Publications by authors named "Moustapha Hamdi"

93 Publications

Reply: Quality and Quantity-Cultured Human Mononuclear Cells Improve the Human Fat Graft Vascularization and Survival in an In Vivo Murine Experimental Model.

Plast Reconstr Surg 2021 Aug 30. Epub 2021 Aug 30.

Departments of Plastic and Reconstructive Surgery and Regenerative Therapy Juntendo University School of Medicine Tokyo, Japan.

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http://dx.doi.org/10.1097/PRS.0000000000008348DOI Listing
August 2021

Corrigendum to: Nano-Surface Implants: Indications and Limitations.

Authors:
Moustapha Hamdi

Aesthet Surg J 2021 Sep;41(10):NP1353

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http://dx.doi.org/10.1093/asj/sjab256DOI Listing
September 2021

The 10-Year Experience with Volume Distribution Mastopexy: A Novel, Safe, and Efficient Method for Breast Rejuvenation.

Plast Reconstr Surg 2021 Jul;148(1):55-64

From the Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrije Universiteit Brussel.

Background: Recurrent ptosis may occur after mastopexy procedures over time. The volume distribution mastopexy technique provides breast lifting with projection enhancement and maintains breast suspension.

Method: Since 2010, 50 patients underwent volume distribution mastopexy procedures. The technique consists of a superior or superomedial pedicle, dissection of a Würinger-septum-based chest wall flap, suspension of the flap to the pectoralis major muscle using a prosthetic mesh, gland suture to the mesh, and fat grafting if required. A prospective study was conducted. Nipple position and length of the lower pole distance of the breast were noted. Patient satisfaction and results evaluation were reported using a Likert scale.

Results: A Vicryl mesh was used in the first 23 patients and a mixed polyester/Vicryl mesh was used in the following 27 patients. Wound dehiscence occurred in one patient. At an average follow-up of 3 years, nipple position remained stable in position, but lower pole distance elongation was observed in five patients (20 percent) and in one patient (3 percent) who had Vicryl mesh and mixed mesh respectively (p < 0.05). Only four breasts (4.7 percent) demonstrated significant lower pole elongation over time (>15 percent), all in the Vicryl mesh group. Worth noting, both the patients and the independent evaluators provided high ratings of the result of 4.7 and 4.6, respectively, on a Likert scale.

Conclusions: The volume distribution mastopexy technique repositions the ptotic gland with a mesh to suspend the breast gland and to maintain the lifting effect. However, the synthetic mixed mesh proved to be significantly more effective in achieving this goal.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000008112DOI Listing
July 2021

Case Report of Two Patients With COVID-19 and Sacral Pressure Injuries Associated with Pyoderma Gangrenosum.

Adv Skin Wound Care 2021 Aug;34(8):438-443

In the Department of Plastic and Reconstructive Surgery, University Hospital Brussels, Belgium, Rania Elkhatib, MD, is Attending Physician; Gabriele Giunta, MD, FEBOPRAS, is Consultant; Valerie Hanssens, MSc, is Nurse Specialist; Ayush Kapila, MD, MRCS, is Resident; Randy De Baerdemaeker, MD, FEBOPRAS, is Consultant; Assaf Zeltzer, MD, PhD, is Consultant; and Moustapha Hamdi, MD, PhD, is Head of Department. Acknowledgment: Drs Elkhatib and Giunta contributed equally to this work. The authors have disclosed no financial relationships related to this article. Submitted September 2, 2020; accepted in revised form October 28, 2020; published online ahead of print April 16, 2021.

Abstract: During the COVID-19 pandemic, an increasing number of patients have been admitted to the ICU with severe respiratory complications requiring prolonged supine positioning. Recently, many case reports have been published regarding dermatologic manifestations associated with COVID-19. However, there is little information about the clinical features of these manifestations. Pyoderma gangrenosum (PG) is an ulcerative noninfectious inflammatory disease of the skin. In at least 50% of the cases, the etiology is unknown. Nevertheless, PG is associated with many systemic diseases. In this article, the authors report two critically ill patients with COVID-19 who developed sacral ulcers during their recovery in the ICU. These ulcers had an atypical course and were exacerbated by surgical debridements. Accordingly, providers suspected PG, which was confirmed by the clinical evolution of the ulcers and biopsies taken from the wounds. To the best of the authors' knowledge, no previous articles have reported sacral pressure injuries associated with PG in patients with COVID-19. Providers should suspect PG in patients with COVID-19 who develop nonhealing pressure injuries.
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http://dx.doi.org/10.1097/01.ASW.0000744356.54317.c2DOI Listing
August 2021

Commentary on: Scarless Composite Breast Reconstruction Utilizing an Advancement Skin Flap, Loops, and Lipofilling.

Authors:
Moustapha Hamdi

Aesthet Surg J 2021 Mar 25. Epub 2021 Mar 25.

Department of Plastic and Reconstructive Surgery, Brussels University Hospital-Vrij Universiteit Brussel (VUB), Brussels, Belgium.

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http://dx.doi.org/10.1093/asj/sjab071DOI Listing
March 2021

The "Hug Flap": Surgical Technique to Enhance the Aesthetic Breast Projection in Autologous Breast Reconstruction.

Aesthet Surg J 2021 Jan 22. Epub 2021 Jan 22.

