[Cytosteatonecrosis after breast reconstruction by fat flap with or without ischemic preconditioning]

INTRODUCTION

Cytosteatonecrosis (CTN) is a frequent postoperative complication after breast autologous reconstruction using DIEP (deep inferior epigastric perforator) flap. CTN radiological diagnostic reveals different types of lesions, as nodes or extended fat necrosis, which become in some cases infected, or pass for tumor recurrence after breast cancer treatment. CTN is caused by intraoperative ischemia of the flap, and no current method can prevent postoperative CTN development after DIEP breast reconstruction. Mechanical ischemic preconditioning, consisting in intraoperative briefs consecutive cycles of ischemia reperfusion using vascular clamp upon the graft pedicle, is used in transplantation surgery. This procedure improves the graft tolerance towards ischemic surgical lesions. The aim of this retrospective observational study was to assess PCIM effects on CTN development after DIEP surgery, comparing CTN occurrence after breast reconstruction using DIEP flap with or without intraoperative PCIM.

MATERIAL AND METHODS

All patients breats reconstructed using DIEP flap between novembre 2020 and may 2022, presenting 6 months postoperative breast echography were retrospectively included. Primary outcome was the ultrasonic existence of CTN, according to the Wagner classification. Clinical data, postoperative outcomes such as infection, hematoma or surgical revision, and length of stay in hospital were also recorded.

RESULTS

Twenty nine patients among which 8 PCIM were included. CTN occurrence rate after PCIM (25%) was quite lower than CTN rate without PCIM (71,4%), although the difference was not significant (P=0,088). Other postoperative complications rates were not significantly different with or without PCIM.

CONCLUSION

PCIM seems to improve CTN occurrence after DIEP breast reconstruction, improving fat flap tolerance to ischemic perioperative lesions. Those preliminary results need to be confirmed with clinical prospective study.

Training in microvascular anastomosis - A randomized comparative study between chicken thigh specimen and live rat

Training in microsurgical techniques on live rats is the gold standard, but raises ethical issues related to animal welfare and cost. The aim of this study was to compare acquisition of microsurgical techniques with primary training on chicken thigh specimens. Seventy six students were randomly assigned: 23 to exclusive rat training and 53 to primary chicken-leg training. Both groups were then evaluated on aortic suture and jugular aortic bypass surgery in live rats. The primary criterion for successful anastomosis was the patency test. The survival of the rat, the number of severe vascular wounds and the quality of the dissection were also assessed. Aortic anastomoses were of significantly better quality in the chicken group (p = 0.041). There was no significant difference in the number of serious injuries, rat mortality, or quality of dissection (p > 0.05). For jugular aortic bypass surgery, dissection quality (p = 0.02) and patency test (p = 0.05) were better in the chicken-leg group. There was no significant difference in number of severe wounds or rat mortality (p > 0.05). Students who started their microsurgical training on a chicken leg did not perform worse than those with exclusive live rat training. Initial training on chicken thigh specimens seems to be a reliable alternative to training on live models. LEVEL OF EVIDENCE: Level II - Randomized controlled trial.

Improved sexuality and satisfactory lubrication after genital affirmation surgery using penile skin inversion in transgender women: A satisfaction study

INTRODUCTION

Genital affirmation surgery (GAS) requests are consistently increasing in demand. The gold standard is penile skin inversion, using cutaneous grafting for neovagina creation. The aim is to achieve the most realistic results both physically and functionally. Different studies have contradictory results, and the use of lubrication is insufficiently clear, while the use of sigmoidoplasty has been defended for constant lubrication.

AIMS

Our aim was to evaluate transgender women's sexual function and lubrication after vaginoplasty by penile skin inversion.

METHODS

We performed a prospective study on 45 patients who underwent primary penile inversion vaginoplasty. Participants answered two questionnaires during the follow-up consultation: the Female Sexual Function Index (FSFI) and an 18-item custom questionnaire.

RESULTS

The average FSFI score of our patients was 28.9, up to the cut-off defining a sexual disorder. Compared to the Wylomanski control group, no differences were found for the FSFI score and in the subgroups. Considering lubrication, 69% of the patients were satisfied or very satisfied with their lubrication. Furthermore, 53% reported a fluid release at each orgasm.

CONCLUSION

This study reported high satisfaction for both sexuality and lubrication, proning against penile inversion's GAS bad reputation concerning postoperative lubrication. A squirting effect was described for the first time and was present in 53% of our transpatients.

Multimodal high-resolution retinal imaging using a camera-based DMD-integrated adaptive optics flood-illumination ophthalmoscope

We demonstrate the feasibility of a multimodal adaptive optics flood-illumination ophthalmoscope, able to provide both bright-field and dark-field images (such as phase contrast). The multimodality was made possible by integrating a digital micromirror device (DMD) at the illumination path to project a sequence of complementary high-resolution patterns into the retina. Through a versatile post-processing method that digitally selects backscattered or multiply scattered photons, we were able: (1) to achieve up to four-fold contrast increase of bright-field images when imaging the photoreceptor mosaic and nerve fibers; and (2) to visualize translucent retinal features such as capillaries, red blood cells, vessel walls, ganglion cells, and photoreceptor inner segments through phase contrast.

Observation of natural flexural pulse waves in retinal and carotid arteries for wall elasticity estimation

The risk of cardiovascular events is linked to arterial elasticity that can be estimated from the pulse wave velocity. This symmetric wave velocity is related to the wall elasticity through the Moens-Korteweg equation. However, ultrasound imaging techniques need improved accuracy, and optical measurements on retinal arteries produce inconsistent results. Here, we report the first observation of an antisymmetric pulse wave: the flexural pulse wave. An optical system performs in vivo wave velocity measurements on retinal arteries and veins. Velocity estimation ranges between 1 and 10 millimeter per second. The theory of guided waves confirms the existence of this wave mode and its low velocity. Natural flexural waves can also be detected at the bigger scale of a carotid artery using ultrafast ultrasound imaging. This second natural pulse wave has great potential of becoming a biomarker of blood vessel aging.

