[Assessment of REC (Reduction in Earning Capacity) after Thermal Trauma as Part of the Appraisal Process for Statutory Accident Insurance in Germany (Part 2): The New REC Form Developed by Ottomann and Hartmann in 2010]. / Die Einstufung der MdE nach thermischem Trauma im Rahmen der Begutachtung der gesetzlichen Unfallversicherung (Teil II): Der neue MdE Bogen nach Ottomann und Hartmann 2010.

The calculation of REC forms the basis of expert opinions for the purposes of making accident insurance assessments after an occupational accident or an accident suffered en route while travelling to or from the workplace. The estimation of REC is based on a procedure quoted in the 1995 "Jahrbuch der Versicherungsmedizin" (Yearbook of Insurance Medicine) using a form developed by Henkel von Donnersmarck and Hoerbrand. The overall estimation of damages resulting from the accident comprises 3 main components, namely the functional impairment, the assessment of local findings and the resulting somatic and vegetative complaints. The criteria for all 3 components are nevertheless imprecise and open to a great deal of interpretation on the part of the evaluator, leading to a highly variable and subjective overall assessment of REC. The new REC form includes a modified factor-based categorisation of the scar quality and the localisation, so that assessment can now be carried out in a differentiated manner. Visible, stigmatising areas such as the neck are provided with their own Q values. The pigmental and textural alterations describing the scar quality are now more precisely defined. Considering the complexity of the somatic and vegetative alterations, more precise (objective) assessments can now be derived. The new REC form increases the validity and transparency of post-thermal trauma REC assessments for the purposes of making statutory accident insurance assessments.

[The Assessment of REC after Thermal Trauma as Part of the Appraisal Process for Statutory Accident Insurance in Germany (Part 1): Low Validity of the REC Form Developed by Donnersmarck and Hörbrand]. / Die Einstufung der MdE nach thermischen Trauma im Rahmen der Begutachtung der gesetzlichen Unfallversicherung (Teil I): Geringe Validität des MdE Bogens nach Donnersmarck und Hörbrand.

The total REC (reduction in earning capacity) after a thermal trauma is usually assessed using an appraisal form for burns victims, initially developed by Hoerbrandt and von Donnersmarck (1995). The criteria for functional impairment, local findings and vegetative-somatic complaints are somewhat imprecise given the broad scope of interpretation which the evaluator can employ in making an appraisal. This means that the overall appraisal of REC is subjective on the part of the evaluator. In addition, one can only calculate an overall REC of at most 40% from local findings and vegetative-somatic symptoms, even in patients with extensive large area burns. Considering these points we investigated the dependency of the results on the evaluator as well as the limited validity of the appraisal form originally developed by Hörbrand and Donnersmark.

[The social background of male to female transsexuals]. / Der soziale Rahmen und Hintergrund von Mann-zu-Frau-Transsexualität.

Gender alignment surgery was introduced into German law in 1981. Judicial guidelines for the change of first names and gender were established and transsexuality was labelled as a psychosomatic and somatopsychic syndrome and disorder, thus opening the way for treatment to the social health-care under well-defined conditions requesting cross-dressing and hormone therapy as well as psychological counselling by 2 independent psychologists or psychiatrists. In a retrospective, chart-related survey of questionnaires on male to female transsexuals it was found that patients start to suspect being born into the wrong gender at the onset of puberty, it takes them however approximately 20 years to have gender alignment surgery. More than half the patients are single at this time, while the remaining group is married or divorced with equal rates. 68% regard themselves as heterosexual, 21% lesbian and 11% were undecided. About half the patients experienced support by their families for their decision. Despite numerous secondary corrections of the surgical alignment, patients were content with the result, although emotional acceptance of the desired result took about one year. In general plastic surgical gender alignment treatment was perceived as the major contribution to harmonise their phenotype with their identity.

Pirogow's Amputation: A Modification of the Operation Method.

Introduction. Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers the ability to stay mobile without the use of a prosthesis, it is rarely performed. This paper proposes a modification regarding the operation method of the Pirogow amputation. The results of the modified operation method on ten patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score). Material and Methods. We modified the original method by rotating the calcaneus. To fix the calcaneus to the tibia, Kirschner wire and a 3/0 spongiosa tension screw as well as a Fixateur externe were used. Results. 70% of those questioned who were amputated following the modified Pirogow method indicated an excellent or very good result in total points whereas in the control group (original Pirogow's amputation) only 40% reported excellent or very good result. In addition, the level of pain experienced one year after the completed operation showed different results in favour of the group being operated with the modified way. Furthermore, patients in both groups showed differences in radiological results, postoperative leg length difference, and postoperative mobility. Conclusion. The modified Pirogow amputation presents a valuable alternative to the original amputation method for patients with the corresponding indications. The benefits are found in the significantly reduced pain, difference in reduced radiological complications, the increase in mobility without a prosthesis, and the reduction of postoperative leg length difference.

