 12, 18 and 24 months after surgery). Oncological follow-up will be conducted annually for 10 years. ClinicalTrials.gov identifier: NCT04293146. Eligibility We include women ≥ 18 years, with an indication for NSM or SSM and IBBR in the therapeutic or risk-reducing setting, the ability to complete QoL questionnaires and the adequateness of skin flap(s) for pre-pectoral IBBR (intraoperative decision of the surgeon). Specific aims The primary objective is to test whether pre-pectoral IBBR provides better QoL with respect to long-term (24 months) physical well-being of the chest (BREAST-Q) compared to sub-pectoral IBBR for patients undergoing SSM or NSM for prevention or treatment of BC. Secondary endpoints include loss of expander or implant, complications, other BREAST-Q QoL and patient satisfaction domains, aesthetic outcomes and recurrence free survival. Interference of different dose distributions of radiation therapy and its consequences on the distribution of local tumor recurrences will be assessed. Statistical methods The primary analysis will be performed on the full analysis set following the intention-to-treat principle. To test the primary hypothesis, a linear mixed model will be fitted with the BREAST-Q score as response variable and treatment assignment as independent variable. The analysis will be adjusted for baseline BREAST-Q score, stratification factors (i.e. uni- vs bilateral surgery and NSM vs SSM) and other potential confounders. A random intercept to account for the center effect will be included. As a sensitivity analysis, an unadjusted t-test will be performed on the BREAST-Q score change from baseline to compare the two treatment arms. The sample size was determined for the primary endpoint, with an expected mean score of 76 points for sub-pectoral and 80 points for pre-pectoral implants. The clinically relevant difference to be detected in this superiority design is 4 points, with an expected common standard deviation of 13 points. A sample size of 334 patients provides an 80% power for a two-sided t-test at level α = 0.05. Compensating for a 10% dropout rate, the total sample size was calculated to include 372 patients. Present accrual and target accrual By June 2020, one study site (Basel) has been initiated. During a 21-month recruitment period, we plan to include 372 patients at 21 sites in Switzerland, USA, China, Austria, Germany, Hungary and Sweden. Contact information Prof. Dr. Walter Paul Weber, Chefarzt Brustchirurgie, Breast Surgeon SSO, Universitätsspital Basel, Spitalstrasse 21, CH-4031 Basel, Tel: +41 61 328 61 49, Walter.Weber@usb.ch Citation Format: Walter Paul Weber, Elisabeth A Kappos, Meredith M Regan, Giusi Moffa, Yves Harder, Karin Ribi, Shelley Potter, Andrea Pusic, Mathias K Fehr, Lars G Hemkens, Thomas Holzbach, Jian Farhadi, Colin Simonson, Michael Knauer, Ralph Verstappen, Heiner Bucher, Daniel Zwahlen, Frank Zimmermann, Matthias Schwenkglenks, Rosine Mucklow, Vesna Bjelic-Radisic, Amelia Chiorescu, Yoon Chun, Subrina Farah, Xiasong Chen, Linda Nigard, Sherko Kümmel, Roland Reitsamer, Maik Hauschild, Ilario Fulco, Christoph Tausch, Thomas Fischer, Dimitri Sarlos, Mihai Constantinescu, Judith E Lupatsch, Florian Fitzal, Joerg Heil, Zoltán Mátrai, Jana de Boniface, Christian Kurzeder, Martin Haug, Alexandra Schulz. Pre- versus sub-pectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02 PREPEC): A pragmatic, multicenter, randomized, superiority trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-23-03.

The wound healing promoting effect of negative wound pressure therapies (NPWT) takes place at the wound interface. The use of bioactive substances at this site represents a major research area for the development of future NPWT therapies. To assess wound healing kinetics in pressure ulcers treated by NPWT with or without the use of a thin interface membrane consisting of poly-N-acetyl glucosamine nanofibers (sNAG) a prospective randomized clinical trial was performed. The safety of the combination of NPWT and sNAG was also assessed in patients treated with antiplatelet drugs. In the performed study, the combination of NPWT and sNAG in 10 patients compared to NPWT alone in 10 patients promoted wound healing due to an improved contraction of the wound margins (p = 0.05) without a change in wound epithelization. In 6 patients treated with antiplatelet drugs no increased wound bleeding was observed in patients treated by NPWT and sNAG. In conclusion, the application of thin membranes of sNAG nanofibers at the wound interface using NPWT was safe and augmented the action of NPWT leading to improved wound healing due to a stimulation of wound contraction.

