Abstract Background Large skull base defects are extremely difficult to treat and have a severe impact on patients’ physical appearance and functional aspects. These extensive defect zones are mainly ...caused by trauma, surgical interventions or wide tumor excision. High-level microsurgical techniques are necessary in order to provide sufficient treatment. The aim of this study is to describe successful reconstructive strategies for surgical treatment. Methods 9 patients with skull base defects were treated in our department from 2008-2014 (n=9). Plastic surgical reconstruction was performed with latissimus dorsi (LD) (n=4), LD-scapula flaps (n=2), vertical rectus abdominis (VRAM) flaps (n=2) and a greater omentum flap (n=1). Mean follow-up period was 2.3 years +/- 2.2 years (0.5 – 4.5 years). Oncologic diseases (8 patient) and iatrogenic damage (1 patient) caused the massive skull base defects. Results In all cases, we obtained the final surgical treatment of large skull base defects via free flaps with permanent wound closure. The mean operating time was 5:53 h (range: 4:45 – 7:52 h). Primary outcome measures were survival and sufficient defect coverage. Flap-survival rate was 100% and none of the patients deceased during follow-up period. Furthermore, we demonstrate the surgical key points of LD-scapula flap closure in detail. Conclusion Plastic surgical defect coverage by well-perfused tissue flaps of large skull base defects provides an efficient and effective treatment option. Complex skin, soft tissue, and dura defects can be successfully covered with these preformed free flaps. The choice of flap has to be defined on the basis of the individual case.
Free flaps in scar treatment Vogt, Peter M.; Alawi, Seyed Arash; Ipaktchi, Ramin
Innovative surgical sciences,
12/2017, Letnik:
2, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Scar management needs defined concepts and an algorithm to restore functional and aesthetic units. After an unsuccessful conservative treatment, surgical measures provide a vast spectrum of ...possibilities for remediation. The spectrum of possibilities consists of excision and Z-plasty, regional flaps, vascularized pedicled flaps, tissue expansion, and finally free tissue transfer. Severe scarring and highly destructed tissues with inferior functional and aesthetic units can be effectively treated with radical excision and free flap reconstruction. The complexity of flap architecture and tissue qualities allows for an individualized approach. Specific attention should be paid to the long-term consequences of severe scarring with progressive loss of functionality.
We worked out the most common surgical approaches and treatment algorithm for a stepwise and effective approach. Part of this algorithm is a seven-step surgical approach.
This article provides modern plastic and reconstructive surgery concepts with an algorithm for scar management.
The treatment of scars follows an algorithm with the level of complexity of techniques adjusted to the individual case and the conditions. Disabilities induced by scarring can lead to further functional loss. In these cases, surgical strategies have to be considered.
Despite the obvious advantages, face transplantation requires strict patient selection to guarantee optimal outcomes. Therefore, it is not suitable for all patients with severe facial disfigurements. ...Simultaneously, conventional plastic and reconstructive surgery techniques, as well as medical spa techniques, have evolved, offering minimally invasive treatment of complex deformities.
The entire face of a young woman was severely disfigured because of a mistreated juvenile acne, with severe ectropions, oral incompetence and substantial midfacial tissue defect. We are describing the reconstruction with a combination of conventional reconstructive methods, such as scar release, skin transplantation, local flaps, medical needling and lipofilling.
Oral competence, unhindered breathing and adequate lid closure was achieved. Previously unable to participate in social life in any meaningful way, our patient was able to reintegrate fully and take a job.
For selected patients, combined, invasive and non-invasive conventional techniques can provide satisfying outcomes in complex facial reconstruction. Modern regenerative approaches such as lipofilling and medical needling should be considered as integral parts of treatment strategies.
Burn patients are predisposed for nosocomial infections during their stay on a burn intensive care unit. Moreover, several outbreaks affecting burn units for example caused by Methicillin-resistant ...Staphylococcus aureus (MRSA) have been reported. One attempt to address these challenges is the use of universal decolonization.
In 2015 we implemented universal decolonization for all burn patients using the antiseptic agent octenidine for intact skin and the nasopharyngeal mucosa. We conducted a retrospective analysis to evaluate the effect of the decolonization on primary, central line (central venous catheter)-associated bloodstream infections (CLABSI), the frequency of nosocomial clusters (4 or more cases with epidemiologic link and identical molecular pattern) with multidrug-resistant bacteria (MDRB) and the incidence of MRSA.
