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A single immediate reconstruction with free tissue transfer is the method of choice after major head and neck cancer (HNC) resection, but this is frequently associated with long operating hours. Considering regulatory working hour constraints, we investigated whether a two-staged reconstructive approach with temporary defect coverage by an artificial tissue substitute would be feasible. HNC patients underwent either immediate or delayed reconstruction after tumor resection. Patients with delayed reconstruction received preliminary reconstruction with an artificial tissue substitute followed by definitive microvascular reconstruction in a separate, second procedure. Of the 33 HNC patients, 13 received delayed reconstruction and 20 received immediate reconstruction. Total anesthesia time (714 vs. 1011 min; p < 0.002) and the total duration of hospital stay (34 ± 13 vs. 25 ± 6 days; p = 0.03) were longer in the delayed reconstruction group. Perioperative morbidity (p = 0.58), functional outcome (p > 0.1) and 5-year postoperative survival rank (p = 0.28) were comparable in both groups. Delayed reconstruction after HNC resection was feasible. Perioperative morbidity, functional outcome and overall survival were comparable to immediate reconstruction.

The globally increasing incidence of cutaneous malignancies leads, in parallel, to increasing numbers of locally advanced skin cancer resulting in reconstructive surgery. Reasons for locally advanced skin cancer may be a patient’s neglect or aggressive tumor growth, such as desmoplastic growth or perineural invasion. This study investigates characteristics of cutaneous malignancies requiring microsurgical reconstruction with the aim of identifying possible pitfalls and improving diagnostic and therapeutic processes. A retrospective data analysis from 2015 to 2020 was conducted. Seventeen patients (n = 17) were included. The mean age at reconstructive surgery was 68.5 (±13) years. The majority of patients (14/17, 82%) presented with recurrent skin cancer. The most common histological entity was squamous cell carcinoma (10/17, 59%). All neoplasms showed at least one of the following histopathological characteristics: desmoplastic growth (12/17, 71%), perineural invasion (6/17, 35%), or tumor thickness of at least 6 mm (9/17, 53%). The mean number of surgical resections until cancer-free resection margins (R0) were achieved was 2.4 (±0.7). The local recurrence rate and the rate of distant metastases were 36%. Identified high-risk neoplastic characteristics, such as desmoplastic growth, perineural invasion, and a tumor depth of at least 6 mm, require a more extensive surgical treatment without concerns about defect size.

Growth differentiation factor 15 (GDF15) is a stress-responsive cytokine also known as a mitokine; however, its role in mitochondrial homeostasis and cellular senescence remained elusive. We show here that knocking down GDF15 expression in human dermal fibroblasts induced mitochondrial dysfunction and premature senescence, associated with a distinct senescence-associated secretory phenotype. Fibroblast-specific loss of GDF15 expression in a model of 3D reconstructed human skin induced epidermal thinning, a hallmark of skin aging. Our results suggest GDF15 to play a so far undisclosed role in mitochondrial homeostasis to delay both the onset of cellular senescence and the appearance of age-related changes in a 3D human skin model.

Orbital exenteration is a disfiguring procedure that often results in free tissue transfer for reconstructive purposes. The reconstructive focus is the obliteration of dead space while sparing the nasal airway, particularly if the medial orbital wall was resected. Prolapse of transferred tissue into the nasal airway may cause breathing difficulties drastically compromising quality of life. The objective of this study was to demonstrate the effectiveness and feasibility of temporary nasal septum splints as mechanical support for transferred tissue, to prevent airway obstruction. This novel application technique was employed in three patients between 2017 and 2018. No flap loss or sino‐orbital fistulas were observed. On postoperative MRI and endoscopy, a patent nasal airway was observed at all times. Temporary nasal splinting in combination with free tissue transfer proved to be a simple, but effective reconstructive option for securing the nasal airway following orbital exenteration with resection of the medial orbital wall.

ZusammenfassungDer tiefe sternale Wundinfekt (TSWI) ist eine seltene Komplikation nach Sternotomie, die mit hoher Morbidität und Mortalität behaftet ist und Krankenhausaufenthalt sowie die Behandlungskosten signifikant ansteigen lässt. Eine mikrobiologische Besonderheit ist die Ausbildung von Biofilmen auf Implantatmaterial und/oder Knochensequestern. Die Diagnose wird anhand der klinischen Symptomatik der lokalen Entzündungsreaktion gestellt und durch systemische Infektionszeichen gestützt. Eine frühzeitige und gemeinsame Konsensfindung, welche die oft interdisziplinäre Behandlungsstrategie festlegt, ist dabei essenziell. Die Behandlung besteht i. d. R. aus mehreren chirurgischen Wunddebridements mit zwischenzeitlicher Wundkonditionierung, bis ein ausreichend sauberer Wundstatus erreicht ist. Zur Infektsanierung und für den Wundverschluss stehen je nach Größe und Lokalisation des Gewebedefektes eine Vielzahl verschiedener gestielter und freier Lappenplastiken zur Auswahl.