Department of Plastic and Reconstructive Surgery, Brussels University Hospital - Vrij Universiteit Brussel (VUB), Laarbeeklaan, Brussels, Belgium.

Background: Obtaining a natural breast mound shape contributes profoundly to a symmetrical and successful outcome in breast reconstruction.

Objectives: This paper describes a new and efficient technique that enhances breast projection with natural ptosis in delayed breast reconstruction using abdominal free flaps, and compares it to the standard methods employed nowadays.

Methods: The charts of all patients who underwent delayed breast reconstruction using free abdominal perforator flaps were reviewed between 2007-2017. Three methods of breast reconstruction were compared: undermining, de-epithelialization and the "Hug flap". In the newly described technique: the caudal mastectomy skin was de-epithelialized and then the medial and lateral thirds were undermined and folded over to cover the central part (hug flap). 570 free abdominal flaps were performed in 490 patients for delayed breast reconstruction (410 unilateral breast reconstructions and 80 bilateral reconstructions).

Results: The de-epithelization technique was the most commonly used (328 cases) followed by the undermining technique (153 cases). The Hug flap technique was employed in 89 cases. The majority of Hug flaps were done in unilateral breast reconstruction. Bilateral cases were done in only 12 patients. The rate of complications and secondary corrections were analyzed and compared between the three groups. The need for additional fat grafting was significantly (p=0,003) less required in the Hug Flap group compared to the undermining and de-epithelializing groups (resp. 12% vs. 28% and 21%).

Conclusions: While all breast enhancing options can be mixed and matched based on the surgeon's preference and experience as well as each patient's needs, the Hug Flap can be considered as an adjunct tool to provide adequate flap projection and enhance breast symmetry.
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http://dx.doi.org/10.1093/asj/sjab030DOI Listing
January 2021

Is Autologous Fat Grafting an Oncologically Safe Procedure following Breast Conserving Surgery for Breast Cancer? A Comprehensive Review.

J Invest Surg 2020 Dec 11:1-10. Epub 2020 Dec 11.

The London Breast Institute, Princess Grace Hospital, London, UK.

Background: Autologous fat grafting (AFG) is a recognized surgical procedure to correct deformities following breast conservation surgery (BCS) for breast cancer. However, there are concerns about the oncological safety of this technique. In this study we have reviewed the current literature to assess whether AFG adversely influences the oncological outcome after BCS for breast cancer.

Methods: We have searched the medical literature using the Embase and PubMed search engines from conception until May 2019 to identify all relevant studies of patients who underwent AFG after BCS. Meta-analysis and meta-regression methodologies were used to calculate the overall relative risk (RR) of loco-regional recurrence (LRR) rates for case-control and case series studies (with historical controls) respectively.

Results: We have identified 26 eligible studies with a total of 1640 patients who had undergone fat transfer after lumpectomy for breast cancer. The meta-analysis of 11 studies revealed an overall RR for LRR of 0.82 [95% confidence interval (CI):0.14-1.66]. The meta-regression of case series revealed an overall incidence of LRR of 1.85% compared with 2.53% for historical controls.

Conclusions: Our study lends further support to the notion that fat transfer after lumpectomy for breast cancer does not seem to increase the risk of LRR. However further prospective research is required in order to confirm this.
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http://dx.doi.org/10.1080/08941939.2020.1852343DOI Listing
December 2020

Decreasing donor site morbidity after groin vascularized lymph node transfer with lessons learned from a 12-year experience and review of the literature.

J Plast Reconstr Aesthet Surg 2021 03 24;74(3):540-548. Epub 2020 Oct 24.

Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrije Universiteit Brussel (VUB), UZB - Laarbeeklaan 101, 1090 Brussels, Belgium.

Introduction: Donor site morbidity related to vascularized lymph node transfer (VLNT) remains a cause of worry among surgeons. As such, our study explores donor site morbidity after VLNT with or without concomitant deep inferior epigastric artery perforator (DIEP) flap breast reconstruction. Furthermore, we evaluate our surgical approach to ascertain whether it reduces the morbidity rate.

Materials And Methods: A retrospective chart review of donor site complications and surgical techniques was performed from 2006 to 2018. The patients' medical histories and demographic data were analyzed for risk factors. Patients were contacted by telephone for a long-term follow-up questionnaire. A literature review was implemented to evaluate the reported donor site complications and surgical strategies in literature. Complications were evaluated with and without concomitant autologous breast reconstruction (DIEP flap).

Results: Eighty-nine patients were included in our case series. Sixty-five cases (73%) were combined with DIEP flap breast reconstruction. Seroma rate diminished from 60% in the first 39 cases to 18% in the last five years (50 cases) (p < 0,001). Lymphedema of the afferent lower limb is described in the literature but did not occur in our series.

Conclusions: Seroma formation is the most common donor site morbidity after groin VLNT flap harvest, particularly when combined with DIEP flap breast reconstruction. This paper contains the largest reported series of combined VLNT + DIEP flaps and describes surgical strategies on how to decrease seroma formation and avoid iatrogenic lymphedema of the lower limb.
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http://dx.doi.org/10.1016/j.bjps.2020.10.012DOI Listing
March 2021

Quality and Quantity-Cultured Human Mononuclear Cells Improve Human Fat Graft Vascularization and Survival in an In Vivo Murine Experimental Model.

