Search

Journal of cellular and molecular medicine 26(16), 4463-4478 (2022). doi:10.1111/jcmm.17471, Published by Wiley-Blackwell, Hoboken, NJ

SUMMARY Background Cinematic Rendering (CR) is a recently introduced post-processing 3D-visualization imaging tool. The aim of this study was to assess its clinical value in the preoperative planning of deep inferior epigastric artery perforator (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flaps, and to compare it to maximum intensity projection (MIP) images. The study presents the first application of CR for perforator mapping prior to autologous breast reconstruction. Methods Two senior surgeons independently analyzed CR and MIP images based on computed tomography angiography (CTA) datasets of 20 patients in terms of vascular pedicle characteristics, the possibility to harvest a DIEP or MS-TRAM flap, and the side of the flap harvest. We calculated inter- and intra-observer agreement in order to examine the accordance of both image techniques. Results We observed a good inter- and intra-observer agreement concerning the type of flap and the side of the flap harvest. However, the agreement on the pedicle characteristics varies depending on the considered variable. Both investigators identified a significantly higher number of perforators with MIP compared to CR (observer one p Conclusion The current study serves as an explorative study, showing first experiences with CR in abdominal-based autologous breast reconstruction. In addition to MIP images, CR might improve the surgeon's understanding of the individual's anatomy. Future studies are required to compare CR with other 3D visualization tools and its possible effects on operative parameters.

Background There is still no consensus regarding the ideal zoning in abdominal-based autologous breast reconstruction using free DIEP or ms-TRAM flaps. In particular, the perfusion pattern of the flap according to the number of perforators used and their location remains controversial. In this study, the perfusion of free DIEP and ms-TRAM flaps is assessed intraoperatively and analyzed with regard to different perfusion patterns. Methods A retrospective analysis of 100 free flaps for breast reconstruction was performed. Following complete flap harvest, we used indocyanine green angiography for perfusion analysis. By applying two different contour levels, DIEP flaps with lateral or medial perforators and ms-TRAM flaps were assessed for their respective perfusion patterns. Results No statistically significant differences were found in the size of the perfusion area between the different flap types when applying the contour level of 20% (p >0.05). For the contour level of 30%, however, statistically significant differences were found between DIEP flaps with medially or laterally located perforators (p = 0.038). Laterally or medially located perforators in DIEP flaps showed no significant differences in their ability to cross the midline (contour level 20%, p = 0.068; contour level 30%, p = 0.058). Conclusion Considering the variability of the perfusion of the abdominal wall and the high sensitivity of indocyanine green angiography for their detection, the abdominal zonings play a minor role. By using intraoperative indocyanine green angiography, a precise and patient-specific free flap surgery for autologous breast reconstruction is possible independent of perforator location.

Soft-tissue sarcomas (STS) are rare, but potentially life-threatening malignancies. STS can occur anywhere in the human body with the limbs being the most common site. Referral to a specialized sarcoma center is crucial to guarantee prompt and appropriate treatment. STS treatment strategies should be discussed in an interdisciplinary tumor board to involve expertise from all available resources, including an experienced reconstructive surgeon for an optimal outcome. In many cases, extensive resection is needed to achieve R0 resection, resulting in large defects after surgery. Hence, an evaluation of whether plastic reconstruction might be required is mandatory to avoid complications due to insufficient primary wound closure. In this retrospective observational study, we present data of patients with extremity STS treated at the Sarcoma Center, University Hospital Erlangen, in 2021. We found that complications were more frequent in patients who received secondary flap reconstruction after insufficient primary wound closure compared to patients who received primary flap reconstruction. Additionally, we propose an algorithm for an interdisciplinary surgical therapy of soft-tissue sarcomas regarding resection and reconstruction and present two problematic cases to emphasize the complexity of surgical sarcoma therapy.

Rekonstruktive Masnahmen nach onkologischen Eingriffen in der Perianalregion stellen neben der progredienten Weiterentwicklung chirurgisch-onkologischer Techniken bei malignen Tumoren des Rektums, des Analkanals und der Vulva einen wesentlichen Pfeiler der postoperativen Lebensqualitat der Patienten dar. Moderne Therapiemodalitaten des Rektumkarzinoms mit neoadjuvanter Radiochemotherapie erhohen speziell durch die zylindrische extralevatorische Rektumexstirpation die Uberlebensrate und senken gleichzeitig das lokale Rezidivrisiko auf 5–10 %. Als Preis fur die zunehmende chirurgische Radikalitat und die hohere onkologische Sicherheit werden dafur grosere Gewebedefekte in Kauf genommen. Der einfache Nahtverschluss von Perinealwunden heilt haufig nicht primar, was zu Wunddehiszenz, -infektion, chronischen Fisteln und Hohlenbildungen fuhrt. Die interdisziplinare einzeitige/zweizeitige Rekonstruktion der Perianalregion mit gut durchblutetem vaskularisiertem Gewebe hat sich als zuverlassiges Verfahren zur Vorbeugung solcher Komplikationen bewahrt.

The muscle-sparing latissimus dorsi flap poses an alternative to the conventional latissimus dorsi flap when a defect requires a smaller flap volume with a long vascular pedicle. The aim of the study was to analyze the functional outcome following muscle-sparing versus conventional harvest of a latissimus dorsi flap.Patients who received a muscle-sparing latissimus dorsi muscle flap transplantation (group 1) and patients with a complete latissimus dorsi muscle flap harvest (group 2) for defect reconstruction at the University Hospital of Erlangen between 2007 and 2016 were examined. The evaluation included a physical examination with the measurement of strength and range of motion of the shoulder of both the donor side as well as the nonoperated side. Furthermore, the DASH score was evaluated. Additionally, patients in group 1 received a neurophysiological examination.The DASH score did not show statistically significant differences between both groups. Both strength (p = 0.031) and range of motion (p0.05) of the shoulder of the donor side were statistically significantly lower than the nonoperated side in group 2, while no difference was found in group 1. The neurophysiological examination in group 1 showed a reduced nerve conduction velocity of the donor side as compared to the nonoperated side in most patients (60% and n = 3).Harvesting the muscle-sparing latissimus dorsi flap leads to less functional impairments of the shoulder than harvesting the complete latissimus dorsi flap.

