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Loss of skin grafts can be a dangerous complication during the early postoperative course of patients with extensive burns. A major risk factor for impaired healing of grafts is local wound infection due to bacterial colonization. Burn wounds are particularly prone to bacterial colonization. In this retrospective cohort study, we analyzed correlations between bacteria isolates from burn wounds and loss of skin grafts after surgical treatment. A cohort of patients with burn wounds who received split-skin grafts for wound coverage was divided into groups with and without loss of skin grafts. Demographics, comorbidities, trauma characteristics and bacterial isolates from wound cultures were reviewed and compared. Bacterial colonization isolated from burn wounds upon hospital admission was found to be a significant predictor of skin-graft loss. Additionally, an Abbreviated Burn Severity Index greater 6 predicted graft loss. When comparing bacterial swab results from admission with isolates from revision surgery after graft loss, causative pathogens were found to have changed.

We carried out a retrospective single-center study and analyzed all patients who have been admitted to our intensive care burn unit following suicide attempt and accidental burns within 14 years. Clinical and demographic parameters were collected and evaluated. Propensity score matching was performed in order to minimize the confounding effect of the parameters age, sex, total body surface area (TBSA), and the presence of full-thickness burns and inhalation injury. 45 burn patients following attempted suicide by burning and 1266 patients following accidental burn injury were admitted. Patients with suicidal burn injuries were significantly younger and showed significantly higher burn severity, reflected by larger TBSA affected, higher incidence of full-thickness burns and inhalation injury. They also experienced increased hospital length of stay (LOS) and longer ventilation durations. Their in-hospital mortality was significantly higher. Following propensity score matching in 42 case pairs, no differences were detected with regard to in-hospital mortality, hospital LOS, duration of mechanical ventilation, and frequency of surgical interventions. Attempted suicide by burning is associated with overall worse outcomes and higher mortality rates. Following propensity score matching, significant differences in outcomes were no longer detectable. Given the comparable survival probability compared to accidentally burned patients, life-sustaining treatment should not be withheld in burn patients following suicide attempt.

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

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

Functional construction of tissue-engineered vessels as an alternative to autologous vascular grafts has been shown to be feasible, however the proliferation of seeded smooth-muscle cells remains a limiting factor. We employed a rotating bioreactor system to improve myoblast cell differentiation on a spider silk scaffold for tissue-engineered vessel construction. C2C12 myofibroblast cells were seeded on the surface of spider silk scaffold constructs and cultivated in a rotating bioreactor system with a continuous rotation speed (1 rpm). Cell function, cell growth and morphological structure and expression of biomarkers were analyzed using scanning electron microscopy, the LIVE/DEAD® assay, Western blot and quantitative real-time PCR analyses. A dense myofibroblast cell sheet could be developed which resembled native blood vessel muscular tissue in morphological structure and in function. Bioreactor perfusion positively affected cell morphology, and increased cell viability and cell differentiation. The expression of desmin, MYF5 and MEF2D surged as an indication of myoblast differentiation. Cell-seeded scaffolds showed a tear-down at 18 N when strained at a set speed (20 mm min−1). Spider silk scaffolds appear to offer a reliable basis for engineered vascular constructs and rotating bioreactor cultivation may be considered an effective alternative to complex bioreactor setups to improve cell viability and biology.