Plast Reconstr Surg 2021 02;147(2):373-385

From the Department of Plastic and Reconstructive Surgery, Juntendo University School of Medicine; and the Department of Plastic and Reconstructive Surgery, Vrije Universiteit Brussel, Universitair Ziekenhuis Brussel.

Background: Fat graft ischemia impedes us from having satisfying long-term results. The quality and quantity culture is a 1-week cell culture that increases the vasculogenic potential of peripheral blood mononuclear cells (PBMNC). This in vivo murine model investigates whether enrichment with quality and quantity-cultured human mononuclear cells (MNC-QQ) improves the vascularization in the human fat graft and whether this decreases the tissue loss.

Methods: Human adipose tissue, PBMNC, MNC-QQ, and stromal vascular fraction were prepared. First, PBMNC, MNC-QQ, and stromal vascular fraction were compared in vitro for vasculogenic potential by endothelial progenitor cell colony-forming and culture assays. Second, 0.25-g fat grafts were created with 1 × 106 PBMNC (n = 16), 1 × 106 MNC-QQ (n = 16), 1 × 106 stromal vascular fraction (n = 16), or phosphate-buffered saline as control (n = 16) before grafting in BALB/c nude mice. Grafts were analyzed for weight persistence, vessel formation by CD31 immunohistochemistry, and angiogenic markers by quantitative polymerase chain reaction.

Results: MNC-QQ develop more definitive endothelial progenitor cell colonies and more functional endothelial progenitor cells compared to PBMNC and stromal vascular fraction. Weight persistence after 7 weeks was significantly higher in grafts with MNC-QQ (89.8 ± 3.5 percent) or stromal vascular fraction (90.1 ± 4.2 percent) compared with control (70.4 ± 6.3 percent; p < 0.05). MNC-QQ-enriched grafts had the highest vessel density (96.6 ± 6.5 vessels/mm2; control, 70.4 ± 5.6 vessels/mm2; p < 0.05). MNC-QQ exerted a direct vasculogenic effect through vascular integration and a potential paracrine vascular endothelial growth factor-mediated effect.

Conclusion: Quality and quantity-cultured human mononuclear cells containing endothelial progenitor cells stimulate fat graft vascularization and enhance graft survival in a rodent recipient.
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http://dx.doi.org/10.1097/PRS.0000000000007580DOI Listing
February 2021

Nano-Surface Implants: Indications and Limitations.

Authors:
Moustapha Hamdi

Aesthet Surg J 2021 07;41(8):NP1141-NP1142

Brussels University Hospital - Vrij Universiteit Brussel (VUB), Brussels, Belgium.

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http://dx.doi.org/10.1093/asj/sjaa265DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8279309PMC
July 2021

Letter to the Editor: A Comprehensive Review of Medicinal Leeches in Plastic and Reconstructive Surgery.

Plast Reconstr Surg Glob Open 2020 Aug 14;8(8):e2997. Epub 2020 Aug 14.

Department of Plastic and Reconstructive Surgery Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium.

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http://dx.doi.org/10.1097/GOX.0000000000002997DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7489649PMC
August 2020

The Impact of Coronavirus Disease 2019 on Plastic Surgery Training: The Resident Perspective.

Plast Reconstr Surg Glob Open 2020 Jul 1;8(7):e3054. Epub 2020 Jul 1.

Department of Plastic and Reconstructive Surgery, University Hospital (UZ) Brussels, Brussels, Belgium.

The coronavirus disease 2019 (COVID-19) pandemic has led to marked changes in surgical training, including that of plastic surgery residents. We performed a survey to gain an insight into the self-reported current and future impact of COVID-19 on plastic surgery residents.

Methods: A 20-point questionnaire was designed by a panel of surgical trainees and trainers, which was filled in by Belgian plastic surgery residents and their international network of peers between 19 and 26 April 2020-week 6 of stringent Belgian lockdown measures. Questions covered the impact of COVID-19 on surgical activity, surgical training, and the future of training.

Results: Thirty-five of 38 plastic surgery residents in Belgium filled in the questionnaire, as did 51 of their international peers from 9 other countries. Decreased surgical activity of >75% was reported by 86% of Belgian trainees and by 73% of international colleagues. All consultations were stopped for 26% of Belgian trainees and 37% of international peers. Forty-six percents of Belgian trainees and 27% of international peers were reassigned to different departments. Eighty-five percent of all trainees felt surgical training had suffered, yet 54% of Belgian residents and 39% of international peers felt training should not be prolonged. Anxiety regarding the pandemic was present in 54% of Belgian residents and 69% of international colleagues.

Conclusions: This is the first report, expressing the voice of a representative group of plastic surgery residents, showing a significant impact of COVID-19 on training and activity. A joint effort is needed to provide continued forms of education by virtual education and skills-based learning.
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http://dx.doi.org/10.1097/GOX.0000000000003054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413754PMC
July 2020

Low-Energy Extracorporeal Shockwave Therapy as a Therapeutic Option for Patients with a Secondary Late-Stage Fibro-Lymphedema After Breast Cancer Therapy: A Pilot Study.

Lymphat Res Biol 2021 04 11;19(2):175-180. Epub 2020 Aug 11.

Lymphology Clinic & European Center of Lymphatic Surgery, UZ Brussels, Brussels, Belgium.

