[The proximally pedicled anterolateral thigh flap for reconstruction of complex soft tissue wounds of the hip and caudal trunk region]. / Die proximal gestielte Anterior-lateral-thigh-Lappenplastik zur Rekonstruktion komplexer Weichteilwunden der Hüft- und kaudalen Rumpfregion.

INTRODUCTION: Groin and lower trunk defects are common problems, especially for elderly patients. While groin defects are often due to prior vascular interventions, trochanteric defects are mainly caused by pressure sores. Plastic reconstructive methods are manifold; however, the pedicled anterolateral thigh (ALT) flap is supposed to be reliable with sustainable results. OBJECTIVE: We present our experiences using the pedicled ALT flap for soft tissue reconstruction in patients with large wounds of the medial and lateral proximal thigh. MATERIALS AND METHODS: A total of 16 patients with groin and lower trunk defects due to prior vascular surgery or pressure sores received locoregional soft tissue reconstruction using a proximal pedicled ALT flap. Patient characteristics, defect size, surgery time, clinical outcome and complication rate were assessed. RESULTS: With the exception of two cases, sufficient soft tissue reconstruction was achieved. In all, 81,3% of patients were categorized as ASA (American Society of Anesthesiologists) 3. The average duration of surgery was 149 min. Length of stay was 18,3 days. A total of 31% needed revision surgery due to limited wound healing problems. Two patients died. All patients showed healed wound conditions when they were discharged. CONCLUSION: The proximal pedicled ALT-flap is a reliable method for soft tissue reconstruction in groin and lower trunk defects. This reconstructive procedure enables reliable wound closure, especially in elderly patients with substantially reduced general health condition.

Anesthesia of the conditioned limb does not abolish the remote ischemic conditioning stimulus on cutaneous microcirculation in humans.

BACKGROUND: Mechanism of remote ischemic conditioning (RIC) remain not fully understood yet. Thus, a clinical trial was performed to assess the neuronal influence on its signal induction. METHODS: RIC was conducted on 45 patients who were randomized into 3 groups. Group A and B underwent brachial plexus anesthesia while RIC was performed on the blocked (A) and non-blocked side (B), respectively. In group C, RIC was conducted before regional anesthesia, thus serving as control group. All measurements were taken contralateral to RIC. The relative increase of microcirculatory parameters compared to baseline was evaluated and compared between the groups. RESULTS: Superficial blood flow (sBF) significantly increased in group A and C but values were higher among group C. Compared to group A, group C showed a significant increase of sBF during the initial 5 minutes of reperfusion (1.75; CI 1.139 - 2.361 vs. 0.97, CI 0.864 - 1.076, p < 0.05). Deep blood flow, tissue oxygen saturation and relative hemoglobin content were marginally influenced by RIC irrespectively of the presence of regional anesthesia. CONCLUSION: Despite regional anesthesia a significant RIC stimulus can be induced although its microcirculatory response is attenuated compared to control. Hence, RIC induction does not merely depend on neuronal signaling.

Improvement of local microcirculation through intermittent Negative Pressure Wound Therapy (NPWT).

BACKGROUND: Negative Pressure Wound Therapy (NPWT) is widely used across different kinds of surgical disciplines. A controversial debate was raised by diverging results from studies that were conducted to examine the impact of NPWT on local perfusion. Thus, there is a lack of evidence for one important underlying factors that influences the physiology of wound healing under an applied NPWT-dressing. OBJECTIVE: To investigate the immediate local perfusion changes due to an applied intermittent NPWT protocol. MATERIAL AND METHODS: A NPWT dressing was applied to the antero-lateral thigh of seven healthy volunteers with two probes of both pressure and microcirculatory measuring devices. One of each probe was placed under the NPWT dressing, the other one in close proximity next to it. A protocol consisting of two cycles of 10 min of -125 mmHg pressure, followed by 10 min of 0 mmHg pressure was applied. Measurements of local pressure to the underlying tissue, as well as microcirculatory changes were performed continuously. RESULTS: Applied vacuum caused compressional forces (27.33 mmHg, p < 0.05) towards the underlying tissue. Blood Flow was increased after both suction periods (+52.5%, +108.7%; p < 0.05) and continued increasing until the end of measurements (+145.3%). This was accompanied by significant increase in Oxygen Saturation (+21.6%; p < 0.05) and Relative Hemoglobin Content (+16.7%). Red Blood Cell Velocity was found to be increased without statistical significance. Next to the dressing, changes were also significant but less pronounced. CONCLUSION: Intermittent NPWT improves local microcirculation with consecutive enhancement of oxygen supply.

