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Elia R, Chen HC, Cazzato G, Di Summa PG, Giudice G, Maruccia M. Evaluation of modulation of immunity by lymph node transfer: A preliminary histological evidence in lymphedema patients. Microsurgery 2024; 44:e31123. [PMID: 37788091 DOI: 10.1002/micr.31123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 09/07/2023] [Accepted: 09/21/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND The exact knowledge of the local biological and immunological effects of vascularized lymph node transfer (VLNT) continues to be an emerging science but a positive control positive control over infectious and immune-mediated processes is often advocated. Knowing the characterization of the inflammatory infiltrate associated with lymphedema, the aim of this paper is to verify the hypothesis that VLNT is able to modulate the inflammatory and immune microenvironment of lymphedematous tissue by evaluating any modification of the local inflammatory cell infiltrate. PATIENTS AND METHODS A prospectively database of patients who received VLN transfer for lower extremity lymphedema between January 2018 and December 2020 was reviewed. Nine patients diagnosed with extremities' stage II secondary lymphedema were included, with a mean age of 55.3 (range 39-66 years) years. Gastroepiploic lymph node transfer was performed in all patients and transferred heterotopically. Full thickness 6-mm skin punch biopsies were obtained from all voluntary lymph node transfer patients at identical sites of the lymphedematous limb during the surgical procedure of VLNT (T0) and 1 year later (T1). Immunohistochemistry was performed using antibodies against the following markers: anti-CD3; anti-CD4; anti-CD8; anti-CD68. Data at T0 were compared to those at T1. RESULTS Post-operative course was uneventful in all cases experiencing a significant reduction (almost a third) in terms of cellulitis episodes: The median duration of follow-up for patients was 28.3 months (range 12-40). The analysis of the density of the inflammatory cells as a whole revealed a significant reduction at T1 compared to T0. Specifically, CD3 expression levels turned from 16.36 ± 3.421 (cells/mm2 ) pre-operatively to 7.6 ± 1.511 (cells/mm2 ) post-operatively (p < .0001). CD4+ cells turned from 7.270 ± 3.421 (cells/mm2 ) at T0 to 4.815 ± 1.511 cells/mm2 at T1 (p = .0173). CD8 expression values decreased from 4.360 ± 3.421 (cells/mm2 ) to 2.753 ± 1.451 (cell/mm2 ) at T1 (p = .0003). Monocyte/macrophage marker CD68 varied from 8.208 ± 2.314 (cells/mm2 ) at T0 to 7.600 ± 1876 (cells/mm2 ) at T1 (p = .0003). CONCLUSION VLNT decreases skin and subcutaneous tissues' infiltration of inflammatory cells, providing one explanation for the positive control of lymph node transfer procedure over infectious and immune-mediated processes.
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Affiliation(s)
- Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Gerardo Cazzato
- Section of Pathology, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, University of Bari "Aldo Moro", Bari, Italy
| | - Pietro G Di Summa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy
| | - Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy
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Di Summa PG, de Schoulepnikoff C, Guillier D, Cigna E, Jiga LP, Jandali Z, Vezza D, Giacalone F, Ciclamini D, Battiston B, Elia R, Maruccia M. Orthoplastic limb reconstruction using free fibula flap after trauma: Outcomes from a retrospective European multicenter study. Microsurgery 2024; 44:e31054. [PMID: 37170919 DOI: 10.1002/micr.31054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 03/08/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023]
Abstract
BACKGROUND Free vascularized fibula flap represents the gold standard vascularized bone graft for the management of segmental long bone defects after traumatic injury. The current study represents the largest retrospective multicenter data collection on the use of free fibula flap (FFF) for extremities' orthoplastic reconstruction after trauma aiming to highlight current surgical practice and to set the basis for updating current surgical indications. METHODS The study is designed as a retrospective analysis of prospectively collected data between 2009 and 2021 from six European University hospitals. Patients who underwent fibula flap reconstruction after acute traumatic injury (AF) or as a late reconstruction (LF) after post-traumatic non-union of upper or lower limb were included. Only extra-articular, diaphyseal fracture were included in the study. Surgical data were collected. Time to bone healing and complications were reported as clinical outcomes. RESULTS Sixty-two patients were included in the study (27 in the AF group and 35 in the LF group). The average patients' age at the time of the traumatic event was 45.3 ± 2.9 years in the AF group and 41.1 ± 2.1 years in the LF group. Mean bone defect size was 7.7 ± 0.6 cm for upper limb and 11.2 ± 1.1 cm (p = .32) for lower limb. Bone healing was uneventful in 69% of treated patients, reaching 92% after complementary procedures. Bone healing time was 7.6 ± 1.2 months in the acute group and 9.6 ± 1.5 months in the late group. An overall complication rate of 30.6% was observed, with a higher percentage of late bone complications in the LF group (34%), mostly non-union cases. CONCLUSIONS FFF reconstruction represents a reliable and definitive solution for long bone defects with bone healing reached in 92% cases with a 8.4 months of average bone healing time.