Secondary lymphedema (LE) can occur after breast cancer (BC) therapy with axillary lymph node surgery and/or radiotherapy. Reported incidence varies around 20%. The aim of this study was to see whether low-energy extracorporeal shockwave therapy (ESWT) is a therapeutic option in end-stage secondary upper limb fibro-LE. A pilot study was performed on 10 adult patients who presented with an end-stage LE after BC treatment. They were all treated with usual physical therapy and all had lymphatic surgery before. Eight sessions of ESWT were applied, 2600 shocks at 0.1 mJ/mm, 2/week during 4 weeks. Upper limb volume decreased nonsignificantly, from 3086.4 ± 539.47 to 2909.1 ± 471.60 mL. Mean circumference of the upper limb was significantly decreased from 32.3 ± 3.01 to 31.4 ± 2.71 cm at the height of the upper arm, from 29.1 ± 2.89 to 28.1 ± 2.71 cm at the height of the elbow, and from 27.5 ± 4.08 to 26.8 ± 3.75 cm at the height of the forearm. Subjective measurements by visual analog scale showed significant decrease in both hardness from 57.3 ± 15.84 to 24.4 ± 21.89 mm and subjective feeling of edema from 44.2 ± 16.90 to 23.2 ± 21.16 mm. No adverse features were reported. We added some evidence that low-energy ESWT is well supported and has additional benefits also in longstanding fibro-lipo-LE on swelling of the arm leading to more subjective comfort for the patients.
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http://dx.doi.org/10.1089/lrb.2020.0033DOI Listing
April 2021

Comments on "The use of lower abdominal perforator flaps in soft-tissue reconstruction after sarcoma resection".

Microsurgery 2020 Oct 7;40(7):829-830. Epub 2020 Aug 7.

Department of Plastic and Reconstructive Surgery, University Hospital Brussels (VUB), Brussels, Belgium.

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http://dx.doi.org/10.1002/micr.30636DOI Listing
October 2020

Perforator Mapping Practice for Deep Inferior Epigastric Artery Perforator Flap Reconstructions: A Survey of the Benelux Region.

J Reconstr Microsurg 2021 Feb 29;37(2):111-118. Epub 2020 Jul 29.

Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Vrij Universiteit Brussel, Brussels, Belgium.

Background:  Numerous new and novel imaging techniques for preoperative perforator selection in deep inferior epigastric artery perforator (DIEP) flap planning have been introduced. To what extent, these have been adopted into or replaced routine practice has hitherto remained unknown. The purpose of this study was to identify the currently preferred technique by reconstructive surgeons, the criteria that they regard as most relevant and what impact these have on the preoperative decision-making.

Methods:  An online survey consisting of 25 questions was sent to members of the Benelux Societies for Plastic Surgery. Information regarding experience and preferred imaging modality was requested. Specific questions addressed the utilization of computed tomography angiography (CTA) and factors that could inform preoperative perforator selection. Results were anonymously collected, managed using REDCap, and analyzed using Chi-square statistic.

Results:  Seventy-nine principal surgeons could be included. A variation in surgeon experience was observed. On CTA, the preferred imaging modality, large-caliber vessels, the location of the perforator in the flap, and its intramuscular course were considered the most significant criteria. Surgeons doing more than 20 DIEP flaps per year are less concerned about the distance of the perforator from the umbilicus ( = 0.003) but more likely to choose a medial perforator ( = 0.011). No statistical difference was found in surgeons' experience between those who would choose and use one specific (medial or lateral) perforator when they are analogous on CTA, and those who would delay the decision until both perforators have been exposed.

Conclusion:  Advantages and disadvantages of the current practice of preoperative perforator selection by surgeons who are primarily responsible for harvesting a DIEP flap have been clearly identified. Indications are that these could be widely representative in which case, the quest for a protocol or modality that maximizes the benefit and minimizes harm in preoperative perforator mapping is urgently required.
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http://dx.doi.org/10.1055/s-0040-1714427DOI Listing
February 2021

The "ART" of facial filler injections: Avoid, recognize, and treat hyaluronic acid-induced complications.

J Cosmet Dermatol 2020 Sep 2;19(9):2229-2236. Epub 2020 Aug 2.

Department of Plastic and Reconstructive Surgery, Universitair Ziekenhuis Brussel (UZ Brussel), Brussels, Belgium.

Background: Hyaluronic acid (HA) fillers are frequently used for cosmetic purposes as volumizers or as wrinkle fillers. One of the major advantages of hyaluronic acid use is the possibility to neutralize it by using hyaluronidase should complications occur.

Patient: A case of a 21-year-old female patient is presented, in whom a hyaluronic acid injection-induced vascular occlusion was seen four days after the initial injection, with increasing pain and severe signs of ischemia.

Method: Treatment consisted of an immediate hyaluronidase injection, supplemented with administration of acetylsalicylic acid, piracetam, low molecular weight heparin (LMWH), corticosteroids, analgesics, prophylactic antibiotics, application of topical nitroglycerin and warmth, smoking cessation, and hyperbaric oxygen therapy.

Results: The initial progress and evolution of the deformity with possible therapeutic options are being discussed.

Conclusion: The "ART" (avoid, recognize, and treat) in handling filler complications is presented, as a new universal guideline for clinical aesthetic practitioners and injectors.
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http://dx.doi.org/10.1111/jocd.13611DOI Listing
September 2020

Anterograde Flow Rerouting in Venous Supercharged DIEP Flap.

J Reconstr Microsurg 2018 Jul 23;34(6):e5. Epub 2019 Oct 23.

