The impact of neoadjuvant systemic treatment on postoperative complications in breast cancer surgery.

PURPOSE: The aim of the study was to analyze the impact of neoadjuvant systemic treatment (NST) on postoperative complications and the beginning of adjuvant treatment. METHODS: This study includes data from a prospectively maintained database including patients with breast cancer (BC) stage I-IV with or without NST undergoing breast cancer surgery between January 2010 and September 2021. RESULTS: Out of 517 enrolled patients, 77 received NST, 440 had primary breast surgery. After NST patients underwent surgery after a meantime of 34 days (26.5-40 days). No statistical significance could be found comparing the complication grading according to the Clavien Dindo classification. The complications were most frequently rated as grade 3b. There were no complications with grade 4 or higher. When differentiating into short and long-term, the overall rate of short-term complications was 20.3% with no significant difference between the two groups (20.8% vs. 20.2%). Regarding long-term complications, there was more impairment of shoulder mobility (26.0% vs. 9.5%, p ≤ 0.001) and chronic pain (42.9% vs. 28.6%, p ≤ 0.016) for patients with NST. The beginning of the administration of the adjuvant treatment was comparable in both groups (46.3 days vs. 50.5 days). CONCLUSION: In our cohort, complications between both groups were comparable according to Clavien Dindo. This study shows that NST has no negative impact on postoperative short-term complications and most importantly did not lead to a delay of the beginning of adjuvant treatment. Therefore, NST can be safely admitted, even when followed by extensive breast reconstruction surgery.

The impact of age on patient-reported outcomes after oncoplastic versus conventional breast cancer surgery.

PURPOSE: Some studies have indicated age-specific differences in quality of life (QoL) among breast cancer (BC) patients. The aim of this study was to compare patient-reported outcomes after conventional and oncoplastic breast surgery in two distinct age groups. METHODS: Patients who underwent oncoplastic and conventional breast surgery for stage I-III BC, between 6/2011-3/2019, were identified from a prospectively maintained database. QoL was prospectively evaluated using the Breast-Q questionnaire. Comparisons were made between women < 60 and ≥ 60 years. RESULTS: One hundred thirty-three patients were included. Seventy-three of them were ≥ 60 years old. 15 (20.5%) of them received a round-block technique (RB) / oncoplastic breast-conserving surgeries (OBCS), 10 (13.7%) underwent nipple-sparing mastectomies (NSM) with deep inferior epigastric perforator flap (DIEP) reconstruction, 23 (31.5%) underwent conventional breast-conserving surgeries (CBCS), and 25 (34.2%) received total mastectomy (TM). Sixty patients were younger than 60 years, 15 (25%) thereof received RB/OBCS, 22 (36.7%) NSM/DIEP, 17 (28.3%) CBCS, and 6 (10%) TM. Physical well-being chest and psychosocial well-being scores were significantly higher in older women compared to younger patients (88.05 vs 75.10; p < 0.001 and 90.46 vs 80.71; p = 0.002, respectively). In multivariate linear regression, longer time intervals had a significantly positive effect on the scales Physical Well-being Chest (p = 0.014) and Satisfaction with Breasts (p = 0.004). No significant results were found concerning different types of surgery. CONCLUSION: Our findings indicate that age does have a relevant impact on postoperative QoL. Patient counseling should include age-related considerations, however, age itself cannot be regarded as a contraindication for oncoplastic surgery.

Color Doppler ultrasound and computed tomographic angiography for perforator mapping in DIEP flap breast reconstruction revisited: A cohort study.

