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Human-adipose-tissue-derived mesenchymal stromal cells (AD-MSCs) are currently being tested as autologous-cell-based therapies for use in tissue healing and regeneration. Recent studies have also demonstrated that AD-MSC-derived exosomes contribute to tissue repair and peripheral nerve regeneration. Subcutaneous abdominal adipose tissue (AAT) is divided into two layers: the superficial layer (sAAT) and the deep layer (dAAT). However, it is unclear whether there are particular characteristics of each layer in terms of AD-MSC regenerative potential. Using AD-MSCs purified and characterized from three abdominoplasties, we compared their secretomes and exosome functions to identify which layer may be most suitable as a source for cell therapy. Phenotypical analysis of the AD-MSCs containing stromal vascular fraction did not reveal any difference between the two layers. The AD-MSC secretomes showed a very similar pattern of cytokine content and both layers were able to release exosomes with identical characteristics. However, compared to the secretome, the released exosomes showed better biological properties. Interestingly, dAAT exosomes appeared to be more effective on neuromodulation, whereas neither sAAT nor dAAT-derived exosomes had significant effects on endothelial function. It thus appears that AD-MSC-derived exosomes from the two abdominal adipose tissue layers possess different features for cell therapy.

Plastic surgery is a dynamic field but remains poorly understood by general practitioners, medical students, health professionals, and the public. The main health care professionals in the community who are involved in the follow-up of plastic surgery patients are nurses; they help to facilitate wound healing and rehabilitation in the postoperative period. In this study, the authors assessed the medical knowledge and perceptions of plastic surgery by nurses working in the community setting and explored their understanding of classical scenarios commonly encountered in reconstructive surgery. An online survey was designed to assess the demographics of nurses working in the community in France and their knowledge of plastic surgery. This was disseminated to all practicing nurses working outside of hospitals by means of an online social network from the period of April 2019 to June 2019. The survey was completed by 318 nurses. Specific training in plastic surgical nursing will be required to optimize the management of these patients following discharge from hospital. This gap in knowledge may affect patient recovery negatively.

International audience; Significance: Wound healing is a complex process involving pain and inflammation, where innervation plays a central role. Managing wound healing and pain remains an important issue, especially in pathologies such as excessive scarring (often leading to fibrosis) or deficient healing, leading to chronic wounds. Recent Advances: Advances in therapies using mesenchymal stromal cells offer new insights for treating indications that previously lacked options. Adipose-derived mesenchymal stromal cells (AD-MSCs) are now being used to a much greater extent in clinical trials for regenerative medicine. However, to be really valid, these randomized trials must imperatively follow strict guidelines such as consolidated standards of reporting trials (CONSORT) statement. Indeed, AD-MSCs, because of their paracrine activities and multipotency, have potential to cure degenerative and/or inflammatory diseases. Combined with their relatively easy access (from adipose tissue) and proliferation capacity, AD-MSCs represent an excellent candidate for allogeneic treatments. Critical Issues: The success of AD-MSC therapy may depend on the robustness of the biological functions of AD-MSCs, which requires controlling source heterogeneity and production processes, and development of biomarkers that predict desired responses. Several studies have investigated the effect of AD-MSCs on innervation, wound repair, or pain management separately, but systematic evaluation of how those effects could be combined is lacking. Future Directions: Future studies that explore how AD-MSC therapy can be used to treat difficult-to-heal wounds, underlining the need to thoroughly characterize the cells used, and standardization of preparation processes are needed. Finally, how this a priori easy-to-use cell therapy treatment fits into clinical management of pain, improvement of tissue healing, and patient quality of life, all need to be explored.