Polytraumatisierte Brandverletzte stellen ein seltenes Patientenkollektiv dar und erfordern aufgrund der besonderen Kombinationsverletzung ein eigenes Behandlungskonzept. Vor dem Hintergrund dieses speziellen Verletzungsmusters stellt sich die Frage nach einem interdisziplinaren Behandlungsalgorithmus, insbesondere wenn tiefgradige Verbrennungen uber der Frakturzone lokalisiert sind. Grundlagen des vorliegenden Beitrags sind eine PubMed-basierte Literaturrecherche und eigene Erfahrungen eines universitaren Traumazentrums fur Schwerbrandverletzte mit Darstellung der besonderen therapeutischen Anforderungen und Zielsetzungen anhand eines Fallbeispiels. Die Auswertung der Literaturrecherche und eigener Behandlungsergebnisse kommt zu dem Ergebnis, dass Amputationen und Infektionen bei rechtzeitiger und interdisziplinarer Einbindung des plastischen Chirurgen durch fruhe kombinierte Frakturstabilisierung, Nekrosektomie und sofortige Hauttransplantation in Haufigkeit und Ausmas reduziert werden konnen. Plastisch-rekonstruktive Eingriffe ermoglichen zudem eine funktionelle und asthetische Wiederherstellung mit optimierter Prothesenversorgung. Polytraumatisierte Schwerbrandverletzte erfordern einen interdisziplinaren Behandlungsansatz, wobei Langenerhalt, Funktionalitat und Asthetik der betroffenen Extremitaten unter Vermeidung von Knochen- und Weichteilinfektionen oberstes Behandlungsprimat sind.

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

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

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

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

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

Ray and proximal phalanx amputations present valid surgical options for the management of severe traumatic finger injuries. However, among these procedures, the superior one for optimal functionality and quality of life for patients still remains unknown. This retrospective cohort study compares the postoperative effects of each amputation type to provide objective evidence and to create a paradigm for clinical decision-making. A total of forty patients who had received either ray or proximal phalanx-level amputations reported on their functional outcomes using a combination of questionnaires and clinical testing. We found a decreased overall DASH score following ray amputation. Particularly, Part A and Part C of the DASH questionnaire were consistently lower compared with amputation at the proximal phalanx. Pain measurements in the affected hand were also significantly decreased during work and at rest in ray amputation patients, and they reported decreased cold sensitivity. Range of motion and grip strength were lower in ray amputations, which is an important preoperative consideration. We found no significant differences in reported health condition, evaluated according to the EQ-5D-5L, and blood circulation in the affected hand. We present an algorithm for clinical decision-making based on patients’ preferences to personalize treatment.

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

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

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

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

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

Background: Hand infections can spread quickly and destroy functional structures. Early diagnosis and adequate therapy can prevent severe morbidities. The aim of this study was to evaluate systematically the spread of hand infections according to injury mechanism, pathogens, and entry site. Methods: The data and medical records of 425 patients were collected and analyzed retrospectively. Results: The entry site had a significant influence on the severity of hand infections. Especially finger lesions led to severe infections. Furthermore, a high C-reactive protein (CRP) concentration correlated with more involved compartments of the hand. Bacterial counts also correlated with the number of compartments involved. Conclusions: Compared with known factors for the severity of hand infections finger lesions lead to especially severe infections and should not be underestimated. If there is a higher CRP concentration or more than one bacterial species isolated, compartments adjacent to the site of injury should be checked intra-operatively.