INTRODUCTION: Preoperative imaging by Computed Tomographic Angiography (CTA) has been promoted a gold standard tool for perforator mapping in abdominally based microsurgical breast reconstruction, while Color Doppler Ultrasound (CDU) has lost its popularity. As the CTA X-ray exposure might have long-term consequences for patients, CDU has regained importance for preoperative workup in our center. Our aim was to revisit the role of CDU by comparing the reliability of CDU and CTA in predicting intraoperative perforator selection. MATERIALS AND METHODS: We performed a retrospective chart review study of patients who underwent microsurgical breast reconstructions with DIEP flaps at our institution. Both CTA and CDU were performed prior to the surgery, and both imaging entities were thoroughly examined by the surgical team. Perforator identification, number, size, and location were assessed and correlated with CTA and CDU data and with intraoperative findings. RESULTS: We identified 98 patients who received 125 DIEP flap surgeries. A significantly stronger correlation was found between CDU and intraoperative findings of perforator detection and size (p<0.0001) and selection (r = 0.9987, CI 0.9981-0.9991, p < 0.0001 and r = 0.01, CI -0.18-0.2, p = 0.91, respectively), when compared with CTA data. If none of the preoperative imaging studies matched intraoperative perforator selection, an association with a higher incidence of flap loss (Odds ratio 4.483, CI 0.5068-39.65, p = 0.2171) was found. CONCLUSIONS: Our data suggests that CDU might regain relevance as a safe and reliable preoperative imaging study, without the risk and potential consequences of X-ray exposure. Preoperative imaging tools like CDU and CTA should be considered part of the gold standard in abdominally based free flap breast reconstruction.

MyoRobot 2.0: An advanced biomechatronics platform for automated, environmentally controlled skeletal muscle single fiber biomechanics assessment employing inbuilt real-time optical imaging.

We present an enhanced version of our previously engineered MyoRobot system for reliable, versatile and automated investigations of skeletal muscle or linear polymer material (bio)mechanics. That previous version already replaced strenuous manual protocols to characterize muscle biomechanics properties and offered automated data analysis. Here, the system was further improved for precise control over experimental temperature and muscle single fiber sarcomere length. Moreover, it also now features the calculation of fiber cross-sectional area via on-the-fly optical diameter measurements using custom-engineered microscope optics. With this optical systems integration, the MyoRobot 2.0 allows to tailor a wealth of recordings for relevant physiological parameters to be sequentially executed in living single myofibers. Research questions include assessing temperature-dependent performance of active or passive biomechanics, or automated control over length-tension or length-velocity relations. The automatically obtained passive stress-strain relationships and elasticity modules are important parameters in (bio)material science. From the plethora of possible applications, we validated the improved MyoRobot 2.0 by assessing temperature-dependent myofibrillar Ca2+ sensitivity, passive axial compliance and Young's modulus. We report a Ca2+ desensitization and a narrowed dynamic range at higher temperatures in murine M. extensor digitorum longus single fibers. In addition, an increased axial mechanical compliance in single muscle fibers with Young's moduli between 40 - 60 kPa was found, compatible with reported physiological ranges. These applications demonstrate the robustness of our MyoRobot 2.0 for facilitated single muscle fiber biomechanics assessment.

Nose to back: compatibility of nasal chondrocytes with environmental conditions mimicking a degenerated intervertebral disc.

Nasal chondrocytes (NCs) have gained increased recognition for cartilage tissue regeneration. To assess NCs as a source for cell therapy treatment of intervertebral disc (IVD) degeneration, tissue-forming properties of NCs under physiological conditions mimicking the degenerated IVD were compared to those of mesenchymal stromal cells (MSCs) and articular chondrocytes (ACs), two cell sources presently used in clinical trials. Cells were cultured in a combination of low glucose, hypoxia, acidity and inflammation for 28 d. Depending on the conditions, cells were either cultured in the absence of instructive growth factors or underwent chondrogenic instructional priming by addition of transforming growth factor ß1 (TGFß1) for the first 7 d. Histology, immunohistochemistry, biochemistry, enzyme-linked immunosorbent assay (ELISA) and quantitative real-time reverse transcriptase-polymerase chain reaction (qRT-PCR) analyses demonstrated limited cell maintenance and accumulation of cartilaginous extracellular matrix for MSCs in IVD conditions. ACs maintained a steady accumulation of glycosaminoglycans (GAGs) throughout all non-acidic conditions, with and without priming, but could not synthesise type II collagen (Col2). NCs accumulated both GAGs and Col2 in all non-acidic conditions, independent of priming, whereas MSCs strongly diminished their GAG and Col2 accumulation in an inflamed environment. Supplementation with inflammatory cytokines or an acidic environment affected NCs to a lower extent than ACs or MSCs. The data, overall indicating that in an inflamed IVD environment NCs were superior to ACs and MSCs, encourage further assessment of NCs for treatment of degenerative disc disease.