Zusammenfassung Ziel Diese retrospektive, unizentrische Kohortenstudie untersucht die klinischen und subjektiven Ergebnisse nach temporärer K-Drahttransfixation in leichter Überstreckung des distalen Interphalangealgelenkes bei Strecksehnenabrissen. Patienten und Methoden Die demografischen Daten der Patienten, der Bewegungsumfang des Endgelenkes, der Quick-DASH-Score sowie die Patientenzufriedenheit (0 = unzufrieden, 10 = sehr zufrieden), fortbestehende Schmerzen (ja/nein) und postoperative Komplikationen wurden anhand eines eigens entworfenen Fragebogens und einer zur Bestimmung des Bewegungsausmaßes des Fingerendgelenkes durch die Patienten selbst entwickelten Schablone ermittelt. Fragebogen und Schablone wurden 132 Patienten zugesandt, bei denen im Zeitraum von Januar 2009 bis Dezember 2019 ein Strecksehnenabriss am Fingerendgelenk mittels temporärer K-Drahttransfixation behandelt wurde. 65 Patienten (49,2 %) – 40 Männer und 25 Frauen mit einem durchschnittlichen Alter von 53,3 Jahren – sandten Fragebogen und Schablone vollständig ausgefüllt zurück. 40-mal lag eine akute, 25-mal eine chronische Verletzung vor. 35-mal (54 %) war der Mittel-, 19-mal (29 %) der Klein-, 10-mal (15 %) der Ring- und nur einmal (2 %) der Zeigefinger betroffen. Das Gesamtergebnis wurde unter Berücksichtigung des Streckdefizits entsprechend der Crawford-Klassifikation und dem Vorhandensein von persistierenden Schmerzen bewertet. Ergebnisse Entsprechend der modifizierten Crawford-Klassifikation fanden sich 75 % exzellente, 14 % gute und 11 % befriedigende Ergebnisse. Die Patienten waren subjektiv im Durchschnitt mit 7,9 von 10 Punkten sehr zufrieden. 15 Patienten berichteten über Komplikationen, 6 davon beklagten anhaltend Schmerzen. Der Quick-DASH-Score lag durchschnittlich bei 5,4 Punkten. Schlussfolgerung Die temporäre Transfixation des distalen Interphalangealgelenkes in Hyperextensionsstellung stellt ein effektives Verfahren zur Behandlung subkutaner Strecksehnenabrisse mit hoher Patientenzufriedenheit dar.

Irrespective of numerous technical developments, lymphadenectomy remains a necessary component of surgical tumor therapy. Depending on the extent and anatomical localization, complications associated with the lymph vessels such as lymphoceles, lymphatic fistulas or secondary lymphedema can occur with varying frequency, despite a meticulous dissection technique. Chronic lymph fistulas or lymphoceles often require interventional or surgical procedures. Pedicled or free microsurgical flaps are often required in the case of coexisting wound healing disorders or skin soft tissue defects, especially in an irradiated area. For secondary lymphedema a number of conservative and surgical treatment methods have been established. Adequate guideline-based conservative treatment is the method of first choice. If this does not lead to the desired result, microsurgical reconstructive, deviating or resecting procedures are available.Ungeachtet zahlreicher technischer Entwicklungen stellen Lymphadenektomien einen notwendigen Bestandteil der chirurgischen Tumortherapie dar. Abhängig von der Ausdehnung und anatomischen Lokalisation können trotz sorgfältiger Präparationstechnik lymphgefäßassoziierte Komplikationen wie Lymphozelen oder Lymphfisteln oder ein sekundäres Lymphödem in unterschiedlicher Häufigkeit auftreten. Bei chronischen Lymphfisteln oder Lymphozelen sind oftmals interventionelle oder chirurgische Verfahren erforderlich. Bei gleichzeitig bestehenden Wundheilungsstörungen oder Hautweichteildefekten, insbesondere in einem bestrahlten Areal, sind häufig gestielte oder freie mikrochirurgische Lappenplastiken erforderlich. Für das sekundäre Lymphödem sind konservative und operative Therapiemethoden etabliert. Eine adäquate leitliniengerechte konservative Therapie ist die Methode der 1. Wahl. Wenn diese nicht zum gewünschten Ergebnis führt, stehen mikrochirurgisch-rekonstruktive, deviierende oder resezierende Verfahren zur Verfügung.

The effects of topical negative pressure therapy (TNP) have been a subject of research for many years. In this study, we investigated new imaging devices to detect clinical changes that TNP causes on healthy tissue and identified differences in microcirculation created by different pressure levels. We used near-infrared spectroscopy (NIS), thermography, and a vein illuminator to measure the differences in oxygen saturation, tissue temperature, and vein pattern. A control group (−125 mmHg) and three comparison groups with only TNP dressing (Group 1), −25 mmHg (Group 2), and −175 mmHg (Group 3) were established. Thirty minutes of TNP on intact skin was followed by 30 min of resting. A total of 24 participants were measured by all imaging devices at predetermined time points. Oxygen saturation and skin temperature increased by 8.07% and 1.67 °C for the control group, 4.00% and 1.65 °C for Group 2, and 8.45% and 1.68 °C for Group 3. Group 1 showed a slight increase in oxygen saturation and a 2.7 °C increase in skin temperature. Over the 30 min following removal of TNP, oxygen saturation and temperature decreased gradually for all groups. The vein illuminator did not show significant differences in the venous pattern or flow. Our study showed that higher negative pressure values resulted in higher oxygen saturation and higher tissue temperature.