Myositis ossificans traumatica (MOT) describes a benign form of ectopic ossification of soft tissue, most commonly skeletal muscle, that occurs in reaction to trauma. Treatment is indicated if important neurovascular structures are compressed or displaced and in case of functional restrictions that hamper movements of daily life. We report the case of a patient who developed increasing palsy of the left deltoid and biceps brachii muscles 8 weeks after multiple injuries sustained in a car accident. Ultrasound and x-rays pointed towards a calcified mass compressing the left brachial plexus. Four months after the precipitating trauma, the mass was surgically resected. Surgical exploration and histopathology yielded the diagnosis of MOT. At a 3-month follow-up visit, the patient experienced complete functional recovery and has remained recurrence free. To our knowledge, this case represents the first report in which MOT caused complete brachial plexus palsy. The findings support the argument that surgical treatment for MOT does not have to be delayed until 6–12 months after the initial trauma to await full maturation. Clinical symptoms extending to complete palsy can result from posttraumatic ectopic calcification. Early surgical intervention in the case of persistence or deterioration of symptoms is indicated. A full remission of nerve and motor function is possible. Level of evidence: Level V, risk/prognostic study.

The role of Ras-Mitogen-activated protein kinase (MAPK) signaling in cellular aging is not precisely understood. Recently, we identified Sprouty1 (SPRY1) as a weight-loss target gene in human adipose stem/progenitor cells (ASCs) and showed that Sprouty1 is important for proper regulation of adipogenesis. In the present study, we show that loss-of-function of Sprouty1 by CRISPR/Cas9-mediated genome editing in human ASCs leads to hyper-activation of MAPK signaling and a senescence phenotype. Sprouty1 knockout ASCs undergo an irreversible cell cycle arrest, become enlarged and stain positive for senescence-associated β-galactosidase. Sprouty1 down-regulation leads to DNA double strand breaks, a considerably increased number of senescence-associated heterochromatin foci and induction of p53 and p21Cip1. In addition, we detect an increase of hypo-phosphorylated Retinoblastoma (Rb) protein in SPRY1 knockout ASCs. p16Ink4A is not induced. Moreover, we show that Sprouty1 knockout leads to induction of a senescence-associated secretory phenotype as indicated by the activation of the transcription factors NFκB and C/EBPβ and a significant increase in mRNA expression and secretion of interleukin-8 (IL-8) and CXCL1/GROα. Finally, we demonstrate that adipogenesis is abrogated in senescent SPRY1 knockout ASCs. In conclusion, this study reveals a novel mechanism showing the importance of Sprouty1 for the prevention of senescence and the maintenance of the proliferation and differentiation capacity of human ASCs.

Zusammenfassung Hintergrund Die Bildung von beruflichen Netzwerken und Kooperationen ist neben einer guten Weiterbildung für eine erfolgreiche Karriere meist grundlegend. In etlichen Fachdisziplinen existieren hierfür bereits kleinere Symposien oder Konferenzen. Im Forschungszweig der Mikrochirurgie gab es bislang jedoch noch keine dezidierte Möglichkeit für Nachwuchswissenschaftler sich untereinander zu vernetzen. Methoden Im Jahre 2017 wurde erstmalig eine Wissenschaftsakademie durch die Deutschsprachige Arbeitsgemeinschaft für Nerven und Gefäße (DAM) initiiert. Das Ziel war es, mikrochirurgisch forschende junge Ärzte sowie Wissenschaftler im kleinen Rahmen einmal jährlich zusammenzubringen und zu vernetzen, um Synergien für gemeinsame Forschungsprojekte zu entwickeln. Hierfür wurden jeweils von den Vorständen der Forschungseinrichtungen, die in der DAM organisiert sind, motivierte Nachwuchswissenschaftler zur Akademie entsendet. Nach einem Kennenlernen in lockerer Atmosphäre, bekamen die Teilnehmer die Möglichkeit, sich im Rahmen von Themenblöcken und unter Moderation durch erfahrene Mentoren ihr jeweiliges Forschungsprojekt vorzustellen. Es schloss sich eine Diskussionsrunde sowie Kleingruppenarbeit an, in der Kenntnisse und Methoden ausgetauscht sowie Anknüpfungspunkte für mögliche spätere Kooperationen identifiziert wurden. Ergebnisse Die DAM Wissenschaftsakademie erwies sich in den vergangenen 3 Jahren als ein optimales Format, um Netzwerke von jungen mikrochirurgisch interessierten Ärzten und Wissenschaftlern zu initiieren und zu fördern. Es ergaben sich zahlreiche lebhafte und vertiefte Diskussionen, die vor allem durch die offene Arbeitsatmosphäre und die Verpflichtung zur Vertraulichkeit zustande kamen. Die meisten Synergien zeigten sich u. a. auf dem Gebiet Angiogenese, Bioreaktor, Karzinom-ADSC Interaktionen, Stammzellen, AV loop Modell, Ischämie/Reperfusion und Nervenregeneration. Die Teilnehmer gaben in abschließender Evaluation durchweg ein sehr positives Feedback mit dem Wunsch der Fortsetzung dieser Akademie. Schlussfolgerung Die DAM Wissenschaftsakademie kann als eine sinnvolle Ergänzung zu den bereits bestehenden Möglichkeiten der Vernetzung unter mikrochirurgischen Forschern betrachtet werden. Die bisherigen Erfahrungen lassen annehmen, dass sich hieraus langfristige Kooperationen und ein dauerhafter Wissenstransfer unter den Teilnehmern ergeben.

