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Background The interest in youthful appearance and rejuvenating procedures is unbroken in our society. Besides surgical procedures, permanent fillers are utilized. The incorrect and unprofessional use of these substances, auto-injections in particular, have devastating results for patients and are challenging for the plastic surgeon. The aim of this retrospective study was to delineate the differences between permanent and non-permanent filler complications and appropriate treatment options. Methods We conducted a retrospective study and researched the hospital information system in the time period from 2001 to 2020. Patients with unprofessional use of permanent fillers, auto-injections and injections of unformulated substances were determined. Age, gender, localization, complications, length of hospital stay, comorbidities, histopathological workups and surgical salvage procedures were noted. Descriptive statistics were calculated. Results Seventeen patients were identified from 2001 till 2020. In four cases, auto-injections by the patients were the cause, whereas in the other patients the injections were performed by medical staff. Ages range from 18 to 57 years. Fourteen patients were female and three were male. The injected substances could be recognized as synthol, silicone, vaseline, fat tissue, hyaluronic acid as well as non-medical substances. Surgical procedures were necessary in eleven cases. One patient died because of the underlying diseases. Conclusion Our results indicate different sequels of filler materials injected in an unprofessional way, possible complications, conservative and surgical techniques to resolve these rare complications. We suggest a staged therapy adjusted to the clinical symptoms. Milder symptoms can be handled conservatively, whereas severe infections, skin breakdowns or persistent granuloma are justifying indications for surgical treatment. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Infections of the hand and forearm are a frequently seen surgical emergency of the hand. Patients of all age groups are affected and underlying systemic diseases are risk factors. Posttraumatic causes are the leading cause of infections. This includes cuts and stab wounds, animal and human bites but often also minor injuries. Due to the anatomical peculiarities of the hand, rapid progression of initially inconspicuous infections can occur resulting in functional limitations. If an infection is suspected, a symptom-oriented evaluation by a hand surgeon should be performed. This includes a detailed patient history, clinical examination, laboratory analyses and imaging. This is followed by the development of an individualized and interdisciplinary treatment concept with the aim of achieving the shortest possible rehabilitation period. The treatment includes surgical cleansing of the infection, accompanied by antibiotic treatment taking the expected possible spectrum of pathogens into account. Cephalosporins and aminopenicillins in combination with beta-lactamase inhibitors are the antibiotics of first choice. Follow-up treatment includes early functional exercise under the guidance of a hand therapist to minimize postinfectious restrictions in the range of motion and to enable occupational rehabilitation. In rare cases, fulminant necrotizing infections with resulting skin and soft tissue defects can occur. In these cases, secondary plastic reconstruction is usually required after cleansing of the infection.

Attempted suicide by self-immolation or burning constitutes an uncommon form of attempted suicide in high income countries, presenting substantial challenges to burn units. The aim of this study was to analyze the epidemiologic characteristics and outcomes in intensive care burn patients treated for attempted suicide by burning. For this purpose, we examined intensive care burn patients admitted to a single major burn unit between March 2007 and December 2020. Demographic, clinical, epidemiological, and mortality data were collected and analyzed. Major psychiatric comorbidities were evaluated according to ICD-9 and ICD-10 classifications. A total of 1325 intensive care unit burn patients were included. Suicide by burning was attempted in 45 cases (3.4%). Attempted suicide victims presented with significantly higher burn severity, reflected by higher abbreviated burn severity index scores, and larger TBSA affected. Burned TBSA ≥30% and inhalation injuries were observed more frequently in suicidal patients. These patients also experienced prolonged hospital and intensive care unit length of stay, required surgical interventions and mechanical ventilation more frequently, and had significantly longer periods on ventilation, causing an overall higher mortality rate (24.4%). Psychiatric comorbidities were present in 75.6% of patients who attempted suicide. Despite the low prevalence, burn severity and mortality are considerably high in patients who attempted suicide by burning, presenting a significant challenge for healthcare providers. The majority of patients had a history of psychiatric disorder, highlighting the importance of identifying patients at high-risk who may profit from increased psychiatric intervention.

Purpose Therapeutic success of surgical interventions is significantly affected by patients’ adherence. Patient autonomy can lead to unreasonable behavior. We analyzed the consequences and predisposing factors of patient self-discharge in a plastic and hand surgery cohort. Study design and setting Data was collected retrospectively in a case–control study with n = 73 patients who had self-discharged in a 10-year time period and n = 130 controls (discharge by the surgeon). Data was collected through the hospital information systems and a particular questionnaire. Statistical analyses were performed via chi-squared test and logistic regression analyses. Results Patients who self-discharged against medical advice had a significantly higher complication rate (p = 0.045) and a higher number of revision operations (p p p = 0.002; OR 5.387 (1.734–16.732)) or had to take care of their children at home (p = 0.006; OR 1.481 (1.280–1.741)). There was a significantly lower pain score (NAS) on time of self-discharge (p = 0.002) as well as 24 h after self-discharge (p Conclusion Self-discharge was associated with predisposing factors and poorer outcomes. Patient autonomy can lead to health-compromising behavior and patients should be counseled accordingly.

Burn injuries can be life-threatening, thus standardized procedures are essential to ensure the best medical care is provided after injury. Therefore, burn care guidelines were created throughout the world. There are many similarities within the different burn guidelines, especially in basic burn care procedures. Taking a closer look, it becomes clear that there are also a lot of disparities within the guidelines. In this review the guidelines of the German Society of Burn Treatment (DGV), British Burn Association (BBA), European Burns Association (EBA), American Burn Association (ABA), Australian and New Zealand Burn Association (ANZBA), and the International Society for Burn Injuries (ISBI) are compared. The DGV-guidelines focus on pre-hospital treatment measures, intensive care treatment and acute wound therapy, whereas the BBA puts emphasis on infrastructure and staff qualification. The EBA created guidelines for medical practitioners and non-medical staff to standardize burn care in European countries with special focus on clear treatment recommendations and best infrastructural facilities. The ABA underlines the need for best qualified medical staff and ABLS- (Advanced Burn Life Support) standards. The ANZBA focuses on best treatment options including novel wound healing biotechnologies and post-burn return-to-function rehabilitation. In contrast to all other guidelines, the ISBI does not only deal with burn care in developed countries but also in resource-limited settings. Special focus lies on the discussion of ethical issues and cost-effectiveness. In this review, advantages and disadvantages of each guideline are discussed. These findings are supposed to help improving burn care procedures worldwide.