Background: The exact influence of tourniquet ischemia on a treated extremity remains unclear. Methods: Twenty patients received an operation on one hand under tourniquet ischemia. Twenty healthy volunteers received 10 min of tourniquet ischemia on one of their arms. Measurements of tissue oxygen saturation using near-infrared reflectance-based imaging and skin temperature of the dorsum of the hand were performed at five different timepoints (t0 was performed just before the application of the tourniquet ischemia, t1 directly after the application of the tourniquet ischemia, t2 before the release of the ischemia, t3 directly after the release of the ischemia, and t4 on the following day). Results: In both groups, tissue oxygen saturation dropped after the application of the tourniquet ischemia compared to t0 and increased after the release of the tourniquet ischemia. In the patient group, tissue oxygen saturation at t4 was higher compared to t0; in contrast, the level of tissue oxygen saturation in the participant group dropped slightly at t4 compared to t0. The measured skin temperature in the patient group showed an increase during the observation period, while it continuously decreased in the group of healthy participants. Conclusions: Short-term ischemia did not appear to permanently restrict perfusion in this study design. The non-invasive imaging modalities used were easy to handle and allowed repetitive measurement.

Durch die zunehmende Weiterentwicklung der chirurgisch-onkologischen Verfahren, insbesondere der extralevatorischen Rektumexstirpation in Kombination mit neoadjuvanter Bestrahlung des Beckens, konnte das lokale Rezidivrisiko des Rektumkarzinoms auf 5–10 % gesenkt werden. Die kurative Behandlung eines lokal rezidivierenden Rektumkarzinoms (LRRC) erfordert eine vollstandige Resektion mit mikroskopisch tumorfreien Randern (R0). Die onkologisch sinnvolle chirurgische Radikalitat fuhrt jedoch haufig zu einem erheblichen strukturellen und funktionellen Beckenboden- und perinealen Defekt. Die resultierende, meist vorbestrahlte Wundhohle nach abdominoperinealer Exstirpation (APE) oder pelviner Exenteration bedingt ein hohes Risiko fur Wundheilungsstorungen nach primarem Verschluss. Fur das primare als auch rezidivierende Rektum- und Analkarzinom wurde gezeigt, dass eine interdisziplinare einzeitige plastisch-chirurgische Rekonstruktion des Beckenbodens und des Perineums sowie ggf. auch der Vagina, z. B. durch einen transpelvinen vertikalen Rectus-abdominis-Muskel-Haut(VRAM)-Lappen, die Lebensqualitat verbessern und die Hospitalisierungszeit verkurzen kann. Auch im langfristigen Verlauf konnen durch diese Methode langwierige sekundare Wundheilungsstorungen und Komplikationen minimiert oder vermieden werden. Bei Sarkomen der Beckenregion kann im Sinne der onkologischen Sicherheit die Rekonstruktion auch erst im Intervall, nach Vorliegen einer R0-Situation erfolgen. Das Spektrum der plastisch-rekonstruktiven Verfahren umfasst, in Abhangigkeit der Defektgrose, die gesamte Palette moderner rekonstruktiver Moglichkeiten. Ziel ist eine Wiederherstellung der Beckenbodenfunktion, eine effiziente Komplikationsvermeidung und ggf. die zeitnahe Einleitung einer adjuvanten Therapie.

Peri-prosthetic breast infections pose a risk of severe complications after breast implant surgery. The need to remove the breast implant, control the infection and perform additional surgical procedures are the consequences. Reimplantation of an alloplastic implant is only appropriate after an infection-free interval. In this retrospective cohort study, we investigated the effectiveness of negative pressure wound treatment with instillation and dwell time (NPWTi-d) on peri-prosthetic breast infections in combination with implant removal and antibiotic therapy. Twelve patients treated with NPWTi-d due to breast implant infection were included in the study. The bacterial burden was analyzed using wound swabs before and after NPWTi-d. Additionally, laboratory values were determined before NPWTi-d and immediately before wound closure. A total of 13 peri-prosthetic breast infections in 12 patients were treated using implant removal and NPWTi-d. In 76.9% (n = 10) of the cases, the patients had undergone alloplastic breast reconstruction following cancer-related mastectomy, whereas 23.1% (n = 3) of the patients had undergone breast augmentation for cosmetic reasons. The bacterial burden in the breast pocket decreased statistically significant after implant removal and NPWTi-d. No shift from Gram-positive to Gram-negative bacteria was observed. Inflammatory markers rapidly decreased following treatment. NPWTi-d had a positive impact on the healing process after peri-prosthetic breast infections, leading to a decrease in bacterial burden within the wounds and contributing to uneventful healing. Therefore, secondary reimplantation of breast prostheses might be positively influenced when compared to conventional implant removal and simple secondary closure. Further studies are required to conclusively establish the beneficial long-term effects of using NPWTi-d for the treatment of peri-prosthetic breast infections.

