Body Contouring Surgery After Bariatric Surgery Improves Long-Term Health-Related Quality of Life and Satisfaction With Appearance: An International Longitudinal Cohort Study Using the BODY-Q

OBJECTIVE

To examine health-related quality of life (HRQL) and satisfaction with appearance in patients who have undergone bariatric surgery (BS) with or without subsequent body contouring surgery (BCS) in relation to the general population normative for the BODY-Q.

BACKGROUND

The long-term impact of BS with or without BCS has not been established using rigorously developed and validated patient-reported outcome measures. The BODY-Q is a patient-reported outcome measure developed to measure changes in HRQL and satisfaction with appearance in patients with BS and BCS.

METHODS

Prospective BODY-Q data were collected from 6 European countries (Denmark, the Netherlands, Finland, Germany, Italy, and Poland) from June 2015 to February 2022 in a cohort of patients who underwent BS. Mixed-effects regression models were used to analyze changes in HRQL and appearance over time between patients who did and did not receive BCS and to examine the impact of patient-level covariates on outcomes.

RESULTS

This study included 24,604 assessments from 5620 patients. BS initially led to improved HRQL and appearance scores throughout the first postbariatric year, followed by a gradual decrease. Patients who underwent subsequent BCS after BS experienced a sustained improvement in HRQL and appearance or remained relatively stable for up to 10 years postoperatively.

CONCLUSIONS

Patients who underwent BCS maintained an improvement in HRQL and satisfaction with appearance in contrast to patients who only underwent BS, who reported a decline in scores 1 to 2 years postoperatively. Our results emphasize the pivotal role that BCS plays in the completion of the weight loss trajectory.

[Treatment of Sternal Osteomyelitis after Median Sternotomy in 130 Patients with Pedicled Myocutaneous Latissimus Flap]

BACKGROUND

After median sternotomy in cardiac surgery, deep sternal wound infections develop in 0.8 - 8% of patients, resulting in prolonged hospital stay and increased morbidity and mortality. Our treatment strategy combines radical surgical debridement, removal of extraneous material and reconstruction of large and deep defects by a pedicled M. latissimus dorsi flap. With retrospective analysis of patient characteristics and pre- und perioperative data we could identify risk factors in regard to proper wound healing and bleeding complications.

MATERIAL AND METHODS

Patient characteristics (age, BMI, gender), medical history (diabetes mellitus, chronic obstructive lung disease, renal insufficiency and pre- and perioperative data (anticoagulation, bacterial colonization during reconstruction) were collected for 130 patients treated by latissimus flap to cover sternal wounds between 2009 and 2015.

RESULTS

The mean age was 68.72 ± 9.53 years; 37% of patients were female. The in-hospital mortality was 3.8%. Reoperation rate because of wound healing problems was 21.5%; bleeding complications leading to reoperation occurred in 10.8% of all patients. At the point of reconstruction, Staphylococcus (S.) aureus and S. epidermidis were detected most frequently. Age over 80 (p = 0.04), female sex (p = 0.002), detection of fecal bacteria (p = 0.006), or multiresistant bacteria (p = 0.007) and Klebsiellae were regarded as significant risk factors for wound healing problems leading to reoperation after flap surgery. High dose therapy with danaparoid/fondaparinux was a significant risk factor for bleeding complications needing reoperation.

CONCLUSION

The pedicled latissimus flap has to be considered as the preferred method in large sternal wounds to achieve sufficient defect filling. The risk of wound healing disruption is significantly influenced by bacteria detected in the sternal wound at the point of reconstructive surgery.