[Frontal sinus anatomical scanographic study of transgender patients for feminization frontoorbitoplasty surgery]

INTRODUCTION

Little is known about the anatomical elements that allow safe and predictable performance of fronto orbital surgery for facial feminization. The primary objective of this study was to analyze the characteristics (dimensions, pneumatization rate, and anterior wall thickness) of the frontal sinus in MtF transgender patients. The secondary objective was to establish reproducible criteria for CT measurements that could guide preoperative planning of frontal impaction in feminization frontoplasty (FF).

MATERIALS

Fifty preoperative facial mass scans of FF surgery patients were included. The mean age of the operated patients was 34 years. The F line represented the ideal forehead tilt in the absence of a frontal hump.

RESULTS

The height, width, depth, and thickness of the anterior sinus wall were 26.6mm (±5.7), 49.5mm (±11.3), 10.9mm (±3.3), and 3mm (±0.7), respectively. The mean sinus width to skull width ratio was 0.73 (±0.12). Six percent of patients had bilateral frontal sinus agenesis. An osteotomy of the anterior wall of the frontal sinus was performed in the 64% of patients with frontal sinus projection anterior to the F-line. The emergence of the supraorbital nerves from the frontal bone was through a bony notch in 73.8% of cases.

CONCLUSIONS

Knowledge of the anatomy of the frontal sinus and preoperative study of the scans of the facial mass is essential for planning the FF. These characteristics guide the surgical technique of bone remodeling as well as the procedure for releasing the supraorbital nerves.

Adipocytes secretome from normal and tumor breast favor breast cancer invasion by metabolic reprogramming

BACKGROUND

Adipose tissue is a major component of breast stroma. This study focused on delineating the effects of adipose stem cells (ASCs) derived from breast of healthy women and cancer patients with normal or tumor breast cells.

METHODS

The ASCs were induced to differentiate into adipocytes, and the subsequent adipocyte conditioned media (ACM) were evaluated for their fatty acid profile, adipokine secretion and influence on proliferation, migration and invasion on tumoral (MCF-7 and SUM159) and normal (HMEC) human breast cell lines.

RESULTS

An enrichment of arachidonic acid was observed in ACM from tumor tissues. Adipose tissues from tumor free secrete twice as much leptin than those from proximal or distal to the tumor. All ACMs display proliferative activity and favor invasiveness of SUM159 cells compared to MCF-7 and HMEC. All ACMs induced lipid droplets accumulation in MCF-7 cells and increased CD36 expression in tumor cells.

CONCLUSION

We conclude that among secreted factors analyzed, only arachidonic acid and leptin levels did discriminate ASCs from tumor-bearing and tumor-free breasts emphasizing the importance that other cell types could contribute to the adipose tissue secretome in a tumor context.

Outcomes and Reliability of Perforator Flaps in the Reconstruction of Hidradenitis Suppurativa Defects: A Systemic Review and Meta-Analysis

INTRODUCTION

Hidradenitis suppurativa (HS) is a common and debilitating disease, in which the only effective treatment involves a wide excision of the affected skin. Secondary wound healing and skin grafting are two well-known options for managing these defects, but perforator flaps provide a new therapeutic alternative by ensuring reconstructions of large defects, reducing donor site morbidity, and enhancing functional recovery. The aim of this study was to achieve a systematic review of perforator flaps use in HS.

PATIENTS AND METHODS

PubMed and Cochrane databases were searched from 1989 to 2021. The PRISMA statement was used in the study selection process and the review was registered on PROSPERO. Furthermore, patient characteristics, operative technique, complications, and recurrences were searched.

RESULTS

Thirty-six articles were selected including 286 patients and 387 flaps. Axillary localization was mostly represented (83.2%). Direct donor site closure was achieved in 99.1% of cases. In total, 15.1% of the flaps presented at least one of the following complications: wound dehiscence (5.5%), partial necrosis (2.9%), hematoma or seroma (2.1%), infection (2.1%), venous congestion (1.8%), and nerve injury (0.3%). Two cases of total necrosis were recorded. Recurrence of the disease was observed in 2.7% of the defects.

CONCLUSIONS

Pedicled perforator flaps are a reliable and reproducible technique in the reconstruction of HS defects. They are associated with a low recurrence rate while ensuring an effective reconstruction with reduced morbidity and faster recovery compared to the techniques classically used in this indication.

Inhibition of Adipose Tissue Beiging by HIV Integrase Inhibitors, Dolutegravir and Bictegravir, Is Associated with Adipocyte Hypertrophy, Hypoxia, Elevated Fibrosis, and Insulin Resistance in Simian Adipose Tissue and Human Adipocytes

For people living with HIV, treatment with integrase-strand-transfer-inhibitors (INSTIs) can promote adipose tissue (AT) gain. We previously demonstrated that INSTIs can induce hypertrophy and fibrosis in AT of macaques and humans. By promoting energy expenditure, the emergence of beige adipocytes in white AT (beiging) could play an important role by limiting excess lipid storage and associated adipocyte dysfunction. We hypothesized that INSTIs could alter AT via beiging inhibition. Fibrosis and gene expression were measured in subcutaneous (SCAT) and visceral AT (VAT) from SIV-infected, dolutegravir-treated (SIVART) macaques. Beiging capacity was assessed in human adipose stromal cells (ASCs) undergoing differentiation and being exposed to dolutegravir, bictegravir, or raltegravir. Expression of beige markers, such as positive-regulatory-domain-containing-16 (PRDM16), were lower in AT of SIVART as compared to control macaques, whereas fibrosis-related genes were higher. Dolutegravir and bictegravir inhibited beige differentiation in ASCs, as shown by lower expression of beige markers and lower cell respiration. INSTIs also induced a hypertrophic insulin-resistant state associated with a pro-fibrotic phenotype. Our results indicate that adipocyte hypertrophy induced by INSTIs is involved via hypoxia (revealed by a greater hypoxia-inducible-factor-1-alpha gene expression) in fat fibrosis, beiging inhibition, and thus (via positive feedback), probably, further hypertrophy and associated insulin resistance.