Zusammenfassung Hintergrund Bei Rezidiv-Plattenepithelkarzinom des Hypopharynx/Larynx nach Bestrahlung stellt die Salvage-Laryngektomie (Salvage-LE) die beste kurative Therapieoption dar. Vorbestrahlung begünstigt die Entstehung pharyngokutaner Fisteln (pk-Fisteln). Transfer von unbestrahltem Gewebe in das OP-Gebiet reduziert die Fistelrate. Hierfür wird oft ein myokutaner Pectoralis-major-Lappen (PML) verwendet. Wir beschreiben einen muskelsparenden, myofaszialen PML (ms-PML) und dessen funktionelle und ästhetische Resultate. Methoden Über je eine 8 cm lange subklavikuläre und submammäre horizontale Inzision wird ein am R. pectoralis der A. thoracoacromialis gestielter kraniokaudaler Streifen des M. pectoralis major unter Schonung der Pars clavicularis präpariert und supraklavikulär auf den Pharynx aufgebracht. R0-Resektionsraten, Gesamtüberleben (GS), Komplikationen, stationäre Verweildauern und funktionelle und ästhetische Resultate wurden erhoben. Ergebnisse Bei 25 Patienten wurde eine Salvage-LE mit ms-PML durchgeführt. Die R0-Resektionsrate betrug 100 %, das mediane GS 1,3 (Beobachtungszeitraum: 2,8) Jahre, die Komplikationsrate 16 % (4 komplette Lappennekrosen, 3 pk-Fisteln) und die mediane stationäre Verweildauer 20 (11–78) Tage. Gute funktionelle Ergebnisse wurden beobachtet: Einschränkungen der oralen Nahrungsaufnahme traten bei 2, Einschränkungen der Stimmrehabilitation bei 3 Patienten auf. Wundheilungsstörungen ohne Lappennekrosen wurden nicht beobachtet. Die ästhetischen Resultate waren ansprechend. Schlussfolgerung Der ms-PML ist ein wenig invasives und sicheres Verfahren zur Fistelprophylaxe bei Salvage-LE mit günstigem funktionellem und ästhetischem Ergebnis.

The CRISPR/Cas9 system is a powerful tool to generate a specific loss-of-function phenotype by gene knockout (KO). However, this approach is challenging in primary human cells. In this technical report, we present a reliable protocol to achieve a functional KO in the genome of human adipose stem/progenitor cells (ASCs). Using Sprouty1 (SPRY1) as a model target gene for a CRISPR/Cas9 mediated KO, we particularize the procedure including the selection of the CRISPR/Cas9 target sequences and the employment of appropriate lentiviral vectors to obtain a functional gene KO. The efficiency of CRISPR/Cas9 to mutate the SPRY1 gene is determined by a PCR-based mutation detection assay and sequence analysis. Effects on mRNA and protein levels are studied by RT-qPCR and Western blotting. In addition, we demonstrate that CRISPR/Cas9 mediated SPRY1 KO and gene silencing by shRNA are similarly effective to deplete the Sprouty1 protein and to inhibit adipogenic differentiation. In summary, we show a reliable approach to achieve a gene KO in human ASCs, which could also apply to other primary cell types. Abbreviations: ASC: Adipogenic Stem/Progenitor Cell; Cas: CRISPR-associated system; CRISPR: Clustered Regularly Interspaced Palindromic Repeat; gDNA: Genomic DNA; GOI: Gene of interest; gRNA: Guide RNA; NHEJ: Non-homologous end joining; Indel: Insertion/Deletion; PAM: Protospacer adjacent motif; sWAT: Subcutaneous white adipose tissue; TIDE: Tracking of indels by decomposition

Aesthetic complications following neurosurgical procedures impact patient quality of life and self-perception. Postoperative temporal hollowing frequently is seen after temporal craniotomy, resulting mainly from atrophy of the temporal muscle. Autologous fat grafting is a tailorable method to correct such approach-related sequelae. We herein present our clinical patient series and discuss pearls and pitfalls of this method.In this retrospective single-center study, correction of postoperative temporal hollowing using autologous fat grafting was performed in 16 patients. Temporal tissue thickness ratio was measured using magnetic resonance tomography images to visualize the graft. Patients, plastic surgeons, and neurosurgeons evaluated the results independently using the herein presented scale.The mean interval between the neurosurgical procedure and fat grafting was 62 months. A mean volume of 11.5 mL of autologous fat was injected in an average of 2.5 sessions after initial rigottomy. Temporal tissue thickness was significantly augmented at a mean of 2.2 years after the operation (mean 0.71 ± 0.25, range 0.43-1.1; P = 0.0214) as compared with the preoperative finding (mean 0.48 ± 0.1, range 0.32-0.6). Patients were more satisfied with the results than were surgeons, reflecting the significant impact of the deformity on patient self-esteem.Autologous fat grafting is a valuable method for correcting postoperative temporal hollowing that provides stable results, high patient and surgeon satisfaction, and can be tailored to the patient's individual needs. It should not be considered a merely aesthetic operation but an important rehabilitation step towards restoring the patient's quality of life.