Genetic Variation/Evolution and Differential Host Responses Resulting from In-Patient Adaptation of Mycobacterium avium.

Members of the Mycobacterium avium complex (MAC) are characterized as nontuberculosis mycobacteria and are pathogenic mainly in immunocompromised individuals. MAC strains show a wide genetic variability, and there is growing evidence suggesting that genetic differences may contribute to a varied immune response that may impact the infection outcome. The current study aimed to characterize the genomic changes within M.avium isolates collected from single patients over time and test the host immune responses to these clinical isolates. Pulsed-field gel electrophoresis and whole-genome sequencing were performed on 40 MAC isolates isolated from 15 patients at the Department of Medical Microbiology at St. Olavs Hospital in Trondheim, Norway. Isolates from patients (patients 4, 9, and 13) for whom more than two isolates were available were selected for further analysis. These isolates exhibited extensive sequence variation in the form of single-nucleotide polymorphisms (SNPs), suggesting that M. avium accumulates mutations at higher rates during persistent infections than other mycobacteria. Infection of murine macrophages and mice with sequential isolates from patients showed a tendency toward increased persistence and the downregulation of inflammatory cytokines by host-adapted M. avium strains. The study revealed the rapid genetic evolution of M. avium in chronically infected patients, accompanied by changes in the virulence properties of the sequential mycobacterial isolates.

The MyoRobot: A novel automated biomechatronics system to assess voltage/Ca2+ biosensors and active/passive biomechanics in muscle and biomaterials.

We engineered an automated biomechatronics system, MyoRobot, for robust objective and versatile assessment of muscle or polymer materials (bio-)mechanics. It covers multiple levels of muscle biosensor assessment, e.g. membrane voltage or contractile apparatus Ca2+ ion responses (force resolution 1µN, 0-10mN for the given sensor; [Ca2+] range ~ 100nM-25µM). It replaces previously tedious manual protocols to obtain exhaustive information on active/passive biomechanical properties across various morphological tissue levels. Deciphering mechanisms of muscle weakness requires sophisticated force protocols, dissecting contributions from altered Ca2+ homeostasis, electro-chemical, chemico-mechanical biosensors or visco-elastic components. From whole organ to single fibre levels, experimental demands and hardware requirements increase, limiting biomechanics research potential, as reflected by only few commercial biomechatronics systems that can address resolution, experimental versatility and mostly, automation of force recordings. Our MyoRobot combines optical force transducer technology with high precision 3D actuation (e.g. voice coil, 1µm encoder resolution; stepper motors, 4µm feed motion), and customized control software, enabling modular experimentation packages and automated data pre-analysis. In small bundles and single muscle fibres, we demonstrate automated recordings of (i) caffeine-induced-, (ii) electrical field stimulation (EFS)-induced force, (iii) pCa-force, (iv) slack-tests and (v) passive length-tension curves. The system easily reproduces results from manual systems (two times larger stiffness in slow over fast muscle) and provides novel insights into unloaded shortening velocities (declining with increasing slack lengths). The MyoRobot enables automated complex biomechanics assessment in muscle research. Applications also extend to material sciences, exemplarily shown here for spider silk and collagen biopolymers.

Studying the Dynamics of Relativistic Laser-Plasma Interaction on Thin Foils by Means of Fourier-Transform Spectral Interferometry.

We apply Fourier-transform spectral interferometry (FTSI) to study the interaction of intense laser pulses with ultrathin targets. Ultrathin submicrometer-thick solid CH targets were shot at the PHELIX laser facility with an intensity in the mid to upper 10^{19} W/cm^{2} range using an innovative double-pulse structure. The transmitted pulse structure was analyzed by FTSI and shows a transition from a relativistic transparency-dominated regime for targets thinner than 500 nm to a hole-boring-dominated laser-plasma interaction for thicker targets. The results also confirm that the inevitable preplasma expansion happening during the rising slope of the pulse, a few picoseconds before the maximum of the pulse is reached, cannot be neglected and plays a dominant role in laser-plasma interaction with ultrathin solid targets.