2022 Practice Recommendation Updates From the World Consensus Conference on BIA-ALCL

BACKGROUND

Laboratory and clinical research on breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) is rapidly evolving. Changes in standard of care and insights into best practice were recently presented at the 3rd World Consensus Conference on BIA-ALCL.

OBJECTIVES

The authors sought to provide practice recommendations from a consensus of experts, supplemented with a literature review regarding epidemiology, etiology, pathogenesis, diagnosis, treatment, socio-psychological aspects, and international authority guidance.

METHODS

A literature search of all manuscripts between 1997 and August 2021 for the above areas of BIA-ALCL was conducted with the PubMed database. Manuscripts in different languages, on non-human subjects, and/or discussing conditions separate from BIA-ALCL were excluded. The study was conducted employing the Delphi process, gathering 18 experts panelists and utilizing email-based questionnaires to record the level of agreement with each statement by applying a 5-point Likert Scale. Median response, interquartile range, and comments were employed to accept, reject, or revise each statement.

RESULTS

The literature search initially yielded 764 manuscripts, of which 405 were discarded. From the remaining 359, only 218 were included in the review and utilized to prepare 36 statements subdivided into 5 sections. After 1 round, panelists agreed on all criteria.

CONCLUSIONS

BIA-ALCL is uncommon and still largely underreported. Mandatory implant registries and actions by regulatory authorities are needed to better understand disease epidemiology and address initial lymphomagenesis and progression. Deviation from current diagnosis and treatment protocols can lead to disease recurrence, and research on breast implant risk factors provide insight to etiology.

LEVEL OF EVIDENCE: 4

Dunnigan lipodystrophy syndrome: French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins)

Dunnigan syndrome, or Familial Partial Lipodystrophy type 2 (FPLD2; ORPHA 2348), is a rare autosomal dominant disorder due to pathogenic variants of the LMNA gene. The objective of the French National Diagnosis and Care Protocol (PNDS; Protocole National de Diagnostic et de Soins), is to provide health professionals with a guide to optimal management and care of patients with FPLD2, based on a critical literature review and multidisciplinary expert consensus. The PNDS, written by members of the French National Reference Center for Rare Diseases of Insulin Secretion and Insulin Sensitivity (PRISIS), is available on the French Health Authority website (in French). Dunnigan syndrome is characterized by a partial atrophy of the subcutaneous adipose tissue and by an insulin resistance syndrome, associated with a risk of metabolic, cardiovascular and muscular complications. Its prevalence, assessed at 1/100.000 in Europe, is probably considerably underestimated. Thorough clinical examination is key to diagnosis. Biochemical testing frequently shows hyperinsulinemia, abnormal glucose tolerance and hypertriglyceridemia. Elevated hepatic transaminases (hepatic steatosis) and creatine phosphokinase, and hyperandrogenism in women, are common. Molecular analysis of the LMNA gene confirms diagnosis and allows for family investigations. Regular screening and multidisciplinary monitoring of the associated complications are necessary. Diabetes frequently develops from puberty onwards. Hypertriglyceridemia may lead to acute pancreatitis. Early atherosclerosis and cardiomyopathy should be monitored. In women, polycystic ovary syndrome is common. Overall, the management of patients with Dunnigan syndrome requires the collaboration of several health care providers. The attending physician, in conjunction with the national care network, will ensure that the patient receives optimal care through regular follow-up and screening. The various elements of this PNDS are described to provide such a support.

Three-Dimensional Custom-Made Surgical Guides in Facial Feminization Surgery: Prospective Study on Safety and Accuracy

BACKGROUND

Facial feminization surgery (FFS) includes several osseous modifications of the forehead, mandible, and chin, procedures that require precision to provide the patient with a satisfactory result. Mispositioned osteotomies can lead to serious complications and poor aesthetic outcomes. Surgical cutting guides are commonly employed in plastic and maxillofacial surgery to improve safety and accuracy. Yet, to our knowledge, there is no report in the literature on the clinical application of cutting guides in FFS.

OBJECTIVES

The authors sought to assess the safety and accuracy of custom surgical cutting guides in FFS procedures.

METHODS

A prospective follow-up of 45 patients regarding FFS with preoperative virtual planning and 3-dimensional custom-made surgical guides for anterior frontal sinus wall setback, mandibular angle reduction, and/or osseous genioplasty was conducted. Accuracy (superimposing preoperative data on postoperative data by global registration with a 1-mm margin of error), safety (intradural intrusion for the forehead procedures and injury of the infra alveolar nerve for chin and mandibular angles), and patient satisfaction were assessed.

RESULTS

A total 133 procedures were documented. There was no cerebrospinal fluid leak on the forehead procedures or any infra alveolar nerve or tooth root injury on both chin and mandibular angle operations (safety, 100%). Accuracy was 90.80% on the forehead (n = 25), 85.72% on the mandibular angles (n = 44), and 96.20% on the chin (n = 26). Overall satisfaction was 94.40%.

CONCLUSIONS

Custom-made surgical cutting guides could be a safe and accurate tool for forehead, mandibular angles, and chin procedures for FFS.

LEVEL OF EVIDENCE: 4

Metformin alleviates stress-induced cellular senescence of aging human adipose stromal cells and the ensuing adipocyte dysfunction

Aging is associated with central fat redistribution and insulin resistance. To identify age-related adipose features, we evaluated the senescence and adipogenic potential of adipose-derived stromal cells (ASCs) from abdominal subcutaneous fat obtained from healthy normal-weight young (<25 years) or older women (>60 years). Increased cell passages of young-donor ASCs (in vitro aging) resulted in senescence but not oxidative stress. ASC-derived adipocytes presented impaired adipogenesis but no early mitochondrial dysfunction. Conversely, aged-donor ASCs at early passages displayed oxidative stress and mild senescence. ASC-derived adipocytes exhibited oxidative stress, and early mitochondrial dysfunction but adipogenesis was preserved. In vitro aging of aged-donor ASCs resulted in further increased senescence, mitochondrial dysfunction, oxidative stress, and severe adipocyte dysfunction. When in vitro aged young-donor ASCs were treated with metformin, no alteration was alleviated. Conversely, metformin treatment of aged-donor ASCs decreased oxidative stress and mitochondrial dysfunction resulting in decreased senescence. Metformin's prevention of oxidative stress and of the resulting senescence improved the cells' adipogenic capacity and insulin sensitivity. This effect was mediated by the activation of AMP-activated protein kinase as revealed by its specific inhibition and activation. Overall, aging ASC-derived adipocytes presented impaired adipogenesis and insulin sensitivity. Targeting stress-induced senescence of ASCs with metformin may improve age-related adipose tissue dysfunction.