Introduction Traumatic peroneal nerve injury (PNI) caused by ski or snowboard edges is a severe but scarcely reported accident. Methods In a 20-year retrospective study, all skiers and snowboarders with this injury treated surgically at the Department of Plastic, Reconstructive and Aesthetic Surgery at the Medical University of Innsbruck, Austria, were included, covering a period from 1999/2000 to 2018/2019. Results In total, 34 patients were included in this study (30 males (88.2%) and 4 (11.8%) females). Of these 34 injured skiers or snowboarders, 33 (97.1%) were recreational athletes and Non-Austrian citizens, and 21 (61.8%) patients sustained accidental injuries without collision. All of the injuries under investigation, i.e., open lacerations, most often with complete transection, were the patients’ main injuries. Surgery was performed with direct coaptation in 24 patients (70.6%), and with a suralis nerve graft in the other 10 patients (29.4%). Conclusion Traumatic laceration of the peroneal nerve at the knee level by sharp ski or snowboard edges is a rare but severe injury. Causes for this injury may be multifactorial. Recommendations to reduce the risk of such an injury may follow general instructions and warnings to skiers and snowboarders regarding equipment, familiarity with the region, as well as appropriate skills and training., Highlights • In accidents of skiers and snowboarders traumatic laceration of the peroneal nerve is a severe, but rare injury. • This injury type is rarely reported. • The injuries are caused by the sharp edges of modern skies or snowboards and require urgent microsurgical intervention. • Our 20 years study shows that this injury type primarily affects recreational athletes and guest skiers. • Current equipment, e.g. ski trousers do not protect the affected region on the lateral side of the knee.

Background: The pedicled pectoralis major muscle flap (PMMF) is a well established flap for fistula prophylaxis after salvage laryngectomy. To reduce donor site morbidity, we established a modified muscle-sparing harvesting technique. We herein investigate postoperative shoulder function and health-related quality of life (HRQOL). Methods: A chart review of patients receiving the modified muscle-sparing pectoralis major muscle flap between 2013–2020 was performed. Nineteen patients (male = 18, female = 1) were potentially eligible and six male patients were ultimately enrolled. Postoperative shoulder function was assessed on both sides (flap side versus non-flap side) using the Constant Murley Score and the Bak criteria. Health-related quality of life was assessed with the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire in cancer patients (EORTC QLQ-C30) and head and neck cancer patients (EORTC H&amp, N35). Results: No Constant Murley Score subscale was statistically significant (p ≥ 0.180). Bak criteria was overall rated “Good“. Solely upper extremity adduction force was significantly altered on the flap side (p = 0.039). Median EORTC QLQ-C30 score was 82.2 (IQR 11.1) on the functional scale and 10.3 (IQR 2.6) on the symptomatic scale. Median quality of life score was 75.0 (IQR 33.3) and median EORTC QLQ-H&amp, N35 was 20.6 (IQR 9.8). Conclusions: Postoperative shoulder function after modified muscle-sparing pectoralis major muscle flap surgery is comparable to function of the healthy side with a significant deficiency in adduction force not compromising daily life in this small study cohort.

Summary Background Recently, breast reconstruction with the greater omentum flap has gained more attention, although it has been only rarely reported in the literature. An unpleasant case presented by us here prompted us to perform a literature search on breast reconstruction with the omentum flap concerning postoperative results and complication rates. Case presentation We here present the case of a 46-year-old woman who presented with severe infection 3 months after omentum flap reconstruction in a distant local hospital. Intraoperative revision showed an inflammatory, completely necrotic flap that had to be removed. Conclusion The literature review shows that the omentum flap can be reasonably used only in one-sided reconstructions of very small breasts. Due to the limited indications, unpredictable flap volume, and our negative experience, we recommend that this type of reconstruction be used with restraint.

Background: The aim of this study was to determine whether there is a difference in results between the radial and the inframammary approach in nipple-/skin-sparing mastectomy and immediate reconstruction. Methods: The patients were divided into two groups (group 1: radial incision; group 2: inframammary fold incision [IMF]), each consisting of two subgroups for direct-to-implant reconstruction (1a, 2a) and expander reconstruction (1b, 2b). The patients were operated on between March 2012 and May 2017. Preoperative tumor parameters, reconstruction parameters, postoperative tumor parameters, and immediate and late complications were assessed. Postoperative photographs were evaluated by the patients and 8 plastic surgeons by means of grading (1–5) and the visual analog scale (VAS; 1–10). Results: Enrolled in this study were 28 patients, namely, 7 patients in each subgroup. The median age was 46 years, and the median follow-up period was 40 months. No immediate complications occurred. Three patients had late complications, but there was no case of evident capsular fibrosis. Twenty-seven patients (96.42%) evaluated the postoperative result as excellent/good. The postoperative evaluation by the plastic surgeons was excellent/good for a median of 18 patients (64.28%). Group 1 showed a median VAS score of 7.63 (expander group: 7.50; direct-to-implant group: 7.75); the median VAS score for group 2 was 8.25 (expander group: 8.75; direct-to-implant group: 7.50). Conclusions: Our study shows good results for implant breast reconstruction in both groups, with minimally better results for the IMF group. In the direct-to-implant subgroups, the radial group showed slightly better results.

