Abdominoplasty in a Patient With Type 3 von Willebrand Disease: A Case Report

ABSTRACT

von Willebrand disease (vWD) is an inherited bleeding disorder that is characterized by a quantitative or qualitative deficiency of the von Willebrand factor (vWF). Type 3 is the most severe form of vWD with a near-complete absence of vWF and a significantly increased risk of excessive bleeding and hematoma during a surgical procedure. To date, no data on surgical and hemostatic management of a type 3 vWD patient undergoing body-contouring surgery has been published. We report the case of a 47-year-old woman with type 3 vWD requiring medically indicated abdominoplasty after massive weight loss due to bariatric surgery. The case was successfully managed with individualized bodyweight-adapted substitution of recombinant vWF vonicog alfa and tranexamic acid under close monitoring of vWF and factor VIII activity. For further risk stratification, we propose the multidisciplinary treatment of patients with severe vWF undergoing elective plastic surgery in specialized centers providing around-the-clock laboratory testing and access to a blood bank. In addition, strict hemostasis during surgery and early postoperative mobilization with fitted compression garments are recommended to further reduce the risk of bleeding and thromboembolic complications.

Artificial decellularized extracellular matrix improves the regenerative capacity of adipose tissue derived stem cells on 3D printed polycaprolactone scaffolds

Ideal tissue engineering frameworks should be both an optimal biological microenvironment and a shape and stability providing framework. In this study we tried to combine the advantages of cell-derived artificial extracellular matrix (ECM) with those of 3D printed polycaprolactone (PCL) scaffolds. In Part A, both chondrogenic and osteogenic ECMs were produced by human adipose derived stem cells (hASCs) on 3D-printed PCL scaffolds and then decellularized to create cell free functionalized PCL scaffolds, named acPCL and aoPCL respectively. The decellularization resulted in a significant reduction of the DNA content as well as the removal of nuclei while the ECM was largely preserved. In Part B the bioactivation and the effect of the ac/aoPCL scaffolds on the proliferation, differentiation, and gene expression of hASCs was investigated. The ac/aoPCL scaffolds were found to be non-toxic and allow good adhesion, but do not affect proliferation. In the in vitro investigation of cartilage regeneration, biochemical analysis showed that acPCL scaffolds have an additional effect on chondrogenic differentiation as gene expression analysis showed markers of cartilage hypertrophy. The aoPCL showed a large influence on the differentiation of hASCs. In control medium they were able to stimulate hASCs to produce calcium alone and all genes relevant investigated for osteogenesis were significantly higher expressed on aoPCL than on unmodified PCL. Therefore, we believe that ac/aoPCL scaffolds have a high potential to improve regenerative capacity of unmodified PCL scaffolds and should be further investigated.

[Economic aspects of interdisciplinary plastic surgery: change in Diagnosis-Related Groups (DRG) due to procedures of reconstructive microsurgery]

BACKGROUND

 Advances in reconstructive microsurgery have led to significant improvements in the surgical care of complex interdisciplinary cases. At the same time, however, this also increases the resource expenditure of the plastic surgeon involved. This study aimed to analyse the relationship between increase in revenue and resource expenditure in reconstructive microsurgery at a university hospital of maximum care with regard to the treatment of interdisciplinary patients.

METHODS

 In 2018 and 2019, all cases of interdisciplinary cooperation were followed up at one location of a plastic surgery department of a university clinic. The interdisciplinary surgical cases were identified from the collective and evaluated prospectively with regard to inpatient treatment days, surgical resource expenditure and economic development (DRG before and after microsurgical reconstruction).

RESULTS

 In 2018 and 2019, a total of 68 free microsurgical flaps were performed in 64 interdisciplinary cases. 62 of these cases met the criteria for interdisciplinary surgical treatment. Considering the contribution of plastic surgery to the economic development and the associated resource expenditure, there is a significant increase in all parameters (p < 0.0001). Thus, the Case Mix Index (CMI) rose by 20.2 %, inpatient treatment days by 79.1 %, the number of surgical interventions by 62.4 %, cumulative incision-suture time by 131.4 % and total surgeon hours by 75.4 %.