Laser Doppler holography of the anterior segment for blood flow imaging, eye tracking, and transparency assessment

Laser Doppler holography (LDH) is a full-field blood flow imaging technique able to reveal human retinal and choroidal blood flow with high temporal resolution. We here report on using LDH in the anterior segment of the eye without making changes to the instrument. Blood flow in the bulbar conjunctiva and episclera as well as in corneal neovascularization can be effectively imaged. We additionally demonstrate simultaneous holographic imaging of the anterior and posterior segments by simply adapting the numerical propagation distance to the plane of interest. We used this feature to track the movements of the retina and pupil with high temporal resolution. Finally, we show that the light backscattered by the retina can be used for retro-illumination of the anterior segment. Hence digital holography can reveal opacities caused by absorption or diffusion in the cornea and eye lens.

Sutureless venous microanastomosis using thermosensitive poloxamer and cyanoacrylate: experimental study on a rat model

INTRODUCTION

Sutureless microvascular anastomoses could simplify the microvascular field, shortening operative time and improving the final outcome. The use of thermosensitive poloxamers (TP407) together with the application of cyanoacrylate as an alternative method for conventional sutures was well-documented for arteries, but not for veins. The purpose of our study was to prove the feasibility of this technique for venous anastomoses and compare it with the traditional hand-sewn technique on a rat model.

MATERIALS AND METHODS

Twenty male Sprague-Dawley rats that weighed between 265 and 310 g were used. In the sutureless group (SG), 20 left external jugular veins (LEJV) end-to-end anastomoses were performed using a T704 and cyanoacrylate glue. They were compared to 20 right external jugular veins (REJV) anastomoses sutured with conventional 10-0 stitches (control group - CG). Diameters of veins, anastomosis time, and patency rate at 15 days were reported. Foreign body reaction was assessed histologically.

RESULTS

The mean diameter of the LEJV was 0.94 ± 0.1 mm and 0.95 ± 0.09 mm for the REJV. The mean anastomosis time was 11.9 ± 1.37 min for the SG and 27.75 ± 3.31 min for the CG. In the latter group, the immediate patency rate was 95% and 90% at 15 days. For the SG group, 90% of the anastomoses were patent immediately and 85% at 15 days.

CONCLUSION

TP407 and cyanoacrylate could offer a fast and reliable technique for sutureless venous anastomoses. Before human application, effectiveness of this method remains to be confirmed in larger animals in a long-term follow-up.

Lessons Learned From Twenty-Eight Cases of Burns Following Breast Reconstruction: An Underestimated Complication Requiring Inclusion in Consent Information

BACKGROUND

There has over recent years been a constant increase in annual breast reconstruction figures. Although reports indicate that burns following breast reconstruction are a rare occurrence, there has nevertheless been a relative increase in cases. The key underlying causes of this type of condition remain unknown.

OBJECTIVES

The authors launched a new study on the demographic characteristics of burns in the breast reconstruction population with the inclusion of up-to-date data to assess cases and contributing factors.

METHODS

The study was a multicenter retrospective review of patients who underwent any type of breast reconstruction and subsequently sustained burn injuries.

RESULTS

Twenty-eight cases of burn injury following breast reconstruction were documented; 6 involved autologous flaps and 22 involved implants. Nine of the 10 implant exposure cases had previous history of radiotherapy, but there was no statistically significant difference between previous radiotherapy history and implant exposure (P = 0.32). Of the 13 cases sustaining full-thickness burns, a large number included implant-based reconstruction (n = 12, 92%), although no statistically significant difference was observed between type of reconstruction and incidence of full-thickness burns (P = 0.17).

CONCLUSIONS

Each patient undergoing breast reconstruction should be advised of the potential risks and instructed to avoid significant heat exposure and steer clear of dark-colored bathing suits. At the time of writing, this information has yet to be included in the vast majority of surgery-related informed consent documents.

LEVEL OF EVIDENCE: 4

Facelift With Power-Assisted Dissection: A Preliminary Report

BACKGROUND

Subcutaneous elevation of the skin has remained a key component in all facelift techniques.

OBJECTIVES

The aim of this preliminary report was to introduce the ABC facelift as a 3-step method addressing photodamage, soft tissue laxity, and areas of bone and volume loss.

METHODS

The procedure consists of: (A) anatomic and regenerative adipose grafting prior to skin elevation; (B) the use of a Baraf elevator for takedown of perpendicular subcutaneous fibers following hydrodissection of the skin flaps with tumescent solution; and (C) cautery dissection of the superficial muscular aponeurotic system (SMAS) and platysma in the neck.

RESULTS

Thirty-four patients (31 females; 3 male), aged 50 to 77 years at the date of procedure, underwent an ABC facelift. Dissection of the skin flaps and SMAS elevation were faster than with traditional methods, averaging 10 to 15 minutes per hemiface. Bleeding was reduced (average estimated blood loss, 12 mL) and the skin flaps appeared better perfused with less venous engorgement and ecchymosis than achieved with sharp scissor dissection. In general, patients appeared to have shorter postoperative recovery courses and less social downtime secondary to bruising and edema.

CONCLUSIONS

The ABC facelift addresses facial laxity, volume loss, and skin aging with 3 simple steps: anatomic and regenerative fat grafting, combined with power-assisted dissection of the skin and cautery elevation of the SMAS. The use of more advanced hydrodissection tools to achieve further improvements in layer separation is currently being investigated.