Lymphadenectomy is a surgical procedure in which lymph nodes are surgically resected. It is usually carried out for oncological surgical treatment of various malignant diseases. These include carcinomas of the breast, penis, vulva and anus as well as malignant melanomas and the broad field of sarcomas. A distinction is made between the removal of regional lymph nodes, the sentinel lymph node and the radical removal of lymph nodes in a body region. Cervical, axillary, inguinal and iliac lymph nodes are clinically relevant. The strategy of sentinel lymph node dissection, in which the first lymph node in the drainage system is resected and histopathologically examined for malignant tissue, has brought decisive advantages for the patients, as radical lymphadenectomy with its severe morbidities is utilized in fewer cases. This can improve the patient's quality of life by sparing the lymphatic drainage pathways and reducing lymphedema, inflammation and wound healing disorders. In addition, a lymphadenectomy may be indicated as part of palliative interventions. Another form of lymph node removal is the vascularized lymph node transplantation, which is used for reconstructive purposes in lymphedema. Therefore lymph node grafts are transferred to the site where lymph nodes were previously removed. This review presents the current status of lymphadenectomy in accordance with the German guidelines, anatomical knowledge and specific indications for axillary, inguinal and iliac lymphadenectomy. In addition, an overview of vascularized lymph node transfer is given.Die Lymphadenektomie stellt ein chirurgisches Verfahren dar, bei dem Lymphknoten operativ reseziert werden. Sie wird üblicherweise zur onkologisch-chirurgischen Therapie verschiedener maligner Erkrankungen durchgeführt. Zu diesen zählen u. a. das Mamma‑, Penis‑, Vulva‑, Analkarzinom sowie das maligne Melanom und das breite Feld der Sarkome. Es wird differenziert zwischen der Entfernung regionaler Lymphknoten, des Sentinel-Lymphknotens sowie einer radikalen Entfernung kompletter Lymphknoten einer Körperregion. Klinisch relevant sind die zervikale, axilläre, inguinale und iliakale Lymphadenektomie. Die Strategie der Entfernung des Sentinel-Lymphknotens, bei der der erste Lymphknoten im Abflusssystem reseziert und histopathologisch auf Tumorgewebe untersucht wird, hat entscheidende Vorteile für die Patient:innen gebracht, da eine radikale Lymphadenektomie mit den entsprechenden Morbiditäten onkologisch seltener notwendig ist. Dies kann die Lebensqualität der Patient:innen durch Schonung der Lymphabflusswege sowie durch eine Reduktion von Lymphödemen, Entzündungen und Wundheilungsstörungen verbessern. Zusätzlich kann im Rahmen palliativer Eingriffe eine Lymphadenektomie indiziert sein. Eine weitere Form der Lymphknotenentfernung stellt das vaskularisierte Lymphknotentransplantat dar, welches für rekonstruktive Zwecke bei Lymphödemen genutzt wird. Hier werden Lymphknotentransplantate an den Ort transferiert, an dem zuvor eine Lymphknotenentfernung erfolgte. In diesem Beitrag sollen der aktuelle, leitliniengerechte Stand der Lymphadenektomie, anatomische Kenntnisse sowie gezielte Indikationen für die axilläre, inguinale sowie iliakale Lymphadenektomie und den vaskularisierten Lymphknotentransfer dargestellt werden.

Background In painful epicondylitis, previous studies reported deficiencies in elbow proprioception. In line, proprioceptive training of the lower limb has been reported substantial beneficial in a number of indications. Therefore, we have asked if a specified proprioceptive training using training devices that are capable of activating the deep musculature in the upper limb is able to reduce the symptoms of epicondylitis. Materials and methods We included 71 patients with painful lateral epicondylitis > 3 months. Interventions: Group A: Proprioceptive training intervention with a Flexibar® (9 min daily for 12 weeks). Group B: at least 40 min running or walking/week with the XCO® in addition to the proprioceptive training with the Flexibar® (9 min daily for 12 weeks), follow-up for 12 weeks. Primary end point: Pain on visual analogue scale (VAS, 0-10); secondary end points: DASH-Score (0 = very good, 100 = very poor), grip strength according to Jamar dynamometer (kg), vibration sensation measured with a 128 Hz tuning fork. Results The pain on VAS in group A was reduced significantly. 3.6 ± 2.0 to 2.4 ± 2.1 (−33%, p = 0.013), and from 3.7 ± 2.4 to 2.2 ± 1.9 (−41%, p = 0.004) in group B after 12 weeks. There was no significant difference between A and B (p = 0.899). In both groups, there was a significant improvement of the DASH-Score (A: 32 ± 15 to 14 ± 12, −56%, p < 0.001; B: 27 ± 12 to 12 ± 11, −55%, p = 0.001) without any difference between groups A and B (p = 0.339). Grip strength improvement in group A from 24 ± 12 to 33 ± 11 kg (+38%, p < 0.001), and from 29 ± 14 to 34 ± 11 kg (+15%, p < 0.001) in group B. In line, vibration sensation improved in both groups (A: 6.3 ± 0.6 to 6.5 ± 0.5, p = 0.0001; B: 6.3 ± 0.7 to 6.6 ± 0.5, p = 0.003). Conclusion A 12-week proprioceptive training with the Flexibar® improves pain, quality of life, grip strength and vibration sensation in patients with painful lateral epicondylitis. Level of evidence Ib, randomised clinical trial Trial registration German Clinical Trials Register, DRKS00024857, registered on 25 March 2021—retrospectively registered, http://apps.who.int/trialsearch/

Globally, burn-related morbidity and mortality still remain high. In order to identify regional high-risk populations and to suggest appropriate prevention measure allocation, we aimed at analyzing epidemiological characteristics, etiology and outcomes of our 14-year experience with an intensive care unit (ICU) burn patient population.A retrospective observational study was conducted including patients treated between March 2007 and December 2020 in our intensive care burn unit. Demographic, clinical and epidemiological data were collected and analyzed.A total of 1359 patients were included. 68% of the subjects were males and the largest age group affected entailed 45-64-year-old adults (34%). Regarding etiology, flame and contact burns were the most common in all age groups. Mean affected total body surface area (TBSA) was 13 ± 14.5% in all subjects. Most of the burns occurred domestically or during recreational activities. Mean hospital stay was 17.77 ± 19.7 days. The average mortality was 7.7%. The mortality rate showed an overall decreasing trend whilst burn severity remained consistent from 2007 to 2020.Despite consistent burn severity presentations of annual ICU admissions, burn injury mortality showed a decreasing trend, which was in part attributed to substantial progress in burn care and treatment and improved burn prevention awareness. Statistically significant age and gender differences could be detected with regard to burn etiology and seasonality, as well as outcomes, which highlight the importance of individualized primary prevention programs.

Background The aesthetic long-term stability in shape, symmetry, and natural appearance of an aesthetically augmented breast remains a constant challenge. It has become clear that the results depend strongly on the technique applied and the experience of the surgeon. An ongoing controversy concerns the positioning of the implants. Subglandular, submuscular, partial submuscular, and subfascial pockets have different tradeoffs and advantages. However, secondary deformity, unnatural feel, and appearance are not addressed uniformly. The aim of the following study was to establish a standard procedure allowing for the desired and reproducible results to provide long-term stability and aesthetic quality. Methods The authors have developed a standardized dissection of a dynamic implant pocket. In this approach, a submuscular dissection with lower and medial release of the pectoralis muscle is combined with a wide subfascial release of the breast gland and a scoring of the deep plane of the superficial glandular fascia. In the final step, the deep layer of the glandular fascia is sutured tightly and firmly to the deep layer of the abdomino-pectoral fascia. A total of 867 patients received a 4D pocket–based breast implant by the authors. A subset of 33 patients was further analyzed for long-term results. Retrospectively, all data were analyzed from the electronic patient information system and files of patients using GraphPad 8. For comparison of multiple experimental groups, one-way ANOVA was performed where indicated. Results The concept not only addresses the biplanar approach of submuscular implant placement (3D) but adds the 4th dimension (4D) of an aesthetically pleasing dynamic shape of the augmented breast providing long-term stability. Measurements—taken at 3 months, and 1, 2, 3, 5, and ≥ 7 years post augmentation—for SN-N, N-IMF, N-ML, and MC-N distances did not show any significant changes over time. In the patient cohort of 867 patients (1734 implants), the overall complication rate was Conclusions Our results indicate that our technique of multiplane breast augmentation provides long-term stability and aesthetic quality. It may solve some of the existing tradeoffs of the different methods by combining the benefits of each technique supported by an additional shaping through a controlled deep fasciotomy. Level of evidence: Level IV, therapeutic study.