[Pirogow's amputation as an alternative to lower leg amputation?]. / Die Amputation nach Pirogow als Alternative zur Unterschenkelamputation?

Pirogow's amputation at the ankle presents a valuable alternative to lower leg amputation for patients with the corresponding indications. Although this method offers numerous advantages for the patient, such as the ability to stay mobile without the use of a prosthesis, it is rarely performed (0.1% of all lower limb amputations). The results of the operations on 20 patients were objectified 12 months after the operation using a patient questionnaire (Ankle Score), and these results were then compared to those of 20 patients who underwent lower leg amputation. Using a point system the criteria pain, functional and radiological assessment, difference in leg length, and mobility without prosthesis were recorded and evaluated. 65% of those questioned who were amputated following the Pirogow method indicated an excellent or very good result, in the control group 60% of those having undergone a lower leg amputation responded similarly, indicating an excellent or very good result.In 30% in the Pirogow group in contrast to 20% after lower leg amputation postoperative complications lead to a revision-operation. In patients suffering from diabetes or restricted perfusion of the lower extremity an amputation at the level of the ankle has to be considered critically keeping the necessity of a revision-operation in mind. However, if it can be carried out successfully, the benefits of Pirogow-amputation are found in the significantly reduced difference in leg length and the increase in mobility without prosthesis.

[Increased self-confidence and decreased sexual discomfort after subpectoral mammaplasty]. / Gesteigertes Selbstvertrauen und vermindertes körperlich-sexuelles Missempfinden nach subpektoraler Mammaaugmentation.

INTRODUCTION: The study objectively discusses the causal relationship between submuscular breast augmentation mammaplasty and improved aspects of quality of life. The goal was to assess a possible increase in certain aspects after undergoing cosmetic breast enlargement surgery under consideration of 4 different aspects. MATERIALS AND METHODS: Between 2005 and 2006, a total of 65 women were given a standardised patient questionnaire (body image assessment questionnaire) preoperatively as well as 6 months postoperatively after undergoing cosmetic submuscular augmentation mammaplasty: 58 of these questionnaires could be evaluated successfully. All of the patients had undergone augmentation mammaplasty for the first time. The following criteria were assessed and evaluated using a point value system (0-100 points): attractiveness/self-confidence, insecurity/anxiety, emphasis placed on physical appearance, and sexual discomfort. RESULTS: With regard to the questions dealing with attractiveness/self-confidence, a highly significant improvement in the patient's self-assessment of said criteria after undergoing cosmetic submuscular augmentation mammaplasty as compared to their own preoperative assessment was apparent. In addition, a significantly improved level of sexual satisfaction after the medical procedure was also demonstrated. In the same fashion, the answers to the series of questions dealing with emphasis placed on physical appearance also exhibited a positive change. The only topic that exhibited next to no change was the series of questions dealing with insecurity/anxiety. CONCLUSION: Cosmetic augmentation mammaplasty is an available therapy that can increase a patient's own self-assessment of attractiveness and self-confidence in a significant way. In addition, this operation leads to a significant increase in sexual satisfaction, and because of this and the aforementioned change of emphasis placed on physical appearance, an overall improvement in certain aspects of the quality of life can be achieved.

Feasibility and clinical applicability of polihexanide for treatment of second-degree burn wounds.

OBJECTIVES: Due to a partial rejection of mesh split-thickness skin grafts (mesh grafts) after application of povidone-iodine and silver nitrate and due to its better in vitro tolerance, polihexanide was investigated as an alternative and its applicability in the treatment of second-degree burn wounds. METHODS: In 4 patients with poorly healing decubitus ulcers the mesh grafts were each divided into three areas which were pre-treated with either undiluted povidone-iodine solution, 1% silver nitrate solution or 0.04% polihexanide solution. After 7 days of application the wound areas were compared clinically and histologically. Thereafter 14 patients (average extent of burns 28% TBSA) were treated in the same way. RESULTS: Clinically and histologically the mesh grafts treated with polihexanide showed by far the best re-epithelialization compared with the deep tissue necrosis and marked fibrin discharge observed for application of povidone-iodine and silver nitrate. The second-degree burn wounds treated with polihexanide epithelialized without any further débridement after an average of 10 days with remarkable freedom from pain. Compared with silver nitrate treatment, no fibrin film was observed on the wound. CONCLUSION: Polihexanide proved clinically and histologically superior to povidone-iodine and silver nitrate. For the treatment of second-degree burns, which cannot primarily be covered by plastic surgery, polihexanide is suitable because in addition to its antiseptic efficacy it does not inhibit the re-epithelialization process.

