Primary orbital reconstruction with selective laser melted core patient-specific implants: overview of 100 patients.

Contemporary advances in technology have enabled the transfer of industrial laser melting technology to surgery, and its use can improve the accuracy of orbital restoration. The aim of this study therefore was to evaluate the accuracy of primary orbital reconstruction with the use of selective laser melted, patient-specific implants and navigation. A total of 100 patients with complex orbital fractures were included. Planned orbital volumes were compared with those achieved, and angles were compared with the unaffected side. Analysis included the overlay of postoperative on planned images (iPlan® 3.0.5, Brainlab). The mean (SD) orbital volume of the unaffected side was 27.2 (2.8)ml in men and 25.0 (2.6)ml in women. Fractures that involved the posterior third of the orbital floor and comminuted fractures showed significant orbital enlargement (p=0.026). The mean (SD) reconstructed orbital volume was 26.9 (2.7)ml in men and 24.26 (2.5)ml in women. Three-dimensional analysis of the colour mapping showed minor deviations when compared with the unaffected side. The results suggest that a high degree of accuracy can be routinely achieved in these complex cases.

[Reconstruction using the tensor fasciae latae muscle flap]. / Defektdeckung mit Musculus-tensor-fasciae-latae-Lappen.

OBJECTIVE: The tensor fasciae latae (TFL) muscle flap can be used for reconstruction of decubital ulcers in the trochanteric or ischial region. INDICATIONS: Deep decubital ulcers in the gluteal or ischial area after debridement and exhaustion of conservative measures. CONTRAINDICATIONS: Moribund or palliative patients who do not benefit from defect coverage and are likely to suffer a life-threatening complication. Noncompliant patients who cannot follow the postoperative recommendations or protocols in regard to positioning or recurrence prevention. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area can lead to flap necrosis. SURGICAL TECHNIQUE: The TFL flap is commonly used as a regional transposition flap. Rare cases of a free TFL flap have been described. POSTOPERATIVE MANAGEMENT: Following surgery the patient needs to be positioned on the side or prone to prevent recurrence. Drains should be left for 5-7 days. Antibiotics are only needed in the case of persistent florid infection. RESULTS: The TFL muscle flap is known to be a reliable flap for the coverage of ulcers in the ischial and trochanteric region following radical debridement. This flap can also be transferred with its sensitive nerve supply resulting in a reduced chance of a recurring ulcer.

[Flap coverage using the posterior gluteal thigh flap]. / Defektdeckung mit posteriorem Oberschenkellappen.

OBJECTIVE: Defect coverage of the sacral, trochanteric or ischial region with durable tissue (gluteal thigh flap). INDICATIONS: Decubital ulcers of the sacral, trochanteric or ischial region after exhaustion of conservative measures. CONTRAINDICATIONS: Moribund or palliative patients who do not benefit from defect coverage and are likely to suffer a life-threatening complication. Noncompliant patients, who cannot follow the postoperative recommendations or protocols in regard to positioning or recurrence prevention. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area can lead to flap necrosis. SURGICAL TECHNIQUE: The posterior gluteal thigh flap can either be used as a fasciocutaneous flap or in combination with the gluteus muscle as myofasciocutaneous flap. Further microsurgical transfers have been described. POSTOPERATIVE MANAGEMENT: Following surgery the patient needs to be positioned on the side or prone to prevent recurrence. Drains should be left for 5-7 days. Antibiotics are only needed in the case of persistent florid infection. RESULTS: The posterior gluteal thigh flap is a well-known, reliable and versatile option for coverage of decubital ulcers in the sacral and ischial region with low recurrence rates described in the literature.

[Defect coverage using gluteal flaps]. / Defektdeckung durch Gluteuslappen.

OBJECTIVE: Gluteal skin, fasciocutaneous and myocutaneous flaps can be used to cover decubitus ulcers in the sacral and ischiocrural area. INDICATIONS: Decubitus ulcers in the sacral or ischial area that do not heal after exhausted conservative therapy. CONTRAINDICATIONS: Moribund patients who are very likely to suffer a life-threatening complication. Non-cooperative patients who cannot follow the postoperative recommendations. The presence of extensive scars after previous operations in the donor area or irradiation of the donor area which may compromise the flap perfusion. SURGICAL TECHNIQUE: A distinction is made between local skin flaps, perforator-based fasciocutaneous flaps and the myocutaneous gluteus maximus flap. By partial or complete elevation of the gluteus maximus muscle based on the superior and inferior gluteal vessels, this flap is useful for larger and deep defects in the sacral and ischial region. For more superficial defects, fasciocutaneous perforator flaps might be used. Smaller ulcers can be treated with local skin flaps. The donor site should be closed primarily. POSTOPERATIVE MANAGEMENT: Consistent, postoperative relief by prone and lateral positioning of the patient, avoiding new decubitus ulcers. Drainage for at least 5-7 days. Antibiotic therapy is indicated only with appropriate detection of pathogens and in case of persistent infection. RESULTS: With distinct anatomical and improved technical knowledge, the use of fasciocutaneous and myocutaneous flaps in the gluteal region is now an established procedure and can be used for reliable coverage of sacral and ischiocrural decubitus ulcers.