Aims This study aims at assessing the treatment effect, disease severity and quality-of-life outcomes of botulinum toxin (BTX) injections for focal hyperhidrosis. Methods We included randomized controlled trials of BTX injections compared with placebo for patients with primary or secondary focal hyperhidrosis. PubMed, Embase and the Cochrane Library were searched to August 2020. Gravimetric sweat rate reduction, disease severity measured by Hyperhidrosis Disease Severity Scale and quality-of-life assessment measured by Dermatology Life Quality Index were the outcomes of interest. Cochrane risk-of-bias tools were employed for quality assessment of given randomized controlled trials. Results Eight studies met our inclusion criteria (n=937). Overall, risk bias was mixed and mostly moderate. BTX injections showed reduced risk in comparison with placebo for the gravimetric quantitative sweat reduction of > 50 % from baseline (risk difference: 0.63, 95% CI 0.51 to 0.74). Additionally, improvements were seen for disease severity and quality-of-life assessments evaluated by Hyperhidrosis Disease Severity Score reduction of ≥ 2 points (risk difference: 0.56, 95% CI 0.42 to 0.69) and mean change in Dermatology Life Quality Index (mean difference: − 5.55, 95% CI − 7.11 to − 3.98). The acquired data were insufficient to assess for long-term outcomes and limited to an eight-week follow-up period. Conclusions In focal axillary hyperhidrosis, BTX significantly reduces sweat production and yields superior outcomes in assessments of disease severity and quality-of-life. However, the quality-of-evidence is overall moderate and included studies account for short-term trial periods only. Further studies assessing BTX in comparison with first-line treatments for hyperhidrosis are warranted. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The aim of the study was to show significant differences regarding postoperative complications and outcomes using three different Acellular Dermal Matrices (ADM), namely Epiflex®, Strattice® and Braxon®, in immediate implant-based subpectoral breast reconstruction cases. Background: The use of Acellular Dermal Matrices for implant-based breast reconstruction cases continues to evolve. There is a wide variety of products which differ significantly in their biological features. It remains unclear if and how these differences manifest in clinical practice. Methods: 82 cases of primary breast reconstruction in the Department of Plastic and Aesthetic Surgery of HELIOS Clinics Schwerin, Germany between 2010 and 2018 were analyzed. 25 patients received Strattice® acellular dermal matrix (SADM), 22 cases Epiflex® acellular dermal matrix (EADM) and the remaining 35 cases Braxon® acellular dermal matrix (BADM). The mean follow-up was 1.8 years. Cases were analyzed regarding minor or major complications and rate of capsular contracture grade III or IV (Baker Classification). Results: The overall complication rate was 34.1% for all groups (SADM = 40%, EADM = 50%, BADM = 20%, p-value = 0.051). Of all cases, 6 patients underwent implant exchange or secondary autologous reconstruction due to capsular contracture (7.3%). The mean time between revision due to capsular contracture and reconstruction was 35.8 ± 14.4 months. 50% of patients, who developed capsular contracture, received postoperative radiation. Mean hospitalization time was 8.2 ± 3 days (SADM = 8 ± 3.2 days, EADM = 10 ± 2.8 days, BADM = 6 ± 1.3 days). There were no significant differences between all three groups for demographics, overall complication rate or capsular contracture. However, patients receiving Braxon® matrix showed significantly fewer minor complications (p-value = 0.01). Moreover, patients receiving Braxon® ADM showed a significantly lower time of hospitalization (p ® ADM showed significantly lower minor complication rates and hospitalization time. In addition, these matrices showed a trend towards lower capsular contracture rates. The low rate of capsular contracture hints at possible advantages of ADM-use in direct-to-implant cases.

Background Hand injuries are common in sports and associated with high dropout rates and costs. Hence, efforts should strive for further risk prevention measures in order to increase safety in sports. This implies knowledge of sports injury risk profiles. So far, major surveillance programs exist mainly in Anglo-American countries, reflecting the specific concerns of sports in this part of the world. Data on sports injuries within Europe are scarce. As sports behaviour appears to vary demographically, we hypothesised that risk injury profiles differ as well. Methods To assess whether the described sports injuries of the hand are applicable to the German population, we performed a five-year retrospective, single-centre analysis of sports-related hand injuries, using data from the Enterprise Clinical Research Data Warehouse of the Hannover Medical School. Results Notable differences in comparison to other data were observed. Ball sports, cycling and equestrian sports caused most of the recorded hand injuries, which were predominantly fractures of the wrist and hand. Hand injuries in equestrian sports were associated with significantly higher operation and hospitalisation rates as well as a significantly longer inpatient treatment. Conclusion Risk profiles for sports-related hand injuries appear to differ not only in terms of age- and sex, but also geographically. Nation- and Europe-wide hand trauma registries as well as a broad registry participation are necessary in order to accurately assess the risk patterns in Europe; henceforth reducing hand injuries and their sequelae.

Liquid body contouring by intramuscular injection of site-enhancing oils (SEOs) for muscle volume enlargement has increasingly become a popular practice in bodybuilding. Its immediate and long-term health consequences remain ambiguous, and postinjection complications are sparsely documented in medical literature. We report a series of patients presenting with postinjection complications upon self-attempted liquid body contouring through injection of SEOs. Ten patients visited our departments for plastic and reconstructive surgery for variable local and systemic complications. All patients gave a history of single or multiple SEO use and presented on average nine years postinjection with variable complications. Most patients experienced painful nodular indurations and swellings in the injected target muscles. Two patients showed signs of infection including erythema, fever, and local inflammatory findings. One patient presented additionally with a severe form of nonparathyroid hypercalcemia. Four patients ultimately underwent surgical treatment. The use of SEOs for liquid body contouring is a dangerous practice and is associated with potentially systemic and life-threatening complications. Surgical treatment may be the only therapeutic option in advanced cases and should be performed timely. Guidelines on diagnostic and therapeutic measures are warranted. Educational measures should be undertaken to raise awareness among athletes and medical professionals.

Breast cancer is the most diagnosed malignant neoplasia of female patients worldwide in 2019. Survival has increased making it necessary to offer breast reconstructive procedures to improve quality of life and self-esteem. Implant-based breast reconstruction is the most common approach, making it necessary to quantify the associated complications.A systematic literature review of the PubMed, Cochrane, and Web of Science databases was performed. A total of 9608 citations were identified, and 44 studies met the inclusion criteria.Studies included reported the incidence of complications either per patient or per breast leading consequently to 2 complication rates depending on the type of reporting. A total of 14.3% of patient-related and 28.8% of breast-related complications while undergoing implant-based reconstruction were reported.Among total complications reported, 72.6% of patient-related and 48.5% of breast-related complications were classified as major complications.A total of 37.6% of patients respectively 15.1% of breasts required prosthesis explantation due to severe complications. Depending on reporting, 9.7% of patients and 4% of breasts required autologous flap reconstruction due to reconstructive failure.High complication and failure rates are associated with implant-based breast reconstruction. Lacking randomized controlled trials, the choice between implant-based and autologous breast reconstruction has to be made individually for each patient.

The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia. The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL). A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed. The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=

Scalds in the elderly are frequently associated with the use of a bathtub and a disturbed consciousness. Therefore, the total burn surface area is often high. The initial clinical presentation displays a stark erythema of the skin, which frequently does not represent the true depth. The aim of this study was to characterize and assess medical features and outcome of scalds sustained in the bathtub. We conducted a retrospective study at a burn intensive care unit (BICU) between 2011 and 2018. Medical features as well as the treatment in these patients were statistically analyzed. We identified 16 patients and divided them into two groups regarding survival and lethality. The mean total burn surface area was 37.50 ± 19.47%. In 81.25% of the patients, we found a previous history of neurological or psychiatric disorders. Dementia and alcohol abuse were the most common triggers for the trauma. The statistical analysis showed a significant difference for the ABSI-score and the presence of multi organ failure (P-value .0462, respectively, .0004). Erythematous skin areas tended to progress into full thickness burns. We, therefore, coined the term “lobster redness” for these regions. Scalds sustained in the bathtub are devastating injuries. Initial assessment can be misleading and might delay early necrectomy. The wounds request even more attention, if the injuries occurred due to unconsciousness because of the longer exposure to heat. Early necrectomy should be considered. A biopsy with histological workup can be useful. Furthermore, we recommend special safety precautions for neurologically and psychiatrically affected patients.

