A New Standardized Clinical Model for Evaluation of Nerve Guides: A Single-Blinded Randomized Controlled Prospective Study.

BACKGROUND: Autologous nerve transplantation is the accepted clinical standard for reconstruction of peripheral nerve defects. Bioengineered nerve guides as an alternative to autologous nerve transplantation have been described in previous studies and several different types are commercially available. Examination of the implementation of these devices in the clinical setting is an important step in determining their applicability in reconstructive nerve surgery. METHODS: In a single-blinded randomized controlled prospective study, the authors examined 34 patients undergoing diagnostic nerve biopsy (2 cm). The biopsy-induced nerve gap was interposed using a segment of the lesser saphenous vein in 16 patients. Eighteen patients had no nerve reconstruction and served as a control group. A further 10 participants were included as a healthy cohort. Nerve regeneration was assessed using von Frey filaments preoperatively and 1 day and 3, 6, 9, and 12 months postoperatively. RESULTS: Patients who received defect bridging of the sural nerve with a venous graft showed better regeneration of lateral foot sensitivity than patients without venous graft. CONCLUSIONS: The distal sural nerve biopsy can be used as a baseline model to evaluate peripheral nerve regeneration. Newly developed nerve guides could be tested in other unpredictable and challenging clinical peripheral nerve lesions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Treatment of hand infections using WALANT -when the anesthesiologist is not available: A retrospective cohort study.

BACKROUND: The aim of this study was to determine, if Wide Awake Local Anesthesia No Tourniquet (WALANT) can be used as an alternative method of providing anesthesia in management of deep infections of the hand. Since the advent of WALANT in 2003, infections of the hand have been regarded as a contraindication to its use. Occasional shortage of anesthesiologic manpower, especially during busy call hours and the current COVID-19 pandemic can lead to delay of treatment where urgent surgery is needed, to prevent progress of an infection, that can result in severe morbidity. METHODS: In the period from 2015 to 2020, 16 patients with various infections of the hand underwent 17 operations using WALANT in a Hand Trauma and Replantation Center (HTRC) in Germany. Retrospective cohort analysis of their operation reports, with emphasis on location of infection, time and duration of the operation, intraoperative incidents and complications were carried out. We also evaluated the need for revision surgery or necessity to convert to general anesthesia and factors causing delay till the time of surgery. RESULTS: No case of inadequate analgesia, the need to convert to general anesthesia, ischemic events or cardiovascular complications with the use of the WALANT solution containing adrenaline and lidocaine in the treatment of deep tissue infections.The highest priority of limb preservation was ensured as no patient progressed to amputation of a digit or the hand. There was a statistically significant difference (p ≤ 0.01) in delay from the time of admission until surgery of up to 9h24 m (SD±3h34 m) during the week and 4h10 m (SD±2h28 m) during the weekend. CONCLUSION: The status of infection as an absolute contraindication to the use of WALANT should be revised. Especially when human resources are limited, WALANT is an adequate technique to enable quick anesthesia for urgent treatment to prevent progression of hand infections.

[Reconstruction in polytraumatized burn patients]. / Rekonstruktion beim polytraumatisierten Brandverletzten.

BACKGROUND: Polytraumatized burn patients represent a rare patient collective and necessitate an individualized treatment concept due to the particular combination of injuries. OBJECTIVE: Against the background of this special injury pattern, especially with deep burns overlying the fracture zone, the question of a specific and interdisciplinary treatment algorithm arises. MATERIAL AND METHODS: This article is based on a PubMed database search and experiences of a trauma center for severely injured burn patients at a university hospital, with presentation of the special therapeutic requirements and goals exemplified by a case report. RESULTS: The evaluation of the literature search and own treatment results comes to the conclusion that the rate and extent of amputations and infections can be reduced by an early and interdisciplinary involvement of the plastic surgeon by early combined fracture stabilization, excision of necrotic tissue and immediate skin grafting. Furthermore, plastic reconstructive procedures enable a functional and esthetic reconstruction with optimized prosthesis fitting. CONCLUSION: Polytraumatized severely burned patients necessitate an interdisciplinary treatment approach, whereby preservation of length, functionality and esthetic appearance of the affected extremities and concurrent avoidance of bone and soft tissue infections have utmost priority.

Trigger finger in children with hurler syndrome - distribution pattern and treatment options.