In the decolonization period a reduction of the incidence of CLABSI, nosocomial MRSA acquisition and the frequency of nosocomial MDRB clusters was observed. The incidence rate of CLABSI decreased from 2/1000 central venous catheter days in the pre-decolonization phase to 0.8/1000 central venous catheter days in the decolonization period, although this was not statistically significant. The implementation was accompanied by several feedback talks and training for the staff. The user experience was positive and no adverse effects occurred.
Our results show that universal decolonization in burn patients using octenidine is a promising concept to address hospital acquisition of MRSA; occurrence of CLABSI as well as the spread of MDRB causing clusters. It is of high relevance to further assess the value of this measure in terms of reducing CLABSI in burn patients in larger study groups. Therefore further studies including more burn patients guaranteeing adequate sample size are needed.
Introduction
The aim of the present study is to systematically review the literature on well-selected comparative studies for meta-analysis on outcome differences between collagenase clostridium ...histolyticum (CCH) injection and limited fasciectomy (LF) for Dupuytren’s disease.
Materials and methods
PubMed/Medline, Embase, and the Cochrane Library were searched for comparative studies assessing differences in outcomes of CCH and LF. Effect estimates were pooled across studies using random effects models and presented as weighted mean difference (MD) and odds ratio (OR) with corresponding 95% confidence interval (CI).
Results
A total of 11 studies encompassing 1′051 patients was included (619 patients in the CCH and 432 in the LF group). The residual contracture at a minimal average follow-up of three months was higher in the CCH group than in the LF group (27.8 vs. 16.2°, MD 11.6°, 95% CI 8.7, 14.5°, p < 0.001). The recurrence rate was significantly higher in the CCH group (25.8 vs. 9.3%, OR 5.2, 95% CI 1.5, 18.8, p = 0.01) while the rate of severe complications was significantly higher in the LF group (0.3 vs. 7.3%, OR 0.12, 95% CI 0.03, 0.42, p = 0.001).
Conclusions
Evidence of the present study confirms that CCH injection has a higher rate of disease recurrence whereas LF carries a higher risk for severe complications. It’s imperative that the trade-off between these aspects is considered, keeping in mind that CCH injections may be repeated in case of disease recurrence without increasing procedure related risks, especially in complex cases.
In oral squamous cell carcinoma (OSCC), 20% of patients experience local recurrences. In this study, the addition of autofluorescence to a standard incandescent light examination was evaluated to ...enhance detection rates of recurrences in OSCC.
Patients with OSCC who underwent follow-up examinations were included in this prospective cohort study. All patients (with or without recurrences) were examined clinically and with autofluorescence (using VELscope; Mectron, Cologne, Germany) and biopsy was used to examine suspect lesions for recurrences. Variables likely to influence results were analyzed. An analysis of dependencies, a general log-linear analysis, and a binary regression analysis were performed using SPSS version 26 (SPSS Inc., Chicago, IL).
The study included 195 patients and in 39 cases a biopsy was performed. Results showed significantly more recurrences with the addition of autofluorescence to the usual clinical examination (P ≥ .5). Sensitivity was 95.2% and specificity was 100%.
This study showed the advantages of adding autofluorescence to routine clinical assessments in OSCC follow-up examinations.
Clinical trial registration: German Clinical Trials Register DRKS-ID: DRKS00004836
Preserved allogeneic donor skin still represents one of the gold standard therapies in temporary wound coverage in severely burned patients or chronic wounds. Allogeneic skin grafts are currently ...commercially available as cryo‐ or glycerol‐preserved allografts through skin tissue banks all over the world. Most of the skin tissue banks rely on human cadaveric skin donations. Due to the chronic shortage of human allogeneic transplants, such as skin, and increasing costs in the procurement of allografts from other skin tissue banks, Hannover Medical School has been building up its own skin tissue bank based on allogeneic skin grafts from living donors who underwent surgical treatment (i.e., body‐contouring procedures, such as abdominioplasties). This article presents procedures and protocols for the procurement and processing of allogeneic skin grafts according to national legislation and European regulations and guidelines. Beside protocols, initial microbiological data regarding the sterility of the harvested grafts are presented. The results currently form the basis for further investigations as well as clinical applications. In summary, a microbiological testing and acceptance procedure is presented that ensures adequate patient safety and skin viability.
Background
Irritation of inguinal nerves with laparoscopic hernia repair may cause chronic neuralgia and hypoesthesia. Hypoesthesia in particular is generally not assessed objectively. We objectively ...investigated hypoesthesia and chronic pain after transabdominal preperitoneal inguinal hernia repair (TAPP) with titanium spiral tacks (STs) compared with tissue adhesive (TA) for mesh fixation.