Intermediate and deep second-degree skin burn injuries are an ongoing challenge for burn surgeons, with the difficult decision regarding whether to handle them with either conservative or operative methods. In this study, the outcome of similar deep second-degree skin burn injuries is shown with the example of four family members. Clinical outcomes of the four family members which were treated at our burn center in 2017 were analyzed. The areas of burned skin (IIa&deg, IIb&deg, ) extended from 14% to 38% of the total burned skin area. Surgical treatment was adjusted to the rate of epithelialization after the first debridement. The excellent cosmetic long-term results of this patient cohort support the importance of stage-related therapy of deep dermal burn injuries. An initial debridement followed by early coverage is the key to early reconstitution of the epidermal barrier. However, with regard to the late effects of skin substitutes, more sensory alterations, dysesthesia, hyperpigmentation and unstable skin areas are still visible after coverage with glycerol conserved skin. The best results were seen after the use of autologous STGS and synthetic skin.

Introduction. Methicillin-resistant Staphylococcus aureus (MRSA) is responsible for infections in patients both inside and outside of the hospital and causes outbreaks. Here, we demonstrate the characteristics and control of a MRSA outbreak related to a carbon dioxide hydrotherapy bathtub. Methods. We conducted an outbreak investigation and performed a molecular typing of the outbreak strains with pulsed-field gel electrophoresis (PFGE). In addition, we reviewed PubMed and the Outbreak Database for MRSA outbreaks related to hydrotherapy or other bathing activities. Results. Four patients acquired nosocomial MRSA during the 4-week outbreak period. Environmental sampling revealed the presence of MRSA in the bathtub used for hydrotherapy. The environmental and the patients’ isolates showed an indistinguishable restriction pattern in the PFGE. Subsequent discontinuation of bathing stopped the outbreak. The literature search found 9 MRSA outbreak reports related to bathing activities or hydrotherapy. Conclusion. The epidemiologic outbreak investigation together with the molecular findings suggests monoclonal spread of MRSA due to surface contamination of the bathtub. After enhancing the disinfection and cleaning process accompanied by staff training with respect to hand hygiene, no further cases occurred. Standardized and best practice cleaning and disinfection protocols are crucial, especially in critical facilities such as hydrotherapy units. Regular environmental sampling is helpful to monitor these processes and to detect potential contamination.

Zusammenfassung Hintergrund Die aktuellen Richtlinien für Verletzungen durch Tierbisse empfehlen chirurgisches Debridement und Antibiotikatherapie. Im Allgemeinen führen Bisswunden zu Infektionen mit einem sehr hohen Risiko durch tief eindringende Hautläsionen. Bisswunden können sich jedoch durch die Eindringtiefe und die Beteiligung verschiedener anatomischer Strukturen drastisch unterscheiden. Eine prognostische Klassifikation über die Tiefe oder Schwere gibt es nur für Gesichtsverletzungen bei pädiatrischen Patienten – das ist der Score von Lackmann. In dieser Studie wurden prognostische Faktoren bewertet und ein prospektiver Score für allgemeine Tierbissverletzungen entwickelt. Patienten und Methoden Eine retrospektive Einzelzentrumsanalyse wurde bei Verletzungen von Tierbissen zwischen 2007 und 2017 durchgeführt. Die Patienten wurden nach Tierart, Bissort, Behandlungsart und medizinischer Versorgung, Aufnahme, Verweildauer, Revisionsbedarf und Keimspektrum unterteilt. Es wurde ein Bewertungs-Score ermittelt und verifiziert, der von Grad I (oberflächlicher Kratzer) bis Grad Va (tiefe Wunde mit Knochenbeteiligung) und Grad Vb (tiefe Wunde mit Gelenkbeteiligung) reicht. Ergebnisse 567 Patienten mit Tierbiss-Verletzungen wurden eingeschlossen, von denen 51,7 % von Hunden, 39,2 % von Katzen und 4,1 % von Wildtieren verursacht wurden. 75,7 % der Verletzungen befanden sich an den Händen, 12,9 % an den Armen, 5,1 % im Gesicht und 5,3 % an anderen Stellen. Der häufigste Keim war Pasteurella, gefolgt von Staphylokokken und anderen aeroben Arten. Die antibiotische Behandlung umfasste in 75 % der Fälle Sultamicillin, Cephalosporine in 10,2 %, Clindamycin in 7,6 % und andere Antibiotika in 5,1 %.Es wurde eine signifikante Korrelation (p < 0,001) zwischen der Tierart und dem Vorliegen einer Infektion, der Art der medizinischen Versorgung, dem Bewertungs-Score und dem Keimspektrum festgestellt, ebenso wie zwischen dem Bewertungs-Score und der Notwendigkeit einer Revision, der Dauer der Antibiotikatherapie, der Art der Aufnahme, der Behandlung und der medizinischen Versorgung sowie der Dauer des Krankenhausaufenthaltes. Schlussfolgerung Der prognostische Wert des ermittelten Bewertungs-Scores konnte verifiziert werden. Darüber hinaus wurde die Bedeutung der Tierarten für die Behandlung aufgezeigt. Sultamicillin mit einer Wirksamkeit gegen die meisten der identifizierten Keime sollte als ermittelte Erstlinien-Antibiotikatherapie verwendet werden.

Thermal injuries occur in every age group and are caused by flames, fluids, steam and direct contact. They are often trivialized but should actually be treated immediately to reduce secondary complications, such as infections and hypertrophic scars. Besides the pain, large wound areas are given priority. Surgical treatment is necessary if at least second degree (IIb) deep dermal burns are present. In this case the reconstructive surgeon has various techniques in the therapeutic armamentarium. Furthermore, in cases of severe burns a perioperative intensive care monitoring and treatment are obligatory as massive systemic inflammatory response syndrome (SIRS), shock, sepsis, organ failure, fluid resuscitation and complications, such as delirium and exacerbation of pain have been proven to negatively influence the outcome.

Background: Spare-part surgery is widely accepted and offers an option in extremely traumatized patients for reconstructive maneuvers. Standardized techniques are lacking, and the therapy needs to fit the patient’s clinic. Materials and Methods: In a woman with necrosis of almost all extremities due to septic infection, we used the lower leg as a free osteocutaneous flap to reconstruct a basic hand function after amputation. The fibula segment was buried alongside the remaining first metacarpal bone. On the hand stump, 2 short metacarpals were lengthened using the remaining 2 metacarpals as osteovascular on-top plasties. The flap was microsurgically anastomosed end-to-side to the ulnar artery. After 3 months, the buried fibula was trimmed to the necessary thumb length and fixed to the local metacarpal I stump. Secondary procedures were performed to deepen the first web space. Results: The patient is now able to manage her daily life. Also, she is able to put on her prosthesis on both legs and walk without aids. Conclusions: To our knowledge, this is the first description of successful microvascular transfer of an osteocutaneous free flap from an amputated lower leg of this size and could present a valuable technique for other cases.