Low osmolality and shear stress during liposuction impair cell viability in autologous fat grafting.

BACKGROUND: Liposuction and subsequent autologous fat grafting have become essential techniques for fat augmentation in plastic surgery. However, standard harvesting techniques that ensure the survival of adipocytes and stromal vascular fraction (SVF) cells and thus preserve the transplanted fat volume are lacking. In particular, the effect of different parameters of the tumescent solution has not been studied in this context. We hypothesized that the osmolality of the tumescent solution could have a significant effect on the survival of adipocytes and SVF cells. METHODS: We developed two distinct in vitro models based on freshly harvested excision fat from patients undergoing surgical treatment. First, we investigated the effect of osmolality by incubating excision fat in different tumescent solutions and analyzed the total cell survival and the differentiation potential of SVF cells. Vital whole-mount staining, isolation yield of SVF cells, clonogenicity, and osteogenic and adipogenic differentiation capacities were analyzed. Second, we addressed the additional effect of mechanical stress by simulating a liposuction on pieces of excision fat after incubation with the tumescent solutions. RESULTS: Osmolality of the tumescent solution by itself did not have a significant effect on adipocyte and SVF viability or SVF differentiation. However, when osmolality was combined with liposuction, a significant trend toward lower viability and more lipid droplets with lower osmolality was observed. Especially, SVF viability was significantly lower after liposuction with a hypotonic (150 mOsm/kg) solution. CONCLUSION: This study demonstrates the considerable effect of osmolality during liposuction and may lead to the development of "cell-protective" tumescent solutions.

Standardization of oncoplastic breast conserving surgery.

The emphasis on esthetic outcomes and quality of life after breast cancer surgery has motivated surgeons to develop oncoplastic breast conserving surgery (OPS). Training programs are still rare in most countries, and there is little standardization, which challenges the scientific evaluation of the techniques. The present article attempts to standardize OPS nomenclature, indications, and reconstruction choice selection embedded in a thorough review of the literature. We propose four breast conserving surgery (BCS) categories: Conventional tumorectomy, oncoplastic mastopexy, oncoplastic tumorectomy and oncoplastic reduction mammoplasty. The main volume displacement techniques are glandular re-approximation, use of tailored glandular or dermoglandular flaps and nipple-areola complex pedicles. We developed an indication algorithm based on the size and shape of the breast as well as the size and location of the tumor. A reconstruction algorithm suggests a selection of suitable tailored flaps and pedicles based on tumor location and vascular supply of the breast. The application of these algorithms results in known and novel OPS techniques, which are presented here with long-term results. We designed the algorithms to help tailor every operation to the individual patient in a standardized manner, since OPS is now on the rise, more than two decades after the publication of the first techniques. A rapidly increasing body of observational evidence suggests comparable rates of local recurrence between OPS and conventional BCS. Importantly, the rates of clear resection margins are in favor of OPS despite extended indications to larger tumors. Finally, OPS optimizes patient satisfaction by improving esthetic outcomes after BCS.

CXCR1 Regulates Pulmonary Anti-Pseudomonas Host Defense.

Pseudomonas aeruginosa is a key opportunistic pathogen causing disease in cystic fibrosis (CF) and other lung diseases such as chronic obstructive pulmonary disease (COPD). However, the pulmonary host defense mechanisms regulating anti-P. aeruginosa immunity remain incompletely understood. Here we demonstrate, by studying an airway P. aeruginosa infection model, in vivo bioluminescence imaging, neutrophil effector responses and human airway samples, that the chemokine receptor CXCR1 regulates pulmonary host defense against P. aeruginosa. Mechanistically, CXCR1 regulates anti-Pseudomonas neutrophil responses through modulation of reactive oxygen species and interference with Toll-like receptor 5 expression. These studies define CXCR1 as a novel, noncanonical chemokine receptor that regulates pulmonary anti-Pseudomonas host defense with broad implications for CF, COPD and other infectious lung diseases.