LEVEL OF EVIDENCE: 4

The Integrase Inhibitors Dolutegravir and Raltegravir Exert Proadipogenic and Profibrotic Effects and Induce Insulin Resistance in Human/Simian Adipose Tissue and Human Adipocytes

BACKGROUND

Although some integrase strand transfer inhibitors (INSTIs) promote peripheral and central adipose tissue/weight gain in people with human immunodeficiency virus (PHIV), the underlying mechanism has not been identified. Here, we used human and simian models to assess the impact of INSTIs on adipose tissue phenotype and function.

METHODS

Adipocyte size and fibrosis were determined in biopsies of subcutaneous and visceral adipose tissue (SCAT and VAT, respectively) from 14 noninfected macaques and 19 PHIV treated or not treated with an INSTI. Fibrosis, adipogenesis, oxidative stress, mitochondrial function, and insulin sensitivity were assessed in human proliferating or adipocyte-differentiated adipose stem cells after long-term exposure to dolutegravir or raltegravir.

RESULTS

We observed elevated fibrosis, adipocyte size, and adipogenic marker expression in SCAT and VAT from INSTI-treated noninfected macaques. Adiponectin expression was low in SCAT. Accordingly, SCAT and VAT samples from INSTI-exposed patients displayed higher levels of fibrosis than those from nonexposed patients. In vitro, dolutegravir and, to a lesser extent, raltegravir were associated with greater extracellular matrix production and lipid accumulation in adipose stem cells and/or adipocytes as observed in vivo. Despite the INSTIs' proadipogenic and prolipogenic effects, these drugs promoted oxidative stress, mitochondrial dysfunction, and insulin resistance.

CONCLUSIONS

Dolutegravir and raltegravir can directly impact adipocytes and adipose tissue. These INSTIs induced adipogenesis, lipogenesis, oxidative stress, fibrosis, and insulin resistance. The present study is the first to shed light on the fat modifications observed in INSTI-treated PHIV.

A CD31-Derived Peptide Prevents the Development of Antibody-Mediated Lesions in a Rat Model of Aortic Allograft

BACKGROUND

Antibody-mediated rejection (AMR) is a major cause of graft loss. The development of donor-specific antibodies (DSAs) directed against the allogeneic HLA molecules expressed by the graft also leads to accelerated arteriosclerosis. CD31 is a protein expressed on endothelial and immune cells, ensuring homeostasis at this interface. When strong immune stimulation occurs, the regulatory function of CD31 is lost owing to cleavage of its extracellular portion. P8RI, a synthetic peptide that binds to the ectodomain of CD31, is able to restore the CD31 immunomodulatory function. In this study, we hypothesized that CD31 could represent an attractive molecular target in AMR and investigated whether P8RI could prevent the development of vascular antibody-mediated lesions.

MATERIALS AND METHODS

A rat model of orthotopic aortic allograft was used, and P8RI was administered for 28 days. Circulating DSAs were quantified to assess the alloimmune humoral response, and histologic and immunohistochemical analyses of aortic allografts were performed to estimate antibody-mediated lesions in the allograft.

RESULTS

Aorta-allografted rats receiving P8RI developed fewer DSAs than control animals (mean fluorescence intensity 344 vs 741). The density of nuclei in the media (3.4 x 10^-5 vs 2.2 x 10^-5 nuclei/px²) and media surface area (2.33 x 10⁶ vs 2.02 x 10⁶ px²) were higher in animals treated with P8RI than in control animals.

CONCLUSIONS

These data support a therapeutic potential for molecules able to restore the CD31 signaling to fight AMR. P8RI, an agonist synthetic peptide targeting CD31, might prevent DSA production and have a beneficial effect in limiting arterial antibody-mediated lesions. CD31 agonists may become therapeutic tools to prevent and treat solid organ transplant arteriosclerosis.

Thin submental artery perforator flap for upper lip reconstruction: A case report

Reconstruction of upper lip defects can be challenging even for experienced surgeons. In order to restore both function and morphology, the use of quality soft tissue is essential. To this effect, the most common solution is the use of local flaps, or, in extreme situations, a free flap. However, a thin cutaneous upper lip defect may require a different approach. Perforator flaps are versatile and may allow an efficient reconstruction of soft tissue defects using adjacent similar tissues, providing the benefit of "like with like" coverage. We present the case of a 41-year-old female with a 1 × 1.5 cm basal cell carcinoma of the right-side upper lip, initially treated with a full thickness skin graft. Due to poor aesthetic and functional result, a thin submental artery perforator (SMAP) flap reconstruction was performed. Flaps' dimensions were 6 cm long and 4 cm wide and it was based on a perforator arising from the submental artery. Dissection was conducted above the platysma muscle, and the SMAP flap was transferred into the defect through a subcutaneous tunnel created below the mandible and posterior to the anterior belly of digastric muscle. The pedicle length of 6.5 cm was adequate for a tension free inset of the flap. Postoperative course was uneventful and the patient was discharged after 2 days. The 4-month follow-up showed a satisfying functional and aesthetic outcome with a concealed donor site scar. This report points out the coverage potential of the thin SMAP flap, which can be successfully used for a harmonious reconstruction in both color and texture of the upper lip.

Primary Breast Augmentation with Autologous Fat Grafting Alone: Evaluation of Patient Satisfaction Using the BREAST-Q

BACKGROUND

Autologous fat grafting (AFG) for primary aesthetic breast augmentation has grown in popularity over recent years but patient satisfaction has never been objectively evaluated.

OBJECTIVES

The aim of the present study was to use the standardized BREAST-Q questionnaire to evaluate satisfaction in patients who had received primary aesthetic breast augmentation with AFG alone.

METHODS

All recipients of primary aesthetic breast augmentation by AFG performed between 2013 and 2017 in our plastic surgery department were included. The primary endpoint was assessment of patient satisfaction with the standardized breast augmentation BREAST-Q questionnaire. Three additional questionnaires were used to evaluate patient and surgeon satisfaction.

RESULTS

In total, 42 patients (84 breasts) underwent breast augmentation by AFG. Mean patient age was 34 years (range, 23-53 years). The mean volume of reinjected fat was 312.2 mL per breast (range, 130-480 mL). We observed significant improvement in all BREAST-Q postoperative items (excluding physical well-being) with a mean increase of 39 points (95% confidence interval: 28.97, 49.03; P < 0.001) regarding patient satisfaction with breasts. Overall, 82% of patients were satisfied with the result of their liposuction. Minor complications were encountered in 6 of our patients (14%).