The enlarged nipple-areola-complex (NAC) is a characterizing aspect of gynecomastia.The purpose of this study was to multidimensionally quantify the reduction of the NAC after a subcutaneous mastectomy (SCM) with or without ultrasound-assisted liposuction (UAL).A retrospective assessment of patients who underwent SCM +/- UAL due to gynecomastia over a period of 11 years was conducted. The NAC diameters were measured before and after surgery. In addition, a survey (including the BREAST-Q) regarding patient-oriented outcome was performed.The study cohort consisted of 55 men and resulting 105 NACs (SCM n=63, SCM+UAL n=42). It could be shown that the reduction of the NAC considering all parameters (horizontal and vertical diameter and the area) was significantly larger (p=0.001) in the SCM+UAL compared to the SCM only cohort. The mean reduction of the area in the SCM cohort was 1.60cmThe SCM with UAL showed a larger reduction over time of the NAC compared to the SCM independent from the stage of gynecomastia. When planning the surgical treatment of gynecomastia, a technique and resection weight dependent reduction of the NAC over time must be considered.This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The current guidelines on injuries caused by animal bites recommend surgical debridement and antibiotic treatment. Bite wounds generally lead to high-risk infections due to deep skin lesions. However, bite wounds may differ dramatically in terms of depth and involvement of different anatomic structures. A prognostic classification regarding depth or severity is only available for facial injuries in paediatric patients, provided by Lackmann's score. In this study, we assessed prognostic factors and developed a prospective score for general animal bite injuries.We performed a retrospective single-centre analysis in patients sustaining animal bite injuries from 2007 to 2017. Patients were subdivided according to animal species, location of bite(s), type of treatment and medical care, admission, length of stay, need for revision, and spectrum of microorganisms. We established and verified a rating score ranging from grade I (superficial scratch) to grade Va (deep wound with bone involvement) and grade Vb (deep wound with joint involvement).This study included 567 patients with animal bite injuries, of which 51.7 % were caused by dogs, 39.2 % by cats and 4.1 % by wild animals. 75.7 % of injuries were located in the hands, 12.9 % in the arms, 5.1 % in the face and 5.3 % in other body parts. The most common microorganism was pasteurella, followed by staphylococci and other aerobic strains. Antibiotic treatment comprised Sultamicillin in 75 % of cases, cephalosporins in 10.2 %, Clindamycin in 7.6 % and other antibiotics in 5.1 % of cases.There was a significant correlation (p0.001) between animal species and presence of an infection, type of medical care, rating score and spectrum of microorganisms as well as between rating score and need for revision, duration of antibiotic treatment, mode of admission, treatment and medical care, and length of hospital stay.The prognostic value of the established rating score was verified. In addition, the study demonstrated that animal species are an important factor influencing treatment. Being effective against most of the identified microorganisms, Sultamicillin should be used as first-line antibiotic treatment.Die aktuellen Richtlinien für Verletzungen durch Tierbisse empfehlen chirurgisches Debridement und Antibiotikatherapie. Im Allgemeinen führen Bisswunden zu Infektionen mit einem sehr hohen Risiko durch tief eindringende Hautläsionen. Bisswunden können sich jedoch durch die Eindringtiefe und die Beteiligung verschiedener anatomischer Strukturen drastisch unterscheiden. Eine prognostische Klassifikation über die Tiefe oder Schwere gibt es nur für Gesichtsverletzungen bei pädiatrischen Patienten – das ist der Score von Lackmann. In dieser Studie wurden prognostische Faktoren bewertet und ein prospektiver Score für allgemeine Tierbissverletzungen entwickelt.Eine retrospektive Einzelzentrumsanalyse wurde bei Verletzungen von Tierbissen zwischen 2007 und 2017 durchgeführt. Die Patienten wurden nach Tierart, Bissort, Behandlungsart und medizinischer Versorgung, Aufnahme, Verweildauer, Revisionsbedarf und Keimspektrum unterteilt. Es wurde ein Bewertungs-Score ermittelt und verifiziert, der von Grad I (oberflächlicher Kratzer) bis Grad Va (tiefe Wunde mit Knochenbeteiligung) und Grad Vb (tiefe Wunde mit Gelenkbeteiligung) reicht.567 Patienten mit Tierbiss-Verletzungen wurden eingeschlossen, von denen 51,7 % von Hunden, 39,2 % von Katzen und 4,1 % von Wildtieren verursacht wurden. 75,7 % der Verletzungen befanden sich an den Händen, 12,9 % an den Armen, 5,1 % im Gesicht und 5,3 % an anderen Stellen. Der häufigste Keim war Pasteurella, gefolgt von Staphylokokken und anderen aeroben Arten. Die antibiotische Behandlung umfasste in 75 % der Fälle Sultamicillin, Cephalosporine in 10,2 %, Clindamycin in 7,6 % und andere Antibiotika in 5,1 %.Es wurde eine signifikante Korrelation (p0,001) zwischen der Tierart und dem Vorliegen einer Infektion, der Art der medizinischen Versorgung, dem Bewertungs-Score und dem Keimspektrum festgestellt, ebenso wie zwischen dem Bewertungs-Score und der Notwendigkeit einer Revision, der Dauer der Antibiotikatherapie, der Art der Aufnahme, der Behandlung und der medizinischen Versorgung sowie der Dauer des Krankenhausaufenthaltes.Der prognostische Wert des ermittelten Bewertungs-Scores konnte verifiziert werden. Darüber hinaus wurde die Bedeutung der Tierarten für die Behandlung aufgezeigt. Sultamicillin mit einer Wirksamkeit gegen die meisten der identifizierten Keime sollte als ermittelte Erstlinien-Antibiotikatherapie verwendet werden.