Purpose Indications for nipple-sparing mastectomy (NSM) have broadened to include the risk reducing setting and locally advanced tumors, which resulted in a dramatic increase in the use of NSM. The Oncoplastic Breast Consortium consensus conference on NSM and immediate reconstruction was held to address a variety of questions in clinical practice and research based on published evidence and expert panel opinion. Methods The panel consisted of 44 breast surgeons from 14 countries across four continents with a background in gynecology, general or reconstructive surgery and a practice dedicated to breast cancer, as well as a patient advocate. Panelists presented evidence summaries relating to each topic for debate during the in-person consensus conference. The iterative process in question development, voting, and wording of the recommendations followed the modified Delphi methodology. Results Consensus recommendations were reached in 35, majority recommendations in 24, and no recommendations in the remaining 12 questions. The panel acknowledged the need for standardization of various aspects of NSM and immediate reconstruction. It endorsed several oncological contraindications to the preservation of the skin and nipple. Furthermore, it recommended inclusion of patients in prospective registries and routine assessment of patient-reported outcomes. Considerable heterogeneity in breast reconstruction practice became obvious during the conference. Conclusions In case of conflicting or missing evidence to guide treatment, the consensus conference revealed substantial disagreement in expert panel opinion, which, among others, supports the need for a randomized trial to evaluate the safest and most efficacious reconstruction techniques. Electronic supplementary material The online version of this article (10.1007/s10549-018-4937-1) contains supplementary material, which is available to authorized users.

Summary Background Autologous native cartilage from the nasal septum, ear, or rib is the standard material for surgical reconstruction of the nasal alar lobule after two-layer excision of non-melanoma skin cancer. We assessed whether engineered autologous cartilage grafts allow safe and functional alar lobule restoration. Methods In a first-in-human trial, we recruited five patients at the University Hospital Basel (Basel, Switzerland). To be eligible, patients had to be aged at least 18 years and have a two-layer defect (≥50% size of alar subunit) after excision of non-melanoma skin cancer on the alar lobule. Chondrocytes (isolated from a 6 mm cartilage biopsy sample from the nasal septum harvested under local anaesthesia during collection of tumour biopsy sample) were expanded, seeded, and cultured with autologous serum onto collagen type I and type III membranes in the course of 4 weeks. The resulting engineered cartilage grafts (25 mm × 25 mm × 2 mm) were shaped intra-operatively and implanted after tumour excision under paramedian forehead or nasolabial flaps, as in standard reconstruction with native cartilage. During flap refinement after 6 months, we took biopsy samples of repair tissues and histologically analysed them. The primary outcomes were safety and feasibility of the procedure, assessed 12 months after reconstruction. At least 1 year after implantation, when reconstruction is typically stabilised, we assessed patient satisfaction and functional outcomes (alar cutaneous sensibility, structural stability, and respiratory flow rate). Findings Between Dec 13, 2010, and Feb 6, 2012, we enrolled two women and three men aged 76–88 years. All engineered grafts contained a mixed hyaline and fibrous cartilage matrix. 6 months after implantation, reconstructed tissues displayed fibromuscular fatty structures typical of the alar lobule. After 1 year, all patients were satisfied with the aesthetic and functional outcomes and no adverse events had been recorded. Cutaneous sensibility and structural stability of the reconstructed area were clinically satisfactory, with adequate respiratory function. Interpretation Autologous nasal cartilage tissues can be engineered and clinically used for functional restoration of alar lobules. Engineered cartilage should now be assessed for other challenging facial reconstructions. Funding Foundation of the Department of Surgery, University Hospital Basel; and Krebsliga beider Basel.

Since the late 1960s, surgeons and scientists envisioned use of tissue engineering to provide an alternative treatment for tissue and organ damage by combining biological and synthetic components in such a way that a long-lasting repair was established. In addition to the treatment, the patient would also benefit from reduced donor site morbidity and operation time as compared with the standard procedures. Tremendous efforts in basic research have been done since the late 1960s to better understand chondrocyte biology and cartilage maturation and to fulfill the growing need for tissue-engineered cartilage in reconstructive, trauma, and orthopedic surgery. Starting from the first successful generation of engineered cartilaginous tissue, scientists strived to improve the properties of the cartilaginous constructs by characterizing different cell sources, modifying the environmental factors influencing cell expansion and differentiation and applying physical stimuli to modulate the mechanical properties of the construct. All these efforts have finally led to a clinical phase I trial to show the safety and feasibility of using tissue-engineered cartilage in reconstructive facial surgery. However, to bring tissue engineering into routine clinical applications and commercialize tissue-engineered grafts, further research is necessary to achieve a cost-effective, standardized, safe, and regulatory compliant process.

Objective outcome analysis of nasal surgery remains difficult. Recently, evaluation of nasal shape following rhinosurgery shifted from two-dimensional evaluation to more sophisticated three-dimensional (3D) analysis techniques, including stereophotogrammetry, computed tomography, and 3D laser scanning. This article explores the feasibility of using 3D laser surface scanners as a tool for preoperative planning and quality control in rhinosurgery.