Background Carpal tunnel release is one of the most common procedures in hand surgery. There is only scarce evidence regarding whether platelet inhibitors increase the risk of developing postoperative hemorrhage in carpal tunnel release. Methods This is a multicenter, propensity score-matched study including 635 carpal tunnel releases in 497 patients. Multivariate regression models were adjusted with the propensity score, which was developed to mitigate differences in patients with and without platelet inhibition with acetylsalicylic acid. Propensity score matching provides results close to the statistical quality of randomized controlled trials. The primary study endpoint was postoperative bleeding complication, defined as acute bleeding leading to reoperation or hematoma leading to physician visit. Patient satisfaction, functional outcome measured with the Boston Carpal Tunnel Questionnaire, and onset of surgical-site infection were also analyzed. Results Bleeding complications were observed in 56 procedures (8.8 percent). After propensity score matching, there was no significant difference between the patients with and without acetylsalicylic acid treatment (p = 0.997). History of thyroid disease (p = 0.035) and of rheumatoid arthritis (p = 0.026) were independent risk factors, whereas higher body mass index might have a beneficial effect (p = 0.006). Patients with postoperative bleeding had significantly impaired functional outcome as measured with the Boston Carpal Tunnel Questionnaire (p = 0.026). Median satisfaction in the investigated study population was 10 of 10 points and did not differ significantly between the antiplatelet and the non-antiplatelet cohorts (p = 0.072) CONCLUSION:: Carpal tunnel release under platelet inhibition with acetylsalicylic acid is safe and can be performed without interruption of such medication. Clinical question/level of evidence Therapeutic, III.

BackgroundMany techniques for the surgical treatment of gynaecomastia have been reported to be effective with reasonable limited scar formation. The aim of this study was to develop a grade adopted algorithm for effective and scar sparing techniques in reconstruction of the male breast dependent on aetiology and grading.MethodsOperative techniques, results, rates of revisions and complications were recorded between 2006 and 2018 and results of 164 male patients were analysed, retrospectively. Skin resecting methods have been used in the earlier stage but were later replaced by minimal periareolar incisions and subcutaneous mastectomy. Resections were combined with ultrasound-assisted liposuction up to grade 2b and inferior pedicled breast reduction in 3rd degree gynaecomastias resulting in reduction of scars and effective removal of breast tissue.ResultsRetrospective analysis showed that a periareolar mastopexy was used in 24% of patients with gynaecomastia grade I, IIa and IIb to reshape the breast after subcutaneous mastectomy in the early stage of this study from 2006 to 2010. With the established standardised use of ultrasound-assisted liposuction, only 2% of patients required a mastopexy in the following years. In grade 3 gynaecomastia, the classical approach resulting in an inverted t-scar was later abandoned for an approach with a periareolar and submammary scar and inferior dermoglandular flap. The rate of secondary surgery with the used techniques did not increase.ConclusionsWhen using standardised techniques in reshaping the male breast, an aesthetically pleasing and safe result can be achieved by scar sparing techniques in a safe single-stage procedure.Level of evidenceLevel IV, therapeutic study.

Background Muscle tissue engineering still remains a major challenge. An axial vascular pedicle and a perfusion bioreactor are necessary for the development and maintenance of a large-volume engineered muscle tissue to provide circulation within the construct. This study aimed to determine whether large-volume vascularized muscle-like constructs could be made from rat groin adipose tissue in a perfusion bioreactor. Methods Epigastric adipofascial flaps based on the inferior superficial epigastric vessels were elevated bilaterally in male Lewis rats and connected to the bioreactor. The system was run using a cable pump and filled with myogenic differentiation medium in the perfusion bioreactor for 1, 3, 5, or 7 weeks. The resulting tissue constructs were characterized with respect to the morphology and muscle-related expression of genes and proteins. Results The histological examination demonstrated intact muscle-like tissue fibers; myogenesis was verified by the expression of myosin, MADS box transcription enhancer factor 2 D, desmin-a disintegrin and metalloproteinase domain (ADAM) 12-and M-cadherin using reverse transcription-polymerase chain reaction. Western blot analysis for desmin, MyoD1, N-cadherin, and ADAM12 was performed to verify the myogenic phenotype of the extracted differentiated tissue and prove the formation of muscle-like constructs. Conclusions A large-volume vascularized muscle tissue could be engineered in a perfusion bioreactor. The resulting tissue had muscle-like histological features and expressed muscle-related genes and proteins, indicating that the trans-differentiation of adipose tissue into muscle tissue occurred.

ZusammenfassungDie Wirtschaftlichkeit von Therapien hat im Gesundheitswesen zunehmenden Stellenwert erlangt und wird dadurch auch für Mikrochirurgen ein relevanterer Aspekt ihrer Arbeit. Vor allem der verbundene Kostendruck, langfristig wirtschaftlich zu agieren, nötigt Mikrochirurgen ihre oftmals komplexen Behandlungen gegenüber Krankenversicherungen und Krankenhausträgern zu rechtfertigen. In diesem Positionspaper der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie (DAM) wird der derzeitige Status Quo der Wirtschaftlichkeit in der mikrochirurgischen Extremitäten- und Brustrekonstruktion analysiert, sowie auch die daraus resultierenden Konsequenzen auf Therapiewahl und Weiterbildung. Ebenfalls wurde eine Analyse der Literatur gelegt, welche oftmals gesenkte Folgekosten nach komplexen Rekonstruktionen im Vergleich zu chirurgisch günstigeren Alternativverfahren beschreibt. Die beschriebenen Inhalte wurden auf einem Konsensusworkshop anlässlich der 40. Jahrestagung der DAM 2018 in Lugano erarbeitet.

ZusammenfassungDie Entwicklung der letzten 20 Jahre hat die technischen wie immunologischen Voraussetzungen geschaffen, komplexe Rekonstruktionen amputierter Extremitäten mittels allogener Transplantation möglich zu machen. Dabei sind diese Eingriffe inzwischen aus dem Stadium eines experimentellen therapeutischen Eingriffs zu einer klinisch etablierten Rekonstruktionsmöglichkeit erwachsen. Aufgrund der lebensqualitätsspendenden, aber nicht lebensrettenden Natur dieser Eingriffe müssen die möglichen Risiken und Komplikationen, die aus einem solchen Eingriff erwachsen, sowie der lebenslang notwendigen Immunsuppression, kritisch und individuell evaluiert werden. Aus diesem Grund ist die Indikation auch nur bei Patienten mit bilateraler Verletzung zu stellen. Eine erfolgreiche Transplantation kann den Patienten jedoch dann eine deutliche Verbesserung der sensorischen und motorischen Fähigkeiten mit relevanter Verbesserung der Lebensqualität ermöglichen und sollte daher als Therapieoption bei selektiven Patienten mitbedacht werden.

Autologous tissue reconstruction for defect coverage of lower extremity wounds describes a broad interdisciplinary spectrum of conservative, surgical and interventional treatment options. The goals of reconstruction are a resilient and function-preserving but also esthetically acceptable wound closure, which should enable rehabilitation and the return to participation in social and working life for those affected. Depending on the wound conditions as well as on potentially occurring concomitant injuries and comorbidities, the timing and method of defect coverage is selected in an individualized approach for each patient. It is essential that the plastic surgeon is involved as early as possible in the preparation of a treatment plan and can then select the most appropriate and least invasive reconstructive procedure from the armamentarium, depending on the localization and etiology of the soft tissue defect. These vary from secondary wound closure to skin grafts up to local and free flaps.Die Eigengewebsrekonstruktion zur Defektdeckung der unteren Extremität beschreibt ein breites interdisziplinäres Spektrum an konservativen, operativen und interventionellen Behandlungsoptionen. Die Ziele der Rekonstruktion sind ein belastungsstabiler, funktionserhaltender, aber auch ästhetisch ansprechender Wundverschluss, um Betroffenen die Rehabilitation und Wiederteilnahme am Gemeinschafts- und Arbeitsleben zu ermöglichen. Abhängig von den Wundbedingungen und etwaigen bestehenden Begleitverletzungen oder -erkrankungen werden in einem patientenindividualisierten Vorgehen der Zeitpunkt und die Art der Defektdeckung gewählt. Der plastische Chirurg sollte hierbei frühestmöglich in die Erstellung eines Behandlungsplans mit eingebunden werden und wählt abhängig von der Lokalisation und Ätiologie des Hautweichteildefektes das passendste und schonendste rekonstruktive Verfahren aus seinem Armamentarium: beginnend beim sekundären Wundverschluss bis hin zu Hauttransplantationen oder lokalen und freien Lappenplastiken.