CONCLUSION

 Reconstructive microsurgical procedures lead to a significant increase in revenue in interdisciplinary surgical cases. However, a significant increase in resource consumption is observed as well. Moreover, these additional costs are not always adequately reflected in the revenue of the DRG. This especially applies to DRGs with a high initial cost weight. To ensure modern, individual, patient-oriented and guideline-compliant patient care, there is, therefore, an urgent need to adapt the (G-)DRG system to the additional resource consumption. In addition, in the case of interdisciplinary surgical cases, a clear internal cost allocation must be carried out in accordance with the surgical resource expenditure.

Influence of software parameters on measurements in automatized image-based analysis of fat tissue histology

The understanding of fat tissue plays an eminent role in plastic surgery as well as in metabolic research. Histopathological analysis of tissue samples provides insight in free fat graft survival and culture experiments help to better understand fat tissue derived stem cells (ASCs). To facilitate such experiments, modern image-based histology could provide an automatized approach to a large amount of data to gain not only qualitative but also quantitative data. This study was designed to critically evaluate image-based analysis of fat tissue samples in cell culture or in tissue probes and to identify critical parameters to avoid bias in further studies. In the first part of the study, ASCs were harvested and differentiated into adipocytes in cell culture. Histology was performed with the fluorescent dye BODIPY and the obtained digital images were analyzed using Image J software. In the second part of the study, digitalized histology of a previous in vivo study was subjected to automatized fat vacuole quantification using Image J. Both approaches were critically reviewed, and different software parameter settings were tested. Results showed that automatized digital image analysis allows the quantification of fat tissue probes with enough precision giving significant results. But the testing of different software parameters revealed a significant influence of parameters themselves on calculated results. Therefore, we recommend the use of image-based analysis to quantify fat tissue probes to improve the comparability of studies. But we also emphasize to calibrate software using internal controls in every single experimental approach.

[An algorithmic approach for diagnosis and treatment of breast implant-associated anaplastic large cell lymphoma]

Elective surgeries, especially aesthetic operations in plastic surgery, require surgeons to provide a holistic and comprehensive explanation of possible procedural risks and long-term consequences. Recently, the use of breast implants for aesthetic breast augmentation or breast reconstruction after tumour resection has gained public attention as the numbers of patients with rare breast implant-associated diseases have been rising worldwide, while the aetiopathogenesis remains unclear. BIA-ALCL was classified as a lymphatic neoplasm by the World Health Organization in 2016. Meanwhile, almost 800 cases have been documented, especially in patients that received textured implants. This malignant disease has led to a great level of uncertainty and scepticism in patients and the public. Hence, it is a central task of plastic surgeons to understand this rare disease, to recognise it at an early stage and help those affected by clear recommendations for action. The following manuscript summarises current approaches for diagnosis and treatment.

Addition of decellularized extracellular matrix of porcine nasal cartilage improves cartilage regenerative capacities of PCL-based scaffolds in vitro

Composite scaffolds can improve regenerative capacities of scaffolds in various tissue-engineering approaches. In order to generate a 3D printable scaffold that is capable of cartilage regeneration, decellularized extracellular matrix (DECM) of porcine nasal cartilage was added to 3D printed polycaprolactone (PCL) scaffolds. Subsequently, scaffolds (PCL, PCL/DECM and DECM) were seeded with human primary nasoseptal chondrocytes and differentiated with cartilage inductive medium for up to 42 days in vitro. Afterwards samples were analyzed with scanning electron microscopy, histology, biochemical assays and gene expression analysis. In short, results showed cell attachment and proliferation on all scaffolds. There was a trend towards ossification on pure PCL scaffolds, whereas we found evidence for cartilage tissue formation on DECM scaffolds as well as on PCL/DECM scaffolds. Moreover, biochemical analysis indicated an enhanced differentiation on novel PCL/DECM scaffolds. In conclusion, the addition of DECM to 3D printable PCL scaffolds may yield a new composite material for regenerative approaches in cartilage for facial reconstructive surgery. Further research will be necessary to evaluate these findings in vivo.