Methods
Mesh fixation in 80 TAPP procedures was randomized to fixation with ST (
n
= 40) or TA (
n
= 40). The outcome parameters included hypoesthesia assessed with von Frey monofilaments, early postoperative and chronic pain with the visual analog scale (VAS), morbidity (surgical-site infection, hematoma/seroma, relapse of hernia, trocar hernia), and recovery time to normal activity.
Results
Median (range) follow-up was 38 (13–56) months. Demographic and baseline parameters were similar in the two groups. Prevalence of hypoesthesia was significantly higher at all postoperative times in the ST group (6 weeks: 32 vs. 6%; 6 months: 38 vs. 14%; 12 months: 34 vs. 13%; 13–56 months: 32 vs. 4%). Mean hypoesthesia scores over all time points were significantly higher in the ST group. The percentages of regions with hypoesthesia (abdominal, inguinal, or genitofemoral) following all procedures were higher in the ST group after 6 weeks (14 vs. 2%), 6 months (15 vs. 5%), and 13–56 months (22 vs. 4%). The intensity of pain decreased significantly in both groups over time.
Conclusions
Postoperative hypoesthesia depends on the method of mesh fixation during TAPP and is significantly reduced with TA compared with stapling.
Complications arising from accidental intraarterial drug injections have been described in the past. However, given the multitude of injected substances and complex pathophysiology, guidelines ...regarding diagnosis and management of patients with intraarterial injections remain vague. As such it remains unclear, when to expect limb ischemia and whether and for how long to monitor patients after intraarterial injections.
We present the case of a "near miss event" in an i.v. drug abuser presenting to the emergency department 3 hours after injection of water dissolved zolpidem (Ambientrade mark) tablets into the right ulnar artery. Chief complaint was forearm pain. Clinical examination at the time revealed no concern for limb ischemia and patient was discharged. The patient returned unplanned 18 hours after injection with an ischemic right hand. Angiography revealed no flow in the distal ulnar artery and minimal flow in the palmar arch. Emergent intraarterial thrombolysis with Urokinase was performed and restored hand perfusion. Clinical follow-up 3 months after injury showed full recovery with regular recapillarisation and normal Allen test.
This case report highlights the need to rigorously monitor patients with suspected intraarterial injections for potential delayed onset of limb ischemia. This is to our knowledge the first described case report of a successful revascularization after prolonged ischemia with delayed onset after zolpidem injection. We recommend close monitoring of these patients for at least 24 hours in addition to starting prophylactic anticoagulation.
Introduction
The reconstruction of the body shape after post-bariatric surgery or high-grade gynecomastia involves, besides skin tightening, the repositioning of anatomical, apparent landmarks. The ...surgeon usually defines these during the preoperative planning. In particular, the positions of the nipple–areola complexes (NAC) should contribute to the gender-appropriate appearance. While in the female breast numerous methods have been developed to determine the optimal position of the NACs, there are only a few, metric and often impractical algorithms for positioning the nipples and areoles in the male. With this study, we show the accuracy of the intuitive positioning of the nipple–areola complex in men.
Material and Methods
From a pre-examined and measured quantity of 10 young and healthy men, six subjects were selected, which corresponded, on the basis of their chest and trunk dimensions, to the average of known data from the literature. The photographed frontal views were retouched in two steps. Initially, only the NACs were removed and the chest contours were left. In a second step, all contours and the navel were blurred. These pictures were submitted to resident and consultant plastic surgeons, who were asked to draw the missing NACs without any tools. The original positions of the nipples were compared with the inscriptions. Furthermore, the results were compared between the contoured and completely retouched pictures and between the residents and consultants.
Results
A total of 8 consultants and 7 residents were included. In the contoured and completely retouched images, a significant deviation of the marked positions of the missing features was found. The height of the NAC was determined somewhat more precisely than the vertical position. There was no significant difference between the contoured and completely retouched images, with a discretely more accurate tendency on the contoured images. In comparison with the professional experience, the consultants were tangentially more precise, but without a statistically significant impact.
Discussion
The intuitive determination of the NACs is a challenge for the plastic surgeon. In this study, a statistically significant deviation was seen in almost all dimensions, although the clinical relevance cannot be conclusively assessed. We found a positional relationship of the NAC to the infraclavicular groove (“Mohrenheim pit”) in the vertical and 4–4.5 cm above the submammary fold. The position of the NAC can be satisfactorily determined by a combination of plastic surgical intuition, patient wishes and practical metric methods using the Mohrenheim-Estimated-Tangential-Tracking-Line (METT-Line).
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 Table of Contents or the online Instructions to Authors
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