Sternal Reconstruction with the Omental Flap-Acute and Late Complications, Predictors of Mortality, and Quality of Life.

BACKGROUND: The omental flap is a reliable flap for the coverage of sternal defects. However, little is known about the predictors of mortality and the long-term outcome in such patients. METHODS: We, therefore, performed a retrospective study from 2002 to 2013, including all patients who underwent sternal reconstruction with the omental flap. RESULTS: A total of 50 patients were identified and mean follow-up was 3.8 years. Patient data was collected from the charts and 14 patients were available for telephone interviews. The majority of patients suffered from deep sternal wound infections. There was no complete flap loss and an overall success rate was 96%. In-hospital mortality was 14% and overall survival over follow-up was 50%. Significant predictors of mortality were age > 65, American Society of Anesthesiologists' status, defect size, prolonged ventilation, and the need for tracheotomy. Postoperative quality of life was reduced compared with other cohorts, especially with regard to bodily function. Pain was also a major problem for most patients along with herniation. CONCLUSION: The omental flap is a safe option even in patients with severe comorbidities. However, based on the data in this study, we would recommend the omental flap as a reserve option rather than first-line treatment for sternal defects.

[Remote Ischemic Conditioning - Endogenous Tissue Protection and its Possible Applications in Surgery]. / Remote ischemic Conditioning ­ endogene Gewebeprotektion und ihre Einsatzmöglichkeiten in der Chirurgie.

Tissue perfusion is pivotal to wound healing and tissue regeneration after surgery. Ischemia and reperfusion lead to inflammatory reactions with consecutive tissue damage and necrosis. Multiple conditioning techniques have been described to protect tissue from those damaging mechanisms in the perioperative period. However, most of these fail to meet the requirements of a good therapeutic effect, time and cost efficiency, non-invasiveness and applicability without the need for additional devices or drugs. Remote ischemic conditioning (RIC) is a technique to provide endogenous tissue protection, which fully meets those requirements. Repeated, short cycles of ischemia/reperfusion applied to a circumscribed vascular territory lead to the activation of endogenous signal pathways resulting in increased tolerance to hypoperfusion and limiting the damage caused by reperfusion, even in tissues located far away from the conditioned area. The non-invasive application of the conditioning stimulus requires no more than a pressure cuff, which is placed on the upper arm and is repeatedly inflated to suprasystolic pressures. Different concepts of remote ischemic pre-, peri- and postconditioning enable the usage in both elective and emergency surgical interventions. Based on encouraging experimental studies, the application of RIC has increased in the clinical setting. In addition to studies addressing cardio-, nephro- or neuroprotection there are some initial findings supporting a potential beneficial application in reconstructive microsurgery. This article aims to give an overview of the development, concepts and mechanisms of RIC with a focus on its clinical application in the field of surgery.

Ten minutes of ischemia is superior to shorter intervals for the remote ischemic conditioning of human microcirculation.

BACKGROUND: Surgical flaps have become reliable tools in the microsurgical armamentarium, but are still faced with tissue loss due to impaired perfusion which can lead to complete flap failure. Remote Ischemic Conditioning (RIC) has been demonstrated to be an effective way to improve microcirculation in surgical flaps in humans. However, little is known about the optimal amount and length of RIC cycles. OBJECTIVE: Determination of a superior protocol for RIC of cutaneous microcirculation in humans. METHODS: 60 healthy volunteers were randomized into different groups and received a RIC protocol, consisting of three cycles of either 1 second, 1, 5, or 10 minutes of ischemia followed by ten minutes of reperfusion. RIC was applied with a inflatable tourniquet placed on the upper arm. Changes in microcirculation were assessed via combined laser doppler/spectroscopy (O2C device) at the anterior lateral thigh. Relative increase at the end of conditioning vs. baseline measurements was calculated and compared between groups. RESULTS: RIC caused significant changes in cutaneous microcirculation (p < 0.05) which were more pronounced in groups with longer ischemia intervals. The ten minutes group was significantly superior. CONCLUSION: A conditioning protocol containing three cycles of ten minutes of ischemia is superior to protocols with shorter ischemia intervals for RIC of cutaneous microcirculation.