The temporal muscle has been an essential tool in maxillo-facial reconstruction for more than a century. Despite many technical advances, depression in the temporal fossa after its use is a constant issue. There are several ways to fill this defect. However, their efficiency has not been proven. Currently, biomaterials (e.g. polymethylmethacrylate [PMMA] and polyethylene [PE]) are the alternative most frequently used and studied. This is the first case report of temporal depression filling with a porcine dermal matrix (Permacol™). A 58-year-old woman underwent limited maxillectomy for squamous cell carcinoma of the upper vestibular mucosa, after which a pure temporalis muscle flap was used for immediate reconstruction. A custom-shaped Permacol™ sheet was used with a PMMA spacer to fill the resulting depression at the temporal fossa. The procedure went smoothly without any complications. The surgeon and the patient are satisfied with the cosmetic result. Permacol™ is a safe and effective tool to fill defects after temporalis muscle flap and is an excellent alternative to other biomaterials currently on the market.

Summary Ectodermic dysplasia corresponds to genetic pathologies characterized by two or more defects that involved ectodermal-derived structures. Breast anomalies in female patients were uncommon. Just a few articles in the literature retrieved this association. The main anomalies concerning breast region were amastia and areolar complex malformation. Two types of reconstruction have been already studied: implants with or without tissue preexpansion, and autologous flap like latissimus dorsi or DIEP. We described in this article a series of three female patients issue from the same family. They presented various type of breast malformation with other defects characteristics of ectodermic dysplasia. They all benefit of a bilateral breast reconstruction by implants on a one-staged reconstruction. Patients and surgeon were satisfied of the reconstruction. This case series demonstrate that reconstruction by implants without tissue preexpansion was a good choice in this pathology.

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Background: The thumb plays a key role in hand function for precise dexterity. The surgical treatment of full avulsions of the digital skin sheath by tearing (ring syndrome) is complex and the management of these lesions is challenging for the reconstructive surgeon. When replantation is not possible, other alternatives are available if the covering tissue is thin and flexible. Case presentation: A 30-year-old male, tobacco addict, had a thumbsequelae similar to a stage III ring finger. Revascularization attempt failed and the skin envelope necrosed secondarily. A groin pocket flapgraft allowed a conservation of his thumb with a satisfactory aesthetic and functional result. Conclusions: We described a thumb coverage by a groin flapgraft using an original pocket design. This simple and safe procedure, in the carefully selected patient can successfully address functional and aesthetic concerns simultaneously, with minimal sequelae at the donor site. This technique can be used to treat a cutaneous tearing of the other fingers.

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Background Plastic surgery is a transversal discipline that many people misunderstand, including general practitioners, medical students, paramedics and the public. Plastic surgeons often collaborate with physiotherapists for post-acute care and rehabilitation. They ensure optimal post-operative recovery of the patient. Herein, the authors assessed the medical knowledge and perceptions of plastic surgery by physiotherapists working outside health centers and explored their attitudes towards classic reconstructive surgery scenarios. Methods To assess physiotherapists' medical knowledge and perceptions of plastic surgery, the authors conducted an online questionnaire survey. A total of 1,262 physiotherapists responded. Results The physiotherapists confirmed the suspected lack of knowledge regarding the plastic surgery field. Although they were generally aware that plastic surgeons perform cosmetic procedures and treat burns, they were largely unaware that plastic surgeons perform hand surgeries and microsurgical operations. More than 70% of them stated that they did not have the necessary knowledge to properly manage patients in this specialty. This lack of knowledge can sometimes have a negative impact on patients' recovery, particularly for fear of making a mistake. Conclusions Physiotherapists, outside the hospital, have an incomplete conception of plastic surgery. They would need a specific plastic surgery training in order to manage these patients in an optimal way.