A multimodal infection control concept in a burn intensive care unit - lessons learnt from a meticillin-resistant Staphylococcus aureus outbreak.

BACKGROUND: Meticillin-resistant Staphylococcus aureus (MRSA) is a frequently encountered pathogen in burn units. Burn patients are especially susceptible to MRSA acquisition and MRSA spread may cause outbreaks in burn units. AIM: To report the characteristics and successful control of an MRSA outbreak and to demonstrate a multimodal infection control concept. METHODS: In addition to a pre-existing infection control concept, several control measures were implemented including weekly prevalence screenings for MRSA, reinforcement of disinfection, restriction of admissions, and short-term unit closure. Epidemiologic investigation and environmental examinations were performed. The outbreak isolates were analysed by pulsed-field gel electrophoresis and spa-typing. A PubMed search was conducted, focusing on MRSA outbreaks in burn units. FINDINGS: This outbreak of hospital-acquired MRSA affected eight patients during a seven-month period, yielding an attack rate of 8%. Epidemiologic and environmental examinations suggested patient-to-patient transmission, which was confirmed by molecular analysis of bacterial isolates revealing a monoclonal pattern. In accordance with findings from other outbreaks in burn units, the implemented measures including patient screening and temporary unit closure resulted in successful control of the outbreak. CONCLUSION: A comprehensive concept is required to control the spread of all multidrug-resistant micro-organisms including MRSA on a burn unit. Where patients colonized or infected with MRSA appear to be the main reservoir, transfer of these patients to other units, or temporary closure of the unit, accompanied by intensive cleaning are very effective measures to stop transmission events.

Infection control in german-speaking burn centres: results of an online survey.

To systematically evaluate which infection control measures are in place in burn units, we conducted an online survey among 43 German-speaking burn units. The 29 units that responded and agreed to publication represented more than 125 patient beds. All units were located in advanced care hospitals. A total of 14 units provided single rooms only, and 22 units had a nurse-to-patient ratio of at least 1:2. Infection control practices included pre-emptive barrier precautions (29 units), the use of sterile filters for tap water supply (29 units), and an antibiotic stewardship program (24 units). Microbial screening of the patients on admission (23 units), regular prevalence screening (26 units) and surveillance of nosocomial infections (21 units) were also widely used. The high reply rate to the survey indicates the special relevance of infection control for burn units. Our survey shows that great efforts and several measures are being undertaken to address infection control challenges in burn patient care, but it also underlines the need for increased interdisciplinary infection control and antibiotic stewardship activities.

Afin d'évaluer les mesures préventives des infections déployées, nous avons réalisé une enquête en ligne auprès de 43 Centres de Traitement des Brûlés germanophones. Les 29 CTB ayant répondu (et accepté la publication) représentent 125 lits. Tous les CTB étaient situés dans des hôpitaux de référence. Quatorze CTB n'avaient que des chambres seules, 22 avaient un ratio infirmière/patient de1/2. Les mesures préventives comprenaient les précautions barrière (29), des filtres aux points d'eau (29), un programme d'évaluation de l'antibiothérapie (24). La cartographie bactérienne à l'entrée (23), la surveillance de la prévalence des infections (26) et des infections nosocomiales (21) étaient aussi régulièrement déployées. Le taux de réponse élevé pour ce type d'étude montre l'intérêt porté à la prévention des infections en CTB. Cette étude montre que les CTB portent une attention particulière à la prévention et à la surveillance des infections. Elle démontre aussi l'intérêt d'une approche multidisciplinaire et de la mise en place de programmes d'évaluation de l'antibiothérapie.

Interdisciplinary reconstruction of oncological resections at the skull base, scalp and facial region.