Backround The aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of deep infections of the hand. Since the advent of WALANT in 2003, infections of the hand have been regarded as a contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours and the current COVID-19 pandemic can lead to delay of treatment where urgent surgery is needed, to prevent progress of an infection, that can result in severe morbidity. Methods In the period from 2015 to 2020, 16 patients with various infections of the hand underwent 17 operations using WALANT in a Hand Trauma and Replantation Center (HTRC) in Germany. Retrospective cohort analysis of their operation reports, with emphasis on location of infection, time and duration of the operation, intraoperative incidents and complications were carried out. We also evaluated the need for revision surgery or necessity to convert to general anesthesia and factors causing delay till the time of surgery. Results No case of inadequate analgesia, the need to convert to general anesthesia, ischemic events or cardiovascular complications with the use of the WALANT solution containing adrenaline and lidocaine in the treatment of deep tissue infections. The highest priority of limb preservation was ensured as no patient progressed to amputation of a digit or the hand. There was a statistically significant difference (p≤0.01) in delay from the time of admission until surgery of up to 9h24 m (SD±3h34 m) during the week and 4h10 m (SD±2h28 m) during the weekend. Conclusion The status of infection as an absolute contraindication to the use of WALANT should be revised. Especially when human resources are limited, WALANT is an adequate technique to enable quick anesthesia for urgent treatment to prevent progression of hand infections., Highlights • Wide Awake Local Anesthesia No Tourniquet can be used to treat deep hand infections. • In the COVID-19 pandemic alternative ways of providing anesthesia are needed. • Absolute contraindication to the use of WALANT should be reevaluated. • “time is function”, urgent treatment remains key in management of hand infections.