To achieve adequate nasal proportions, nostril surgery can be a complementary technique useful in facial surgery. To help surgeons with the decision to realize nostril surgery, we conducted a systematic review to summarize reported cases on surgical procedures with a specific interest on indications, surgical procedures and postoperative outcomes. A therapeutic algorithm is also proposed. We carried out this review in accordance with the PRISMA criteria. Twenty-two eligible studies were identified using Medical databases, including 1599 patients. A qualitative and quantitative analysis was carried out. Excision techniques were realized on 728 patients (45.5%), followed by cinching sutures on 642 patients (40%) and combined techniques: excision techniques with flap advancement techniques in 189 cases (12%), excision techniques with flap advancement techniques and cinching suture in 40 patients (2.5%). When excessive alar flaring was present, alar wedge resection was preferred in the 92% of followed by alar and sill resection. Cinching sutures were realized when excessive alar flaring was associated with a vertical alar axis, in cases of wide alar base, of associated orthognathic surgery. When excessive alar flaring was associated with wide alar bases, indications changed basing on the associated deformities. In 795 patients, nostril surgery was conducted simultaneously with rhinoplasty. Nostril surgery through excision techniques, cinching sutures or flaps advancement techniques, reveals good outcomes and can be complementary to rhinoplasty or orthognathic surgery. Through this systematic review, we tried to orient surgeons to find the best treatment for nostril base surgery. This 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 .

Autologous fat transfer, or lipofilling, is a common technique used for soft tissue reconstruction. It has been used for many years, but the technique is associated with a significant graft resorption rate (20% to 80%). To improve the fat graft survival rate, several methods have been tested, and one has appeared more promising: cell-assisted lipotransfer (CAL). In the CAL method, fat is enriched with adipose-derived stromal cells (ASC), contained in the stromal vascular fraction (SVF) obtained after enzymatic digestion of fat or after cell culture to improve the fat survival rate. In this concise review, we present the clinical indications, and the technical principles of CAL, as well as a presentation of ASC. To conclude, we present the main results (efficacy, complications and safety) obtained from different studies of this technique.

Introduction:. Lumbosacral substance defect is a challenge in reconstructive surgery because few coverage solutions are available in this anatomical region. Lumbar artery perforator flaps (LAPs) have been progressively developed and make it possible to solve very complex situations. We report a multicenter study on LAP performed to treat medium and low lumbar defects of various etiologies, to highlight the versatility of this flap as well as its robustness and reproducibility. Methods:. Between 2012 and 2019, 32 LAPs were performed in the Toulouse and Strasbourg University hospitals. Etiologies of the defects encountered were diverse: chronic wounds following neurosurgery, oncodermatology, burn sequelae, and ballistic injury. All LAPs were used in their pedicled form, turned as propeller, and combined or not with other flaps. Results:. We treated 31 patients with 32 LAPs. Average flap size was 14.3 cm (range 8–26) × 6.5 cm (range 5–10), and average arc of rotation was 131.3 degrees (range 70–180 degrees). Only 4 patients (12.9%) presented partial necrosis, but required no other covering procedure because secondary healing was sufficient. No coverage failure was reported. Average follow-up duration was 9.7 months (range 1–18). Conclusions:. In the case of lumbosacral defects of various etiologies, propeller LAP is a reliable and efficient surgical procedure, offering the advantage of low donor site morbidity. The reconstructive surgeon should propose this technique to patients as a first-line option where surgery is indicated.

International audience; Ever since their discovery in 2001, adipose mesenchymal stromal cells (ASC) have profoundly modified clinical indications and our practice of plastic surgery, thereby placing our discipline at the forefront of regenerative medicine. These cells act through paracrine signaling by synthesizing immunosuppressive and pro-angiogenic factors. They are of key importance with regard to the regenerative properties of autologously grafted adipose tissue (AT). Taken together, they make up the stromal vascular fraction (SVF) comprising all AT cells except for adipocytes. As our knowledge evolves, we are moving from fat grafting towards SVF grafting, of which the essential sought-after effect is tissue regeneration. The objective of the present review is to synthesize present-day information on ASCs and their immunomodulatory properties and, from a practical standpoint, to indicate present-day and future steps towards establishment of clinical routine, particularly through application of techniques favoring mechanical digestion of adipose tissue.