Extensive bone and soft tissue defects of the skull require unique plastic and reconstructive techniques to avoid and optimize aesthetic appearance following oncological resections. Procedures are ideally planned in an interdisciplinary board composed of neurosurgery, otorhinolaryngology, plastic and reconstructive surgery to facilitate reconstructive procedures of soft tissue and bone as early as possible in one approach. Large resections may require plastic surgery involvement from the beginning. Herein, we describe the function of a multidisciplinary approach to complex oncologic resections of the cranial base, scalp, and facial regions for neuro-oncologic patients.

[Plastic reconstruction of radiation injuries]. / Plastische Rekonstruktion von Strahlenfolgen.

In addition to surgical and drug therapy, radiotherapy (or radiation therapy) is one of the three mainstays of modern oncological therapy regimes. It uses ionizing radiation to control tumors by damaging the DNA of cancerous tissue leading to cellular death. Although advances have been made in recent years resulting in a reduced dosage to the surrounding tissues, radiation injuries and tissue-related side effects cannot be completely avoided. Knowledge of the pathophysiology, treatment modalities and interdisciplinary treatment approaches are essential for effective therapy whilst limiting side effects. Surgery within the irradiated area is technically demanding due to tissue alterations and unpredictable wound healing. The plastic reconstructive surgeon either faces the challenge of delayed wound healing following neoadjuvant radiation or chronic radiation-linked changes following previous radiotherapy, which can also occur after a latency period of many years. Reconstructive interventions can be essential to repair deficits of a functional and/or aesthetic nature in order to maintain a high quality of life for oncology patients. This can also be of benefit to patients in a palliative oncological setting to improve daily functions and quality of life.

[Analysis of Critically Perfused Tissues by Laser Speckle Contrast Analysis (LASCA) Perfusion Imaging]. / Quantitative Perfusionsanalyse durch Laser Speckle Contrast Analysis (LASCA) Perfusions-Imaging von kritisch perfundierten Geweben Quantitative Perfusion.

Background: The success of tissue transplantation and long-term tissue stability after wound healing depends on sufficient tissue perfusion. Laser Doppler-supported procedures allow for an objective measurement of relative tissue perfusion. The development of Speckle-based Laser Doppler imaging now enables a real-time representation of tissue perfusion. The perfusion of tissues relevant in plastic surgery such as scars, phalangeal replantations and burn wounds were systematically analysed by Laser Speckle Contrast Analysis (LASCA) imaging. Method: Perfusion of skin, scars, replanted fingers and different burn wound degrees (IIa, IIb and III) were systematically examined by LASCA imaging. Baseline perfusion of control tissue and perfusion values of compromised tissues were quantified and compared. Results: LASCA imaging shows significant differences in baseline perfusion of skin compared to atrophic scars, hypertrophic scars and keloids. Finger replantations with subsequent replantation failure show a characteristic and significant hypoperfusion in line with the expected clinical feature. A significant difference in tissue perfusion is seen in superficial (IIa) and superficial deep (IIb) burns, which are hard to distinguish on clinical examination. Deep burns (III) are characterised by hypoperfusion, which differs significantly from grade IIa and IIb burn wound perfusion, but not from baseline skin perfusion. Furthermore, the characteristic perfusion values of different burn degrees correspond to the varying treatment strategies. Conclusion: LASCA imaging is a robust method of perfusion imaging, which combines high resolution and speed. Hypoperfusion of tissues relevant to plastic surgery such as scars, phalangeal replantations and the different burn degrees (IIa, IIb and III) can be detected by LASCA imaging with high precision. Ease of use and immediate real-time imaging make LASCA imaging a reliable tool for the evaluation of tissue perfusion after plastic surgery procedures, which may influence further treatment decisions.

German, European or American burn guidelines - Is one superior to another?

Adequate medical care of severe burn injuries requires special organizational infrastructure and high educational standards, with an appropriate number of health care professionals. Guidelines were written by the German Society for Burn Treatment (DGV), the European Burns Association (EBA) and the American Burn Association (ABA) to assist with the delivery of such care. Current DGV (2010), EBA (2013) and ABA (2001/2006/2008) guidelines are compared, focusing on similarities, differences, conciseness and completeness. This publication presents advantages and disadvantages of each of them. DGV guidelines outline understandable treatment recommendations for first aid measures, clinical procedures and wound care. Extensive rehabilitation guidelines with clearly defined indications and precise infrastructure requirements for a Burn Centre are stated. Negative aspects are the presence of multiple documents containing redundant and confusing information. EBA guidelines offer the most comprehensive treatment recommendations with multidisciplinary approaches. Overall, infrastructural requirements are weighted much higher than staff qualification demands - in contrast to ABA guidelines. However, lack of conciseness and complicated criteria regarding transfer of patients to a Burn Center - including imprecise indications for rehabilitation treatment - have to be mentioned as disadvantages. ABA guidelines have a clear focus on staff qualifications and easy-to-understand transfer criteria. Another focus is on detailed clinical procedures. However, these guidelines lack burn definition and precise treatment recommendations for rehabilitation. The reviewed guidelines provide standardized treatment recommendations for burn patients. Despite their usefulness, they all have weaknesses and discrepancies. Findings should be used to improve each of them.