Background: Subcutaneous masses of the scalp have a wide range of differential diagnosis. After removal of a meningioma in the patient’s history, scalp metastasis from the previously resected meningioma should be considered. Methods: A 86 year old patient presented with a local swelling on the left temporal forehead and no other clinical symptoms. Eleven years earlier an extra-axial meningioma was resected. The patient was receiving immunosuppressive therapy subsequent to kidney transplantation. After clinical examination and MRI, a lipoma was suspected. The mass was resected under local anesthesia. Results: Histopathology revealed a metastasis of the previously removed meningioma (WHO grade II). No further treatment was recommended. Clinical follow-up was without pathological findings so far. Conclusion: Scalp metastases of meningiomas are a rare finding. However, if patient history reveals removal of a meningioma, scalp metastasis must be a differential diagnosis for subcutaneous masses even years after the initial surgery.

The emphasis on esthetic outcomes and quality of life after breast cancer surgery has motivated surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of the techniques. The present article attempts to standardize OPS nomenclature, indications, and reconstruction choice selection embedded in a thorough review of the literature. We propose four breast conserving surgery (BCS) categories: Conventional tumorectomy, oncoplastic mastopexy, oncoplastic tumorectomy and oncoplastic reduction mammoplasty. The main volume displacement techniques are glandular re-approximation, use of tailored glandular or dermoglandular flaps and nipple-areola complex pedicles. We developed an indication algorithm based on the size and shape of the breast as well as the size and location of the tumor. A reconstruction algorithm suggests a selection of suitable tailored flaps and pedicles based on tumor location and vascular supply of the breast. The application of these algorithms results in known and novel OPS techniques, which are presented here with long-term results. We designed the algorithms to help tailor every operation to the individual patient in a standardized manner, since OPS is now on the rise, more than two decades after the publication of the first techniques. A rapidly increasing body of observational evidence suggests comparable rates of local recurrence between OPS and conventional BCS. Importantly, the rates of clear resection margins are in favor of OPS despite extended indications to larger tumors. Finally, OPS optimizes patient satisfaction by improving esthetic outcomes after BCS.

Speziell bei Brustkrebspatientinnen steht die Symbolkraft der weiblichen Brust fur die Integritat der Patientin, weshalb hier aufgrund der zunehmend hohen asthetischen Erwartungshaltung die plastisch-rekonstruktive Chir­urgie eine immer wichtigere Rolle spielt.

Summary:. The first description of simultaneous pelvic and abdominal soft-tissue reconstruction with a giant lower limb fillet flap after hip exarticulation and open abdomen is presented. The unfortunate circumstances of a 67-year-old female patient are described leading to soft-tissue necrosis over a periprosthetic femur fracture and open abdomen after emergency implantation of an aortic bifemoral Y-prosthesis because of thrombotic obliteration of the aortic bifurcation. After removal of the hip prosthesis, the neurovascular pedicled myocutaneous fillet flap of the entire left leg was raised and folded proximally at the level of the exarticulated joint of the hip and set into the pelvic and abdominal defect. A giant pedicled neurovascular myocutaneous fillet flap raised over the entire lower extremity is a safe, effective, durable, and sensation-preserving treatment to reconstruct combined pelvic and abdominal soft-tissue defects.

The wound healing promoting effect of negative wound pressure therapies (NPWT) takes place at the wound interface. The use of bioactive substances at this site represents a major research area for the development of future NPWT therapies. To assess wound healing kinetics in pressure ulcers treated by NPWT with or without the use of a thin interface membrane consisting of poly-N-acetyl glucosamine nanofibers (sNAG) a prospective randomized clinical trial was performed. The safety of the combination of NPWT and sNAG was also assessed in patients treated with antiplatelet drugs. In the performed study, the combination of NPWT and sNAG in 10 patients compared to NPWT alone in 10 patients promoted wound healing due to an improved contraction of the wound margins (p = 0.05) without a change in wound epithelization. In 6 patients treated with antiplatelet drugs no increased wound bleeding was observed in patients treated by NPWT and sNAG. In conclusion, the application of thin membranes of sNAG nanofibers at the wound interface using NPWT was safe and augmented the action of NPWT leading to improved wound healing due to a stimulation of wound contraction.

Pain impulses from neuroma of the overlying skin territory can effectively be stopped by neuroma excision and nerve reconstruction or relocation into muscle, vein, or bone or nerve-to-nerve techniques. Clinical series in the literature prove that the positive results obtained for partial joint denervation and surgical neuroma therapy in the upper extremity also apply to lower-extremity joints (eg, the ankle and sinus tarsi). Based on a thorough examination and patient selection, a reliable and simple operation effectively alleviates symptoms and may prevent more invasive traditional surgical techniques. These techniques offer an ambulatory, minimally invasive, and rehabilitation-free approach for an increasing number of patients.

Effects of in vitro pre-culture on the biomechanical properties and further in vivo development of human nasal engineered cartilage grafts J. Farhadi , I. Fulco , S. Miot , M. Haug , G. Pierer , M. Heberer , I. Martin b a Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital Basel, Switzerland b Institute for Surgical Research and Hospital Management, University Hospital Basel, Switzerland