This retrospective, unicenter cohort study analyse the clinical and subjective results following temporarily K-wire transfixation of the distal interphalangeal joint (DIPJ) in hyperextension in Mallet fingers.By means of a self-designed questionnaire demographic data, patient´s satisfaction (0 = unsatisfied, 10 = very satisfied), persisting pain (yes/no), postoperative complications, and the Quick-DASH score were evaluated. In addition, range of motion of the DIPJ was measured with use of a self-designed template for self-evaluation by the patients. Questionnaire and template were send to 132 patients in whom a Mallet finger was treated between January 2009 and December 2019 with K-wire transfixation of the DIPJ. 65 (49,2 %) questionnaires and templates from 40 men and 25 women with an average age of 53.3 years returned. There were 40 acute and 25 chronic Mallet fingers in 35 (54 %) middle, 19 (29 %) small, 10 (15 %) ring, and 1 (2 %) index fingers. The extension deficit was classified according to Crawford.According to the Crawford classification, there were 75 % excellent, 14 % good, and 11 % satisfied results. With an average of 7,9 points the patients were very satisfied. 15 patients reported about complications with six complaining persisting pain. The Quick-DASH score averaged 5.4 points.The treatment of Mallet fingers by transfixation of the DIPJ using a K-wire is an appropriate method leading to a good.ZIEL: Diese retrospektive, unizentrische Kohortenstudie untersucht die klinischen und subjektiven Ergebnisse nach temporärer K-Drahttransfixation in leichter Überstreckung des distalen Interphalangealgelenkes bei Strecksehnenabrissen.Die demografischen Daten der Patienten, der Bewegungsumfang des Endgelenkes, der Quick-DASH-Score sowie die Patientenzufriedenheit (0 = unzufrieden, 10 = sehr zufrieden), fortbestehende Schmerzen (ja/nein) und postoperative Komplikationen wurden anhand eines eigens entworfenen Fragebogens und einer zur Bestimmung des Bewegungsausmaßes des Fingerendgelenkes durch die Patienten selbst entwickelten Schablone ermittelt. Fragebogen und Schablone wurden 132 Patienten zugesandt, bei denen im Zeitraum von Januar 2009 bis Dezember 2019 ein Strecksehnenabriss am Fingerendgelenk mittels temporärer K-Drahttransfixation behandelt wurde. 65 Patienten (49,2 %) – 40 Männer und 25 Frauen mit einem durchschnittlichen Alter von 53,3 Jahren – sandten Fragebogen und Schablone vollständig ausgefüllt zurück. 40-mal lag eine akute, 25-mal eine chronische Verletzung vor. 35-mal (54 %) war der Mittel-, 19-mal (29 %) der Klein-, 10-mal (15 %) der Ring- und nur einmal (2 %) der Zeigefinger betroffen. Das Gesamtergebnis wurde unter Berücksichtigung des Streckdefizits entsprechend der Crawford-Klassifikation und dem Vorhandensein von persistierenden Schmerzen bewertet.Entsprechend der modifizierten Crawford-Klassifikation fanden sich 75 % exzellente, 14 % gute und 11 % befriedigende Ergebnisse. Die Patienten waren subjektiv im Durchschnitt mit 7,9 von 10 Punkten sehr zufrieden. 15 Patienten berichteten über Komplikationen, 6 davon beklagten anhaltend Schmerzen. Der Quick-DASH-Score lag durchschnittlich bei 5,4 Punkten.Die temporäre Transfixation des distalen Interphalangealgelenkes in Hyperextensionsstellung stellt ein effektives Verfahren zur Behandlung subkutaner Strecksehnenabrisse mit hoher Patientenzufriedenheit dar.

OBJECTIVE Expression of dipeptidylpeptidase 4 (DPP-4) identifies a dermal fibroblast lineage involved in scarring during wound healing. The role of DDP-4 in tissue fibrosis is, however, unknown. The aim of the present study was to evaluate DPP-4 as a potential target for the treatment of fibrosis in patients with systemic sclerosis (SSc). METHODS Expression of DPP-4 in skin biopsy samples and dermal fibroblasts was analyzed by real-time polymerase chain reaction, immunofluorescence, and Western blot analyses. The activity of DPP-4 was modulated by overexpression, knockdown, and pharmacologic inhibition of DPP4 using sitagliptin and vildagliptin. The effects of DPP4 inhibition were analyzed in human dermal fibroblasts and in different mouse models of SSc (each n = 6). RESULTS The expression of DPP-4 and the number of DPP-4-positive fibroblasts were increased in the fibrotic skin of SSc patients, in a transforming growth factor β (TGFβ)-dependent manner. DPP-4-positive fibroblasts expressed higher levels of myofibroblast markers and collagen (each P < 0.001 versus healthy controls). Overexpression of DPP4 promoted fibroblast activation, whereas pharmacologic inhibition or genetic inactivation of DPP4 reduced the proliferation, migration, and expression of contractile proteins and release of collagen (each P < 0.001 versus control mice) by interfering with TGFβ-induced ERK signaling. DPP4-knockout mice were less sensitive to bleomycin-induced dermal and pulmonary fibrosis (P < 0.0001 versus wild-type controls). Treatment with DPP4 inhibitors promoted regression of fibrosis in mice that had received bleomycin challenge and mice with chronic graft-versus-host disease, and ameliorated fibrosis in TSK1 mice (each P < 0.001 versus untreated controls). These antifibrotic effects were associated with a reduction in inflammation. CONCLUSION DPP-4 characterizes a population of activated fibroblasts and shows that DPP-4 regulates TGFβ-induced fibroblast activation in the fibrotic skin of SSc patients. Inhibition of DPP4 exerts potent antifibrotic effects when administered in well-tolerated doses. As DPP4 inhibitors are already in clinical use for diabetes, these results may have direct translational implications for the treatment of fibrosis in patients with SSc.

Background Free tissue transfer has become a routine procedure with low failure. In case of a compromised vascular pedicle, flap survival is time dependantly possible due to flap autonomization. However it remains unknown at what time and to which degree different factors influence flap autonomization. Methods We investigated 16 patients after free flap reconstruction at different anatomic locations who eventually presented for other medical reasons. To assess the perfusion pattern we performed Indocyanine Green angiography. Results The mean follow-up after free flap reconstruction was 58,1 month. A total of 16 flaps were examined at different anatomic locations. In 2 cases digital subtraction angiography demonstrated an occlusion of the anastomosis after arteriovenous loop despite vital flaps. Indocyanine Green angiography showed no signs of mal-perfusion or non-perfusion in the transplanted flaps and capillaries across the flap borders in 9 cases. Conclusion Flap autonomization is possible even in patients with problem wounds and poorly vascularized wound beds independent from the anatomic localization. Multiple factors exist, that influence the autonomization process over time. Indocyanine Green angiography seems to be a promising tool to visualize and study the skin perfusion pattern of free flaps over longer periods.

The aim of the study was to compare physical activity (PA) in patients who had undergone massive weight loss (MWL), before and after body contouring procedures. All patients undergoing body contouring surgery after MWL between 2007 and 2017 with a minimum follow-up of 6 months after the last procedure were included in this retrospective study. Excluded were those with a body mass index > 35 kg/m2 and those with comorbidities leading to impaired PA. Quality of life (QOL) was assessed using the Moorehead-Ardelt QOL Questionnaire II. Evaluation of PA was obtained with the International Physical Activity Questionnaire (IPAQ) short form and the Freiburg PA Questionnaire. Functional impairment during exercise was analyzed using a self-designed functional impairment score (FIS). In the 45 patients completing the survey (37 female, 8 male), an improvement in QOL (p

Background Negative pressure wound therapy applied over closed incisions (ciNPT) has been shown to influence wound healing. Therefore, the aim of this study was to examine the short-term effects of ciNPT on skin perfusion patterns in postbariatric wounds. Methods 17 patients were included. Patients from the study group received a ciNPT dressing with a continuous negative pressure of - 125 mmHg for five days. Two intra- and two postoperative measurements were performed using both a combined laser Doppler spectrophotometry and an ICG angiography system to determine oxygen saturation (sO2), hemoglobin content (rHb) and perfusion patterns. Results Three days postoperatively the sO2 was significantly higher in the study group compared to the control group and also compared to the end of the operation. Concerning the rHb, there was no statistical significant alteration in or between the groups, but a trend towards a correlated alteration of sO2 and rHb. ICG angiography showed an earlier and stronger enhancement of perfusion parameters in the study group. Conclusion CiNPT has a positive effect on oxygen saturation and tissue perfusion, which are both associated with the wound healing process. The use of ciNPT could therefore possibly reduce the risk of wound healing complications in this high-risk patient group.

