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Summary Background The face is affected in more than 50% of patients with extensive burn trauma. Effective treatment is of importance to avoid hypertrophic scarring, functional impairment and social stigmatization. Material and methods All patients treated with Acticoat7™ due to superficial and deep partial thickness burns of the face between 2008 and 2017 at the intensive care unit (ICU) for burn trauma at the Department for Plastic and Reconstructive Surgery of the Medical University of Vienna were retrospectively analyzed. Patients were evaluated for the number of required dressing changes until complete re-epithelialization, bacterial colonization, potential complications and the need for primary and secondary surgery. Results A total of 100 patients were analyzed. It took a median dressing change rate of 1 (range 0–5) in the superficial partial thickness and 3 (range 1–11) in the deep partial thickness group. Conservative treatment of deep partial thickness wounds was possible in 79% and 17% of these patients required secondary scar revision. Although bacterial colonization of the wounds frequently occurred, wound infections were rarely observed. Conclusion Acticoat7™ is a valuable dressing for treating superficial and deep partial thickness burn wounds of the face in an intensive care unit setting. It enables extended time intervals between dressing changes without an increased risk for complications.

Zusammenfassung Einleitung Hidradenitis suppurativa (HS) ist eine chronische, wiederkehrende, entzündliche Erkrankung der Haut, welche Bereiche des Körpers befällt, die reich an apokrinen Schweißdrüsen sind. Ausgedehnte Erkrankungen bedürfen oft einer chirurgischen Therapie mit antibiotischer Begleitung. Verwendete Substanzen sind etwa Clindamycin, auch in Kombination mit Rifampicin, oder Tetracycline. Für die perioperative Anwendung gibt es derzeit kaum genaue Empfehlungen. Patienten/Material und Methoden Eine anonyme Fragebogenuntersuchung wurde durchgeführt, um den Status quo der perioperativen antibiotischen Therapie zu erheben. Befragt wurden Ärztinnen und Ärzte an Abteilungen für Plastische Chirurgie, Allgemeinchirurgie und Dermatologie im deutschsprachigen Raum. Der Fragebogen wurde mit Limesurvey© erstellt und unter Vermittlung der Bundesministerien für Gesundheit an die infrage kommenden Abteilungen versandt. Die Antworten wurden mittels IBM® SPSS® Version 23 ausgewertet. Resultate Mit der antibiotischen Therapie wurde am öftesten präoperativ begonnen. Keimabstriche hatten die bedeutendste Rolle in der Auswahl der Präparate. Diese wurden ungeachtet des Verabreichungszeitpunktes großteils an die mikrobiologischen Ergebnisse angepasst. Clindamycin wurde sowohl topisch als auch systemisch am häufigsten eingesetzt. Die Kombination mit Rifampicin war die gängigste. Adalimumab war der am häufigsten verabreichte Antikörper gegen Tumornekrosefaktor-Alpha (TNF-α). In beinahe der Hälfte der Fälle wurden sie zusammen mit Antibiotika verabreicht, wobei deren Verabreichungsdauer oft deutlich länger war. Die Erkrankungsausprägung war der entscheidendste Faktor für die Notwendigkeit operativer Versorgungen. Ein großflächiges Debridement mit offener Wundbehandlung war in beinahe allen Regionen die operative Behandlungsmethode der Wahl. Schlussfolgerung Diese Studie hat gezeigt, dass große Unterschiede in der Behandlung zwischen den einzelnen Fachdisziplinen und Ländern bestehen. Sowohl die Schwere der Erkrankung, als auch die Erfahrungen und Vorlieben der Behandler selbst haben Einfluss auf die Therapie. Abhängig von der therapieführenden Fachdisziplin werden gewisse Behandlungen seltener oder gar nicht angeboten. Überarbeitete und aktuellere Leitlinien mit Integration aller behandelnden Disziplinen wären zur Vereinheitlichung der Therapie wünschenswert.