CONCLUSIONS

Breast augmentation by AFG enhances patient satisfaction as measured by the BREAST-Q. This procedure has a high satisfaction rate and improves quality of life. Breast augmentation by AFG is a valid surgical option for moderate breast augmentation but is not an alternative to implants in large breast augmentation.

Level of Evidence: 4.

Reverse contrast laser Doppler holography for lower frame rate retinal and choroidal blood flow imaging

Laser Doppler holography (LDH) is an interferometric blood flow imaging technique based on full-field measurements of the Doppler spectrum. LDH has so far been demonstrated in the retina with ultrafast cameras, typically at 75 kHz. We show here that a similar method can be implemented with camera frame rates 10 times slower than before. Due to energy conservation, low and high frequency local power Doppler signals have opposite variations, and a simple contrast inversion of the low frequency power Doppler reveals fast blood flow beyond the camera detection bandwidth for conventional laser Doppler measurements. Relevant blood flow variations and color composite power Doppler images can be obtained with camera frame rates down to a few kHz.

Spatio-temporal filtering in laser Doppler holography for retinal blood flow imaging

Laser Doppler holography (LDH) is a full-field interferometric imaging technique recently applied in ophthalmology to measure blood flow, a parameter of high clinical interest. From the temporal fluctuations of digital holograms acquired at ultrafast frame rates, LDH reveals retinal and choroidal blood flow with a few milliseconds of temporal resolution. However, LDH experiences difficulties to detect slower blood flow as it requires to work with low Doppler frequency shifts which are corrupted by eye motion. We here demonstrate the use of a spatio-temporal decomposition adapted from Doppler ultrasound that provides a basis appropriate to the discrimination of blood flow from eye motion. A singular value decomposition (SVD) can be used as a simple, robust, and efficient way to separate the Doppler fluctuations of blood flow from those of strong spatial coherence such as eye motion. We show that the SVD outperforms the conventional Fourier based filter to reveal slower blood flow, and dramatically improves the ability of LDH to reveal vessels of smaller size or with a pathologically reduced blood flow.

Breast-conserving therapy can be offered to women with prior breast augmentation

INTRODUCTION

Breast cancer in women with cosmetic breast implants is increasingly common. Over the past decade, there has been a push for mastectomy and reconstruction in these patients, based on a fear of poor aesthetic results from small breast volume, and radiation-induced capsular contracture. At the Paris Breast Centre, augmented women routinely undergo lumpectomy with whole-breast irradiation (BCT).

MATERIALS AND METHODS

A consecutive cohort of 50 augmented women, who had attempted BCT for early breast cancer at our institution between 2003 and 2018, were retrospectively identified. Post-treatment complications, oncologic outcomes, capsular contracture rates, long-term cosmetic outcomes, and patient-reported outcomes were evaluated.

RESULTS

The median follow-up was 51 months. Margins were involved in 7 women (14%); 4 of whom underwent successful re-excision, and 3 had a mastectomy, for an early mastectomy rate of 6%. There were no early complications, nor cases of early implant loss. Long-term aesthetic results were evaluated using our 5-point scale: An excellent (5), or good (4) result was obtained in 68%. Significant capsular contracture (Baker grade 3 or 4) developed in 34%, of which, 5 women underwent capsulotomy and fat grafting; 4 of 5 downstaging their Baker grade. The estimated 5-year local recurrence rate was 2.3%. Ninety-five percent of participants would recommend BCT to augmented women.

CONCLUSION

BCT is feasible and safe in augmented women with good long-term aesthetic results, and should be considered to avoid unnecessary mastectomy.

Intrascrotal injection of botulinum toxin A, a male genital aesthetic demand: Technique and limits

INTRODUCTION

Scrotal rejuvenation is a real male aesthetic demand. Scrotal injection of botulinum toxin makes the testicles smoother, less dangling and subjectively larger.

METHODS

Intrascrotal botulinum toxin injections were performed to a 44-year-old patient for aesthetic purposes. We used the intracremasteric injection protocol. Cremaster muscle injections and dartos muscle injections were performed.

RESULTS

The patient was satisfied. No adverse reaction to the intrascrotal botulinum toxin injection was observed. The patient wanted to repeat the procedure in the future.

CONCLUSION

At the moment, there is no recommendation about the aesthetic use of intrascrotal injections of botulinum toxin A and the risks are unknown. The purpose of this article is to show the feasibility, context and technical modalities of intrascrotal injection. The risk of infertility is real, but marginal for men who no longer have progeny's desire.

LEVEL OF EVIDENCE

Level 3.

SIV Infection and the HIV Proteins Tat and Nef Induce Senescence in Adipose Tissue and Human Adipose Stem Cells, Resulting in Adipocyte Dysfunction

Background: Aging is characterized by adipose tissue senescence, inflammation, and fibrosis, with trunk fat accumulation. Aging HIV-infected patients have a higher risk of trunk fat accumulation than uninfected individuals—suggesting that viral infection has a role in adipose tissue aging. We previously demonstrated that HIV/SIV infection and the Tat and Nef viral proteins were responsible for adipose tissue fibrosis and impaired adipogenesis. We hypothesized that SIV/HIV infection and viral proteins could induce adipose tissue senescence and thus lead to adipocyte dysfunctions. Methods: Features of tissue senescence were evaluated in subcutaneous and visceral adipose tissues of SIV-infected macaques and in human adipose stem cells (ASCs) exposed to Tat or Nef for up to 30 days. Results: p16 expression and p53 activation were higher in adipose tissue of SIV-infected macaques than in control macaques, indicating adipose tissue senescence. Tat and Nef induced higher senescence in ASCs, characterized by higher levels of senescence-associated beta-galactosidase activity, p16 expression, and p53 activation vs. control cells. Treatment with Tat and Nef also induced oxidative stress and mitochondrial dysfunction. Prevention of oxidative stress (using N-acetyl-cysteine) reduced senescence in ASCs. Adipocytes having differentiated from Nef-treated ASCs displayed alterations in adipogenesis with lower levels of triglyceride accumulation and adipocyte marker expression and secretion, and insulin resistance. Conclusion: HIV/SIV promotes adipose tissue senescence, which in turn may alter adipocyte function and contribute to insulin resistance.