Department of Plastic and Reconstructive Surgery, University Hospital Brussels (VUB), Brussels, Belgium.

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http://dx.doi.org/10.1055/s-0039-1700557DOI Listing
July 2018

A Rare Case of KID Syndrome: The Use of Hydrosurgery and Strategies for Antiseptic Wound Care.

Adv Skin Wound Care 2019 10;32(10):1-6

In the Department of Plastic and Reconstructive Surgery, Brussels University Hospital, Brussels, Belgium, Ayush K. Kapila, MBBS, MD, MRCS, is a resident; Randy De Baerdemaeker, MD, is a consultant plastic surgeon; Fadi Bakal, MD, is a resident; Valerie Hanssens, MSc, is a specialist wound care nurse; Jeannine Spinael, MSc, is a specialist wound care nurse; Benoit Hendrickx, MD, PhD, is a consultant plastic surgeon; Assaf Zeltzer, MD, PhD, is a consultant plastic surgeon; and Moustapha Hamdi, MD, PhD, is Chief. The authors have disclosed no financial relationships related to this article. Submitted December 25, 2018; accepted in revised form May 20, 2019.

A 14-year-old girl with a history of keratitis-ichthyosis-deafness (KID) syndrome, a rare autosomal dominant condition, was referred to the Department of Plastic Surgery at Brussels University Hospital in June 2016 for progressively worsening inguinoperineal ulceration exacerbated by overapplication of combination drug treclinax (tretinoin and erythromycin). On assessment, a large area of purulent papillomatous hyperkeratosis with follicular plugging, likely superimposed bacterial colonization, and deep ulceration were noted requiring thorough debridement.A first procedure was performed in June 2016 with hydrosurgical debridement (Versajet IITM; Smith & Nephew, Forth Worth, Texas). During the procedure, significant blood loss was noted, and topical adrenaline, blood transfusion, and a short ICU stay were required for monitoring during which the patient remained hemodynamically stable. The wound was primarily dressed with an antimicrobial barrier silver dressing; meropenem, ceftazidime, and fluconazole were started to treat for Gram-negative, Gram-positive, and anaerobic bacilli, as well as Pseudomonas aeruginosa and fungal infections in situ. A further three debridements were required 6, 12, and 26 days after the initial procedure. The patient was discharged 36 days after admission without any antibiotics and with an outpatient wound care plan.Not only was this case rare, but it also reflected the importance of a careful approach when tackling KID syndrome's cutaneous manifestations. Multiple debridements, thorough wound care, and appropriate antibiotic therapy may be required to achieve local healing and a satisfactory result. Hydrosurgical debridement offered a precise and well-controlled method for treating a large ulcerating hyperkeratotic urogenital lesion in this pediatric patient.
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http://dx.doi.org/10.1097/01.ASW.0000580480.86585.3aDOI Listing
October 2019

Quality and Quantity-Cultured Murine Endothelial Progenitor Cells Increase Vascularization and Decrease Fibrosis in the Fat Graft.

Plast Reconstr Surg 2019 Apr;143(4):744e-755e

From the Plastic and Reconstructive Surgery Department, Juntendo University School of Medicine; and the Plastic and Reconstructive Surgery Department, Universitair Ziekenhuis Brussel (University Hospital Brussels), Vrije Universiteit Brussel.

Background: Fat grafting has become a valuable technique for soft-tissue reconstruction; however, long-lasting success depends on several determinants. An early blood supply to the transplanted adipocytes is important to prevent ischemia. The recently developed quality and quantity (QQ) culture increases the vasculogenic potential of endothelial progenitor cells. The authors used a murine fat grafting model to address the hypothesis that QQ-cultured endothelial progenitor cells stimulate the establishment of a blood vessel network and increase graft success.

Methods: c-KitSca-1Lin (KSL) cells were isolated as endothelial progenitor cell precursors from C57BL/6 mice. Adipose tissue was grafted with QQ-cultured KSL cells (QQKSL group), uncultured KSL cells (KSL group), adipose-derived stem cells (ASC group), and a combination (QQKSL+ASC group), and compared to a control group. Five and 10 weeks later, grafts were weighed, histologic and immunohistochemical parameters were evaluated, and gene expression was quantified by quantitative polymerase chain reaction.

Results: The highest vessel density was observed in the combined QQKSL+ASC group (68.0 ± 4.3/mm; p < 0.001) and the QQKSL group (53.9 ± 3.0/mm; p < 0.001). QQKSL cells were engrafted in proximity to the graft vasculature. QQKSL cells decreased the fibrosis percentage (13.8 ± 1.8 percent; p < 0.05). The combined QQKSL+ASC group (22.4 ± 1.8/mm; p < 0.001) showed the fewest local inflammation units. A significant up-regulation of platelet-derived growth factor and adiponectin expression was observed in the QQKSL group and QQKSL+ASC group. Graft weight persistence was not significantly different between groups.

Conclusions: Supplementing fat grafts with quality and quantity-cultured endothelial progenitor cells improves graft quality by stimulating vascularization. The increased vessel density is associated with less fibrosis, less inflammation, and better adipose tissue integrity. Enriching fat grafts with QQ-cultured endothelial progenitor cells is a potential solution to their clinical shortcomings.
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http://dx.doi.org/10.1097/PRS.0000000000005439DOI Listing
April 2019

Association Between Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL) Risk and Polyurethane Breast Implants: Clinical Evidence and European Perspective.