Air-fluidized therapy (AFT) has long been used in the treatment of severe burns. In patients with extensive burns involving the posterior trunk, we aim to keep affected posterior areas dry and to postpone their treatment, initially applying available split-thickness skin grafts in functionally more important regions. We retrospectively assessed the impact of AFT on the survival of patients treated in the burn intensive care unit (ICU) of the Medical University of Vienna, Austria, between 2003 and 2016.This retrospective single-center study included patients aged ≥18 years with burned total body surface area (TBSA) ≥20% and IIb-III° thermal injuries on the posterior trunk who received AFT. Survival rates were compared with those predicted by the abbreviated burn severity index (ABSI). Demographic, clinical, and surgical data were analyzed.Seventy-five of 110 patients with posterior trunk burns received AFT. Their survival rate exceeded that predicted by the ABSI score (mean ABSI, 10.0 ± 2.0; 73.3% (95% CI: 62-83%) survival rate vs. 20-40% predicted; p 0.0001); no such difference was observed in the non-AFT group (mean, 8.8 ± 1.9; 65.7% (95% CI: 48-81%) survival rate vs. 50-70% predicted). Patients receiving AFT had significantly greater TBSA (median, 50% (35-60) vs. 30% (25-45) and longer ICU stays (median, 63 (36-92) vs. 18 (9-52) days; both p 0.0001). Fifty-one (68.0%) patients in the AFT group and 26 (74.3%) patients in the non-AFT group underwent posterior trunk surgery (p = 0.66) a median of 16 (10-26) and 5 (2.5-9.5) days, respectively, after admission (p 0.0001).Patients receiving AFT had significantly better survival than predicted by ABSI score in contrast to patients not receiving AFT although burn injuries in this group were more severe (greater TBSA, higher ABSI). As intensive care was similar in these groups aside from AFT, the better survival could be attributed to this additional therapy.

Zusammenfassung Einleitung Das thermische Trauma im Kindes- und Jugendalter ist weiterhin von hoher sozioökonomischer Relevanz, da es seit Jahren zu keiner Reduktion der jährlich stationär behandelten Patienten/innen gekommen ist. Die Therapie des pädiatrischen Verbrennungspatienten stellt besondere Anforderungen an das medizinische Personal, die verwendeten Verbandsmaterialien und die angewandten Operationstechniken. Ziel dieser Studie war es einen aktuellen Überblick über das stationäre Management und die Therapie des thermischen Traumas bei pädiatrischen Patienten/innen an einer spezialisierten Klinik zu geben. Patienten/Material und Methode Kinder und Jugendliche, die zwischen 2012 und 2016 an der Kinderstation der chirurgischen Fächer der Medizinischen Universität Wien von der klinischen Abteilung für Plastische und Rekonstruktive Chirurgie bei thermischen Trauma behandelt wurden, wurden identifiziert und ihr Therapieverlauf retrospektiv analysiert. Ergebnisse 115 Patienten/innen wurden auf Grund eines akuten thermischen Traumas stationär behandelt. Das mediane Alter lag bei 2 Jahren (0–18). Die Verbrühung stellte mit 74 % den häufigsten Verletzungsmechanismus dar. Im Median zeigten sich 5 % (1–40) der Körperoberfläche betroffen. Konservatives Wundmanagement bei 2a°igem Trauma (62 %) wurde in 98 % mit MepilexAg durchgeführt und dauerte im Median 11 Tage (4–34) bis zur Abheilung. In 38 % (n = 44) lag eine 2b°ige oder 3°ige Verbrennung vor. Die Verwendung von Suprathel nach tangentialer Nekrosektomie bzw. Bürstendebridement bei oberflächlichen 2b°igen Verletzungen zeigte zufriedenstellende Heilungsverläufe. Schlussfolgerung Durch den Einsatzvon modernen Wundverbänden in der konservativen Therapie 2a°iger Wunden kann eine schnelle und unkomplizierte Abheilung mit atraumatischen Verbandswechseln erfolgen. Bei oberflächlichen 2b°igen Wunden bietet Suprathel eine gute Alternative zur klassischen Hauttransplantation, welche jedoch bei tieferen 2b°igen Verbrennungen immer noch als Therapiestandard gelten sollte. Narbenprophylaxe und regelmäßige Nachkontrollen sind wichtig um sekundäre Funktionseinschränkungen durch Narbenstränge zu vermeiden. Um zukünftig die Inzidenz des thermischen Traumas im Kindesalter zu senken ist die prophylaktische Aufklärung und Sensibilisierung der Eltern von großer Wichtigkeit.