ZusammenfassungDie Plastische Chirurgie ist stärker als viele andere Fachgebiete durch ein hohes Maß an multidisziplinärer Vernetzung geprägt. Trotz des breiten fachlichen Spektrums der Plastischen Chirurgie ist das Fachgebiet nicht an jedem Universitätsklinikum oder Haus der Maximalversorgung als eigenständige Abteilung oder Klinik vertreten. Auch haben selbstständige Einrichtungen nicht selten mit einem niedrig angesetzten Stellenschlüssel zu kämpfen. Außer Frage steht, dass das Fachgebiet durch die stetige Entwicklung der rekonstruktiven Mikrochirurgie zu einer deutlich verbesserten und schnelleren Versorgung von Patienten mit komplexen Defektwunden beigetragen hat. Der Zustrom der Patienten erfolgt hierbei zum größten Teil über andere Fachabteilungen. Die Einbindung der zuführenden Abteilung in die Erstellung des rekonstruktiven Planes ist von entscheidender Bedeutung für den qualitativen Erfolg der Behandlung und die Funktionswiederherstellung. Der Schlüssel in der weiteren Entwicklung des Fachgebietes liegt dabei in hohem Maße bei der stärkeren Vernetzung mit unterschiedlichen Fachdisziplinen, um die Behandlung komplexer Fälle zu gewährleisten und stärker in den allgemeinen Fokus der Krankenhausmedizin zu rücken. Im Interesse der Versorgungsqualität ist hierbei die professionelle Implementierung von multidisziplinären Boards, bei denen die Plastisch-rekonstruktive Chirurgie eine wichtige Rolle einnehmen kann, von größter Relevanz.Im Rahmen des Workshops „Der interdisziplinäre Mikrochirurg“ wurde auf der 39. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße das Thema des Stellenwertes, der Initiierung und der Umsetzung von interdisziplinären Boards diskutiert und gemeinsame Empfehlungen konsentiert. Die gemeinsamen Ergebnisse und Erfahrungen werden im vorliegenden Artikel dargestellt und an drei konkreten Beispielen verdeutlicht.

Zusammenfassung Einleitung Eine aktuelle Umfrage unter Ärzten in Weiterbildung zum Facharzt für Plastische und Ästhetische Chirurgie und Klinikleitern zeigt ein großes Interesse an einer hochwertigen mikrochirurgischen Weiterbildung. Leider gefährden ökonomischer Druck sowie forensische Bedenken diese Bemühungen zunehmend und machen eine Verlagerung des Trainings außerhalb des OPs nötig. Zur Förderung der mikrochirurgischen Weiterbildung bietet die Deutschsprachige Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) eine Akademie an, um Kollegen ein breites mikrochirurgisches Spektrum zu bieten und den fachlichen Austausch zu stärken. In dieser Arbeit stellen wir das Kurskonzept und eine erste Evaluation vor. Methodik Seit 2015 wurde jährlich durch die DAM eine praxisorientierte Weiterbildungsakademie mit Gastoperateuren zu allen Schwerpunktbereichen der Mikrochirurgie an der BG-Klinik Ludwigshafen veranstaltet. Pro Tag wurden jeweils mindestens 3 mikrochirurgische Eingriffe in den Fachgebieten Brust-, Nerven-, Knochen/Hand-Extremitäten- und Lymphgefäßrekonstruktion parallel durchgeführt und begleitet von Fachvorträgen. Die Teilnehmer wurden gebeten, anonym ihre Erwartungen zu dem Kurskonzept zu definieren sowie den Kurs und seine Inhalte zu evaluieren. Ergebnisse Das Format und die Ziele der Akademie werden dargestellt. Im zweiten Schritt erfolgte die Evaluation, an der sich 79 % der Teilnehmer beteiligten. 90 % der Teilnehmer waren aus einem Haus der Maximalversorgung oder Universitätsklinik, wobei 57 % der Abteilungen weniger als 5 mikrochirurgische Eingriffe pro Woche durchführten. Alle Teilnehmer sahen die Mikrochirurgie als Teil ihres Arbeitsspektrums und das größte Interesse bestand für die Extremitäten- (90 %) und die mikrochirurgische Rekonstruktion der Hand (80 %). Alle Teilnehmer würden den Kurs weiterempfehlen, empfohlen wurde eine Verbesserung der intraoperativen Video-Übertragung. Diskussion Diese Arbeit zeigt, dass praxisorientierte Akademien am Beispiel der Mikrochirurgie ein hochaktuelles Lernformat sind, um den Limitationen der chirurgischen Aus- und Weiterbildung erfolgreich entgegenzutreten. Insbesondere der enge Austausch mit den Experten wurde als wertvoll erachtet, um ein Netzwerk innerhalb der deutschsprachigen Mikrochirurgie aufzubauen. Die Akademie verfolgt das Ziel, eine junge Generation von Mikrochirurgen dauerhaft und nachhaltig zu begeistern und ein professionelles Netzwerk aufzubauen und weiterzuentwickeln.

Background: Pectoralis major flap reconstruction is often associated with large unappealing scars in head-neck surgery. We recently established an alternative harvesting technique that improves aesthetic outcome. Objectives: The objective of this study was to demonstrate a modified surgical technique that harvests the pectoralis major muscle as an island flap and focuses on minimizing incision lines and applying a muscle-sparing approach. Methods: A retrospective analysis covering the period 2008–2018 was conducted. Patients who underwent pectoralis major island flap reconstruction for fistula prophylaxis after salvage laryngectomy at the Medical University of Innsbruck were included. Flap harvesting was performed subcutaneously using two small incision lines, thereby sparing the clavicular and upper sternocostal aspects of the pectoralis muscle. Results: Twenty-three patients with squamous cell carcinoma of the larynx (n = 19) or pharynx (n = 4) underwent salvage laryngectomy and consecutive reconstruction using a pectoralis major island flap and our muscle-sparing technique. Mean overall operation time was 147 ± 48.6 min. The majority (70%) of patients had an uneventful course of recovery and showed satisfying aesthetic results and low donor site morbidity as compared to traditional harvesting techniques. Six (26%) patients had major complications that required surgical revision. Three (13%) cases were complicated with fistulas. Conclusion: The pectoralis major island flap is shown to be reliable in otolaryngeal surgery. This surgical technique minimizes scarring and preserves thoracic wall architecture by taking a less invasive approach, thereby improving aesthetic outcome and reducing overall patient morbidity.

Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps.Der tiefe sternale Wundinfekt (TSWI) ist eine seltene Komplikation nach Sternotomie, die mit hoher Morbidität und Mortalität behaftet ist und Krankenhausaufenthalt sowie die Behandlungskosten signifikant ansteigen lässt. Eine mikrobiologische Besonderheit ist die Ausbildung von Biofilmen auf Implantatmaterial und/oder Knochensequestern. Die Diagnose wird anhand der klinischen Symptomatik der lokalen Entzündungsreaktion gestellt und durch systemische Infektionszeichen gestützt. Eine frühzeitige und gemeinsame Konsensfindung, welche die oft interdisziplinäre Behandlungsstrategie festlegt, ist dabei essenziell. Die Behandlung besteht i. d. R. aus mehreren chirurgischen Wunddebridements mit zwischenzeitlicher Wundkonditionierung, bis ein ausreichend sauberer Wundstatus erreicht ist. Zur Infektsanierung und für den Wundverschluss stehen je nach Größe und Lokalisation des Gewebedefektes eine Vielzahl verschiedener gestielter und freier Lappenplastiken zur Auswahl.

We explore the status of quiescence, stemness and adipogenic differentiation capacity in adipose stem/progenitor cells (ASCs) ex vivo, immediately after isolation from human subcutaneous white adipose tissue, by sorting the stromal vascular fraction into cell-surface DLK1+/CD34&minus, DLK1+/CD34dim and DLK1&minus, /CD34+ cells. We demonstrate that DLK1&minus, /CD34+ cells, the only population exhibiting proliferative and adipogenic capacity, express ex vivo the bonafide quiescence markers p21Cip1, p27Kip1 and p57Kip2 but neither proliferation markers nor the senescence marker p16Ink4a. The pluripotency markers NANOG, SOX2 and OCT4 are barely detectable in ex vivo ASCs while the somatic stemness factors, c-MYC and KLF4 and the early adipogenic factor C/EBP&beta, are highly expressed. Further sorting of ASCs into DLK1&minus, /CD34+/CD24&minus, and DLK1&minus, /CD34+/CD24+ fractions shows that KLF4 and c-MYC are higher expressed in DLK1&minus, /CD34+/CD24+ cells correlating with higher colony formation capacity and considerably lower adipogenic activity. Proliferation capacity is similar in both populations. Next, we show that ASCs routinely isolated by plastic-adherence are DLK1&minus, /CD34+/CD24+. Intriguingly, CD24 knock-down in these cells reduces proliferation and adipogenesis. In conclusion, DLK1&minus, /CD34+ ASCs in human sWAT exist in a quiescent state, express high levels of somatic stemness factors and the early adipogenic transcription factor C/EBP&beta, but senescence and pluripotency markers are barely detectable. Moreover, our data indicate that CD24 is necessary for adequate ASC proliferation and adipogenesis and that stemness is higher and adipogenic capacity lower in DLK1&minus, /CD34+/CD24+ relative to DLK1&minus, subpopulations.

Das Plattenepithelkarzinom ist nach dem Basalzellkarzinom das zweithaufigste Malignom der Haut und wird vorwiegend an sonnenexponierten Stellen wie der Gesichtshaut diagnostiziert. Diese meist lokal destruktiv wachsende Malignitat kann durchaus auch invasives Wachstumsverhalten, wie perineurale Ausbreitungsmechanismen, aufweisen. Das Plattenepithelkarzinom der periorbitalen Region ist in bis zu 14 % der Falle mit perineuraler Invasion assoziiert. Vor allem in diesem Bereich birgt die anatomische Nahe zu den Hirnnerven das Risiko einer Progression Richtung zentrales Nervensystem, was mit einer schlechteren Prognose assoziiert ist. Der klinisch unauffallige Charakter dieser Entitat resultiert oft in einer Verzogerung der definitiven Diagnosestellung, wodurch die vollstandige Resektion und anschliesende Rekonstruktion erschwert werden. Eine aufmerksame klinische Evaluierung kann bereits vor Erlangen histologischer Befunde Hinweise fur ein perineurales Wachstum liefern. Neben funf herausfordernden Fallen analysiert diese Arbeit Risikofaktoren, klinische als auch histologische Merkmale und Behandlungsoptionen des periorbitalen Plattenepithelkarzinoms mit perineuraler Invasion.