Scars can lead to aesthetic and functional impairments. The treatment of scars requires meticulous planning and an individually adapted therapeutic strategy. A conceptual algorithm for scar treatment makes everyday clinical work easier for the practitioner and offers more safety for the patient. Based on a retrospective analysis of 1427 patients who presented for treatment of a variety of scars, we developed an algorithm for scar management and treatment. The treatments are presented using case descriptions. Additionally, an electronic search of MEDLINE, EMBASE, and ClinicalTrials.gov databases was performed utilizing combinations of relevant medical subject headings for “scar treatment”, “hypertrophic scar treatment” and “keloid treatment”. Reference lists of relevant articles and reviews were hand-searched for additional reports. Observed outcomes included: conservative scar therapy, minimally invasive scar therapy, and surgical scar therapy using local, regional and free flaps. With this work, we provide an algorithm for safe scar treatment. For better understanding, we have described a clinical case for each algorithm modality.

The selection of recipient vessels for microvascular free-flaps is critical in craniofacial reconstruction. Especially the suitability of the superficial temporal vessels is questioned conflictingly in the literature. The aim of this study was to share our experience with microvascular craniofacial free-flap reconstruction and to evaluate a set of factors that are related to the recipient vessels and to determine how these factors influence flap survival. We conducted a retrospective analysis of 39 free-flaps for craniofacial reconstruction that were performed from 2006 until 2020 and evaluated the indication for microvascular reconstruction, recipient vessels, various factors related to the recipient vessels and complications. The most utilized recipient artery was the facial artery, selected in 20 patients followed by the superficial temporal artery selected in 12 patients. The most commonly used recipient vein was the facial vein used in 16 patients, followed by the superficial temporal vein selected in 10 patients and the external jugular vein in 6 patients. Total flap necrosis occurred in one patient. There was no statistically significant association between the selected recipient vessels and patient comorbidities, major and minor complications, revision of anastomosis or flap loss. The results of our study have demonstrated that the superficial temporal artery and vein show similar results when used for face and scalp reconstruction. Considering their technical and aesthetic advantages they may be the first choice recipient vessels in established free-flap treatment algorithms for craniofacial reconstruction.

Infections of the hand and forearm are a frequently seen surgical emergency of the hand. Patients of all age groups are affected and underlying systemic diseases are risk factors. Posttraumatic causes are the leading cause of infections. This includes cuts and stab wounds, animal and human bites but often also minor injuries. Due to the anatomical peculiarities of the hand, rapid progression of initially inconspicuous infections can occur resulting in functional limitations. If an infection is suspected, a symptom-oriented evaluation by a hand surgeon should be performed. This includes a detailed patient history, clinical examination, laboratory analyses and imaging. This is followed by the development of an individualized and interdisciplinary treatment concept with the aim of achieving the shortest possible rehabilitation period. The treatment includes surgical cleansing of the infection, accompanied by antibiotic treatment taking the expected possible spectrum of pathogens into account. Cephalosporins and aminopenicillins in combination with beta-lactamase inhibitors are the antibiotics of first choice. Follow-up treatment includes early functional exercise under the guidance of a hand therapist to minimize postinfectious restrictions in the range of motion and to enable occupational rehabilitation. In rare cases, fulminant necrotizing infections with resulting skin and soft tissue defects can occur. In these cases, secondary plastic reconstruction is usually required after cleansing of the infection.Infektionen der Hand und des Unterarms sind häufig gesehene handchirurgische Notfälle. Betroffen sind Patient*innen aller Altersgruppen, wobei systemische Grunderkrankungen als Risikofaktoren für die Entstehung zählen. Posttraumatische Ursachen stellen den führenden Grund für Infektion dar. Dies schließt Schnitt- und Stichwunden, Tier- und Menschenbiss-, aber häufig auch Bagatellverletzungen ein. Aufgrund anatomischer Besonderheiten der Hand kann es zu einer raschen Progression von zunächst unscheinbaren Infektionen kommen, mit daraus resultierenden funktionellen Einschränkungen. Bei Verdacht auf eine Infektion sollte eine symptomorientierte Abklärung durch einen handchirurgischen Facharzt erfolgen. Diese umfasst eine ausführliche Anamnese, klinische Untersuchung, Labordiagnostik und bildgebende Untersuchung. Anschließend erfolgt die Erarbeitung eines individualisierten und interdisziplinären Behandlungskonzepts mit dem Ziel einer möglichst kurzen Rehabilitationszeit. Die Therapie umfasst die chirurgische Infektsanierung, begleitend sollte eine antibiotische Therapie unter Beachtung des zu erwartenden Erregerspektrum eingeleitet werden. Cephalosporine und Aminopenicilline in Kombination mit β‑Lactamase-Hemmern stellen die Antibiotika der ersten Wahl dar. Die Nachbehandlung umfasst die frühfunktionelle Beübung unter handtherapeutischer Anleitung, um postinfektiöse Einschränkungen auf ein Minimum zu reduzieren und eine zeitnahe berufliche Rehabilitation zu ermöglichen. In seltenen Fällen werden fulminante nekrotisierende Infektionen mit daraus resultierenden Hautweichteildefekten beschrieben; hier bedarf es nach Sanierung des Infekts meist einer sekundären plastischen Rekonstruktion.

Multiple outcome scoring models have been used in predicting mortality in burn patients. In this study, we compared the accuracy of five established models in predicting outcomes in burn patients admitted to the intensive care unit and assessed risk factors associated with mortality. Intensive care burn patients admitted between March 2007 and December 2020 with total body surface area (TBSA) affected ≥ 10% were analyzed. Multivariate analysis was conducted to examine variables associated with mortality. The ABSI, Ryan, BOBI, revised Baux and BUMP scores were analyzed by receiver operating characteristics. A total of 617 patients were included. Morality was 14.4%, with non-survivors being significantly older, male, and having experienced domestic burns. Multivariate analysis identified age, TBSA, full-thickness burns and renal insufficiency as independent mortality predictors. The BUMP score presented the highest mortality prognostication rate, followed by ABSI, revised Baux, BOBI and Ryan scores. BUMP, ABSI and revised Baux scores displayed AUC values exceeding 90%, indicating excellent prognostic capabilities. The BUMP score showed the highest accuracy of predicting mortality in intensive care burn patients and outperformed the most commonly used ABSI score in our cohort. The older models displayed adequate predictive performance and accuracy compared with the newest model.

BackgroundThe acquisition of a medical professorship represents a significant step in a physician’s academic career. The responsibility as well as the honor and the associated obligations are significant; however, the requirements to become a medical professor vary in Germany.ObjectiveWe analyzed the variable requirements for prospective medical professors in Germany, with special focus on the tenure track concept and the U.S. system.MethodsBased on an online research, we queried German medical faculty regulations to obtain a medical professorship within Germany.ResultsWe analyzed 35 German universities. On average, 11 publications are required after “venia legendi” to meet professorship (apl) prerequisites (median x̅ = 10, max = 24, min = 6, n = 16), whereas 6 publications with first or last authorship are required on average (x̅ = 6, max = 16, min = 4, n = 26). In most German universities, it takes an average of 4 years after gaining habilitation to apply for a professorship (x̅ = 5 years, max = 6 years, min = 2 years). Candidates for university chair positions, however, can shorten this period by an average of 38%.DiscussionIn the German academic system, the prerequisites to gain a professorship differ among universities. Due to different scientific cooperation and exchange programs, research and academic activities have reached an intense international exchange level. Yet there is no international or even national standardization, quality assurance, and comparability to gain a medical professorship.