La prise en charge correcte des brûlés graves nécessite une organisation spécifique, une expertise adaptée et un nombre adéquat de personnels entraînés. Des recommandations spécifiques ont été édictées par la « German Society for Burn Treatment ¼ (DGV), l'European Burns Association (EBA) et l'American Burn Association (ABA) afin d'aider à cette prise en charge. Nous les avons comparées, en nous focalisant sur les similarités, les différences, la concision et l'exhaustivité, chacune d'entre eux ayant ses points positifs et négatifs, que nous présentons ici. Les recommandations allemandes insistent sur la prise en charge initiale et le traitement local. La rééducation et les infrastructures nécessaires sont explicitées. Les documents sont cependant multiples et fréquemment redondants, obérant leur facilité d'utilisation. Les recommandations européennes sont plus exhaustives et s'attachent à l'approche multidisciplinaire. Les obligations infrastructurelles y ont un poids supérieur à l'expertise soignante, ce qui diffère des recommandations américaines. Cependant, une concision argumentable et des critères d'hospitalisation en CTB compliqués (ainsi que des critères de rééducation spécialisée flous) doivent être marqués défavorablement. Les recommandations américaines ont l'avantage de la clarté en ce qui concerne le niveau d'expertise des intervenants, les critères d'hospitalisation en CTB et le détail de la prise en charge. Elles pêchent cependant par le flou concernant la définition d'une brûlure et l'absence de préconisation concernant la rééducation. Globalement, ces recommandations ne présentent que des approches incomplètes de la prise en charge des brûlés et devraient toutes être optimisées.

[Pest control in your garden - a case series of severe hand injuries caused by privately used explosives and shot traps]. / Schädlingsbekämpfung im eigenen Garten - Fallserie schwerer Handverletzungen durch Spreng- und Schussfallen in privatem Gebrauch.

Booby traps and gun-like devices for vole control can lead to complex trauma requiring emergency medical care. We present a case series of patients who suffered severe hand and facial trauma through detonation of booby traps and paraphernalia (n = 9, Ø 60 years of age). All patients were admitted to the emergency department of Hannover Medical School for primary care. Between 2011 and 2015 we treated six patients with hand trauma due to gun-like devices, two patients with hand trauma due to booby traps, and one patient with injury to the face including eyes due to a gas cartridge explosion. All hand trauma patients (n = 8) showed injuries of the soft tissue. Six of these patients also presented fractures or lesions of capsular or tendon structures. Therapies included debridement as well as skin grafts or flaps for tissue defect coverage. We informed the Department for Commercial Safety (Gewerbeaufsicht Hannover) in 2014 because we believe that these traps pose a serious safety hazard.

Assessing burn depth in tattooed burn lesions with LASCA Imaging.

Tattoos are on the rise, and so are patients with tattooed burn lesions. A proper assessment with regard to burn depth is often impeded by the tattoo dye. Laser speckle contrast analysis (LASCA) is a technique that evaluates burn lesions via relative perfusion analysis. We assessed the effect of tattoo skin pigmentation on LASCA perfusion imaging in a multicolour tattooed patient. Depth of burn lesions in multi-coloured tattooed and untattooed skin was assessed using LASCA. Relative perfusion was measured in perfusion units (PU) and compared to various pigment colours, then correlated with the clinical evaluation of the lesion. Superficial partial thickness burn (SPTB) lesions showed significantly elevated perfusion units (PU) compared to normal skin; deep partial thickness burns showed decreased PU levels. PU of various tattoo pigments to normal skin showed either significantly lower values (blue, red, pink) or significantly increased values (black) whereas orange and yellow pigment showed values comparable to normal skin. In SPTB, black and blue pigment showed reduced perfusion; yellow pigment was similar to normal SPTB burn. Deep partial thickness burn (DPTB) lesions in tattoos did not show significant differences to normal DPTB lesions for black, green and red. Tattoo pigments alter the results of perfusion patterns assessed with LASCA both in normal and burned skin. Yellow pigments do not seem to interfere with LASCA assessment. However proper determination of burn depth both in SPTB and DPTB by LASCA is limited by the heterogenic alterations of the various pigment colours.