University outpatient clinics are essential for medical research, teaching and treatment of complex and special diseases based on current knowledge and guidelines. Furthermore new therapeutic approaches are developed for complicated and rare diseases. The diversity of disease entities and treatment decisions provided by a specialized university outpatient clinic for plastic and aesthetic surgery is so far unknown and subject to our research. The study results highlight the value of the specialized university outpatient clinic for plastic and aesthetic surgery for medical training purposes, research and advanced health care.In a retrospective study, outpatients consulting the clinic of the Department of Plastic and Aesthetic Surgery of Hannover Medical School university hospital between 2013 and 2014 were analyzed. The epidemiology and distribution of disease entities previously treated in the different medical specialties such as surgery, internal medicine, dermatology, neurology and psychiatry, dentistry and ophthalmology were investigated.During a two-year period (2013/2014) 9272 patients with 821 different ICD-coded diagnoses were seen. 57 % of the primary and secondary diagnoses were related to surgery and 36 % to internal medicine. 7 % of the diagnoses were derived from other clinical specialties such as dermatology, neurology, psychiatry, dentistry and ophthalmology. Geriatric surgery comprised 22 %, post oncological 7 %, postoperative complication management 6 %, sequelae of conservative (non-surgical) treatment 3 % and congenital malformations 3 %. In 29 % of patients, surgical treatment was recommended.The analysis shows that patients with complex and a wide range of disease entities presented at our outpatient clinic of plastic- and aesthetic surgery. The variety of diagnoses requires not only extensive specialized expertise, but also broad medical knowledge in order to reach adequate treatment strategies. The setting of complex as well as a broad spectrum of diseases of the university outpatient clinic is thus particularly suitable for teaching of differential diagnoses, diagnostic algorithms and development of treatment strategies during medical training and student education.Hochschulambulanzen haben eine zentrale Position in der Behandlung, Lehre und Erforschung spezieller und komplexer Erkrankungen inne. Der tägliche Betrieb einer universitären Poliklinik für Plastische, Ästhetische, Hand- und Wiederherstellungschirurgie weist ein weitgefächertes Diagnosespektrum der zugewiesenen Patienten aus. Unsere Hypothese war, dass das Diagnosespektrum über den fachspezifischen Charakter hinaus weitreichend interdisziplinär ist und ein hohes Maß an differenzierter und erweiterter klinischer Kompetenz vermittelt.Die epidemiologischen Daten und Diagnosen der Patienten, die sich zwischen 2013–2014 in unserer Ambulanz vorstellten, wurden anhand des Arztbriefs, der medizinischen Akte und der Leistungsverschlüsselung (ICD) katalogisiert. Eine Unterteilung der Diagnosen erfolgte nach Zugehörigkeit zu den medizinischen Fachdisziplinen.Von 2013 und 2014 wurden 9272 Patienten mit 821 verschiedene ICDs behandelt. Eine operative Haupt- oder Nebendiagnose bestand in 57 % der Fälle. In 36 % der Diagnosen lagen internistische Krankheitsbilder vor, während 7 % aus dem Bereich Dermatologie, Neurologie, Psychiatrie, Zahnmedizin und Augenheilkunde stammten. Die Alterschirurgie umfasste 22 %, postonkologische Folgen 7 %, postoperatives Komplikationsmanagement 6 %, einer Z. n. konservativer Behandlung 3 % und angeborene Fehlbildungen 3,0 % der Diagnosen. Bei 29 % der vorgestellten Patienten stellten wir eine plastisch-chirurgische Behandlungsindikation.Unsere Analyse zeigt, dass in einer Hochschulambulanz für Plastische und Ästhetische Chirurgie, ein Patientenkollektiv mit komplexen Erkrankungen und einem breiten Spektrum an Haupt- und Nebendiagnosen behandelt wird. Dieses Spektrum bildet bei Ärzten eine breite Kompetenz aus und ist aufgrund der Interdisziplinarität und Vermittlung von differentialdiagnostischen Algorithmen und Untersuchungstechniken für die allgemeine Ausbildung von Studierenden besonders geeignet.

This study investigates the impact of the presentation time of patients with hand infections to hand surgeons on hospital stay and the frequency of necessary operations.379 patients with hand infections treated in our clinic from 2007 to 2014 were evaluated retrospectively for time of presentation to hand surgeon, time of trauma, length of stay, and frequency of necessary operations.On average, a surgical presentation delayed by more than one day extended the hospital stay by 1.22 days (KHVD) (95 % CI: 1.20-1.25, p0.001). Also, the odds of having to undergo surgery increased by 13.59 % each day (95 % CI 4.01 % -25.43 %, p0.001). KHVD also increased by a factor of 1.09 (95 % CI: 1.03-1.15, p0.001) with delayed antibiotic challenge. However, the time antibiotics were administered did not correlate with the need to undergo surgery (yes/no) (p = 0.11).Late presentation of patients with hand infections leads to a longer inpatient stay and a higher number of necessary operations. Early presentation of hand infections to an experienced hand surgeon is important to avoid complicated patient pathways that add costs to the healthcare system.ZIEL: Diese Studie untersucht, inwieweit der Vorstellungszeitpunkt bei vorliegender Handinfektion (HI) mit der stationären Liegedauer sowie der Häufigkeit notwendiger Operationen der Patienten korreliert.Retrospektiv wurden die stationären Krankenakten von 379 Patienten mit HI, die zwischen 2007 und 2014 an unserer Klinik (2007–2014) behandelt wurden, statistisch hinsichtlich eines Zusammenhangs zwischen Vorstellungszeitpunkt und Liegedauer sowie der Häufigkeit notwendiger Operationen ausgewertet, wobei auch die Infektionsursache Berücksichtigung fand.Im Durchschnitt führte eine um mehr als einen Tag verzögerte fachchirurgische Vorstellung zu einer längeren Krankenhausverweildauer von 1,22 Tage (KHVD) (95 %-KI: 1,20–1,25; p0,001). Die Notwendigkeit einer operativen Intervention nahm mit jedem Tag Verzögerung um 13,59 % (95 %-KI 4,01 %–25,43 %; p0,001) zu. Der verzögerte Beginn einer Antibiotikagabe führte zur Verlängerung der KHVD um den Faktor 1,09 (95 %-KI: 1,03–1,15; p0,001), wobei jedoch keine Korrelation bestand zwischen Zeitpunkt der Antibiotikagabe und der Notwendigkeit zur operativen Revision (ja/nein) (p = 0,11).Eine verspätete Vorstellung von Patienten mit Handinfektionen führt zu einer längeren stationären Aufenthaltsdauer sowie zu einer höheren Anzahl an notwendigen Operationen. Eine frühzeitige Vorstellung von HI beim Handchirurgen ist wichtig, um komplizierte Krankheitsverläufe und unnötige Kosten für das Gesundheitssystem zu vermeiden.