Authors:
Moustapha Hamdi

Aesthet Surg J 2019 01;39(Suppl_1):S49-S54

Plastic and Reconstructive Surgery Department, and Director of Lymph Clinic, Brussels University Hospital - Vrij Universiteit Brussel (VUB), Brussels, Belgium.

This article aims to present an overview on the use of polyurethane (PU) breast implants and the possible association with the risk of developing breast implant-associated anaplastic large cell lymphoma (BIA-ALCL), with a special look at the current situation in Europe. It is well known that the real cause of BIA-ALCL remains unknown. Although this is a rare disease, many interesting theories surrounding its development have been advanced; however, none of these theories has been able to demonstrate with statistical significance, as required by the criteria of evidence-based medicine, definitive clinical proof as to why BIA-ALCL develops. It is widely assumed that the implant surface plays a crucial role. Most BIA-ALCL cases are associated with macro-textured implants, but from a strictly scientific point of view, this link is not supported by any clear clinical evidence. A deeper discussion of the various implant surfaces indicates that adding further categories to the existing surface classification (smooth, micro-, and macro-textured) should be avoided. Moreover, one of the most common misunderstandings should be clarified: PU breast implants cannot be classified as macro-textured implants. The PU foam that covers breast implants provides a completely different surface, and the mechanisms of action related to tissue adhesion, as well as to fibrous capsule formation, differ substantially from those of smooth or textured implants.
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http://dx.doi.org/10.1093/asj/sjy328DOI Listing
January 2019

Clinicians Should Actively Promote Exercise in Survivors of Breast Cancer.

Clin Breast Cancer 2018 10 18;18(5):e747-e749. Epub 2018 Jun 18.

The Breast Unit, Princess Alexandra Hospital, Harlow, United Kingdom.

Breast cancer is the most common cancer affecting women, causing 29% of all female cancers and afflicting 14% of all female cancer-related deaths worldwide. It remains a significant clinical, psychological, and financial burden. Exercise has been suggested to reduce cancer recurrence and cancer-related mortality from research in the past decade. Recent American and European guidelines advise on exercise for breast cancer survivors, not only to improve quality of life and decrease fatigue, but also to aid in decreasing recurrence and improve breast cancer related mortality. Nonetheless, adherence to guidelines remains low, with lack of awareness and fatigue related to chemotherapy as the most common barriers. It remains to be elucidated whether a particular type of exercise, or whether group or individualized activity is most effective. The importance of exercise in avoiding recurrence and improving quality of life needs to be recognized and taken into account in the management of breast cancer survivors. Further patient awareness and education is essential towards this goal, and the role of group exercise should be further explored.
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http://dx.doi.org/10.1016/j.clbc.2018.06.008DOI Listing
October 2018

MR lymphography in patients with upper limb lymphedema: The GPS for feasibility and surgical planning for lympho-venous bypass.

J Surg Oncol 2018 Sep 16;118(3):407-415. Epub 2018 Aug 16.

Department of Radiology and Medical Imaging, University Hospital Brussels (VUB), Brussel, Belgium.

Background And Objectives: Lymphedema is caused by insufficient lymphatic drainage leading to abnormal accumulation of interstitial fluid within soft tissues. Lympho-venous anastomosis (LVA), as a surgical option for selected patients, is widely applied. Through preoperative localization of functional lymphatics with indocyanine green, real time visualization of functioning lymphatic vessels is possible. This examination is time consuming and operator dependant and is not suitable to differentiate the ratio of fat hypertrophy to liquid edema. We investigated whether MR lymphangiography is accurate for imaging functional lymphatics and adjacent veins in arms. Furthermore, we investigated the accuracy and predictability of preoperative mapping for the feasibility of performing LVA and the preoperative decision making in lymphedema surgery.

Methods: A prospective study was performed in which 25 patients suffering from lymphedema of the upper extremity were examined. MR lymphography with contrast agent injection in a deep dermal plane was performed.

Results: Precise localization of lymphatic vessels crossing a vein was achieved in 18 of 25 arms. In 16 of the 18 patients in whom functional lymphatics were localized with an adjacent vein on MRI an LVA was performed successfully.

Conclusions: MR lymphangiography is an accurate and reproducible method for imaging and mapping of lymphatic channels in the lymphedemateous limb.
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http://dx.doi.org/10.1002/jso.25145DOI Listing
September 2018

A Review of Lymphedema for the Hand and Upper-Extremity Surgeon.

J Hand Surg Am 2018 Nov 19;43(11):1016-1025. Epub 2018 May 19.

Department of Plastic and Reconstructive Surgery, University Hospital Brussels (VUB), Brussels, Belgium.

Secondary lymphedema of the upper limb is frequently seen in Western countries after cancer treatment (most often breast in women). It is a chronic disease that affects quality of life and functioning. In its extreme form, it may be debilitating. A review is given of the pathology, nonsurgical treatment, and surgical treatment with a protocol.
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http://dx.doi.org/10.1016/j.jhsa.2018.03.054DOI Listing
November 2018

Deep inferior epigastric artery perforator flap harvest after full abdominoplasty.

Acta Chir Belg 2019 Oct 1;119(5):322-327. Epub 2018 Mar 1.

Department of Plastic and Reconstructive Surgery, University Hospital Brussels, Vrije Universiteit Brussel (VUB) , Brussels , Belgium.