International audience; Background: The use of stromal vascular fraction and adipose-derived stromal cells in tissue regeneration is now being increasingly investigated, and studies have demonstrated that adipose-derived stromal cells present differentiation and immunomodulatory capacities. The development of a rapid, inexpensive, and enzyme-free technique to isolate adipose-derived stromal cell-enriched stromal vascular fraction is a major goal for stem cell therapy. Therefore, the authors compared innovative mechanical procedures to the gold standard technique, collagenase digestion. Methods: Stromal vascular fraction was prepared from 21 liposuctions using either enzymatic digestion or two different mechanical methods: high vortexing/centrifugation and dissociation by intersyringe processing. The effects of tissue processing on cell count, viability, proliferation, clonogenic enrichment, and the phenotypes of the different native cell were determined. Adipose-derived stromal cell phenotypes from the different protocols, and their differentiation and immunosuppressive potential, were compared. Results: Enzymatic digestion isolated more viable cells than dissociation by intersyringe processing and vortexing/centrifugation. The expansion rate and clonogenic enrichment were higher for stromal vascular fraction isolated with collagenase. The proportion of adipose-derived stromal cells was higher in stromal vascular fraction extracted with dissociation than with enzymatic digestion and vortexing/centrifugation (p < 0.01). Interestingly, all cultured adipose-derived stromal cells displayed similar differentiation and immunosuppressive capacities. Conclusions: Enzymatic digestion extracts more adipose-derived stromal cells, but intersyringe dissociation enables the rapid extraction of adipose-derived stromal cell-enriched stromal vascular fraction. Moreover, mechanical methods enable adipose-derived stromal cell isolation with stemness and immunosuppressive properties, similar to enzymatic digestion. Such mechanical procedures could allow easier and more rapid isolation of adipose-derived stromal cell-enriched stromal vascular fraction for practitioners. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V. Copyright © 2016 by the American Society of Plastic Surgeons.

Introduction In lower limbs, reliability of propeller perforator flaps (PPF) remains uncertain. The main complication is venous congestion, which can lead to distal necrosis. We aim to highlight if venous supercharging of PPF could substantially limit complications in lower limb coverage. Methods Between 2011 and 2016, we developed a standardized procedure of venous supercharging in the lower limb reconstruction with PPF using saphenous veins anastomosis. Then, we prospectively compared a consecutive series of 30 PPF to cover lower limbs defect, with a consecutive series of 30 venous-supercharged PPF (vsPPF). Etiologies of trauma, flap harvesting, complications, and outcomes were compared. Results The etiologies of the defect were acute trauma in 67.6% of reconstruction with PPFs and 60% of reconstruction with vsPPFs (P = 0.826). The average size of the skin paddle was 48.1 ±18.2 cm2 for PPF and 58.9 ±19.5 cm2 for vsPPF, and the average arc of rotation was 126.7° ±33.1 for PPF and 121.3° ±31.9 for vsPPF. The average sizes and rotation arcs between the two flaps were not significantly different (P = 0.031, P = 0.527). The operative time was significantly increased for vsPPF when compared to PPF procedure (128.8 ±8.5 minutes vs. 81.3 ±10.1 minutes, P

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Perforator flaps have become very popular in reconstructive surgery. The thoracodorsal and lateral thoracic artery perforator flaps are highly studied, and successful clinical series have been reported, whereas the literature concerning the lateral intercostal and serratus anterior artery perforator flaps is quite poor and their vascular anatomy needs yet to be clarified. We describe a case of free serratus anterior artery perforator flap for the reconstruction of a dorsal defect of the foot, followed by an anatomic and radiological study. A 17-year-old boy reported a fracture of the first and second metatarsal bone of the left foot, with a dorsal skin defect, due to a motorcycle accident. After the osteosynthesis treatment, a perforator was identified through a handheld Doppler in the lateral chest area and a cutaneous paddle was designed. Retrograde dissection revealed the perforator's direct link to the serratus anterior pedicle. In our knowledge, an elucidated method to preoperatively visualize the perforating vessel of the serratus anterior artery has not yet been described. Thus, an anatomic study on 8 hemithorax and a radiological study on 33 computed tomographic angiographies of the chest were carried out to clarify the vascular anatomy of the serratus anterior artery perforators and to verify the possibility of their preoperative visualization. The authors believe that the serratus anterior artery perforator could be preoperatively investigated, thus making this flap a valuable option when harvesting a perforator flap in the lateral chest area.