Les tatouages sont de plus en plus fréquents, et donc l'incidence des brûlures sur peau tatouée augmente. L'évaluation clinique correcte de la profondeur de la brûlure se heurte à la pigmentation du tatouage. Nous avons utilisé dans ce but l'imagerie laser, chez un patient porteur d'un tatouage multicolore, dans des zones le portant et ne le portant pas. La perfusion relative était mesurée en Unités de Perfusion (UP), comparée à des pigments colorés connus, et à l'aspect clinique. Les brûlures superficielles étaient plus perfusées que la peau normale, quand les brûlures profondes l'étaient moins. Les pigments bleus, rouges et rose entraînent une diminution des UP de la peau saine, les noirs une augmentation, l'effet artéfactuel des oranges et des jaunes étant non significatif. En cas de brûlure superficielle, les zones bleues et noires ont une perfusion diminuée, alors que le jaune ne change pas le résultat comparativement à une telle brûlure en zone non tatouée. L'aspect laser des brûlures profondes sur des tatouages noirs, rouges ou verts est semblable à celui observé avec les mêmes brûlures sur peau non tatouée. Les tatouages changent les résultats de l'évaluation laser de la perfusion cutanée, que la peau soit normale ou brûlée, sauf avec les pigments jaunes. En cas de tatouage multicolore, l'évaluation de la profondeur d'une brûlure par laser est prise en défaut.

[Soft tissue plastic surgery for complications in the skull region]. / Weichteilplastische Maßnahmen bei Komplikationen im Schädelbereich.

Tumor resection and trauma may leave devastating defects in the head and neck area complicating and preventing patient rehabilitation; therefore, plastic surgery methods are required which are able to prevent further complications and provide efficient functional and aesthetic reconstruction. In this review article typical cases and the interdisciplinary management of plastic surgery are presented.

Percutaneous collagen induction-regeneration in place of cicatrisation?

BACKGROUND: Ablative procedures that are used for the improvement of a degenerative process that leads to a loss of skin elasticity and integrity, injure or destroy the epidermis and its basement membrane and lead to fibrosis of the papillary dermis. It was recently shown in clinical and laboratory trials that percutaneous collagen induction (PCI) by multiple needle application is a method for safely treating wrinkles and scars and smoothening the skin without the risk of dyspigmentation. In our study, we describe the effect of PCI on epidermal thickness and the induction of genes relevant for regenerative processes in the skin in a small animal model. METHODS: The purpose of this study in a rat model was to determine the effects of PCI on the skin both qualitatively and quantitatively. The epidermal and dermal changes were observed by histology and immunofluorescence. The changes in gene expression were measured by array analysis for cytokines, such as vascular endothelial growth factor (VEGF), fibroblast growth factor (FGF)-7, epidermal growth factor (EGF) and extracellular matrix molecules such as collagen type I and type III. RESULTS: The present study showed that PCI with topical vitamins resulted in a 140% increase in epidermal thickness; an increase in gene and protein expression of collagen I, glycosaminoglycans (GAGs) and growth factors such as VEGF, EGF and FGF7. The collagen fibre bundles were increased, thickened, and more loosely woven in both the papillary and reticular dermis. CONCLUSION: We were able to show that PCI modulates gene expression in skin of those genes that are relevant for extracellular matrix remodelling.

Laparoscopic ventral hernia repair is safe and cost effective.

BACKGROUND: Ventral hernia repair is increasingly performed by laparoscopic means since the introduction of dual-layer meshes. This study aimed to compare the early complications and cost effectiveness of open hernia repair with those associated with laparoscopic repair. METHODS: Open ventral hernia repair was performed for 92 consecutive patients using a Vypro mesh, followed by laparoscopic repair for 49 consecutive patients using a Parietene composite mesh. RESULTS: The rate of surgical-site infections was significantly higher with open ventral hernia repair (13 vs 1; p = 0.03). The median length of hospital stay was significantly shorter with laparoscopic surgery (7 vs 6 days; p = 0.02). For laparoscopic repair, the direct operative costs were higher (2,314 vs 2,853 euros; p = 0.03), and the overall hospital costs were lower (9,787 vs 7,654 euros; p = 0.02). CONCLUSIONS: Laparoscopic ventral hernia repair leads to fewer surgical-site infections and a shorter hospital stay than open repair. Despite increased operative costs, overall hospital costs are lowered by laparoscopic ventral hernia repair.