[Endoscopic brow lift with resorbable anchors]. / Die endoskopische Brauenanhebung mit resorbierbaren Hautankern.

The fixation of the galea to the skull presents one of the main impairments of endoscopic forehead lifts, which are still to be improved. A precise positioning, variation of force vectors and the ability to correct asymmetries are among the demands on this aesthetic procedure. Since the introduction of resorbable skin anchors, we have used them pairwise in 27 consecutive cases of endoscopic forehead lifts. In a retrospective study we found that the advantage of this system is primarily found in a reduction of operating time, ease and reliability of use and the possibility to individually adjust the direction and strength of tension after inserting the anchors into the skull. The disadvantage - apart from the high cost of the device - lies in the unreliable resorption time which, in all cases controlled, exceeded the 8-month period, proclaimed by the manufacturer. This made it necessary to surgically remove the anchors in 7 out of 27 patients. Consequently every patient is now informed about the possibility of a second intervention as early as 4 to 6 weeks postoperatively to remove the device.

[Tumor-related arthrodesis. Reconstruction of the shoulder contour using a free TRAM (Transverse Rectus Abdominis Musculocutaneous) flap]. / Tumorbedingte Arthrodese. Wiederherstellung der Schulterkontur mit dem freien TRAM-Lappen.

Upper arm bone- and shoulder resection due to cancer have to be performed under oncologic criteria. Soft tissue however may not be sufficient to safely cover a following arthrodeses. To avoid perforation and reconstruct a normal shoulder contour a free myocutaneous TRAM-flap was employed and its vessels anastomosed to branches of A. and V. brachialis. Incorporating the facia and an island of M. rectus abdominis proved to safely cover the arthrodetic material and shape the bulk of the flap, allowing to reconstruct the desired contour. Good vascularisation postoperatively preserved tissue stability and volume and thus safely restored normal shoulder contour even in a long time review.

[Breast reconstruction with the free microvascular abdominal flap. Accessory reconstruction or gold standard?]. / Die Mammarekonstruktion mit dem freien mikrovaskulären Unterbauchlappen. Rekonstruktives Accessoire oder goldener Standard.

Long time results of breast reconstruction after ablative surgery with skin expander and prothesis is perceived as unsatisfactory by most patients. Breast reconstruction with autologous tissue however is connected with a high technical expenditure and especially in the case of the free TRAM-flap connected with the risk of total loss of the transplanted tissue. In view of the total effort in secondary interventions, and reduction of the collateral side, the autologous reconstruction proves to need less time, resources and hospital admissions already after a 2 year period. Minor revisions mark the long time course of breast reconstruction with expander and prothesis. Judging by the patients themselves they prefer the reconstruction with autologous tissue and in this subgroup microsurgical reconstruction yields the better results to the patient. Review shows that the microsurgical procedure allows the transfer of larger volumes and better positioning of the breast including a physiologic breast ptosis. TRAM-flap donorsites seem to yield equal results in dynamic as well as static exercise regardless of the microsurgical or pedicled technique. The review of our own 48 patients with 50 TRAM-flaps coincide with the review of the current literature.

Treatment of partial thickness burns of the hand with the preshaped, semipermeable Procel Burn Cover: results of a multicentre study in the burn centres of Berlin, Duisburg and Munich.

The results of a prospective clinical study conducted in three German burn centres are reported. The subject of the evaluation was to show the effectiveness of a new, preshaped, semipermeable burn dressing that is resistant to fluids and bacteria but highly permeable to vapour. The dressing was used in conjunction with 1 per cent silver sulphadiazine cream in treating partial thickness burns of the hand. In 49 patients, 72 partial thickness burned hands were treated. The application proved to be very easy. The time for a dressing change was short (5-10 min). The duration of treatment was 13 days on average. Complications due to infections did not occur. Because of the semipermeable properties of the dressing material, skin macerations occurred in only a few instances (13 per cent) as a result of inappropriate cream application or extremely high exudation rates, and these did not adversely affect the healing process. Patients achieved the ability to perform activities of daily living early with positive results for the patients, the physician and the nursing team.

[Pyoderma gangraenosum--a rare complication after breast reduction]. / Pyoderma gangraenosum--Eine seltene Komplikation nach Mammareduktionsplastik.

Applying standardized and sound operative techniques, impaired wound healing following reduction mammoplasty is rare. A postoperative case of pyoderma gangraenosum is reported. This necrotizing skin disorder seemed at first to be a postoperative bacterial infection, but correct diagnosis was finally made histopathologically. The clinical course, etiology, diagnostic findings, and therapy are discussed and a review of the literature is presented.