Infection and immunity on a chip: a compartmentalised microfluidic platform to monitor immune cell behaviour in real time.

Cells respond to their environments and self-organise into multicellular assemblies with dedicated functions. The migratory and homing response of cells to soluble ligands can be studied by using different techniques, but for real time studies of complex multicellular self-organisation, novel and simpler systems are required. We fabricated a flexible open access microsystem and tested the design by studying cell recruitment from an immune cell reservoir towards an infectious compartment. The two compartments were connected by a network of bifurcated microchannels allowing diffusion of signalling molecules and migration of cells. Bacterial filters were incorporated in the design to prevent bacteria and activated cells from entering the network, permitting migration only from the recruitment reservoir. The fabricated microsystem allows real-time continuous monitoring of cellular decision-making based on biologically produced gradients of cytokines and chemokines. It is a valuable tool for studying cellular migration and self-organisation in relation to infections, autoimmunity, cancer, stem cell homing, and tissue and wound repair.

[Long-term outcome after surgical treatment of breast asymmetry: analysis of the patient's perspective in 51 cases]. / Langzeitresultate nach chirurgischer Behandlung von Brustasymmetrien aus Sicht der Patientinnen: Eine Analyse von 51 Fällen.

INTRODUCTION: Literature provides 3 studies only investigating the long-term outcome after surgical correction of breast asymmetry. The goal of this study was to analyse from a patient's perspective, which factors influence postoperative satisfaction most. PATIENTS AND METHODS: All patients undergoing surgical treatment for breast asymmetry between 2000 and 2009 were included. With help of the visual analogue scale the patients conducted a subjective assessment of their own long-term result using the following parameters: overall satisfaction, symmetry, size, shape, scarring and sensitivity. Anthropometric measurements of the breasts followed. RESULTS: 51 patients (80% follow-up) were seen 2-11 (mean 5±2.5) years postoperatively. The following mean values were recorded for overall satisfaction 8.31 (±1.91), symmetry 7.86 (±2.25), size 8.42 (±1.93), shape 8.12 (±2.03), scarring 7.82 (±1.94) and sensitivity 7.92 (±2.19). Overall satisfaction increased significantly with good scores for the parameters symmetry [p=0.01] and shape [p=0.048]. Neither size [p=0.46] nor scarring [p=0.69] nor sensitivity [p=0.34] had a statistically significant influence on overall satisfaction. Furthermore, overall satisfaction did not depend on the surgical technique, preoperative size, preoperative asymmetry, age of the patient at time of surgery, period of time between the operation and the assessment, resected weight (absolute and difference between left and right) or on postoperative symmetry of the nipple areola complex. CONCLUSION: In our patients, long-term overall satisfaction after surgical correction of breast asymmetry was primarily dependent on symmetry and shape. Size, scarring and sensitivity did not have a statistically significant influence on postoperative overall satisfaction. This also applied to preoperative size, preoperative extent of asymmetry, age of the patient at time of surgery, surgical technique and the time span between the operation and the assessment.

Postsurgical screening for psychosocial disorders in neurooncological patients.

BACKGROUND: The diagnosis of a brain tumor can cause severe psychosocial distress, which can have a variety of negative consequences on patients' physical and mental well-being. The detection of psychosocial distress in daily clinical routine is difficult and subsequent referral to mental health professionals is rare. The aim of this study was to determine the incidence of psychological disorders of patients early postoperatively and to investigate both the Hornheide Screening Instrument (HSI) and Distress Thermometer (DT) as screening tools in neurooncological practice. METHODS: One hundred and thirty-four patients with brain tumors of different histology were postoperatively evaluated by the Distress Thermometer and Hornheide Screening Instrument. Additionally, correlation to gender, age, localization of the tumor, Karnofsky performance score and tumor entity were analyzed. RESULTS: After initial surgery 36 patients (26.9 %) showed pathologic results in the HSI and 50 patients (36.7 %) were severely distressed (DT Score≥6). Women had the highest rate of psychological disorders, followed by patients suffering from gliomas and meningiomas. Further highlighting the results of both tests, over 80 % of those patients who scored pathologically in both tests were in need of professional psychiatric help due to depression. CONCLUSION: Both the DT and HSI are suitable instruments for identifying patients in psychological distress after brain tumor surgery in neurooncological routine. Our results confirm that nearly one third of patients are unable to overcome the difficulties facing the diagnosis of a brain tumor in this early situation and should be supported by mental health professionals.