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Affiliation(s)
- Pietro G Di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - Camille de Schoulepnikoff
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | - David Guillier
- Department of Plastic and Maxillo-facial Surgery, University Hospital of Dijion, Dijion, France
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, Plastic Surgery Unit, University of Pisa, Pisa, Italy
| | - Lucian P Jiga
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Zaher Jandali
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Daniele Vezza
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Francesco Giacalone
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Davide Ciclamini
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Bruno Battiston
- Department of Orthopaedics and Traumatology, University of Turin, CTO, Turin, Italy
| | - Rossella Elia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Michele Maruccia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
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Maruccia M, Tedeschi P, Caizzi G, Palmiotto F, Di Summa PG, Vicenti G, Moretti B, Giudice G, Elia R. Graft and Flap: Orthoplastic Approach to Achilles Tendon Secondary Rupture. Plast Reconstr Surg 2023; 152:1359-1364. [PMID: 37092978 DOI: 10.1097/prs.0000000000010566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
SUMMARY Achilles tendon rupture represents one of the most common tendon ruptures. Although primary repair remains the treatment of choice, surgical complications, such as secondary rupture and tendon exposure, require salvage procedures. This article aims to present the authors' orthoplastic approach for the functional reconstruction of composite secondary Achilles tendon defects. Seven patients with chronic open-wound and large Achilles tendon defects (Kuwada type IV) underwent one-stage reconstruction between October of 2018 and October of 2020. The size of the average soft-tissue defect was 126.2 cm 2 (range, 86.1 to 175.9 cm 2 ), with a tendon gap of 8.2 cm (range, 7.1 to 10.3 cm). A combined team of orthoplastic surgeons performed the reconstructive procedure, using a turndown gastrocnemius fascial flap and a fascia lata autograft for the tendon reconstruction and a free fasciocutaneous anterolateral thigh flap for soft-tissue coverage (graft and flap). Subjective evaluation and quality-of-life measures were obtained preoperatively and 12 months postoperatively using the American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey questionnaire. Mean follow-up was 18.3 months (range, 12 to 24 months). The flap survival rate was 100%. Overall range of motion of the reconstructed side was 87% of the unaffected side (54 degrees versus 62 degrees). The American Orthopedic Foot and Ankle Score and 36-Item Short-Form Health Survey scores of all patients improved significantly ( P < 0.005) at 12 months of follow-up. A microsurgical approach combined with orthopedic techniques can solve complex cases of Achilles tendon secondary rupture, providing a reconstructed tendon that achieves satisfactory anatomic shape and function. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Michele Maruccia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Pasquale Tedeschi
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Gianni Caizzi
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro"
| | - Florianna Palmiotto
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro"
| | - Pietro G Di Summa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois, University of Lausanne
| | - Giovanni Vicenti
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro"
| | - Biagio Moretti
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, University of Bari "Aldo Moro"
| | - Giuseppe Giudice
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
| | - Rossella Elia
- From the Division of Plastic and Reconstructive Surgery, Department of Emergency and Organ Transplantation, University of Bari
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Maruccia M, Elia R, De Cosmo A, Cigna E, Tedeschi P, Bolletta A, Manrique OJ, Ciudad P, Di Summa PG, Cherubino M, Giudice G. The medial sural artery perforator flap for retromolar trigone reconstruction: A multicenter case series. Microsurgery 2023; 43:546-554. [PMID: 36805669 DOI: 10.1002/micr.31026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 01/07/2023] [Accepted: 02/02/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Retromolar trigone (RMT) cancer is a rare malignancy, which develops in a narrow area of the oral cavity. Surgical intervention requires wide excision and appropriate reconstruction usually with a free tissue transfer. Little has been published regarding the ideal microvascular reconstruction, mainly focusing on radial forearm and anterolateral thigh