Medical Needling: Effect on Skin Erythema of Hypertrophic Burn Scars

Background Burn scars frequently tend to have pathological discolorations, which is manifested in the development of persistent erythema. Affected people suffer from psychological and physiological issues when they are restricted or rejected in their daily life. In this context, medical needling seems to be an efficient therapy for erythematous scars with a relatively low-risk rate of postoperative complications. Study research has already shown significant improvements in the scar quality with reference to the parameters "moisture and transepidermal water loss." Clinical data is up-to-date and provides an innovative therapy outcome of scar treatment with medical needling. Objective The aim of our study was to examine the influence of medical needling on the pathological and persistent erythema of hypertrophic burn scars. By means of reliable measurement methods, we were able to prove positive and sustainable outcomes for normal and healthy skin. The patient cohort included 20 patients with an average age of 34.63 years. Our examinations involved scars that were at least two years old and had healed by secondary intent. Every scar showed the pathological values of persistent erythema according to the participation requirements. Methods For the practical implementation of medical needling or percutaneous collagen induction (PCI), we used a roller covered with needles of 3 mm length. The needling device is rolled over the scar alternatively in a vertical, horizontal, and diagonal orientation. Multiple micro-wounds at a close distance cause intradermal bleeding, which evokes modified skin regeneration provoked by the effects of medical needling. Every patient has been followed up for 12 months postoperatively. Further on, valid results have been evaluated objectively as well as subjectively by the patient and observer. Results Our study has shown that persistent erythema of hypertrophic scars can be considered as an indication of PCI. The needling procedure influences vascularization by stimulating angiogenesis in the post-needling wound healing cascade. As the method is based on percutaneous collagen induction, the synthesis of collagen improves the vital thickness of the epidermis, which is directly associated with less transparency. Examined scars showed a significant reduction of erythema and were less reddened after treatment. Based on the outcomes of objective measurements, medical needling achieves a normalization of the skin color and an adjustment to healthy skin after repetitive treatments. Conclusion Medical needling seems to be a suitable therapy approach for treating erythematous, hypertrophic burn scars.

Platelet-rich Plasma for Skin Rejuvenation and Treatment of Actinic Elastosis in the Lower Eyelid Area

Background

Treatment of the lower eyelid region to rejuvenate the skin or treat actinic elastosis often proves difficult. Established treatment options, such as hyaluronic acid injections, botulinum toxin injections, microneedling, skin resurfacing (microdermabrasion, chemical peel (exfoliation), laser treatment), as well as blepharoplasties and autologous fat transfers, can be associated with significant risks and increased patient burden. Furthermore, they may not be effective for treating the signs of skin aging or actinic elastosis, including dark rings under the eyes, a lack of volume and cutis laxa. A minimally invasive treatment approach which visibly improves the above-mentioned conditions and which involves minimal risk and patient burden would be a desirable alternative.

Materials & methods

Twenty patients were treated a total of three times at monthly intervals with PRP (platelet-rich plasma). The patients were examined on the days of treatment and one month after the third injection. The PRP was obtained directly prior to treatment using the Arthrex ACP double syringe at the point of care. The injections (2 ml PRP per side) were administered laterally using 27 G 38 mm cannulas. Accurate photographic documentation and skin elasticity measurements using a cutometer were performed to objectify the subjective assessments from the patient and practitioner questionnaires.

Results

A progressive improvement in the esthetic outcome and a high level of patient satisfaction were determined. The cutometer measurements showed a statistically significant higher level of skin firmness (due to increased collagen production) and a statistically significant increase in skin elasticity (thanks to increased elastin production). Other than the anticipated visible swelling directly after the PRP injection, no other undesirable side effects or complications occurred. The typical burning sensation during the injection had not been reported.

Conclusion

The results indicate that a series of PRP injections in the lower eyelid region is a safe, efficient, virtually pain-free, simple and rapid treatment option for an area with otherwise limited treatment alternatives.

Medical Needling: Effect on Moisture and Transepidermal Water Loss of Mature Hypertrophic Burn Scars

Background: Burn scars remain a serious psychological and physiological problem for affected people. Clinical studies and scientific research have already shown that medical needling improves the scar quality in terms of skin elasticity and erythema. At the same time, patients are confronted with a low-risk therapy and face comparatively less postoperative complications.

Objective: The goal of our study was to examine the influence of medical needling on the skin moisture and transepidermal water loss (TEWL) of hypertrophic dry scars. Therefore, 20 patients, of an average age of 34.63 years, with deep second- and third-degree burn scars have been treated.

Methods: Medical needling is performed using a roller covered with needles of 3-mm length. The needling device is rolled over the scar in three directions: vertically, horizontally, and diagonally in order to create as many puncture channels as possible. The puncturing leads to multiple micro-wounds and intradermal bleeding, which evokes the post-needling regeneration cascade. The patients were followed up for 12 months postoperatively. The results have been evaluated by means of objective as well as subjective measurement methods.

Results: The objective measures show that medical needling influences epidermal thickness and improves the epidermal barrier function at a molecular level. Outcomes are marked by a measurable increase in skin moisture and a reduction in TEWL.

Conclusion: Medical needling seems to be a promising approach for the treatment of mature hypertrophic burn scars with a focus on skin moisture and TEWL.