Purpose As critical parameter after extravasation of cytotoxic vesicants, anthracyclines were determined in removed tissue from patients requiring surgical intervention due to tissue necrosis. We monitored their distribution within the affected lesion to establish a possible dose–toxicity relation. Methods From six patients scheduled for surgery, removed tissue flaps were systematically analysed by HPLC (epirubicin: 5 subjects; doxorubicin: 1 subject). Results After extravasation, tissue concentrations were highly variable with an individual anthracycline distribution pattern ranging from a few nanograms up to 17 µg per 100 mg tissue, which indicated a substantial difference in tissue sensitivity among patients. The resection borders coincided with the extension of the erythema and guided the surgical intervention after demarcation of the lesion, which occurred usually 2 or 3 weeks after extravasation. At that time, drug was hardly detected at the resection borders. Wound drains were negative for the extravasated drugs while showing a time profile of vascular growth factors and inflammatory cytokines, which was highly similar to routine surgery. In all six patients, surgical debridement with immediate wound closure led to healing within approximately 2 weeks, when therapy was resumed in all patients with reasonable time delay. Conclusion Surgical intervention after demarcation of the extravasation lesion allows for almost uninterrupted continuation of treatment independent of the amount of extravasated anthracycline. As even minor amounts of the vesicants may trigger tissue necrosis, preventive measures merit the highest priority.

Background Abdominal seroma formation after deep inferior epigastric perforator (DIEP) flap breast reconstruction is a common donor-site complication. Additional dissection of one or both of the superficial inferior epigastric veins (SIEVs) in DIEP flap breast reconstruction allows an additional anastomosis for venous superdrainage if venous congestion occurs. However, generally, SIEV dissection involves greater invasiveness into the inguinal region, which can traumatize lymphatic tissue and lead to lymph accumulation. The aim of this study was to evaluate the impact of SIEV dissection on the incidence of postoperative abdominal seroma. Methods A series of 100 consecutive cases performed by the Department of Plastic and Reconstructive Surgery at the Medical University of Vienna from 2001 to 2016 was analyzed. Patients were divided into three groups: unilateral, bilateral, and no SIEV dissection. Abdominal seroma rates, length of hospital stay, abdominal drainage duration, and drainage fluid volumes were compared retrospectively. Results Seromas were observed in 11.5 percent of patients without SIEV dissection, 17.2 percent of patients with unilateral SIEV dissection (p = 0.45 versus no SIEV), and 40 percent of patients with bilateral SIEV dissection (p = 0.02 versus no SIEV). The SIEV was anastomosed to salvage a congested DIEP flap twice. All seromas that developed could be treated with, on average, two fine-needle aspirations without any complications. Conclusions Bilateral, but not unilateral, SIEV dissection increased abdominal seroma rates significantly. Venous congestion was observed rarely, but when it did occur, it endangered flap viability. Because an additional anastomosis of the SIEV can salvage a flap, unilateral SIEV dissection should be considered when raising a DIEP flap. Clinical question/level of evidence Therapeutic, III.