free flap. The medial sural artery perforator flap (MSAP) is not new for head and neck reconstruction but its use for RMT reconstruction has not been previously explored. The purpose of the study is to present a multicentric case series investigating the reliability of MSAP flap for RMT reconstruction. METHODS The study is designed as a retrospective case series. All patients diagnosed with RMT cancer and undergone surgical resection and immediate reconstruction with a MSAP flap between February 2016 and March 2020 were identified. Patients' demographics and surgical details were collected. Functional results were evaluated using the Head and Neck Module of the European Organization for Research and Treatment of Cancer at 12 months of follow-up. A total of 34 patients with a mean age of 58 years were included in the study. An average defect size of 31.5 cm2 was observed after RMT tumor resection. RESULTS The MSAP flaps' average dimensions were 11 ± 3.1 cm in length and 4.7 ± 1.6 cm in width with a mean thickness of 1.4 ± 0.8 cm. No flap complications were observed in 28 cases; four patients developed an orocutaneous fistula. One patient needed surgical revision for venous congestion while only one case of flap failure was observed. At 12 months of follow-up, 87% of the patient cohort had normal, understandable speech. No patient experienced complete loss of swallowing. Results of the H&N35 module showed a significative postoperative improvement in mouth soreness, mouth opening and social (p < .05*). No patient complained difficulty in motility at the donor site. CONCLUSIONS The MSAP flap appears to be appropriate for RMT reconstruction and could be considered the workhorse for small to medium size defect of RTM region. It has a long pedicle of matching caliber and provides adequate tissue volume with minimal donor site morbidity.
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Affiliation(s)
- Michele Maruccia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Rossella Elia
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Alessio De Cosmo
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Emanuele Cigna
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Pasquale Tedeschi
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
| | - Alberto Bolletta
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Oscar J Manrique
- Division of Plastic Surgery, Department of Surgery, University of Rochester, Rochester, New York, USA
| | - Pedro Ciudad
- Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima, Peru
| | - Pietro G Di Summa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Mario Cherubino
- Division of Plastic and Reconstructive Surgery, Department of Biotechnology and Life Sciences, University of Insubria, Varese, Italy
| | - Giuseppe Giudice
- Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area, University of Bari Aldo Moro, Bari, Italy
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Maruccia M, Tedeschi P, Corrao C, Elia R, La Padula S, Di Summa PG, Maggio GMM, Giudice G. Meek Micro-Skin Grafting and Acellular Dermal Matrix in Pediatric Patients: A Novel Approach to Massive Extravasation Injury. J Clin Med 2023; 12:4587. [PMID: 37510702 PMCID: PMC10380205 DOI: 10.3390/jcm12144587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/03/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: Extravasation injuries in pediatric patients can lead to significant harm if they are not promptly diagnosed and treated. However, evidence-based standardization on extravasation management remains limited, particularly for extensive wound necrosis. This case report presents the management of an 8-week-old premature patient with an extensive extravasation injury involving the right forearm and dorsum of the hand. (2) Methods: The patient was evaluated by a multidisciplinary team in our Neonatal Intensive Care Unit. Surgical intervention involved the debridement of necrotic tissues, followed by temporary coverage with an acellular dermal matrix. Definitive coverage was achieved through Meek micrografting after three weeks. Physical therapy was provided with pre- and post-rehabilitation range of motion assessed using goniometric measurements. Scar quality was evaluated using the Vancouver Scar Scale. (3) Results: The engraftment rate of the Meek micrografts was 93%, with 16 out of 226 micrografts lost. The patient achieved a Vancouver Scar Scale score of 6, indicating a moderate degree of scarring. Significant improvements in elbow, wrist, and finger joint range of motion were observed at a 1-year follow-up. (4) Conclusions: Close observation and heightened awareness of extravasation risks by trained personnel are crucial. Meek micrografting combined with dermal substitute coverage represents an innovative approach to managing extravasation wounds in pediatric patients.