Bacterial biofilms and capsular contracture in patients with breast implants.

BACKGROUND: It has been hypothesized that bacterial biofilms on breast implants may cause chronic inflammation leading to capsular contracture. The association between bacterial biofilms of removed implants and capsular contracture was investigated. METHODS: Breast implants explanted between 2006 and 2010 at five participating centres for plastic and reconstructive surgery were investigated by sonication. Bacterial cultures derived from sonication were correlated with patient, surgical and implant characteristics, and the degree of capsular contracture. RESULTS: The study included 121 breast implants from 84 patients, of which 119 originated from women and two from men undergoing gender reassignment. Some 50 breast prostheses were implanted for reconstruction, 48 for aesthetic reasons and 23 implants were used as temporary expander devices. The median indwelling time was 4·0 (range 0·1-32) years for permanent implants and 3 (range 1-6) months for temporary devices. Excluding nine implants with clinical signs of infection, sonication cultures were positive in 40 (45 per cent) of 89 permanent implants and in 12 (52 per cent) of 23 temporary devices. Analysis of permanent implants showed that a positive bacterial culture after sonication correlated with the degree of capsular contracture: Baker I, two of 11 implants; Baker II, two of ten; Baker III, nine of 23; and Baker IV, 27 of 45 (P < 0·001). The most frequent organisms were Propionibacterium acnes (25 implants) and coagulase-negative staphylococci (21). CONCLUSION: Sonication cultures correlated with the degree of capsular contracture, indicating the potential causative role of bacterial biofilms in the pathogenesis of capsular contracture. REGISTRATION NUMBER: NCT01138891 (http://www.clinicaltrials.gov).

The option of delayed reconstructive surgery following mastectomy for invasive breast cancer: why do so few patients embrace this offer?

BACKGROUND: Only a minority of patients who had undergone mastectomy for invasive breast cancer (BC) chose the option for delayed breast reconstruction (BR). We hypothesized that this might partly be (a) due to a lack of information, or (b) because many women cope well with their altered body. METHODS: A cross-sectional survey was completed by 101 early-stage BC survivors who had primary mastectomy. Twenty-six patients had delayed BR. The survey included measures to attitudes to BR and experiences/expectations about information related to BR. RESULTS: The percentage of patients who was informed regarding BR was high (97%). For 39.5% such information was not considered important, neither before mastectomy, nor during follow-up; advanced age was an important factor for the disinterest in information (odds ratio 1.81; 95% CI: 1.04-3.16; p = 0.033). For women without BR, the perception that mastectomy caused a serious damage to their body image changed over time to perceiving the operation as an acceptable alteration of the body (-1.10; 95% CI, -1.52, -0.64; p < 0.001); this process was similar to that in patients who had BR (paired t-test: -2.12; 95% CI, -2.82, -1.41; p > 0.001). From 63 patients who reported no intention to have a BR in the future, 28 (44.4%) responded with answers that showed a high satisfaction with their mastectomies without BR; 30 patients (47.6%) reported reasons, which might potentially be dispelled by information by an experienced reconstructive surgeon. CONCLUSIONS: We did not find any evidence that the low number of patients who chose delayed BR results from a lack of information regarding this procedure. The majority of patients overcome negative attitudes towards their mastectomy quickly and are uninterested in BR. Patients who are ambivalent must be identified; these women require particular attention and should receive intensive counseling.

Intracranial application of free fasciocutaneous flaps in a novel sandwich technique for skull base reconstruction.