Abdominal free flaps such as the muscle sparing transverse rectus abdominis myocutaneous (ms-TRAM) or deep inferior epigastric artery perforator (DIEP) flap represent the gold standard in autologous breast reconstruction. We describe a salvage procedure during bilateral free flap breast reconstruction due to insufficient venous drainage using a venous cross-over bypass. A 54-year-old woman with a thrombosis of the left subclavian port-system in the medical history was elected for simultaneous bilateral breast reconstruction with ms-TRAM and DIEP flaps. Intraoperatively, a venous congestion of the DIEP flap, which was connected to the left cranial internal mammary vessels, appeared. In the absence of sufficient ipsilateral venous recipient vessels, we performed a salvage procedure requiring a 15 cm small saphenous vein graft and presternal subcutaneous tunneling. The flap vein was anastomosed end-to-end with the contralateral caudal internal mammary vein using a coupler system. The postoperative course was uneventful and both flaps survived. We describe the cross-over venous emergency bypass as a useful tool in unexpected venous thrombosis during bilateral free flap breast reconstruction.

Body contouring surgery after massive weight loss was shown to ameliorate the patient’s quality of life and to enhance physical and psychological well-being. However, numerous patients are still obese when presenting for body contouring surgery, not able to lose additional weight for various reasons. Data regarding general feasibility, outcome, and postoperative complications in obese patients is rare. The aim of this study was to investigate the outcome in body contouring procedures in obese patients. A retrospective chart review of 65 cases in 42 patients was performed. Patients with a body mass index (BMI) > 35 kg/m2 at the time of operation were enrolled and all different types of body contouring surgery were included. Complications were classified as major (need for surgical intervention) and minor complications. The median BMI of all patients was 38 kg/m2 (range 35.1–65.1 kg/m2). The majority of performed types of body contouring was abdominal body contouring (panniculectomy n = 27 (42%), abdominoplasty n = 12 (18%)). Complications occurred in 27 cases (41.5%). Twenty-one cases (32.3%) were classified as minor complications, six (9.2%) as major complications. The most common major complications were hematoma and wound dehiscence; the most common minor complication was seroma. A reasonable risk for complications is well known in body contouring surgery especially in obese patients. It is imperative to discuss related risks and expected results. Taking several points into account concerning the perioperative management, reduction of major complications is possible even in still obese patients, making body contouring surgery a discussible option.

In addition to the progressive development of surgical oncological techniques for malignant tumors of the rectum, anal canal and vulva, reconstructive procedures after oncological interventions in the perianal region represent a cornerstone in the postoperative quality of life of patients. Modern treatment modalities for rectal cancer with neoadjuvant chemoradiotherapy increase the survival rate and simultaneously reduce the risk of local recurrence to 5-10%, especially by cylindrical extralevatory extirpation of the rectum. The price for increased surgical radicality and improved oncological safety is the acceptance of larger tissue defects. Simple suture closure of perineal wounds often does not primarily heal, resulting in wound dehiscence, surgical site infections and formation of chronic fistulas and sinuses. The interdisciplinary one-stage or two-stage reconstruction of the perianal region with well-vascularized tissue has proven to be a reliable procedure to prevent or control such complications.Rekonstruktive Maßnahmen nach onkologischen Eingriffen in der Perianalregion stellen neben der progredienten Weiterentwicklung chirurgisch-onkologischer Techniken bei malignen Tumoren des Rektums, des Analkanals und der Vulva einen wesentlichen Pfeiler der postoperativen Lebensqualität der Patienten dar. Moderne Therapiemodalitäten des Rektumkarzinoms mit neoadjuvanter Radiochemotherapie erhöhen speziell durch die zylindrische extralevatorische Rektumexstirpation die Überlebensrate und senken gleichzeitig das lokale Rezidivrisiko auf 5–10 %. Als Preis für die zunehmende chirurgische Radikalität und die höhere onkologische Sicherheit werden dafür größere Gewebedefekte in Kauf genommen. Der einfache Nahtverschluss von Perinealwunden heilt häufig nicht primär, was zu Wunddehiszenz, -infektion, chronischen Fisteln und Höhlenbildungen führt. Die interdisziplinäre einzeitige/zweizeitige Rekonstruktion der Perianalregion mit gut durchblutetem vaskularisiertem Gewebe hat sich als zuverlässiges Verfahren zur Vorbeugung solcher Komplikationen bewährt.

Introduction Osteoarthritis of the first carpometacarpal joint is a common degenerative disease and surgical treatment includes resection suspension interposition arthroplasty (RSIA) with or without temporary transfixation of the first metacarpal. One major drawback includes proximalization of the first metacarpal during the postoperative course. Specific data comparing different transfixation techniques in this context is sparse. Materials and methods In this retrospective study, we measured the trapezial space ratio (TSR) in 53 hands before and after RSIA to determine the proximalization of the first metacarpal depending on the type of Kirschner (K)-wire transfixation. We, therefore, compared transfixation of the first metacarpal to the scaphoid with one K-wire (1K) to transfixation of the first metacarpal with two K-wires (2K), either to the carpus (2Ka), or to the second metacarpal (2Kb), or to both second metacarpal and carpus (2Kc). Results While preoperative TSR did not differ between group 1K and 2K (p = 0.507), postoperative TSR was significantly higher in group 2K compared to 1K (p = 0.003). Comparing subgroups, postoperative TSR was significantly higher in group 2Kc than 1K (p = 0.046), while we found no significant difference comparing either group 2Ka or 2Kb to 1K (p = 0.098; p = 0.159). Neither did we find a significant difference within 2K subgroups, comparing group 2Ka and 2Kb (p = 0.834), 2Ka and 2Kc (p = 0.615), or 2Kb and 2Kc (p = 0.555). Conclusions The results of our study suggest that transfixation with two K-wires should be preferred to transfixation with one K-wire after RSIA. Specifically, transfixation from first to second metacarpal and from first metacarpal to carpus resulted in least proximalization of the first metacarpal postoperatively.