Lower rates of lipofilling sessions in latissimus dorsi flap breast reconstruction with initial higher volume transfer by preservation of subfascial fat: A 3D camera-assisted volumetric case series

Breast reconstruction with latissimus dorsi flap (LDF) is a well-known technique, but the crucial goal is to achieve a satisfying final volume restoration. Our hypothesis is that LDF reconstruction with the preservation of subfascial fat can achieve a higher volume in a one-time procedure than that achieved in a classic LDF harvest. The aim of the study was to quantify the volume resorption in LDF reconstructions with the preservation of subfascial fat. Fifteen breasts were reconstructed with a simple LDF and the remaining 15 with an LDF with the preservation of the subfascial fat between January 2016 and May 2017. Secondly, every patient underwent a lipofilling procedure. A supplemental lipofilling procedure was performed in unsatisfying cases. A Structure-Sensor camera manufactured by Occipital^Ⓡ was used. Each patient received a 3D measurement during immediate postoperative care and then after 3 and 6 months of follow-up. This study shows no difference in volume retention at follow-up between the 2 techniques. The gain of an immediate and stable fatty layer in LDF + subfascial fat technique leads to breast volume improvement in one surgical step. Breast reconstruction with LDF and subfascial fat can be defined as a reliable solution, which provides an optimal result with a reduced number of surgical interventions when compared with a simple LDF.

Waveform analysis of human retinal and choroidal blood flow with laser Doppler holography

Laser Doppler holography was introduced as a full-field imaging technique to measure blood flow in the retina and choroid with an as yet unrivaled temporal resolution. We here investigate separating the different contributions to the power Doppler signal in order to isolate the flow waveforms of vessels in the posterior pole of the human eye. Distinct flow behaviors are found in retinal arteries and veins with seemingly interrelated waveforms. We demonstrate a full field mapping of the local resistivity index, and the possibility to perform unambiguous identification of retinal arteries and veins on the basis of their systolodiastolic variations. Finally we investigate the arterial flow waveforms in the retina and choroid and find synchronous and similar waveforms, although with a lower pulsatility in choroidal arteries. This work demonstrates the potential held by laser Doppler holography to study ocular hemodynamics in healthy and diseased eyes.

Coverage of radial forearm flap donor site with full thickness skin graft and Matriderm®: An alternative reliable solution?

PURPOSE

After harvesting a radial forearm flap (RFF) an optimal aesthetic and functional restitution of the donor site is required. In order to cover the secondary defect of the donor site, several solutions are currently available, but there is still no real evidence of the most reliable option. A retrospective study was conducted in order to evaluate a new technique of forearm coverage with artificial dermis: the association of full thickness skin graft (FTSG) with Matriderm®.

METHODS

Our study included all RFF performed during a 34-month period. Forty-three forearm secondary defects after harvesting a RFF (16 men, 27 female) were included. Forearm donor site was covered using three techniques: a simple FTSG, split thickness skin graft (STSG) with Matriderm® or FTSG with Matriderm®. Clinical evaluations based on residual functionality, skin quality and aesthetic result were assessed using respectively the Disabilities of the Arm, Shoulder and Hand (DASH) score, the Vancouver Scar Scale (VSS) score and a blind panel questionnaire.

RESULTS

FTSG with Matriderm® showed an improved DASH (10.6/100) and VSS score (5.5/13) if compared to the other techniques, mean surgeon satisfaction score was 3/5, mean patient satisfaction score was 3/5 in the FTSG with Matriderm® group.

CONCLUSION

The results of this study revealed that the new association of FTSG with Matriderm® improves the DASH score and the aesthetic outcomes resulting to be a reliable solution in treating full thickness forearm skin defects after RFF harvesting.

[Bilateral breast reduction and obesity: What is the ideal resection enabling significant improvement in back pain according to the body mass index?]

INTRODUCTION

Dorsal pain is the first symptoms about which patients with macromasty complain. Health insurance reimbursement takes place if the resection weight is at least 300grams per breast. However, this weight is not correlated with the body mass index (BMI). In this context, we sought to determine the ideal resection weight leading to significant BMI-based improvement.

MATERIALS AND METHODS

This is a multicentre prospective study of patients operated between November 2016 and July 2017. In the year following the surgical procedure, we studied overall improvement using the INDIC questionnaire. Any INDIC improvement of at least 50% was considered positive. These data were then compared to tissue resection weights and BMI. In order to refine our results, age, bra size, comorbidities and complications were also identified.

RESULTS

Forty-one patients were included in our study. Average age was 41.5±11.4years. Average BMI was 27.9±4.1kg/m². The bra cap chosen after the procedure were C. Average resection weight was 663±352g per breast. The preoperative and postoperative INDIC scores were 734.9±226.6 points and 225.3±319.1 points, respectively (P=0.001). Significant improvement was achieved at 12months in 71.8% of patients. A correlation of 38.7g/kg/m² was found between breast resection weight and BMI.

CONCLUSION

This study clarifies the correlation between the breast resection weight required to relieve optimal back pain and BMI. It defines three categories of patients: patients with standard weights (18<BMI<25), overweight (25<BMI<30) and obese (BMI>30). Overweight and obese patients require greater tissue excretion to be relieved optimally. These findings underline a need to adjust the health insurance threshold for these types of patients.

[Tongue reconstruction by thoracodorsal perforator flap: A new harvesting technique to reduce morbidity]

The thoracodorsal artery perforator flap is increasingly used in head and neck reconstructions. One of its multiple advantages is the low donor site morbidity compared to the other free flaps usually used for this type of surgery, such as the radial forearm free flap and the anterolateral flap of the thigh. However, the current harvesting technique of the thoracodorsal artery free perforator flap needs a vertical incision rising high in the axillary hollow for the dissection of the pedicle, thus impeding optimal discretion of the donor site, especially for women. We describe an original technique to harvest a pure transversal skin paddle on its own perforator, leaving a horizontal scar thoroughly hidden in the bra and preserving the thoracodorsal pedicle. We detail the requirements for this new type of harvesting.