Abdominal scars are no longer a contra-indication for abdominal perforator flap harvesting. Few research data exists about the regeneration potential of the abdominal wall's perforator system. Therefore, previous abdominoplasty with umbilical transposition is an absolute contra-indication for a DIEaP-flap (deep inferior epigastric artery perforator flap). A 50-year-old patient required a breast reconstruction of the right breast, 10 years after an abdominoplasty with undermining of the superior abdomen and umbilical transposition. The patient was scheduled for a free lumbar artery perforator (LaP) flap. The preoperative computed tomography-angiography mapping showed nice lumbar perforators and to our surprise a good-sized DIEa perforator in the peri-umbilical region. The DIEa perforator on the right hemi-abdomen, consisting of two veins and one artery, was pulsatile and found suitable in size. A classical flap harvest and transfer was further performed. This case report is the first in which a dominant perforator is found in the area of undermining after a full abdominoplasty with umbilical repositioning. Further investigations regarding the nature and timing of re-permeation or regeneration of perforators after abdominoplasty are to be done. Nevertheless, we are convinced that with appropriate perforator mapping and a suitable plan B, previous abdominoplasty is no longer an absolute but a relative contra-indication for performing DIEaP-flap.
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http://dx.doi.org/10.1080/00015458.2018.1442966DOI Listing
October 2019

The 'WiFi' otoplasty : Combined concentric posterior microchondrectomies and sutures for correction of prominent ears.

J Plast Reconstr Aesthet Surg 2018 06 19;71(6):900-905. Epub 2018 Feb 19.

Melbourne Institute of Plastic Surgery, 253, Wattletree Road, Malvern, Victoria 3144, Australia. Electronic address:

Background: Prominent ears are by far the most common congenital ear deformity. Many techniques have been described using one or a combination of 3 basic methods: cartilage cutting, cartilage weakening and pure cartilage shaping techniques. The ideal otoplasty technique should yield a natural correction of the deformity, with low recurrence rates and with little risk of complications.

Methods: A new cartilage shaping technique using closing wedge concentric microchondrectomies through an entirely posterior approach is presented. Between 2006 and 2017, 200 bilateral otoplasties using this 'WiFi' pattern technique were performed. This technique combined with Mustarde sutures is based on the excision of concentric partial thickness cartilage wedges designed in the pattern of the WiFi symbol.

Results: There were no major complications such as anterior skin necrosis and no returns to theatre for infections or haematomas. 3 patients (1.5%) had complete recurrence of the deformity and 10 patients (5%) had to undergo a minor revision for recurrence at the upper pole. 5 patients have had exposure of the end of the permanent upper pole scapho-temporal suture more than 3 months after surgery requiring simple outpatient suture trimming/removal without any recurrence of results. Palpable or bridging sutures were present upon clinical examination in 10 patients (5%) but did not require revision surgery.

Conclusions: Here, we describe a fast, safe and reliable technique for otoplasty with no need for extensive dissection, which is applicable to the full range of deformity.
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http://dx.doi.org/10.1016/j.bjps.2018.01.030DOI Listing
June 2018

Percutaneous Purse-String Suture: An Innovative Percutaneous Technique for Inframammary Fold Creation and Improved Breast Projection in Reconstructive Surgery.

Aesthet Surg J 2018 Nov;38(12):1298-1303

Department of Plastic and Reconstructive Surgery, University Hospital Brussels, Vrije Universiteit Brussel, Brussels, Belgium.

Background: Lipofilling for breast reconstruction has become increasingly common. Creation of a well-defined inframammary fold (IMF) is integral to achieving symmetrical aesthetic results. This has traditionally been done under direct vision through an open incision.

Objectives: The authors present their experience in reconstructive breast surgery with a novel percutaneous technique for IMF creation and improvement of projection without the need for large incisions.

Methods: From June 2011 to January 2015, 180 patients underwent a percutaneous purse-string suture (PPSS) to enhance their IMF and improve breast projection. After completion of lipofilling, a curved cannula is tunneled subcutaneously. The suture is placed into the cannula and passed around the circumference of the breast footprint. After the completion of two passes in different anatomic levels around the footprint, the suture is tightened at the breast's tail zone to achieve the desired IMF definition and breast projection. Surgical technique, results, and follow up are presented.

Results: The PPSS technique was combined either with lipofilling only or as part of flap breast reconstruction in 30 and 150 patients, respectively. The average follow-up time was 34 months (range, 11-48 months). PPSS was redone in 25 patients to further improve breast projection. One patient complained of postoperative pain. No other PPSS-related complication was reported.

Conclusions: PPSS is an innovative technique designed to complement the emerging field of lipofilling for breast reconstruction. The technique is safe, easily reproduced, and provides excellent results. Breast IMF and projection are immediately improved without the need for open incisions.

Level Of Evidence 4:
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http://dx.doi.org/10.1093/asj/sjx190DOI Listing
November 2018

The vascularized groin lymph node flap (VGLN): Anatomical study and flap planning using multi-detector CT scanner. The golden triangle for flap harvesting.

J Surg Oncol 2017 Sep 25;116(3):378-383. Epub 2017 May 25.

Universitair Ziekenhuis Brussel, Brussels, Belgium.