[Autologous Skin Cell Transplantation and Medical Needling for Repigmentation of Depigmented Burn Scars on UV-protected and UV-exposed Skin]

Background: Burn scars remain a serious physical and psychological problem for the affected people. Both clinical studies and basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient related to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling does not influence repigmentation of large hypopigmented scars. Objective: The goal is to evaluate whether both established methods - needling (improvement of scar quality) and non-cultured autologous skin cell suspension (NCASCS) "ReNovaCell" (repigmentation) - can be combined. So far, 20 patients with mean age of 33 years (6-60 years) with deep second and third degree burn scars have been treated. The average treated tissue surface was 94 cm² (15-250 cm²) and was focused on areas like face, neck, chest and arm. Methods: Medical needling is performed using a roller covered with 3 mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, NCASCS is applied, according to the known protocol. The patients have been followed up for 15 months postoperatively. The scars were subdivided into "UV-exposed" and "UV-protected" to discover whether the improved repigmentation is due to transfer of melanocytes or to reactivation of existing melanocytes after exposure to UV or the sun. Results: The objective measures show improved pigmentation in both UV-exposed and UV-protected groups. Melanin increases 1 year after NCASCS treatment in the UV-protected group are statistically significant. Conclusion: Medical needling in combination with NCASCS shows promise for repigmentation of burn scars, even in sun protected scars.

Combination of medical needling and non-cultured autologous skin cell transplantation (ReNovaCell) for repigmentation of hypopigmented burn scars

Burn scars remain a serious physical and psychological problem for the affected people. Clinical studies as well as basic scientific research have shown that medical needling can significantly increase the quality of burn scars with comparatively low risk and stress for the patient with regards to skin elasticity, moisture, erythema and transepidermal water loss. However, medical needling has no influence on repigmentation of large hypopigmented scars. The goal of this study is to evaluate whether two established methods - needling (for improvement of scar quality) and non-cultured autologous skin cell suspension (for repigmentation) - can be successfully combined. Twenty subjects with mean age of 33 years (6-60 years) with scars from deep second and third degree burns have been treated. The average treated surface area was 94cm² (15-250cm²) and was focused on prominent areas such as the face, neck, chest and arm. Percutaneous collagen induction or "medical needling" was performed using a roller covered with 3mm long needles. The roller is vertically, horizontally and diagonally rolled over the scar, inducing microtrauma. Then, non-cultured autologous skin cell suspension (NCASCS) was produced and applied using the ReNovaCell Autologous Cell Harvesting Device (Avita Medical), according to the manufacturer's instructions. The patients were followed 12 months postoperatively. Pigmentation changes were measured objectively, as well as with patient and observer ratings. Patient satisfaction/preference was also obtained. Taken together, the pigmentation ratings and objective measures indicate individual improvement in 17 of the study participants. The melanin increases seen 12 months after NCASCS treatment are statistically significant. Medical needling in combination with NCASCS shows promise for repigmentation of burn cars.

[Surgical intensive care medicine. Current therapy concepts for septic diseases]

The clinical appearance of septic disorders is characterized by an enormous dynamic. The sepsis-induced dysbalance of the immune system necessitates immediate and aggressive therapeutic interventions to prevent further damage progression of the disease to septic shock and multiple organ failure. This includes supportive therapy to normalize and maintain organ and tissue perfusion as well as the identification of the infection focus. In cases where an infectious focus is identified, surgical source control frequently is a key element of the treatment strategy besides pharmacologic and supportive measures. The integrative approach of the management of septic patients requires rapid communication between the involved medical disciplines and the nursing personnel. Therefore, this article outlines current therapeutic concepts of septic diseases as well as central nursing aspects.

[A flap simulator for training in local defect coverage]

The Hannover Medical School (Germany) developed the"Flap Lab I" flap simulator, a practical improvement to surgeon training. It provides realistic conditions for understanding and following the principles for planning and performing local flaps for coverage of skin defects. The Flap Lab I has proved to be a very good training model in several training courses. This article introduces among others the Z-flap, reverse Z-flap (so-called hanging man), and Limberg flap.

Combined NT-pro-BNP and CW-Doppler ultrasound cardiac output monitoring (USCOM) in epirubicin and liposomal doxorubicin therapy

BACKGROUND

Chemotherapy with epirubicin is approved in women with breast cancer and is associated with a certain degree of cardiotoxicity.

HYPOTHESIS

Epirubicin changes stroke volume, cardiac output and systemic vascular resistance, while liposomal doxorubicin does not.

METHODS

75 patients with HER-2-positive metastatic breast cancer were continuously measured with CW-Doppler ultrasound for stroke volume (SV), cardiac output (CO), and systemic vascular resistance (SVR) before, during and after drug infusion in combination with NT-pro-BNP before and 10 min after drug infusion.