Choroidal vasculature imaging with laser Doppler holography

The choroid is a highly vascularized tissue supplying the retinal pigment epithelium and photoreceptors. Its implication in retinal diseases is gaining increasing interest. However, investigating the anatomy and flow of the choroid remains challenging. Here we show that laser Doppler holography provides high-contrast imaging of choroidal vessels in humans, with a spatial resolution comparable to state-of-the-art indocyanine green angiography and optical coherence tomography. Additionally, laser Doppler holography contributes to sort out choroidal arteries and veins by using a power Doppler spectral analysis. We thus demonstrate the potential of laser Doppler holography to improve our understanding of the anatomy and flow of the choroidal vascular network.

[A giant sacral chordoma resection and reconstruction with a gluteal perforator flap, a case report and literature review]

BACKGROUND

Sacral chordomas are rare primary bone tumors and represent more than half of all primary malignant sacral tumors. Surgical resection is the only treatment with close to 50% of remission at 10 years, with or without radiotherapy. This tissue removal can be very extensive and morbid, particularly for evolved tumors. The reconstruction mostly uses myocutaneous flaps, notably the gluteus maximus flap and the latissimus dorsi flap, increasing morbidity of the surgical procedure. To avoid a muscular sacrifice and reduce the post-surgical morbidity, we describe the case of a patient who underwent a giant sacral chordoma resection and a reconstruction with a superior gluteal artery perforator flap.

CASE REPORT

A 57-y.o. patient with a voluminous sacral chordoma had undergone a partial sacrectomy and abdomino-perineal resection. Firstly, a laparoscopy was realized to create a colostomy, to dissect an omental flap and to prepare the monobloc resection. In a prone position, the resection of the tumor was achieved and a de-epithelialized superior gluteal artery perforator flap was performed to fill the space and to support pelvic organs.

CONCLUSION

For resections of sacral chordomas, coelioscopy has considerably reduced the surgical morbidity. However, the majority of reconstructions use myocutaneous flaps, specifically gluteus maximus and latissimus dorsi, which their postural function is considerable. Muscular sacrifice can lead to functional impotence with difficulty walking and standing up and run contrary to the diminution morbidity initiated by oncologic surgeons.

In vivo laser Doppler holography of the human retina

The eye offers a unique opportunity for the non-invasive exploration of cardiovascular diseases. Optical angiography in the retina requires sensitive measurements, which hinders conventional full-field laser Doppler imaging schemes. To overcome this limitation, we used digital holography to perform laser Doppler perfusion imaging of human retina with near-infrared light. Two imaging channels with a slow and a fast CMOS camera were used simultaneously for real-time narrowband measurements, and offline wideband measurements, respectively. The beat frequency spectrum of optical interferograms recorded with the fast (up to 75 kHz) CMOS camera was analyzed by short-time Fourier transformation. Power Doppler images drawn from the Doppler power spectrum density qualitatively revealed blood flow in retinal vessels over 512 × 512 pixels covering 2.4 × 2.4 mm² on the retina with a temporal resolution down to 1.6 ms. The sensitivity to lateral motion as well as the requirements in terms of sampling frequency are discussed.

Interleukin-32 promotes detachment and activation of human Langerhans cells in a human skin explant model

BACKGROUND

Cross-talk between skin keratinocytes (KCs) and Langerhans cells (LCs) plays a fundamental role in the body's first line of immunological defences. However, the mechanism behind the interaction between these two major epidermal cells is unknown. Interleukin (IL)-32 is produced in inflammatory skin disorders. We questioned the role of IL-32 in the epidermis.

OBJECTIVES

We aimed to determine the role of IL-32 produced by KCs on surrounding LCs.

METHODS

We used an ex vivo human explant model from healthy donors and investigated the role of IL-32 on LC activation using imaging, flow cytometry, reverse transcriptase quantitative polymerase chain reaction and small interfering (si)RNA treatment.

RESULTS

Modified vaccinia virus ankara (MVA) infection induced KC death alongside the early production of the proinflammatory cytokine IL-32. We demonstrated that IL-32 produced by MVA-infected KCs induced modest but significant morphological changes in LCs and downregulation of adhesion molecules, such as epithelial cell adhesion molecule and very late antigen-4, and CXCL10 production. The treatment of KCs with IL-32-specific siRNA, and anti-IL-32 blocking antibody significantly inhibited LC activation, demonstrating the role of IL-32 in LC activation. We also found that some Toll-like receptor ligands induced a very high level of IL-32 production by KCs, which initiated LC activation.

CONCLUSIONS

We propose, for the first time, that IL-32 is a molecular link between KCs and LCs in healthy skin, provoking LC migration from the epidermis to the dermis prior to their migration to the draining lymph nodes.

Design, characterization and in vivo performance of synthetic 2 mm-diameter vessel grafts made of PVA-gelatin blends

Since the development of the first vascular grafts, fabrication of vessel replacements with diameters smaller than 6 mm remains a challenge. The present work aimed to develop PVA (poly (vinyl alcohol))-gelatin hybrids as tubes suitable for replacement of very small vessels and to evaluate their performance using a rat abdominal aorta interposition model. PVA-gelatin hybrid tubes with internal and external diameters of 1.4 mm and 1.8 mm, respectively, composed of 4 different gelatin ratios were prepared using a one-step strategy with both chemical and physical crosslinking. By 3D Time of Flight MRI, Doppler-Ultrasound, Computed Tomography angiography and histology, we demonstrated good patency rates with the 1% gelatin composition until the end of the study at 3 months (50% compared to 0% of PVA control grafts). A reduction of the patency rate during the time of implantation suggested some loss of properties of the hybrid material in vivo, further confirmed by mechanical evaluation until one year. In particular, stiffening and reduction of compliance of the PVA-gelatin grafts was demonstrated, which might explain the observed long-term changes in patency rate. These encouraging results confirm the potential of PVA-gelatin hybrids as ready-to-use vascular grafts for very small vessel replacement.