BACKGROUND Treating advanced finger joint contractures from Dupuytren disease remains a challenge. We evaluated the effectiveness of a skeletal distraction device versus alternative treatment options. MATERIAL AND METHODS We analyzed the surgical treatment of contracted finger joints in stage III and stage IV Dupuytren's disease over a 10-year period. Data were obtained from inpatient and outpatient medical records, including postoperative clinical examinations and extended Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores. Complications of infection, postoperative pain, and wound healing disorders were recorded. RESULTS A total of 79 patients (83 hands) were assigned to 2 treatment groups. Patients in group 1 underwent an initial open transection of the main fibrous cord, Z-plasty, distraction with the Erlangen external distraction device, and fasciectomy. The distraction period was 13 to 81 days (mean 31 days). Group 2 underwent a conventional single-stage fasciectomy and arthrolysis. DASH scores and subjective patient satisfaction were lower in group 1 (20.7/33%) than in group 2 (10.3/50%). However, the staged approach of group 1 to treat proximal interphalangeal joint contractures in the long term (improvement >40%) was more effective than the approach of group 2 (>33%). Distraction device pin infections occurred in 20% of hands. Postoperative pain and complex regional pain syndrome type I occurred in 25% of hands in group 1 and 3% in group 2. CONCLUSIONS A screw thread driven external fixation device is useful in end-stage Dupuytren's finger joint contractures. It is indicated when joint contractures are advanced and simple arthrolysis is insufficient.

In reconstructive surgery, the latissimus dorsi (LD) muscle is known as a workhorse flap and is commonly used as a pedicled or free flap. Postoperative complications of a reconstructive procedure with an LD flap include seroma and hematoma formation at an early stage after LD transfer. Late-onset hematoma at the donor site are considered to be extremely rare postoperative complications; late, expanding pseudotumor-like hematoma can occur months or years after surgery. Shearing forces and poor coagulation are thought to be the primary reasons for these postoperative complications.This report presents 2 cases of pseudotumors 12 and 29 years after LD transfer. Magnetic resonance imaging was performed prior to complete surgical excision. After surgical removal, patients received negative-pressure wound therapy with instillation and dwell time (NPWTi-d) for several days. After vacuum-assisted wound bed preparation, wound closure was performed with secondary sutures.The case report presented 2 incidences of rare late-onset pseudotumors many years after the initial LD reconstruction. To the authors' knowledge, this late-onset occurrence (ie, after 3 decades) has not been reported in the literature to date. If solidification of the late hematoma makes aspiration impossible, surgical intervention is required. Negative pressure wound therapy with instillation and dwell time potentially minimizes the wound size and reduces shear forces at the back donor-site.

Introduction Soft tissue reconstruction of the hand and distal upper extremity is challenging to preserve the function of the hand as good as possible. Therefore, a thin flap has been shown to be useful. In this retrospective study, we aimed to show the use of the free temporoparietal fascial flap in soft tissue reconstruction of the hand and distal upper extremity. Methods We analysed the outcome of free temporoparietal fascial flaps that were used between the years 2007and 2016 at our institution. Major and minor complications, defect location and donor site morbidity were the main fields of interest. Results 14 patients received a free temporoparietal fascial flap for soft tissue reconstruction of the distal upper extremity. Minor complications were noted in three patients and major complications in two patients. Total flap necrosis occurred in one patient. Conclusion The free temporoparietal fascial flap is a useful tool in reconstructive surgery of the hand and the distal upper extremity with a low donor site morbidity and moderate rates of major and minor complications.

Journal of Personalized Medicine 12(5), 701 (2022). doi:10.3390/jpm12050701 special issue: "Special Issue "Plastic and Reconstructive Surgery in Personalized Medicine" / Special Issue Editors: Prof. Dr. Andreas Arkudas, Guest Editor; Prof. Dr. Raymund E. Horch, Guest Editor", Published by MDPI, Basel

Background: Obesity is frequently present in patients suffering from end-stage renal disease (ESRD). However, overweight kidney transplant candidates are a challenge for the transplant surgeon. Obese patients tend to develop a large abdominal panniculus after weight loss creating an area predisposed to wound-healing disorders. Due to concerns about graft survival and postoperative complications after kidney transplantation, obese patients are often refused in this selective patient cohort. The study aimed to analyze the effect of panniculectomies on postoperative complications and transplant candidacy in an interdisciplinary setting. Methods: A retrospective database review of 10 cases of abdominal panniculectomies performed in patients with ESRD prior to kidney transplantation was conducted. Results: The median body mass index was 35.2 kg/m2 (range 28.5–53.0 kg/m2) at first transplant-assessment versus 31.0 kg/m2 (range 28.0–34.4 kg/m2) at panniculectomy, and 31.6 kg/m2 (range 30.3–32.4 kg/m2) at kidney transplantation. We observed no major postoperative complications following panniculectomy and minor wound-healing complications in 2 patients. All aside from 1 patient became active transplant candidates 6 weeks after panniculectomy. No posttransplant wound complications occurred in the transplanted patients. Conclusion: Abdominal panniculectomy is feasible in patients suffering ESRD with no major postoperative complications, thus converting previously ineligible patients into kidney transplant candidates. An interdisciplinary approach is advisable in this selective patient cohort.