Remote ischaemic conditioning decreases blood flow and improves oxygen extraction in patients with early complex regional pain syndrome.

BACKGROUND: Remote ischaemic conditioning (RIC) is the cyclic application of non-damaging ischaemia leading to an increased tissue perfusion, among others triggered by NO (monoxide). Complex regional pain syndrome (CRPS) is known to have vascular alterations such as increased blood shunting and decreased NO blood-levels, which in turn lead to decreased tissue perfusion. We therefore hypothesized that RIC could improve tissue perfusion in CRPS. METHOD: In this proof-of-concept study, RIC was applied in the following groups: in 21 patients with early CRPS with a clinical history less than a year, in 20 age/sex-matched controls and in 12 patients with unilateral nerve lesions via a tourniquet on the unaffected/non-dominant upper limb. Blood flow and tissue oxygen saturation (StO2 ) were assessed before, during and after RIC via laser Doppler and tissue spectroscopy on the affected extremity. The oxygen extraction fraction was calculated. RESULTS: After RIC, blood flow declined in CRPS (p < 0.01). StO2 decreased in CRPS and healthy controls (p < 0.01). Only in CRPS, the oxygen extraction fraction correlated negatively with the decreasing blood flow (p < 0.05). CONCLUSION: Contrary to our expectations, RIC induced a decrease of blood flow in CRPS, which led to a revised hypothesis: the decrease of blood flow might be due to an anti-inflammatory effect that attenuates vascular disturbances and reduces blood shunting, thus improving oxygen extraction. Further studies could determine whether a repeated application of RIC leads to a reduced hypoxia in chronic CRPS. SIGNIFICANCE: Remote ischaemic conditioning leads to a decrease of blood flow. This decrease inversely correlates with the oxygen extraction in patients with CRPS.

Prednisolone but not selenium and rtPA reduces edema and improves angiogenesis after burn in mice.

OBJECTIVE: Despite dramatic improvements in burn care, the major part of the therapy of thermal injuries remains symptomatical in nature. A targeted approach to accelerate angiogenesis and woundhealing and reduce edema formation remains to be found. We therefore aimed to investigate the impact of anti-inflammatory, anti-coagulative and thrombolytic agents on microcirculation after thermal injuries on the mentioned parameters. METHODS: Full thickness burns were inflicted on the ears of hairless mice (n=48). The effects of five intraperitoneal injections of either recombinant tissue plasminogen activator (rtPA), selenium, prednisolone or sodium chloride on microcirculation, edema formation, leukocytes and angiogenesis were investigated over a 13 day period using intravital fluorescent microscopy. RESULTS: Prednisolone slightly improved angiogenesis (100.0% day 0 vs. 91.4% non-perfused area on day 1 post burn, p<0.05) and reduced edema formation (93.3% vs. 123.1% control on day 3, p<0.05). The rtPA-group showed the highest number of sticking leukocytes up to day 7 post burn (233%, 265%, 254% on days 1, 3, and 7, p<0.05 compared to baseline). A post-traumatic expansion of the non perfused area could only be observed in the selenium group (100.0% day 0, 103.1% day 1 post burn). In addition, selenium caused an increase of rolling leukocytes over the complete observation time. CONCLUSION: The often described positive influences of selenium for the treatment of burn patients could not be confirmed, on the contrary we found a post-traumatic expansion of the non perfused area and an increase of leukocytes in this group. The expectations to rtPA did not fulfill. Prednisolone improved angiogenesis and reduced the edema formation, both Parameters are essential for wound healing and survival of burned patients.

[Prognostic factors and surgical tactics in patients with locally recurrent soft tissue sarcomas]. / Prognostische Faktoren und chirurgische Taktik bei lokal rezidivierten Weichteilsarkomen.