Zusammenfassung Hintergrund Hochschulambulanzen haben eine zentrale Position in der Behandlung, Lehre und Erforschung spezieller und komplexer Erkrankungen inne. Der tägliche Betrieb einer universitären Poliklinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie weist ein weitgefächertes Diagnosespektrum der zugewiesenen Patienten aus. Unsere Hypothese war, dass das Diagnosespektrum über den fachspezifischen Charakter hinaus weitreichend interdisziplinär ist und ein hohes Maß an differenzierter und erweiterter klinischer Kompetenz vermittelt. Methode Die epidemiologischen Daten und Diagnosen der Patienten, die sich zwischen 2013–2014 in unserer Ambulanz vorstellten, wurden anhand des Arztbriefs, der medizinischen Akte und der Leistungsverschlüsselung (ICD) katalogisiert. Eine Unterteilung der Diagnosen erfolgte nach Zugehörigkeit zu den medizinischen Fachdisziplinen. Ergebnisse Von 2013 und 2014 wurden 9272 Patienten mit 821 verschiedene ICDs behandelt. Eine operative Haupt- oder Nebendiagnose bestand in 57 % der Fälle. In 36 % der Diagnosen lagen internistische Krankheitsbilder vor, während 7 % aus dem Bereich Dermatologie, Neurologie, Psychiatrie, Zahnmedizin und Augenheilkunde stammten. Die Alterschirurgie umfasste 22 %, postonkologische Folgen 7 %, postoperatives Komplikationsmanagement 6 %, einer Z. n. konservativer Behandlung 3 % und angeborene Fehlbildungen 3,0 % der Diagnosen. Bei 29 % der vorgestellten Patienten stellten wir eine plastisch-chirurgische Behandlungsindikation. Schlussfolgerung Unsere Analyse zeigt, dass in einer Hochschulambulanz für Plastische und Ästhetische Chirurgie, ein Patientenkollektiv mit komplexen Erkrankungen und einem breiten Spektrum an Haupt- und Nebendiagnosen behandelt wird. Dieses Spektrum bildet bei Ärzten eine breite Kompetenz aus und ist aufgrund der Interdisziplinarität und Vermittlung von differentialdiagnostischen Algorithmen und Untersuchungstechniken für die allgemeine Ausbildung von Studierenden besonders geeignet.

Zusammenfassung Hintergrund Tiefgradige Verbrennungen bedürfen eines frühzeitigen Débridements und der Transplantation von Haut nach der MEEK/MESH-Technik oder weitere rekonstruktive Operationen. Infektionen von Verbrennungswunden oder transplantierten Arealen limitieren den chirurgischen Erfolg und erhöhen die Mortalität. Spalthauttransplantate nach der MEEK-Technik werden mit Textilien als Träger transplantiert und ähnlich der MESH-Technik mit einem Schaumstoff-Überknüpfer fixiert. Die Auflage dieser Fremdmaterialien wird in der Regel fünf Tage belassen. Dieses Fremdmaterial könnte jedoch potentiell eine Brutstätte für Bakterien und Erreger darstellen. Eine Identifikation von drohenden Infektionen und die frühzeitige Identifizierung einer erhöhten Bakterienlast bei Verbrennungswunden durch die Darstellung mittels der Autofluoreszenz (AF) sind hilfreich, um Wunden adäquat zu beurteilen und Hauttransplantate zu sichern. Material und Methoden Zur Charakterisierung von Verbrennungswunden, die mit Spalthaut nach der MEEK/MESH Technik gedeckt wurden und mit Schaumstoff-Überknüpfer behandelt wurden, erfolgte die Darstellung der Erregerlast mittels MolecuLight i:X™. Es erfolgte zusätzlich die Bildgebung mittels einer Digitalkamera und die Bestimmung der Erreger mit mikrobiologischen Abstrichen. Mit dieser Pilotstudie wird die Besiedlung von Fremdmaterialien auf Verbrennungswunden sowie die diagnostische Wertigkeit der Autofluoreszenz im Vergleich zur klinischen Wundbeurteilung bei Verbrennungswunden geprüft. Ergebnisse Wir untersuchten Verbrennungswunden (n = 14) von drei intensivmedizinischen Patienten. Es erfolgte die Unterteilung in insgesamt 53 Wundareale. Die MolecuLight i:X™ Kamera zeigte eine starke Besiedlung der transplantierten Areale und Fremdmaterialien, korrespondierend zu den mikrobiologischen Befunden. Die MEEK-Transplantationen heilten zu 90 % im Vergleich zu MESH-transplantierten Arealen mit etwa 60 % ein. Es zeigte sich ein positiv prädiktiver Wert von 81,8 % der AF. Der negativ prädiktive Wert betrug 90,3 % bei einer Sensitivität von 86,7 % und einer Spezifität von 87,5 %. Schlussfolgerung Die Dauer des Belassens von Fremdmaterial sollte auf die kürzeste Zeit begrenzt werden.Die Darstellung der Erregerlast mittels AF zeigt eine starke Besiedlung sowohl bei der MEEK-Technik mit der Seidenschicht als auch bei der MESH-Technik mit dem Schaumstoff-Überknüpfer. Die real-time Darstellung der Verbrennungswunden mittels AF kann durch die hohe Sensitivität und Spezifität eine gezielte Intervention an der Verbrennungsoberfläche ermöglichen.

Zusammenfassung Ziel Diese Studie untersucht, inwieweit der Vorstellungszeitpunkt bei vorliegender Handinfektion (HI) mit der stationären Liegedauer sowie der Häufigkeit notwendiger Operationen der Patienten korreliert. Patienten und Methoden Retrospektiv wurden die stationären Krankenakten von 379 Patienten mit HI, die zwischen 2007 und 2014 an unserer Klinik (2007–2014) behandelt wurden, statistisch hinsichtlich eines Zusammenhangs zwischen Vorstellungszeitpunkt und Liegedauer sowie der Häufigkeit notwendiger Operationen ausgewertet, wobei auch die Infektionsursache Berücksichtigung fand. Ergebnisse Im Durchschnitt führte eine um mehr als einen Tag verzögerte fachchirurgische Vorstellung zu einer längeren Krankenhausverweildauer von 1,22 Tage (KHVD) (95 %-KI: 1,20–1,25; p < 0,001). Die Notwendigkeit einer operativen Intervention nahm mit jedem Tag Verzögerung um 13,59 % (95 %-KI 4,01 %–25,43 %; p < 0,001) zu. Der verzögerte Beginn einer Antibiotikagabe führte zur Verlängerung der KHVD um den Faktor 1,09 (95 %-KI: 1,03–1,15; p < 0,001), wobei jedoch keine Korrelation bestand zwischen Zeitpunkt der Antibiotikagabe und der Notwendigkeit zur operativen Revision (ja/nein) (p = 0,11). Schlussfolgerung Eine verspätete Vorstellung von Patienten mit Handinfektionen führt zu einer längeren stationären Aufenthaltsdauer sowie zu einer höheren Anzahl an notwendigen Operationen. Eine frühzeitige Vorstellung von HI beim Handchirurgen ist wichtig, um komplizierte Krankheitsverläufe und unnötige Kosten für das Gesundheitssystem zu vermeiden.