BACKGROUND The transverse myocutaneous gracilis (TMG) flap is a widely used alternative to abdominal flaps in autologous breast reconstruction. However, secondary procedures for aesthetic refinement are frequently necessary. Herein, we present our experience with an optimized approach in TMG breast reconstruction to enhance aesthetic outcome and to reduce the need for secondary refinements. METHODS We retrospectively analyzed 37 immediate or delayed reconstructions with TMG flaps in 34 women, performed between 2009 and 2015. Four patients (5 flaps) constituted the conventional group (non-optimized approach). Thirty patients (32 flaps; modified group) underwent an optimized procedure consisting of modified flap harvesting and shaping techniques and methods utilized to reduce denting after rib resection and to diminish donor site morbidity. RESULTS Statistically significant fewer secondary procedures (0.6 ± 0.9 versus 4.8 ± 2.2; P

Summary Background Autologous breast reconstruction is an integral part in the treatment of breast cancer. While computed tomography angiography (CTA) is an established preoperative diagnostic tool for microsurgeons, no study has so far evaluated and compared five different imaging methods and their value for the reconstructive team. In order to determine the feasibility of each of the tools for routine or specialized diagnostic application, the methods’ efficiency and informative value were analyzed. Methods We retrospectively analyzed imaging data of 41 patients used for perforator location and assessment for regional perfusion and vessel patency in patients undergoing autologous breast reconstruction with deep inferior epigastric perforator flap (DIEP), transverse rectus abdominis muscle flap (TRAM), or transverse myocutaneous gracilis flap (TMG). Five different imaging techniques were used: hand held Doppler (HHD), CT angiography (CTA), macroscopic indocyanine green (ICG) video angiography, microscope-integrated ICG video angiography, and laser Doppler imaging (LDI). Results CTA proved to be the best tool for preoperative determination of the highly variable anatomy of the abdominal region, whereas HHD showed the same information on perforator localization with some false-positive results. Intraoperative HHD was an excellent tool for dissection and vessel patency judgment. Microscope-integrated ICG was an excellent tool to document the patency of microanastomoses. In our series, macroscopic perfusion measurement with ICG or LDI was only justified in special situations, where information on perfusion of abdominal or mastectomy flaps was required. LDI did not add any additional information. Conclusion Preoperative assessment should be performed by CTA with verification of the perforator location by HHD. Intraoperative HHD and microscope-integrated ICG contribute most toward the evaluation of vessel patency. ICG and LDI should only be used for special indications.

BACKGROUND The latissimus dorsi muscle flap represents a valuable option in breast reconstruction but can result in postoperative twitching and retraction, discomfort, arm movement limitations, and breast deformation. These complications can be avoided by denervation of the thoracodorsal nerve; however, the optimal method of nerve management is unknown. This study presents the authors' experience with the outcomes of latissimus dorsi flaps for breast reconstruction in the light of thoracodorsal nerve management strategies. METHODS The authors retrospectively collected data from 74 patients who underwent partial or total breast reconstruction with a latissimus dorsi flap alone or with an implant between January of 1999 and October of 2011. Follow-up data were collected at 12 and 24 months postoperatively. RESULTS In 56 patients (75.7 percent), the latissimus dorsi muscle was denervated at the time of surgery, whereas the thoracodorsal nerve remained intact in 18 patients (24.3 percent). No partial or total flap loss was observed. At 12 and 24 months' follow-up, all patients with an intact thoracodorsal nerve showed twitching of the muscle, and 50 percent and 67.9 percent, respectively, of the denervated patients showed twitching (p < 0.001). No patient had twitching if more than 4 cm of nerve was excised at 12 or 24 months postoperatively, and the length of nerve resection was predictive of the presence of twitching. CONCLUSION Denervation of the latissimus dorsi is a safe and reliable procedure that should be performed at the time of breast reconstruction and should include more than 4 cm to achieve a nontwitching breast with a stable volume and shape.