BACKGROUND: The aim of this study was to identify prognostic indicators of survival in patients with locally recurrent soft tissue sarcoma through a long-term follow-up. METHODS: We retrospectively assessed the relationship between post-recurrence survival (PRS) and potential predictive factors in 135 patients who had experienced local recurrence after surgical treatment. The median follow-up time after initial recurrence was 12.3 years (95% confidence interval [CI]: 10.4-14.2 years). RESULTS: The 5-year estimate of the PRS rate was 53.1% (95% CI: 44.3-61.2%) for the entire series. Synovial sarcoma and fibrosarcoma were associated with a significantly worse post-recurrence outcome compared with other STS histotypes. Patients with negative margins after the final surgery experienced improved survival compared with patients with positive margins (5-year survival: 46.7% [35.2-57.5%] vs. 35.5% [23.4-47.8%]; P=0.01). In a multivariate analysis, the significant prognostic indicators for PRS were histologic grade, tumour site, time to initial recurrence, the number of recurrences and the surgical margin status attained at the last resection. CONCLUSIONS: Complete surgical resection with microscopically clear margins is desirable in patients with locally recurrent STS. However, when achieving clear surgical margins will require major functional impairment of the extremity, a radical surgical approach should be carefully weighed out for the patient in each case.

[Free fasciocutaneous parascapular flap. Coverage of extensive skin and soft tissue defects]. / Freie fasziokutane Paraskapularlappenplastik. Deckung ausgedehnter Haut-Weichteil-Defekte.

Coverage of extensive tissue defects is one of the tasks of plastic surgery. For the surgeon there are a series of possibilities differing in safety level and difficulty. With extensively exposed bones, however, there is mostly the indication for free tissue transfer. In the following case a possibility of wound closure of an extensive defect by one single free flap without preconditioning the tissue is demonstrated.

[Options for reconstructive surgery of the thoracic wall]. / Plastisch-chirurgische Möglichkeiten der Thoraxwandrekonstruktion.

The integrity of the thoracic wall and therefore the protection of the thoracic organs is paramount for survival. This integrity can be compromised by various factors, be it tumours, wound-healing disorders or injuries. An adequate surgical therapy for these entities often requires (partial) resections of the thoracic wall resulting in a loss of its protective function. A safe and timely reconstruction of the thoracic wall is therefore mandatory and can be achieved by means of reconstructive procedures. This article therefore aims to illustrate such reconstructive procedures utilising our own clinical cases while also giving a review of the literature in order to construct an algorithm for the reconstruction procedure.

[Reconstruction options for pelvic defects after abdominal exenteration]. / Defektdeckungsoptionen nach Eviszeration.

Soft tissue defects after oncological pelvic exenteration still represent a significant problem. Because of the anatomic and functional peculiarities, the reconstruction of defects in the pelvic region is challenging and requires a differentiated approach. In this paper, current strategies and options for reconstructive procedures are presented considering preoperative conditions and factors related to surgical planning. The relevance of interdisciplinary collaboration and the resulting benefits are set out. The inclusion of the plastic surgeon already in the preoperative planning of tumour resection is recommended.

Upper extremity ischemia is superior to lower extremity ischemia for remote ischemic conditioning of antero-lateral thigh cutaneous blood flow.

Remote ischemic conditioning (RIC) is known to improve microcirculation in various settings, but little is known about the impact of the amount of ischemic tissue mass or the limb itself. Since ischemia and subsequent necrosis of flaps is one of the most dreaded complications in reconstructive surgery, adjuvant methods to improve microcirculation are desirable. We therefore performed a randomized trial to compare the effect of arm versus leg ischemia for RIC of the cutaneous microcirculation of the antero-lateral thigh. Forty healthy volunteers were randomized to undergo 5 min of ischemia of either the upper or lower extremity, followed by 10 min of reperfusion.Ischemia was induced by a surgical tourniquet applied to the proximal limb, which was inflated to 250 mmHg for the upper and 300 mgHg for the lower extremity. This cycle was repeated a total of three times. Cutaneous microcirculation was assessed by combined laser doppler spectrophotometry on the antero-lateral aspect of the thigh to measure cutaneous blood flow (BF), relative hemoglobin content (rHb), and oxygen saturation (StO2). Baseline measurements were performed for 10 min, after which the ischemia/reperfusion cycles were begun. Measurements were performed continuously and were afterwards pooled to obtain a mean value per minute. Both groups showed significant increases in all three measured parameters of cutaneous microcirculation after three cycles of ischemia/reperfusion when compared to baseline (BF: 95.1% (P < 0.001) and 27.9% (P = 0.002); rHb: 9.4% (P < 0.001) and 5.9% (P < 0.001), StO2: 8.4% (P = 0.045) and 9.4% (P < 0.001). When comparing both groups, BF was significantly higher in the arm group (P = 0.019 after 11 min., P = 0.009 after 45 min). In conclusions, both ischemic conditioning of the upper and lower extremity is able to improve cutaneous BF on the ALT donor site. However, RIC of the upper extremity seems to be a superior trigger for improvement of cutaneous BF.