RESULTS

Epirubicin infusion increased stroke volume significantly in low-level NT-pro-BNP (62+/-23 ml vs. 74+/-29 ml, p=0.004) and high-level NT-pro-BNP (48+/-5 ml vs. 64+/-20 ml, p=0.131), while liposomal doxorubicin infusion increased stroke volume significantly in low-level NT-pro-BNP (54+/-16 ml vs. 67+/-22 ml, p=0.001) and high-level NT-pro-BNP (65+/-22 ml vs. 82+/-27 ml, p=0.001). Cardiac output was significantly increased in epirubicin (p=0.004) by 20% (NT-pro-BNP<125 pg/ml) and not significantly 38% (NT-pro-BNP>125 pg/ml; p=0.144), while in liposomal doxorubicin cardiac output was significantly increased by 23% (NT-pro-BNP<125 pg/ml; p=0.023) and 33% (NT-pro-BNP>125 pg/ml; p=0.001). In liposomal doxorubicin cardiac index was significantly increased by 26% (NT-pro-BNP<125 pg/ml; p=0.021) and 33% (NT-pro-BNP>125 pg/ml; p=0.0001). SVR was significantly reduced during and after epirubicin therapy.

CONCLUSION

Using the CW-Doppler USCOM a different hemodynamic response to epirubicin vs. liposomal doxorubicin is evident. Epirubicin leads to a significant upregulation of stroke volume and cardiac output, which is even more pronounced in the high-level NT-pro-BNP group, while liposomal doxorubicin does not change immediate hemodynamics. No deterioration of cardiac function using the real-time CW-Doppler ultrasound USCOM or an increase in NT-pro-BNP levels was evident during epirubicin or liposomal doxorubicin therapy.

Palmar microcirculation does not deteriorate 2 years after radial artery harvesting—implications for reconstructive free forearm flap transfer

BACKGROUND

The functional consequences after radial artery-based forearm flaps for hand microcirculation remain unclear. We hypothesized that palmar microcirculation is compromised after radial artery removal in arteriosclerotic patients.

MATERIALS AND METHODS

A total number of 114 patients were included undergoing elective coronary revascularization using the radial artery of the nondominant forearm with non-pathological Allen's test. Palmar microcirculatory mapping with 1596 measurements was applied 2 years after removal of the radial artery regarding capillary flow, finger tip oxygenation, as well as postcapillary venous filling pressures throughout both hands using combined noninvasive real-time laser Doppler flowmetry and spectrophotometry.

RESULTS

Only 2/56 positions revealed a difference beyond a 5% threshold 25 +/- 5 months after radial artery removal. Superficial capillary blood flow decreased by 13% at the hypothenar eminence (242.0 +/- 153.6 vs 275.6 +/- 169.2, p = 0.009). Deep postcapillary venous filling pressure (8 mm) was significantly increased by 9% only at the fingertip of the fifth finger (112.4 +/- 49.7 vs 103.0 +/- 25.0, p = 0.033). No clinical signs of malperfusion were found after radial artery removal, and no patient was impaired in his daily palmar motor activity.

CONCLUSIONS

Pedicled removal of the radial artery does not compromise superficial or deep palmar capillary blood flow, finger tip oxygenation, or postcapillary venous filling pressures in a long-term perspective in arteriosclerotic patients. No clinical relevant signs of malperfusion or any deterioration of palmar motor function was encountered. The blood flow via the ulnar artery and the interosseal artery compensates palmar perfusion without microcirculatory deterioration even more than 2 years after removal of the radial artery.

[Lymphadenectomy of the inguinal region and pelvis]

The draining lymph nodes of extra-abdominal tumors and malignant lesions of the lower extremity are located in the groin and iliac region. Malignancies with lymphatic drainage into this region include tumors of the anorectum, penis and vulva, skin (melanoma, squamous cell carcinoma), and soft tissue sarcomas. Current clinical research in biology, routes of lymphatic spread, and the possibility of marking the sentinel lymph node has directed lymphadenectomy strategy toward differential procedures, depending on the type of underlying malignancy. The spectrum of lymphadenectomy includes diagnostic lymph node removal of clinically enlarged nodes, removal of the sentinel node, and radical lymphadenectomy. Lymphadenectomy can also be indicated as a palliative procedure. The indications also depend on the type of tumor, previous treatment, and disease prognosis. This review presents the current state of indications and surgical techniques of inguinal and iliacal lymphadenectomy.