Squamous cell carcinoma is the second most common malignancy of the skin after basal cell carcinoma and mainly found in sun-exposed areas such as the face. This mostly locally destructive malignancy may show invasive growth and insidious mechanisms of dissemination such as perineural invasion. Periorbital squamous cell carcinoma is associated with perineural invasion in up to 14 % of cases. Specifically in this region, the proximity to cranial nerves and therefore the associated risk of progression to the central nervous system are associated with poor prognosis. The clinically concealed character of this entity often leads to a delay in diagnosis and consequently makes complete resection and reconstruction demanding. Careful clinical evaluation often hints at perineural invasion before obtaining histology. Aside from presenting five challenging cases, this work analyzes risk factors, clinical as well as histological features, and treatment options for periorbital squamous cell carcinoma with perineural invasion.

Summary Between 2000 and 2014, five patients received bilateral hand (n = 3), bilateral forearm (n = 1), and unilateral hand (n = 1) transplants at the Innsbruck Medical University Hospital. We provide a comprehensive report of the long‐term results at 20 years. During the 6–20 years follow‐up, 43 rejection episodes were recorded in total. Of these, 27.9% were antibody‐related with serum donor‐specific alloantibodies (DSA) and skin‐infiltrating B‐cells. The cell phenotype in rejecting skin biopsies changed and C4d‐staining increased with time post‐transplantation. In the long‐term, a change in hand appearance was observed. The functional outcome was highly depending on the level of amputation. The number and severity of rejections did not correlate with hand function, but negatively impacted on the patients´ well‐being and quality of life. Patient satisfaction significantly correlated with upper limb function. One hand allograft eventually developed severe allograft vasculopathy and was amputated at 7 years. The patient later died due to progressive gastric cancer. The other four patients are currently rejection‐free with moderate levels of immunosuppression. Hand transplantation remains a therapeutic option for carefully selected patients. A stable immunologic situation with optimized and individually adopted immunosuppression favors good compliance and patient satisfaction and may prevent development of DSA.

In recurrent hypopharyngeal/laryngeal squamous cell carcinoma after radiation salvage-laryngectomy (salvage-LE) represents the best curative treatment option. Pre-irradiation promotes development of pharyngocutaneous fistulas (pc-fistula). Transfer of unirradiated tissue to the surgical site reduces fistula rate. Frequently, a myocutaneous Pectoralis-major-flap (PMF) is applied. We describe a muscle sparing, myofascial PMF (ms-PMF) and its functionalaesthetic results.For the ms-PMF, the pectoralis major is exposed via two 8 cm long subclavicularsubmammary horizontal incisions. The pectoral branch of the thoracoacromial artery, which represents the blood supply for the ms-PMF, is identified between the clavicular and sternocostal aspect of the muscle. A craniocaudal stripe of the pectoralis major is recovered and supraclaviculary transposed towards the pharynx. The clavicular and sternocostal part of the muscle remain untouched.The clear-margin resection rate (CMRR), mean overall survival (OS), complications, median length of hospital stay,functionalaesthetic outcome were assessed.In 25 patients, salvage-LE with ms-PMF was performed. The CMRR was 100 %, median OS 1.3 (follow-up 2.8) years, complications rate 16 % (4 complete lobe necroses, 3 pc-fistulas) and median inpatient stay 20 (11-78) days. Good functional outcome were observed: limitations of oral food intake occurred in 2-, limitations in voice rehabilitation in 3 patients. Wound healing disorders without lobe necrosis were not observed. The aesthetic results were appealing.The ms-PMF is a less invasivesafe procedure for fistula prophylaxis in salvage-LE with favorable functional aesthetic results.Bei Rezidiv-Plattenepithelkarzinom des Hypopharynx/Larynx nach Bestrahlung stellt die Salvage-Laryngektomie (Salvage-LE) die beste kurative Therapieoption dar. Vorbestrahlung begünstigt die Entstehung pharyngokutaner Fisteln (pk-Fisteln). Transfer von unbestrahltem Gewebe in das OP-Gebiet reduziert die Fistelrate. Hierfür wird oft ein myokutaner Pectoralis-major-Lappen (PML) verwendet. Wir beschreiben einen muskelsparenden, myofaszialen PML (ms-PML) und dessen funktionelle und ästhetische Resultate.Über je eine 8 cm lange subklavikuläre und submammäre horizontale Inzision wird ein am R. pectoralis der A. thoracoacromialis gestielter kraniokaudaler Streifen des M. pectoralis major unter Schonung der Pars clavicularis präpariert und supraklavikulär auf den Pharynx aufgebracht. R0-Resektionsraten, Gesamtüberleben (GS), Komplikationen, stationäre Verweildauern und funktionelle und ästhetische Resultate wurden erhoben.Bei 25 Patienten wurde eine Salvage-LE mit ms-PML durchgeführt. Die R0-Resektionsrate betrug 100 %, das mediane GS 1,3 (Beobachtungszeitraum: 2,8) Jahre, die Komplikationsrate 16 % (4 komplette Lappennekrosen, 3 pk-Fisteln) und die mediane stationäre Verweildauer 20 (11–78) Tage. Gute funktionelle Ergebnisse wurden beobachtet: Einschränkungen der oralen Nahrungsaufnahme traten bei 2, Einschränkungen der Stimmrehabilitation bei 3 Patienten auf. Wundheilungsstörungen ohne Lappennekrosen wurden nicht beobachtet. Die ästhetischen Resultate waren ansprechend.Der ms-PML ist ein wenig invasives und sicheres Verfahren zur Fistelprophylaxe bei Salvage-LE mit günstigem funktionellem und ästhetischem Ergebnis.