Background End-to-end and end-to-side anastomoses remain the most common techniques in microsurgical free flap reconstruction. Still, there is an ongoing effort to optimize established techniques and develop novel techniques. Numerous comparative studies have investigated flow dynamics and patency rates of microvascular anastomoses and their impact on flap survival. In contrast, few studies have investigated whether the type of anastomosis influences the outcome of microvascular free flap reconstruction of a lower extremity. Patients and Methods Retrospectively, we investigated the outcome of 131 consecutive free flaps for lower extremity reconstruction related to the anastomotic technique. Results No statistical significance between arterial or venous anastomoses were found regarding the anastomotic techniques (p = 0.5470). However, evaluated separately by vessel type, a trend toward statistical significance for anastomotic technique was observed in the arterial (p = 0.0690) and venous (p = 0.1700) vessels. No thromboses were found in arterial end-to-end anastomoses and venous end-to-side anastomoses. More venous (n = 18) than arterial thromboses (n = 9) occurred in primary anastomoses undergoing microsurgical free flap reconstruction (p = 0.0098). Flap survival rate was 97.37% in the end-to-end arterial group versus 86.36% in the end-to-side group. No thromboses were found in five arterial anastomoses using T-patch technique. Conclusion For lower extremities, there is a connate higher risk for venous thrombosis in anastomotic regions compared with arterial thrombosis. We observed divergent rates for thromboses between end-to-end and end-to-side anastomoses.However, if thrombotic events are explained by anastomotic technique and vessel type, the latter carries more importance.

Recent research has vigorously pursued the development of tissue-engineered vascular grafts (TEVs). One of the striking points of the early phase is the instability of the artificial blood vessels and lack of vascular resistance, which is supposed to be a consequence of unstable scaffolds. Therefore, alternative biological approaches are necessary to improve the physical properties of the artificial vessel walls. We developed blood vessel-like constructs based on native spider silk as a scaffold. C2C12 and ST1.6R cells were seeded on the surface of scaffolds and cultivated under pulsatile flow (max. ~135 mmHg and min. ~90 mmHg) in a bioreactor. Constructed grafts were compared to human blood vessels and cell seeded scaffolds cultured in the absence of bioreactor. Mechanical properties, morphological structures and expression of marker genes were assessed by strength and strain experiments, SEM, histological staining, immunohistology, Western blotting and quantitative real-time PCR. The results indicate that the constructed vessel resembles native blood vessels in morphological structure as well as in function and expression of biomarkers. Spider silk scaffolds seem to provide an optimal and stable basis for vessel constructs.