[Electromyographic studies of myocutaneous sliding flaps for the covering of sacral decubitus ulcer]. / Elektromyographische Untersuchungen an myokutanen Verschiebelappen zur Deckung des sakralen Dekubitus.

Gluteus maximus myocutaneous sliding flaps from one or both sides are useful in covering deep, usually infected sacral pressure sores. Although skin is known to tolerate higher pressure in the covered area, muscle offers far better conditions for flap healing of infected defects. In spite of excellent early results, the long-term fate of the transposed muscle remains uncertain. An electromyography study was performed on eleven patients out of 29 with sliding gluteus maximus myocutaneous flaps in periods up to seven months after surgery. Our results show that signs of denervation parallel reinnervation and functional integrity of the transposed muscle.

Repair of the upper eyelid by means of the prepuce after severe burns.

Burns to the eyelid often constitute difficult problems for reconstruction or repair. Functional and aesthetic aspects have to be considered, and suitable donor sites are not readily available in severely burned patients. In male patients, the prepuce yields an almost ideal skin for eyelid repair because of its high elasticity and adequate texture. Two patients with repair of both upper eyelids using the prepuce are demonstrated. The color match of this skin graft is satisfying. If both layers of the prepuce are transplanted, they yield enough tissue to cover both upper eyelids. This method seems to be an adequate method of reconstruction of burned eyelids in severely burned male patients when the usual donor sites for skin grafts are not available.

More arguments in favor of myocutaneous flaps for the treatment of pelvic pressure sores.

The use of myocutaneous flaps for the treatment of pelvic pressure sores is well accepted, yet there are still unanswered questions about why myocutaneous flaps are clinically superior to skin flaps. An experiment involving 16 pigs revealed new data on the diffusion of infection through myocutaneous and cutaneous flaps, showing that the muscles can act as a barrier against such infection. In 51 patients seen consecutively in 1988, osseous specimens of the infected bottom of the decubital ulcers were taken. There was florid osteomyelitis in 65.9% of all specimens, further emphasizing the importance of muscle flaps in the treatment of pelvic pressure sores when infection is still present. The fate of 16 transposed gluteus maximus muscles was monitored by electromyography postoperatively; 15 still showed voluntomotoricity up to 7 months after transposition.

[Skin replacement after electric burns]. / Hautersatz nach Elektroverbrennung.

Skin reconstruction following electrical injuries is characterized by the difficulty of early diagnosis. There are two forms of tissue damage: (1) thermal trauma, (2) damage of cells due to high field strengths. For the diagnosis of macroskopically undetectable damage we use scintigraphy with technetium pyrophosphate and quantitative histological examination of the necrosis. After efficient debridement split thickness skin graft is only feasible in a few cases. Sometimes local flaps from areas without any tissue damage can be employed but mostly microvascular free flaps are used to cover the defect.

[Indication for and results of the application of glycerol-preserved homologous split-thickness skin following burns]. / Indikation und Ergebnisse der Anwendung glycerol-konservierter homologer Spalthaut nach Verbrennungen.

Since 1983 the treatment of second-degree burns with glycerol-conserved allogenic split-thickness skin grafts is published. In case of actual problems with AIDS the gathering of split-thickness skin was modified and a new method for gaining split-thickness skin of organ-donors created to prevent the virus transfer. Because of these high security in contagiousness the skin graft transplantation with allogenic glycerol-conserved donor-skin in case of second-degree-burns was standardized in the Berlin Burn Center. To prevent the formation of granulation tissue after second-degree burns a tangential debridement of necrotic corium will be done in 1/10 mm thick slices on the third posttraumatic day and the defects covered with 1:1.5 mesh grafts extended. The results of 267 patients in 1988 and 1989, who were treated in accordance to this regimen, will be demonstrated. In 11% of cases the alloplastic skin graft in adults was not rejected 6 month after transplantation and in 2% of cases the depth of burn was not estimated properly and hypertrophic scars had to be excised and covered with autogenous split-thickness skin. General second-degree-burn healed after debridement and covering with allogeneic split-thickness skin without formation of hypertrophic scars.

[Regeneration of bone following thermal injury]. / Regeneration des Knochens nach thermischer Schädigung.

In an animal experiment we could prove, that a spontaneous regeneration of periosteum on thermally injured bone is not to be seen within three month, when the bone is covered by soft tissue only. Using a periosteal flap to cover a burned bone, regeneration could be observed from the endosteum and the periosteum alike. After making the bone with a fluorescent labels, paths and velocity of bony regeneration could be defined.