Squamous cell carcinoma of the skin (SCC) and basal cell carcinoma (BCC) are common entities, often with a benign course. Tumour biology, however, is different in immunosuppressed individuals, such as organ transplant recipients (OTR). As immunosuppression-sparing protocols have not yet been successfully introduced to the clinics, nonmelanoma skin cancers (NMSCs) will continue to affect a majority of OTR, leading to significant morbidity and mortality. Interdisciplinary treatment including the transplant physician, dermatologist and the plastic surgeon is warranted for optimal patient management. This review focuses on special tumour characteristics and therapeutic requirements among OTR. Recommendations for local treatment and oncoplastic surgery are discussed.

ZusammenfassungEin besseres Verständnis und die zunehmende Routine in der Mikrochirurgie während der letzten zwei Jahrzehnte, unter anderem aufgrund verbesserter Instrumente und technischer Geräte, wie auch die zunehmende Anzahl verfügbarer Gewebe-Spenderstellen für den freien Lappentransfer, ermöglichen heutzutage bei geeigneter Indikation individualisierte, sicherere und erfolgreichere mikrochirurgische Rekonstruktionen nahezu unabhängig vom Patientenalter. Trotz dieser stetigen Entwicklungen ist die Literatur bezüglich der Thematik im Hinblick auf die spezifischen Probleme bei älteren Patienten bisher noch spärlich. In zwei Konsensus-Workshops der DAM (Deutschsprachige Arbeitsgemeinschaft für die Mikrochirurgie der peripheren Nerven und Gefäße) anlässlich der Jahrestagungen 2014 und 2016 wurden die neuesten Erkenntnisse und Erfahrungen zum mikrochirurgischen Wiederaufbau beim älteren Patienten von einer Expertengruppe erarbeitet und aktuelle Empfehlungen formuliert. Basierend auf diesen Konsensus-Treffen und der aktuellen Literatur diskutiert dieser Artikel die relevanten Aspekte.

To precisely characterize CD146 in adipose stromal/progenitor cells (ASCs) we sorted the stromal vascular faction (SVF) of human abdominal subcutaneous white adipose tissue (sWAT) according to cell surface (cs) expression of CD146, DLK1 and CD34. This test identified three main SVF cell populations: ~50% cs-DLK1−/cs-CD34+/cs-CD146− ASCs, ~7.5% cs-DLK1+/cs-CD34dim/+/cs-CD146+ and ~7.5% cs-DLK1+/cs-CD34dim/+/cs-CD146− cells. All cells contained intracellular CD146. Whole mount fluorescent IHC staining of small vessels detected CD146+ endothelial cells (CD31+/CD34+/CD146+) and pericytes (CD31−/CD34−/CD146+ ASCs). The cells in the outer adventitial layer showed the typical ASC morphology, were strongly CD34+ and contained low amounts of intracellular CD146 protein (CD31−/CD34+/CD146+). Additionally, we detected wavy CD34−/CD146+ and CD34dim/CD146+ cells. CD34dim/CD146+ cells were slightly more bulky than CD34−/CD146+ cells. Both CD34−/CD146+ and CD34dim/CD146+ cells were detached from the inner pericyte layer and protruded into the outer adventitial layer. Cultured early passage ASCs contained low levels of CD146 mRNA, which was expressed in two different splicing variants, at a relatively high amount of the CD146-long form and at a relatively low amount of the CD146-short form. ASCs contained low levels of CD146 protein, which consisted predominantly long form and a small amount of short form. The CD146 protein was highly stable, and the majority of the protein was localized in the Golgi apparatus. In conclusion, the present study contributes to a better understanding of the spatial localization of CD34+/CD146+ and CD34−/CD146+ cells in the adipose niche of sWAT and identifies CD146 as intracellular protein in cs-DLK1−/cs-CD34+/cs-CD146− ASCs.

Capnocytophaga canimorsus is a bacterium transmitted through the saliva of dogs. An infection can cause severe sepsis with acral necrosis and is potentially fatal. Here, we report the case of a 41-year-old man who was infected through a wound that was licked by his dog. He went into septic shock with disseminated intravascular coagulation and subsequently lost both lower legs, his nose and all the fingers on both hands.

Pressure sore rates remain high in both nursing homes as well as in hospitals. Numerous surgical options are available for defect coverage in the sacral region. However, objective data is scarce as to whether a specific flap design is superior to another. Here, we aim to compare two fasciocutaneous flap designs for sacral defect coverage: the gluteal rotation flap and the gluteal V-Y flap. All primary sacral pressure sores of grades III-IV that were being covered with gluteal fasciocutaneous rotational or V-Y flaps between January 2008 and December 2014 at our institution were analysed. A total of 41 patients received a total of 52 flaps. Of these, 18 patients received 20 gluteal rotational flaps, and 23 patients received 32 V-Y flaps. Both groups were comparable with regards to demographics, comorbidities and complications. Significantly more V-Y flaps were needed to cover smaller defects. Mean length of hospital stay was significantly prolonged when surgical revision had to be carried out. Both flap designs have proven safe and reliable for defect coverage after sacral pressure sores. Gluteal rotational flaps appear to be more useful for larger defects. Both flap designs facilitate their reuse in case of pressure sore recurrence. Complication rates appear to be comparable in both designs and to the current literature.