Background In Dupuytren's disease (DD), limited fasciectomy is the mainstay of surgical therapy in patients at risk of contractures and disease recurrences. New minimally invasive treatments such as injection of collagenase clostridium histolyticum have evolved as a common tool for the preliminary treatment of Dupuytren's contractures. However, recurrences and their therapy remain controversial. In this study, we evaluate the benefit of repeated limited fasciectomy in patients with aggressive forms of the disease and multiple recurrences of contractures. Methods We evaluated the outcome of 16 patients undergoing limited fasciectomy 3 or more times on a single hand. Results Postoperatively, 10 of 13 (76.9%) patients were satisfied with the clinical result after the last operation; 10 of 12 (83.3%) patients would choose to have their surgery repeated, if so needed. The mean improvement of proximal interphalangeal joint range of motion was 59.2 degrees (SD 26.8) and 86.2% (SD 19.9). There were no severe complications after treatment within the observed time period. Conclusions Our findings demonstrate that patients with recurrence of contractures after multiple previous treatments in aggressive forms of DD can benefit from surgical intervention. In conclusion, repeated limited fasciectomy remains indicated in patients after previous surgeries with DD.

The treatment of lower limb tumors has been shifted by advancements in adjuvant treatment protocols and microsurgical reconstruction from limb amputation to limb salvage. Standard approaches include oncological surgery by a multidisciplinary team in terms of limb sparing followed by soft tissue reconstruction and adjuvant therapy when indicated. For the development of a comprehensive surgical plan, the identity of the tumor should first be determined by histology after biopsy. Then the surgical goal and comprehensive treatment concept should be developed by a multidisciplinary tumor board and combined with soft tissue reconstruction. In this article, plastic surgical reconstruction options for soft coverage of the lower extremity following oncological surgery will be described along with the five clinical cases.

Various diseases, injuries, and congenital abnormalities may result in degeneration and loss of organs and tissues. Recently, tissue engineering has offered new treatment options for these common, severe, and costly problems in human health care. Its application is often based on the usage of differentiated stem cells. However, despite intensive research and growing knowledge, many questions remain unresolved in the process of cell differentiation. The aim of this study was to find standardized cell models for analyzing molecular mechanisms of cell differentiation. We investigated the multipotency of three standardized murine embryonic fibroblast cell cultures using histological staining, western blotting, and quantitative real-time reverse transcription polymerase chain reaction (qRT-PCR). Our results demonstrated that NIH-3T3 and mouse embryonic fibroblast (MEF) cells were able to differentiate into adipogenic, chondrogenic, and osteogenic lineages expressing typical differentiation markers. Interestingly, Flp-In-3T3 cells did not differentiate into any of the three mesenchymal lineages, although this cell line is genetically closely related to NIH-3T3. The results were confirmed by histological staining. Flp-In-3T3, NIH-3T3, and MEF cells have usually been used for DNA transfections, recombinant protein expression, and as "feeder cells." Unlike mesenchymal stem cells (MSCs) and mesenchymal progenitor cells (MPCs), they are easy to obtain and to expand and are less prone to change their structure and morphology, even at higher passages. Our results suggest that Flp-In-3T3, MEF, and NIH-3T3 cells are highly suitable to be used as models to analyze molecular mechanisms of cell differentiation.

In the last century there has been great progress in the treatment of breast cancer by improving drug and radiation therapy as well as surgical techniques. Despite this development, breast cancer remains a major cause of death among women in Europe and the US. The cause of breast cancer at the cellular level is still not fully understood. In the present study, we investigated the expression of the Lifeguard β-isoform in breast cancer tissues. In contrast to Lifeguard, the β-isoform has one transmembrane domain less, which is the last of seven (99 bp), and due to this we suspect that the Lifeguard β-isoform exhibits a different function. We determined the expression and function of the β-isoform of Lifeguard in breast cancer cell lines (MCF-7 and MDA-MB-231), a human breast epithelial cell line (MCF10A) and in breast tumour tissue sections. Western blotting, PCR arrays and immunofluorescence were used to investigate the expression of Lifeguard and its β-isoform. Moreover, we investigated the ability of Lifeguard β-isoform expression to inhibit apoptosis induced by Fas. Our results indicated that Lifeguard β-isoform is strongly expressed in breast tumour tissues. More notably, we demonstrated that Fas sensitivity was reduced in the MCF10A breast cells expressing the Lifeguard β-isoform. Taken together, our findings indicate the role of the Lifeguard β-isoform as an anti-apoptotic protein and provide further evidence of the potential of the Lifeguard β-isoform as a target for the development of novel therapeutic strategies.