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Affiliation(s)
- Michele Maruccia
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Piazza Giulio Cesare, 70121 Bari, Italy
| | - Pasquale Tedeschi
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Piazza Giulio Cesare, 70121 Bari, Italy
| | - Claudia Corrao
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Piazza Giulio Cesare, 70121 Bari, Italy
| | - Rossella Elia
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Piazza Giulio Cesare, 70121 Bari, Italy
| | - Simone La Padula
- Department of Plastic and Reconstructive Surgery, Università degli Studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Pietro G Di Summa
- Department of Plastic and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne (UNIL), 1015 Lausanne, Switzerland
| | - Giulio M M Maggio
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Piazza Giulio Cesare, 70121 Bari, Italy
| | - Giuseppe Giudice
- Division of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari Aldo Moro, Piazza Giulio Cesare, 70121 Bari, Italy
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Di Summa PG, Schiraldi L, Cherubino M, Oranges CM, Kalbermatten DF, Raffoul W, Madduri S. Adipose Derived Stem Cells Reduce Fibrosis and Promote Nerve Regeneration in Rats. Anat Rec (Hoboken) 2018; 301:1714-1721. [PMID: 29710394 PMCID: PMC6667902 DOI: 10.1002/ar.23841] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 12/31/2017] [Accepted: 01/27/2018] [Indexed: 01/17/2023]
Abstract
Peripheral nerve regeneration is critical and challenging in the adult humans. High level of collagen infiltration (i.e., scar tissue), in the niche of injury, impedes axonal regeneration and path finding. Unfortunately, studies focusing on the modulation of scar tissue in the nerves are scarce. To address part of this problem, we have evaluated the differentiated adipose derived stem cells (dASCs) for their antifibrotic and regenerative effects in a 10 mm nerve gap model in rats. Three different animal groups (N = 5) were treated with fibrin nerve conduits (empty), or seeded with dASCs (F + dASCs) and autograft, respectively. Histological analysis of regenerated nerves, at 12 weeks postoperatively, reveled the high levels of collagen infiltration (i.e., 21.5% ± 6.1% and 24.1% ± 2.9%) in the middle and distal segment of empty conduit groups in comparison with stem cells treated (16.6% ± 2.1% and 12.1% ± 2.9%) and autograft (15.0% ± 1.7% and 12.8% ± 1.0%) animals. Thus, the dASCs treatment resulted in significant reduction of fibrotic tissue formation. Consequently, enhanced axonal regeneration and remyelination was found in the animals treated with dASCs. Interestingly, these effects of dASCs appeared to be equivalent to that of autograft treatment. Thus, the dASCs hold great potential for preventing the scar tissue formation and for promoting nerve regeneration in the adult organisms. Future experiments will focus on the validation of these findings in a critical nerve injury model. Anat Rec, 301:1714–1721, 2018. © 2018 The Authors. The Anatomical Record published by Wiley Periodicals, Inc. on behalf of American Association of Anatomists
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Affiliation(s)
- Pietro G Di Summa
- Department of Plastic, Reconstructive and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Luigi Schiraldi
- Department of Plastic, Reconstructive and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Mario Cherubino
- Department of Biotechnology, University of Insubria, Varese, Italy
| | - Carlo M Oranges
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel 4031, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel 4031, Switzerland
| | - Wassim Raffoul
- Department of Plastic, Reconstructive and Hand Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne, Switzerland
| | - Srinivas Madduri
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Basel 4031, Switzerland.,Department of Biomedicine, University of Basel, Basel 4031, Switzerland.,Department of Biomedical Engineering, University of Basel, Allschwil 4123, Switzerland
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