Influence of ISDN, L-NAME and selenium on microcirculation, leukocyte endothelium interaction and angiogenesis after frostbite.

BACKGROUND: The body of knowledge regarding the different facets of frostbite injury continues to expand. However, beside the administration of physiological saline, local rewarming, local disinfection and symptomatic medications, today no causal therapy is known which would accelerate angiogenesis and wound healing. The aim of this study was to investigate the influences of dilative acting drugs on microcirculation, angiogenesis and leukocyte behavior. MATERIALS AND METHODS: Ears of male hairless mice (n=40) were inflicted with full thickness frostbites using a cold air jet. Then the affects of four intraperitoneal injections of isosorbitdinitrate (ISDN, n=10), l-nitroarginine-methyl-ester (l-NAME, n=10), selenium (n=10) or sodium chloride (n=10; each administered to one of four corresponding study groups), on microcirculation, leukocyte-endothelial interaction and angiogenesis were investigated over a 12-day period using intravital fluorescent microscopy. RESULTS: Angiogenesis was most improved by ISDN (36.8 vs. 54.5% non-perfused area on day 3, 3.9 vs. 17.0% on day 7 compared to selenium, p<0.006). Venular diameter was most significantly dilated in the ISDN-group, l-NAME showed significantly decreased diameter over the complete time of 12 days. ISDN had positive influences on edema formation, which was significantly reduced compared to control (27% lower values compared to control; p=0.007 on day 3). The l-NAME-group showed the significant highest leukocyte-adhesion compared to control on days 7 and 12 (53% resp. 58% higher, p<0.006). CONCLUSION: Overall, out of all the drugs tested, ISDN improved angiogenesis, dilated venules and decreased edema formation and therefore seems to have the greatest positive impact on these crucial parameters after frostbite injury.

Thoracic Wall Reconstruction in Advanced Breast Tumours.

In advanced mammary tumours, extensive resections, sometimes involving sections of the thoracic wall, are often necessary. Plastic surgery reconstruction procedures offer sufficient opportunities to cover even large thoracic wall defects. Pedicled flaps from the torso but also free flap-plasties enable, through secure defect closure, the removal of large, ulcerated, painful or bleeding tumours with moderate donor site morbidity. The impact of thoracic wall resection on the respiratory mechanism can be easily compensated for and patients' quality of life in the palliative stage of disease can often be improved.

[Therapeutic options for reconstruction of the dorsal trunk wall]. / Therapieoptionen zur Rekonstruktionen der dorsalen Rumpfwand.

Posterior trunk defects represent a major reconstructive problem, which require the entire armamentarium of the reconstructive surgeon. Given the special anatomy of the back, flap selection includes transposition flaps, perforator flaps, muscle flaps, turn-over flaps and free flaps, eventually with interposition of vein grafts. The majority of the defects can be closed with pedicled muscle or musculocutaneous flaps. In our patient collective, sufficient closure could be obtained with all procedures, except the latissimus dorsi turn-over flap. Based on our clinical experience, we propose an algorithm for closure of posterior trunk defects related to the anatomical region.

Repetitive extracorporeal shock wave applications are superior in inducing angiogenesis after full thickness burn compared to single application.