Management of the nipple-areola complex is an important issue in primary breast reconstruction. When nipple-sparing mastectomy is not suitable, alternatives are immediate nipple-areola complex replantation and delayed reconstruction. The aim of this study was to examine whether patients benefit more from nipple-areola complex preservation by immediate replantation or delayed nipple-areola complex reconstruction.Postoperative results and patient satisfaction after 54 primary breast reconstructions with immediate nipple-areola complex replantation or delayed nipple-areola complex reconstruction were retrospectively evaluated.The nipple-areola complex was replanted immediately in 37 cases and reconstructed later with nipple sharing and full-thickness skin grafting in 17 cases. Compared with immediate replantation, delayed reconstruction resulted in significantly better postoperative nipple projection (P = 0.01*, Mann-Whitney U test), greater similarity of color and projection with the contralateral side and greater patient satisfaction (Breast-Q). Complete loss of projection occurred in 4 of the 37 replanted nipple-areola complexes. No complete nipple-areola complex necrosis or tumor recurrence was observed in any patient.Immediate nipple-areola complex replantation is a safe and reliable procedure for selected patients with contraindications for nipple-sparing mastectomy who have a strong desire to maintain their own nipple-areola complexes, or in bilateral cases. However, drawbacks of this procedure include loss of projection and depigmentation. Delayed reconstruction with nipple sharing and full-thickness skin grafting is a good alternative, especially in unilateral cases; it leads to better postoperative results and greater patient satisfaction, but it involves a nipple-areola complex-free period.

Nipple reconstruction is of importance in achieving the best possible aesthetic outcome after breast reconstruction. Nipple sharing is a common technique; this study focused on the potential morbidity at the donor nipple. Between 2008 and 2012, 26 patients underwent nipple sharing at our institution. The donor nipple was examined before and after the procedure (mean follow-up of 21 months). Sensitivity, projection, diameter, and patient satisfaction were evaluated. The sensitivity in the donor nipple decreased, albeit insignificantly, from 1.2 g/mm2 (0.8-1.6) to 1.8 g/mm2 (0.8-4.8) (p=0.054, n=26). The projection due to graft removal decreased from 8.0 mm (6.8-10.0) to 4.5 mm (4.0-5.0) (p=0.001). Of the patients, 88% were "very satisfied" or "somewhat satisfied" with the sensitivity and 89% with the symmetry between the donor and reconstructed nipple. At least 60% of the patients were "very satisfied" with all aesthetic outcome parameters (projection, appearance, naturalness, color, and shape). All patients would agree to undergo this procedure again, if necessary. Nipple sharing was associated with minimal morbidity at the donor nipple. The postoperative projection was adequate. Regardless of whether simultaneous mastopexy was performed, the loss of sensitivity was minimal and presumably imperceptible to the patient. By using no sutures after graft removal and letting the donor nipple heal spontaneously, scarring was minimized and the natural appearance and good sensitivity of the donor nipple were preserved.

BACKGROUND: Extravasation of cytotoxic drugs is a serious complication of systemic cancer treatment. Still, a reliable method for early assessment of tissue damage and outcome prediction is missing. Here, we demonstrate that the evaluation of blood flow by indocyanine green (ICG) angiography in the extravasation area predicts for the need of surgical intervention. METHODS: Twenty-nine patients were evaluated by ICG angiography after extravasation of vesicant or highly irritant cytotoxic drugs administered by peripheral i.v. infusion. Tissue perfusion as assessed by this standardized method was correlated with clinical outcome. RESULTS: The perfusion index at the site of extravasation differed significantly between patients with reversible tissue damage and thus healing under conservative management (N = 22) versus those who needed surgical intervention due to the development of necrosis (N = 7; P = 0.0001). Furthermore, in patients benefiting from conservative management, the perfusion index was significantly higher in the central extravasation area denoting hyperemia, when compared with the peripheral area (P = 0.0001). CONCLUSIONS: In this patient cohort, ICG angiography as indicator of local perfusion within the extravasation area was of prognostic value for tissue damage. ICG angiography could thus be used for the early identification of patients at risk for irreversible tissue damage after extravasation of cytotoxic drugs.