Transforming growth factor-β (TGFβ) is a key mediator of fibroblast activation in fibrotic diseases, including systemic sclerosis. Here we show that Engrailed 1 (EN1) is reexpressed in multiple fibroblast subpopulations in the skin of SSc patients. We characterize EN1 as a molecular amplifier of TGFβ signaling in myofibroblast differentiation: TGFβ induces EN1 expression in a SMAD3-dependent manner, and in turn, EN1 mediates the profibrotic effects of TGFβ. RNA sequencing demonstrates that EN1 induces a profibrotic gene expression profile functionally related to cytoskeleton organization and ROCK activation. EN1 regulates gene expression by modulating the activity of SP1 and other SP transcription factors, as confirmed by ChIP-seq experiments for EN1 and SP1. Functional experiments confirm the coordinating role of EN1 on ROCK activity and the reorganization of cytoskeleton during myofibroblast differentiation, in both standard fibroblast culture systems and in vitro skin models. Consistently, mice with fibroblast-specific knockout of En1 demonstrate impaired fibroblast-to-myofibroblast transition and are partially protected from experimental skin fibrosis.

Relapsing or far advanced rectal and anal cancers remain difficult to treat and require interdisciplinary approaches. Due to modern standard protocols all patients receive irradiation and neoadjuvant chemotherapy – and in case of a relapse a second irradiation - rendering the surgical site prone to surgical site infections and oftentimes long lasting sinus and septic complications after exenteration in the pelvis. Despite an improved overall survival rate in these patients the downside of radical tumor surgery in the pelvis is a major loss of quality of life, especially in women when parts of the vagina need to be resected. Derived from our experince with over 300 patients receiving pelvic and perineal reconstruciton with a transpelvic vertical rectus abdominis myocutaneous (VRAM) flap we studied the impact of this surgical technique on the outcomes of female patients with or without vaginal reconstruction following pelvic exenteration. We found out that the tpVRAM flap is reliably perfused and helps to reduce long term wound healing desasters in the irradiated perineal/vaginal/gluteal region.

The purpose of this study was to analyse the outcome of our established triple treatment strategy in therapy‐resistant deep‐thickness chronic lower leg ulcers. This limb salvage approach consists of ultra‐radical surgical debridement, negative‐pressure wound therapy (NPWT) with or without instillation, and split‐thickness skin grafting. Between March 2003 and December 2019, a total of 16 patients and 24 severe cases of lower leg ulcers were eligible for inclusion in this highly selective population. A total of seven patients received immunosuppressive medication. Complete wound closure was achieved in 25% and almost 90% of included lower leg ulcer cases after 3 and 24 months of our triple treatment strategy, respectively. The overall limb salvage rate was 100%. Bacterial colonisation of these wounds was significantly reduced after multiple surgical debridements and NPWT. Fasciotomy and radical removal of devitalised tissue such as deep fascia, tendons, and muscles combined with NPWT showed promising results in terms of the overall graft take rate. This treatment strategy was considered as last resort for limb salvage in such a critically ill and immunocompromised patient population. Surgeons should be aware of its efficacy and consider the triple treatment strategy especially if no other limb salvage option remains.

Background: Breast cancer is the most common malignancy in women. The interdisciplinary treatment is based on the histological tumor type, the TNM classification, and the patient's wishes. Following tumor resection and (neo-) adjuvant therapy strategies, breast reconstruction represents the final step in the individual interdisciplinary treatment plan. Although manifold flaps have been described, abdominal free flaps, such as the deep inferior epigastric artery perforator (DIEP) or the muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) flap, are the current gold standard for autologous breast reconstruction. This retrospective study focuses on the safety of autologous breast reconstruction upon mastectomy using abdominal free flaps. Methods: From April 2012 until December 2018, 193 women received 217 abdominal free flaps for autologous breast reconstruction at the University Hospital of Erlangen. For perforator mapping, we performed computed tomography angiography (CTA). Venous anastomosis was standardized using a ring pin coupler system, and flap perfusion was assessed with fluorescence angiography. A retrospective analysis was performed based on medical records, the surgery report, and follow-up of outpatient course. Results: In most cases, autologous breast reconstruction was performed as a secondary reconstructive procedure after mastectomy and radiotherapy. In total, 132 ms1-TRAM, 23 ms2-TRAM, and 62 DIEP flaps were performed with 21 major complications (10%) during hospital stay including five free flap losses (2.3%). In all cases of free flap loss, we found an arterial thrombosis as the main cause. In 24 patients a bilateral breast reconstruction was performed without free flap loss. The majority of free flaps (96.7%) did not need additional supercharging or turbocharging to improve venous outflow. Median venous coupler size was 2.5 mm (range, 1.5–3.5 mm). Conclusion: Using CTA, intraoperative fluorescence angiography, titanized hernia meshes for rectus sheath reconstruction, and venous coupler systems, autologous breast reconstruction with DIEP or ms-TRAM free flaps is a safe and standardized procedure in high-volume microsurgery centers.

Capsular contracture remains a challenge in plastic surgery and represents one of the most common postoperative complications following alloplastic breast reconstruction. The impact of the surface structure of silicone implants on the foreign body reaction and the behaviour of connective tissue-producing cells has already been discussed. The aim of this study was to investigate different pore sizes of silicone surfaces and their influence on human fibroblasts in an in vitro model. Four different textures (no, fine, medium and coarse texture) produced with the salt-loss technique, have been assessed in an in vitro model. Human fibroblasts were seeded onto silicone sheets and evaluated after 1, 4 and 7 days microscopically, with viability assay and gene expression analysis. Comparing the growth behaviour and adhesion of the fibroblasts on the four different textures, a dense cell layer, good adhesion and bridge-building ability of the cells could be observed for the fine and medium texture. Cell number and viability of the cells were increasing during the time course of experiments on every texture. TGFß1 was lowest expressed on the fine and medium texture indicating a trend for decreased fibrotic activity. For silicone surfaces produced with the salt-loss technique, we were able to show an antifibrotic effect of smaller sized pores. These findings underline the hypothesis of a key role of the implant surface and the pore size and pore structure in preventing capsular contracture.