ZusammenfassungDie Beurteilung der Lebensqualität-Veränderung mittels Patientenfeedback ist eine der wichtigsten Informationsquellen zur Qualitätssteigerung körperformender und/oder postbariatrischer Eingriffe. Standardisierte Messmethode ist dabei von außerordentlicher Bedeutung. BODY-Q (A. Klassen et al.) ist ein vielseitiges valides Messinstrument und umfasst auf insgesamt 26 Skalen die Beurteilung des äußeren Erscheinungsbildes einzelner Körperregionen, die psychosozialen bzw. gesellschaftlichen Aspekte, die Funktionalität und Einschränkungen im Alltag sowie die Zufriedenheit mit dem medizinischen Personal und der Behandlung. All diese Aspekte werden zum ersten Mal in einem Prozess objektiviert und letztendlich quantifiziert. Jede Skala beinhaltet vier bis 10 Aussagen, welche von Patienten zu vier möglichen Ausprägungen zugeordnet werden können. BODY-Q wurde entsprechend den Richtlinien der ISPOR-Organisation (International Society for Pharmacoeconomics and Outcomes Research) kreiert und zahlreichen psychometrischen Tests unterzogen. BODY-Q zeigte konsistente Ergebnisse und wurde somit zu einem standardisierten PRO-Messinstrument (Patient Related Outcome) zur Beurteilung der Lebensqualität nach postbariatrischen und/oder körperformenden Eingriffen.Zwecks internationaler Anwendbarkeit bestehen Richtlinien zur sprachlichen Validierung solcher Messinstrumente. Diese sind durch eine der Organisationen der ISPOR-Gesellschaft etabliert worden. Folgend diesen Richtlinien erfolgte die sprachliche Validierung in den Niederlanden, Dänemark, Finnland und Polen. In dieser Arbeit führten wir die sprachliche Validierung des BODY-Q zu Deutsch unter Anwendung der entsprechenden Richtlinien durch. Hierbei entstand aus einer Rohfassung der Übersetzung die Rückübersetzung in die Original-Sprache Englisch, welche von den Originalautoren kommentiert wurde. Diese Kommentare wurden berücksichtigt und mehrfache Patienteninterviews wurden geführt, um die Anwendbarkeit des Messinstrumentes ohne inhaltliche Missverständnisse zu erreichen.Angestrebt wird eine internationale Zusammenarbeit mit der Möglichkeit der Erstellung großer und einheitlicher Patientenkohorten, um hierdurch aussagekräftigere Ergebnisse zu generieren, welche wiederum der Verbesserung der Behandlungsqualität in der Plastischen Chirurgie dienen.

Background: Burn patients are predisposed for nosocomial infections during their stay on a burn intensive care unit. Moreover, several outbreaks affecting burn units for example caused by Methicillin-resistant Staphylococcus aureus (MRSA) have been reported. One attempt to address these challenges is the use of universal decolonization. Methods: In 2015 we implemented universal decolonization for all burn patients using the antiseptic agent octenidine for intact skin and the nasopharyngeal mucosa. We conducted a retrospective analysis to evaluate the effect of the decolonization on primary, central line (central venous catheter)-associated bloodstream infections (CLABSI), the frequency of nosocomial clusters (4 or more cases with epidemiologic link and identical molecular pattern) with multidrug-resistant bacteria (MDRB) and the incidence of MRSA. Results: In the decolonization period a reduction of the incidence of CLABSI, nosocomial MRSA acquisition and the frequency of nosocomial MDRB clusters was observed. The incidence rate of CLABSI decreased from 2/1000 central venous catheter days in the pre-decolonization phase to 0.8/1000 central venous catheter days in the decolonization period, although this was not statistically significant. The implementation was accompanied by several feedback talks and training for the staff. The user experience was positive and no adverse effects occurred. Conclusion: Our results show that universal decolonization in burn patients using octenidine is a promising concept to address hospital acquisition of MRSA; occurrence of CLABSI as well as the spread of MDRB causing clusters. It is of high relevance to further assess the value of this measure in terms of reducing CLABSI in burn patients in larger study groups. Therefore further studies including more burn patients guaranteeing adequate sample size are needed. Keywords: Burn unit, Universal decolonization, Octenidine, Bloodstream infection, Multidrug-resistant bacteria, Nosocomial

Summary Artificial and non-artificial nerve grafts are the gold standard in peripheral nerve reconstruction in cases with extensive loss of nerve tissue, particularly where a direct end-to-end suture or an autologous nerve graft is inauspicious. Different materials are marketed and approved by the US Food and Drug Administration (FDA) for peripheral nerve graft reconstruction. The most frequently used materials are collagen and poly(DL-lactide-ε-caprolactone). Only one human nerve allograft is listed for peripheral nerve reconstruction by the FDA. All marketed nerve grafts are able to demonstrate sufficient nerve regeneration over small distances not exceeding 3.0 cm. A key question in the field is whether nerve reconstruction on large defect lengths extending 4.0 cm or more is possible. This review gives a summary of current clinical and experimental approaches in peripheral nerve surgery using artificial and non-artificial nerve grafts in short and long distance nerve defects. Strategies to extend nerve graft lengths for long nerve defects, such as enhancing axonal regeneration, include the additional application of Schwann cells, mesenchymal stem cells or supporting co-factors like growth factors on defect sizes between 4.0 and 8.0 cm.

We introduce a novel technique for the treatment of severe kyphosis in myelomeningocele. A 5-year-old paraplegic boy with myelomeningocele presented with severe thoracolumbar kyphosis and a chronic ulcus at the site of the gibbus. The myelomeningocele had been treated during his first week of life, and an accompanying Chiari type II malformation had been treated by ventriculoperitoneal shunting. He subsequently developed a rapidly progressive thoracolumbar kyphosis with an angle of 180° between T10 and L5. He also suffered from a chronic superinfected skin ulcus at the site of the gibbus. Since the skin ulcus required plastic surgery reconstruction, we deemed classical posterior fixation after kyphectomy unfeasible. The subsequent operative steps of our novel surgical approach were performed in a single-stage surgery. First, a three-level lumbar corporectomy from L1 to L3 was performed. Subsequently, the body of the removed L2 vertebra was isolated and configured as an autologous graft to bridge the gap between the thoracic and the caudal lumbar spine. The graft was fixed via a transcorporal interbody fusion technique with titanium screws, and chopped autologous bone was added for fusion. The skin was closed using rotation flaps. At the 3-year follow-up, the patient and his family reported marked improvement of quality of life, imaging showed solid fusion and the wound was unremarkable. Our novel technique with transcorporal fixation provides new perspectives in the treatment of severe kyphosis and skin ulceration in myelomeningocele.

The ideal wound dressing in particular for burn wounds has not been found yet. The aim of this study was to investigate native spider silk as a novel wound dressing. Release of inflammatory cytokines of macrophages and neutrophile granulocytes was determined via ELISA after exposure to spider silk. Migration of dermal cells as well as angiogenesis on spider silk was visualized with live video microscopy or chorioallantois membrane model, respectively. Native spider silk was placed in full-thickness skin wounds in a sheep in vivo-model and wounds were evaluated after 2, 4, 6, and 8weeks histologically as well as per quantitative real-time PCR. Minimal inflammatory cytokine release could be seen for spider silk. Ingrowth of single capillaries into bundles of spider silk and migration of keratinocytes as well as fibroblasts on spider silk fibres was proven. Macroscopically, a comparable wound closure could be seen in spider silk and in sham controls. In histological evaluation, a thicker epidermis was observed in spider silk treated wounds while collagen III/I expression ratio was comparable in both groups. As native spider silk has been described as highly biocompatible, it might represent an innovative alternative to common wound dressings.