Introduction: A growing number of surgeons perform lymph node transfers for the treatment of lymphedema. When harvesting a vascularized lymph node groin flap (VGLNF) one of the major concerns is the potential risk of iatrogenic lymphedema of the donor-site. This article helps understanding of the lymph node distribution of the groin in order to minimize this risk.

Materials And Methods: Fifty consecutive patients undergoing abdominal mapping by multi-detector CT scanner were included and 100 groins analyzed. The groin was divided in three zones (of which zone II is the safe zone) and lymph nodes were counted and mapped with their distances to anatomic landmarks. Further node units were plotted and counted.

Results: The average age was 48 years. A mean number of nodes of 6.5/groin was found. In zone II, which is our zone of interest a mean of 3.1 nodes were counted with a mean size of 7.8 mm. In three patients no nodes were found in zone II. In five patients nodes were seen in zone II but were not sufficient in size or number to be considered a lymph node unit. On average the lymph node unit in zone II was found to be 48.3 mm from the pubic tubercle when projected on a line from the pubic tubercle to the anterior superior iliac spine, 16.0 mm caudal to this line, and 20.4 mm above the groin crease. On average the lymph node unit was a mean of 41.7 mm lateral to the SCIV-SIEV confluence.

Conclusion: This study provides increased understanding of the lymphatic anatomy in zone II of the groin flap and suggests a refined technique for designing the VGLNF. As with any flap there is a degree of individual patient variability. However, having information on the most common anatomy and flap design is of great value.
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http://dx.doi.org/10.1002/jso.24682DOI Listing
September 2017

Lumbar Artery Perforator Flap: An Anatomical Study Using Multidetector Computed Tomographic Scan and Surgical Pearls for Breast Reconstruction.

Plast Reconstr Surg 2016 Aug;138(2):343-352

Brussels, Belgium.

Background: Breast reconstruction with the lumbar artery perforator flap is indicated in patients with unfavorable abdominal donor site. In addition to their clinical experience with lumbar artery perforator free flap breast reconstruction, the authors present an anatomical study of the origin and course of the perforators.

Methods: Images of multidetector computerized tomography scans were used to visualize the location of the dominant lumbar artery perforator in 20 patients. The medical files of the authors' patients who underwent lumbar artery perforator flap breast reconstruction were also analyzed.

Results: Multidetector computed tomographic imaging in 20 female patients with a mean age of 47 years revealed an equal number of dominant perforators (10 left and 10 right); 60 percent were third lumbar artery perforators, 30 percent were fourth, and the remaining were second. The dominant perforators were mainly located 42.6 mm from the y axis at their origin at the transverse process, and 69.5 mm when emerging in the subcutaneous tissue. Six patients had nine successful lumbar artery perforator flaps for breast reconstruction. Average operative time was 270 minutes. Due to shortness of pedicle and mismatching between diameter of lumbar artery and internal mammary artery, vascular bypass (harvested from the deep inferior epigastric vessels) was required in 50 percent of the cases. The major complication at the donor site was seroma (80 percent).

Conclusions: The lumbar artery perforator has a constant anatomical location. The free lumbar artery perforator flap provides an ample amount of tissue for breast reconstruction; however, its major disadvantages are the small artery diameter, shortness of the pedicle, and high seroma rate at the donor site.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000002347DOI Listing
August 2016

Breast Cancer-Related Lymphedema: Quality of Life after Lymph Node Transfer.

Plast Reconstr Surg 2016 Jun;137(6):1673-1680

Brussels, Belgium.

Background: Breast cancer-related lymphedema affects multiple aspects of patients' daily lives. The main aim of this study was to assess the impact of vascularized lymph node transfer on the quality of life in patients with lymphedema.

Methods: Between 2007 and 2012, 25 female patients with breast cancer-related lymphedema underwent vascularized lymph node transfer. In 22 cases, the patients underwent a simultaneous deep inferior epigastric artery perforator flap breast reconstruction based on the superficial circumflex iliac artery. The influence on quality of life was evaluated using the Upper Limb Lymphedema-27 questionnaire, which includes physical, psychological, and social dimensions. The authors also investigated risk factors for lymphedema, such as body mass index, smoking, age, and time between start of lymphedema and vascularized lymph node transfer, and their impact on quality of life.

Results: Twenty-one patients (84 percent) had an improvement of quality of life after vascularized lymph node transfer. The mean physical, psychological, and social scores were significantly improved postoperatively (p < 0.001). Risk factors for the development of lymphedema did not influence quality of life among patients with breast cancer-related lymphedema. Skin infections disappeared in 50 percent of the cases. Eleven patients (44 percent) discontinued compression therapy at a mean postoperative time interval of 29 months (range, 8 to 64 months). In the other patients (56 percent), the average frequency of compression therapy decreased from three sessions to one session per week.

Conclusion: Vascularized lymph node transfer significantly improves quality of life among patients with breast cancer-related lymphedema.

Clinical Question/level Of Evidence: Therapeutic, IV.
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http://dx.doi.org/10.1097/PRS.0000000000002169DOI Listing
June 2016

TUGs into VUGs and Friendly BUGs: Transforming the Gracilis Territory into the Best Secondary Breast Reconstructive Option.

Plast Reconstr Surg 2016 May;137(5):900e-901e

Plastic and Reconstructive Surgery Department, Brussels University Hospital, Vrije Universiteit Brussel, Brussels, Belgium.

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http://dx.doi.org/10.1097/PRS.0000000000002091DOI Listing
May 2016
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