Free tissue transfer has been the gold standard of extensive skull base reconstruction, but the onlay of free flaps onto skull base defects carries the risk of cerebrospinal fluid (CSF) leakage. The purpose of this study was the evaluation of a novel technique of a combined sub- and onlay concept with a partially intracranially positioned folded free fasciocutaneous flap in terms of flap applicability, versatility and complication rate. Within 5 years, 7 patients with anterior (n=4), middle (n=2) or posterior (n=1) skull base defects were reconstructed with free extended lateral arm (n=3) or anterolateral thigh (n=4) flaps. The flaps were partially intracranially positioned and fixed with osteo-dermal sutures. Both flaps proved to be applicable in terms of sealing efficiency, minimizing intracranial flap volume and folding. No flap loss was observed. Specific complications consisted of one pneumocranium via an accessory frontal sinus and one cerebellar herniation due to lumbar CSF loss. No flap failure or haematoma of the intracranial flap part occurred. This new concept of intracranial positioning of fasciocutaneous flaps in a sandwich technique using osteo-dermal sutures should be considered as a primary treatment for skull base reconstruction rather than merely as a salvage manoeuvre.

Severe respiratory dysfunction in a patient with relapsing polychondritis: should we treat the saddle nose deformity?

SUMMARY: We report a case of surgical correction of a saddle nose deformity, causing severe ventilation restrictions in a 42-year-old man diagnosed with relapsing polychondritis. Relapsing polychondritis is an autoimmune disorder, in which antibodies to type II collagen cause an inflammatory destruction of cartilage. If septal cartilage of the nose is involved, destruction leads to collapse of the dorsum of the nose, causing a saddle nose deformity. Patients suffer from a ventilation disorder of varying degree depending on the response to or onset of immunosuppressive therapy. In the described patient, the destruction of the nasal septum, in addition to unstable tracheal cartilage, caused a severe restriction in ventilation, with total collapse of the internal nasal valves during forced inspiration. To improve the function of the external airways the patient underwent surgery to reconstruct the nasal septum. Although cartilage grafts are the state of the art to reconstruct the nasal septum, we used a bone graft from the iliac crest, because the autoimmune polychondritis precludes cartilage grafting due to expected cartilage destruction. At follow up 2 years postoperatively no signs of bone resorption or deterioration of the improved airway were observed. We conclude that the use of bone grafts is a promising method to restore and improve ventilation disorders caused by a saddle nose deformity in relapsing polychondritis.

[Anatomically and biomechanically based treatment algorithm for foot and ankle soft tissue reconstruction]. / Ein Behandlungsalgorithmus zur Weichteilrekonstruktion am Fuss und Sprunggelenk unter Berücksichtigung anatomischer und biomechanischer Gesichtspunkte.

INTRODUCTION: Successful soft tissue foot and ankle reconstruction is still challenging and needs subdivision into different, interdependent zones due to the limited amount of surrounding skin and soft tissue and the specific functional and anatomic requirements. Interdisciplinary support is often needed if composite defects (skin, soft tissue, bone) are present. However, there is still no coherent concept for treatment in cases of severe skin and soft tissue damage at the foot that meets the aforementioned requirements. METHOD: Using common data of pedobarographic gait analysis for assessment of plantar pressure distribution, we ascertained zones of different load profiles. Based on these data we propose a functional and anatomic subdivision of the foot and ankle region with regard to pressure distribution, soft tissue quality, shear zones between thick and thin skin regions and underlying vital structures. Because of these zones of different anatomic and functional needs, we developed a treatment algorithm that includes the common and well established local, regional and microsurgical reconstructive options. RESULTS: We demonstrate the need for subdividing anatomically and functionally based areas at the foot and ankle region and the practicability of the proposed treatment algorithm. Two clinical cases are discussed with an update on the present literature. CONCLUSION: Skin and soft tissue reconstruction of the foot and ankle should incorporate the specific functional and anatomic needs of the regions and should be accurately timed. The aim of plastic surgeons is the restoration of sensibility, motor function and aesthetic aspects. The proposed treatment algorithm can help by using the most effective operative technique for reconstruction of defects of varying size and localisation.