OBJECTIVE: Burn wounds remain a challenge due to subsequent wound infection and septicemia, which can be prevented by acceleration of wound healing. The aim of the study was to analyze microcirculation and leukocyte endothelium interaction with particular focus on angiogenesis after full-thickness burn using three different repetitions of low energy shock waves. METHODS: Full-thickness burns were inflicted to the ears of hairless mice (n=44; area: 1.6±0.05 mm2 (mean±SEM)). Mice were randomized into four groups: the control group received a burn injury but no shock waves; group A received ESWA (0.03 mJ/mm2) on day one after burn injury; group B received shock waves on day one and day three after burn injury; group C ESWA on day one, three and seven after burn injury. Intravital fluorescent microscopy was used to assess microcirculatory parameters, angiogenesis and leukocyte interaction. Values were obtained before burn (baseline value) immediately after and on days 1, 3, 7 and 12 after burn. RESULTS: Shock-wave treated groups showed significantly accelerated angiogenesis compared to the control group. The non-perfused area (NPA) is regarded as a parameter for angiogenesis and showed the following data on day 12 2.7±0.4% (group A, p=0.001), 1.4±0.5% (group B, p<0.001), 1.0±0.3% (group C, p<0.001), 6.1±0.9% (control group). Edema formation is positively correlated with the number of shock wave applications: day 12: group A: 173.2±9.8%, group B: 184.2±6.6%, group C: 201.1±6.9%, p=0.009 vs. control: 162.3±8.7% (all data: mean±SEM). CONCLUSION: According to our data shock waves positively impact the wound healing process following burn injury. Angiogenesis showed significantly improved activity after shock wave application. In all three treatment groups angiogenesis was higher compared to the control group. Within the ESWA groups, double applications showed better results than single application and three applications showed better results than single or double applications.

Long-term outcome after local recurrence of soft tissue sarcoma: a retrospective analysis of factors predictive of survival in 135 patients with locally recurrent soft tissue sarcoma.

BACKGROUND: The aim of this study was to identify prognostic indicators of survival in patients with locally recurrent soft tissue sarcoma (STS) through a long-term follow-up. METHODS: We retrospectively assessed the relationship between post-recurrence survival (PRS) and potential prognostic factors in 135 patients who had experienced local recurrence, which was suitable for further surgical treatment. The median follow-up time after initial recurrence was 12.3 years (95% confidence interval (CI): 10.4-14.2 years). RESULTS: The 5-year estimate of the PRS rate was 53.1% (95% CI: 44.3-61.2%) for the entire series. Patients with negative margins after the final surgery experienced improved survival compared with patients with positive margins (5-year survival: 46.7% (35.2-57.5%) vs 35.5% (23.4-47.8%); P=0.01). In a multivariate analysis, the significant prognostic indicators for PRS were histologic grade, tumour site, time to initial recurrence, the number of recurrences and the surgical margin status attained at the last resection. CONCLUSIONS: Complete surgical resection with microscopically clear margins is desirable in patients with locally recurrent STS. However, when achieving clear surgical margins will require major functional impairment of the extremity, a radical surgical approach should be weighed for the patient in each case.

[Surgical treatment of extravasation injuries]. / Chirurgische Behandlung von Paravasaten.

OBJECTIVE: Extravasations account for most iatrogenic injuries. The aim of the study was to analyse the results of surgery in patients with extravasations and to draw conclusions for future treatment. MATERIALS AND METHODS: 24 patients with soft-tissue defects after extravasations were treated between 1999 and 2009 in our hospital. The cases were analysed retrospectively. We looked at the drugs causing tissue necrosis and the localisation in relation to the number of interventions and reconstruction complexity. RESULTS: In 83 % (n = 20) of cases tissue necrosis was caused by chemotherapeutic agents, in 8 % (n = 2) by contrast mediums and in 4 % (n = 1) by antibiotics and insulin. 70 % of the cases involved the upper extremity, in 30 % the thoracic wall was affected. 38 % of the extravasations occurred over venous access ports. In mean 2 ±â€Š1.5 interventions were necessary for defect coverage. Two patients died as a direct result of the extravasations, one due to sepsis originating from an infected necrosis area and one due to right-heart failure with prior pulmonary damage. CONCLUSION: Most extravasations can be treated without surgery. In cases of toxic extravasations or pressure-caused ischaemia rapid surgical intervention is necessary to prevent the necrosis progressing to deeper tissue layers.

[Relapse of a parosteal osteochondromateous proliferation (Nora's lesion) of the distal thumb]. / Rezidiv einer bizarren paraossären osteochondromatösen Proliferation (Nora-Läsion) des Daumenendgliedes.

We report the case of a 29-year-old female patient with a relapse of a Nora lesion in an atypic location. The literature for this rare benign lesion is reviewed and etiology, diagnostics and therapy are discussed.