Summary Introduction The management of hidradenitis suppurativa is multidisciplinary, involving general measures, medical treatment and surgery. Non-surgical treatments, often first-line procedures, mainly concern forms of low-to-moderate severity or, conversely, very severe forms in non-operable patients or those refusing surgery. While many treatments have been attempted, few randomized controlled trials have been conducted, so the choice of treatments is most often based on the personal experience of the clinicians. The objective of this systematic review is to propose a synthetic analysis of the currently available non-surgical procedures. Methods This systematic review of the literature was conducted in accordance with the PRISMA criteria. We searched for articles in the Medline®, PubMed Central, Embase and Cochrane databases published between January 2005 and September 2015. Results Sixty-four articles were included. They generally had a low level of evidence; indeed, the majority of them were retrospective observational studies. They involved biotherapy (44%), dynamic phototherapy (16%), antibiotics (11%), Laser (8%), retinoids (6%) and immunosuppressive therapies, anti-inflammatory drugs, zinc, metformin, gammaglobulins and fumarates. Conclusions None of the non-surgical treatments can treat all stages of the disease and offer long-term remission. Antibiotics and biotherapy seem to have real effectiveness but their effect remains suspensive and the disease is almost certain to reappear once they are stopped. As regards antibiotics, no association has shown their superiority in a study with a high level of evidence. And while some biotherapies seem quite effective, due to their side effects they should be reserved for moderate-to-severe, resistant or inoperable forms of the disease. Randomized controlled studies are needed before valid conclusions can be drawn. In the resistant or disabling forms, it is consequently advisable to orientate to the greatest possible extent towards radical surgery, which is the only treatment allowing hope for cure.

Background Autologous fat grafting is a common procedure for soft-tissue reconstruction but is associated with a graft resorption rate ranging from 20% to 80%. To improve the fat graft survival rate, a new technique, called cell-assisted lipotransfer (CAL), was developed. With CAL, fat is injected along with adipose-derived stromal cells (ASCs) that are assumed to improve fat survival rate. We conducted an evidence-based meta-analysis to evaluate the efficacy and safety of CAL as compared with conventional autologous fat grafting (non-CAL). Methods The databases MEDLINE (via PubMed), Cochrane Library, EBSCO, Web of Science and EMBASE were searched for reports of clinical trials, case series and cohorts available from 2008 to 2016. We conducted a meta-analysis of the efficacy of CAL with data analysis concerning fat survival rate. The incidence of complications and need for multiple procedures were evaluated to determine the safety of CAL. Results We identified 25 studies (696 patients) that were included in the systematic review; 16 studies were included in the meta-analysis to evaluate the efficacy of CAL. The fat survival rate was significantly higher with CAL than non-CAL (64% vs 44%, p < 0.0001) independent of injection site (breast and face). This benefit of CAL was significant for only injection volumes < 100 mL (p = 0.03). The two groups did not differ in frequency of multiple procedures after fat grafting, but the incidence of complications was greater with CAL than non-CAL (8.4% vs 1.5%, p = 0.0019). Conclusions The CAL method is associated with better fat survival rate than with conventional fat grafting but only for small volumes of fat grafting (< 100 mL). Nonetheless, the new technique is associated with more complications and did not reduce the number of surgical procedures needed after the first fat grafting. More prospective studies are required to draw clinical conclusions and to demonstrate the real benefit of CAL as compared with common autologous fat grafting.

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