ObjectivesCoactivators are a heterogeneous family of transcriptional regulators that are essential for modulation of transcriptional outcomes and fine-tune numerous cellular processes. The aim of the present study was to evaluate the role of the coactivator peroxisome proliferator-activated receptor gamma coactivator-1α (PGC-1α) in the pathogenesis of systemic sclerosis (SSc).MethodsExpression of PGC-1α was analysed by real-time PCR, western blot and immunofluorescence. Modulation of autophagy was analysed by reporter studies by expression of autophagy-related genes. The effects of PGC-1α knockdown on collagen production and myofibroblast differentiation were analysed in cultured human fibroblasts and in two mouse models with fibroblast-specific knockout of PGC-1α.ResultsThe expression of PGC-1α was induced in dermal fibroblasts of patients with SSc and experimental murine fibrosis. Transforming growth factor beta (TGFβ), hypoxia and epigenetic mechanisms regulate the expression of PGC-1α in fibroblasts. Knockdown of PGC-1α prevented the activation of autophagy by TGFβ and this translated into reduced fibroblast-to-myofibroblast differentiation and collagen release. Knockout of PGC-1α in fibroblasts prevented skin fibrosis induced by bleomycin and by overexpression of a constitutively active TGFβ receptor type I. Moreover, pharmacological inhibition of PGC-1α by SR18292 induced regression of pre-established, bleomycin-induced skin fibrosis.ConclusionPGC-1α is upregulated in SSc and promotes autophagy to foster TGFβ-induced fibroblast activation. Targeting of PGC-1α prevents aberrant autophagy, inhibits fibroblast activation and tissue fibrosis and may over therapeutic potential.

Free flaps in combination with arterial reconstruction by means of arteriovenous loops or bypass have, meanwhile, been established as a therapeutic option in defect reconstruction for areas without recipient vessels. Our aim was to analyse the long‐term performance, flap autonomy, and the flap perfusion. Patients receiving this combined reconstruction at a single‐centre institution were included. During follow‐up examination, the patency of arterial reconstruction was investigated by duplex ultrasound. Flap micro‐circulation was assessed by laser Doppler flowmetry and white light tissue spectrometry (O2C) as well as by indocyanine green fluorescence angiography. Twenty‐three patients could be clinically followed up. Duplex ultrasound showed, in four cases, arterial pedicle occlusion in spite of vital flap. Comparison of the O2C perfusion parameters between flaps with occluded pedicles and those with intact inflow showed no significant difference (parameters sO2: P = .82; Flow: P = .31). Similar results were obtained by fluorescence angiography; no significant difference could be detected between both groups (parameters Ingress P = .13; Ingressrate P = .54). Combined vascular reconstruction with free tissue transfer is associated with a good long‐term outcome and wound closure. Even after flap transplantation to areas with critical tissue perfusion, the flap can develop autonomy and thus survive after pedicle occlusion.

Introduction: The treatment of chronic wounds constitutes a massive financial burden to society and our health-care system. Therefore, efficient wound care is of great importance to all kinds of medical fields. The implementation and modification of negative-pressure wound therapy can be seen as a major improvement in wound healing. Many different NPWT applications evolved trying to address various wound etiologies.Areas covered: This review aims to give an overview of various NPWT applications, show its effects on wound healing, and discuss future modifications.Expert opinion: NPWT as a delivery device for cold plasma, growth factors, or targeted stem cells to the wound bed and the ability to monitor the inflammatory activity, bacterial load and wound healing factors can be seen as possible future steps to individualized wound care. In addition, it requires high-quality experimental studies to develop the ideal foam in terms of microstructure, pore size, and material properties.

Background: Vascular patency is the key element for high flap survival rates. The purpose of this study was to assess and compare the blood flow characteristics of deep inferior epigastric perforator (DIEP) and muscle-sparing transverse rectus abdominis musculocutaneous (ms-TRAM) flaps for autologous breast reconstruction. Methods: This prospective clinical study combined Transit-Time Flowmetry and microvascular Indocyanine Green Angiography for the measurement of blood flow volume, vascular resistance, and intrinsic transit time. Results: Twenty female patients (mean age, 52 years) received 24 free flaps (14 DIEP and 10 ms-TRAM flaps). The mean arterial blood flow of the flap in situ was 7.2 ± 1.9 mL/min in DIEP flaps and 11.5 ± 4.8 mL/min in ms-TRAM flaps (p < 0.05). After anastomosis, the mean arterial blood flow was 9.7 ± 5.6 mL/min in DIEP flaps and 13.5 ± 4.2 mL/min in ms-TRAM flaps (p = 0.07). The arterial vascular resistance of DIEP flaps was significantly higher than that of ms-TRAM flaps. The intrinsic transit time of DIEP flaps was 52 ± 18 s, and that of ms-TRAM flaps was 33 ± 11 s (p < 0.05). The flap survival rate was 100%. One DIEP flap with the highest intrinsic transit time (77 s) required surgical revision due to arterial thrombosis. Conclusion: In this study, we established the blood flow characteristics of free DIEP and ms-TRAM flaps showing different blood flow rates, vascular resistances, and intrinsic transit times. These standard values will help to determine the predictive values for vascular compromise, hence improving the safety of autologous breast reconstruction procedures.

Background: While surgical therapy for Dupuytren’s disease is a well-established standard procedure, severe joint flexion deformities in advanced Dupuytren’s disease remain challenging to treat. Skeletal distraction has proven to be an additional treatment option. Methods: We analyzed the surgical treatment algorithm, including the application of a skeletal distraction device, in patients with a flexion deformity due to Dupuytren’s disease, Iselin stage III or IV, who were operated on from 2003 to 2020 in our department. Results: From a total of 724 patients, we included the outcome of 55 patients’ fingers in this study, who had undergone additional skeletal joint distraction with our Erlangen device. Additional fasciotomy or fasciectomy, in a one- or two-staged procedure, was performed in all patients, according to the individual findings and necessities. The range of motion of the PIP joint improved from 12° to 53°. A number of complications, in all steps of the treatment, were noted in a total of 36.4% of patients, including the development of fractures (16.4%), followed by vessel injury, pin infections, and complex regional pain syndrome (5%). Conclusions: Additional skeletal distraction improves the range of motion of severely contracted joints in Dupuytren’s disease. Nevertheless, careful patient selection is necessary, due to the moderate rate of complications.