Introduction: Mucopolysaccharidosis is a rare and congenital autosomal recessive lysosomal storage disorder of glycosaminoglycans. An enzyme defect leads to cell, tissue and organ dysfunction. Carpal tunnel syndrome and trigger finger are the results of mucopolysaccharid deposition. Material and methods: We are treating 6 patients with mucopolysaccharide associated trigger fingers in an interdisciplinary setting with the department of pediatric hematology and oncology at Hannover Medical School, where each patient is examined inter alia for symptoms of trigger finger annually. Besides an interview of the parents about abnormalities with regard to hand function, pain and/or neurologic symptoms the children are examined by palpation and by assessment of the active and passive range of finger motion. In the case of finger locking due to an impaired excursion of the flexor tendons in the A2 and A3 pulley region, we performed a trap-door incision technique for A2 pulley widening and a simple release of the A3 pulley. Results: In 6 patients 43 fingers were affected. The average age was 10 years. Pulley thickening was palpated in 19 fingers of to the left hand and 24 fingers of the right hand. In 7 fingers the A1 pulley was affected, in 28 fingers the A2 pulley and in 25 fingers the A3 pulley. The A4 and A5 pulley were not affected in any case. Trigger symptoms were seen in 13 fingers. Five of the 6 children were given an operation indication. In these cases we performed carpal tunnel release, release of Loge de Guyon, and trigger finger release, either in combination or alone. In all cases the procedure led to pain relief and functional improvement. Conclusion: The treatment of trigger fingers in children with mucopolysaccharidosis as a rare disease is challenging with regard to diagnostics and indication. The main treatment goal is pain relief and improvement of hand function.

The surgical approach to Pyoderma gangrenosum: A retrospective monocenter study.

Pyoderma gangrenosum is a diagnosis of exclusion. It occurs rarely and is frequently misdiagnosed. It can result in severe tissue loss, particularly in surgical units with little experience. Nevertheless, surgical treatment might be necessary for reconstruction, once the progression of these wounds is controlled. We aimed to characterize medical findings in Pyoderma patients with extensive defects to assess the surgical procedures and their outcome. A retrospective study was conducted at our centre over an 18-year period. Inclusion criteria were the diagnosis of Pyoderma gangrenosum and at least one surgical intervention. Descriptive statistics were used to analyse the data. Sixteen patients were included. The mean size of the lesions was noted with 12 × 8 cm. Surgical procedures comprised debridements/necrectomies, allograft conditioning, negative pressure wound therapy, skin grafts, and microvascular free flaps. Seven patients were discharged with healed wounds, six with minor wound healing disturbances. Three patients succumbed to their underlying diseases. Drug-based therapy can stop the progress of Pyoderma, but severe tissue loss can be a persistent problem. According to our data, reconstructive-surgical treatments (debridement, autologous and allogenous skin transplantation and microvascular free flaps) act as an integral component of the therapy and can be safe options for selected patients. Furthermore, we provide an algorithm that we follow at our department in severe cases.

Application of Critical Care Scores in Severely Burned Patients.

Early detection of sepsis is of crucial importance in patients with severe burn injuries. However, according to the S1-guideline, based on systemic inflammatory response syndrome (SIRS) criteria, the early diagnosis of sepsis in severely burned patients is difficult. The value of the new definition of sepsis based on sequential organ failure assessment (SOFA) according to S3-guidelines for patients with severe burn injuries is not described in detail in the literature. We analyzed retrospectively all data during the period 2014 to 2018 from the electronic patient information system. Using the receiver operating characteristic curve, the area under the curve was calculated for the diagnostic value of procalcitonin, SIRS, and SOFA score according to the burned total body surface area. Six hundred fifty-one patients with burn injuries were admitted to our burn unit, 315 of them had burn injuries affecting more than 10% body surface area with partial- to full-thickness burns (grade 2-4). In this group, 59 patients showed one or more septic events in the course of the intensive care treatment, defined by positive bloodstream infection. Both S1- and S3-guidelines were inappropriate to diagnose sepsis in patients with severe burn injuries. Due to pathophysiological changes of the body function in severely burned patients, which show features of both SIRS and pathological SOFA scores (>2 points) at the outset of burn injury, the diagnosis of sepsis associated with burns is intricate in this patient group. Assessing data for potential hallmarks of sepsis in burn patients we found procalcitonin to show a significant correlation with sepsis.

Hot Bathtub, Cold Consequences-Misleading Wounds After Scald Injuries: A Retrospective Analysis.

Scalds in the elderly are frequently associated with the use of a bathtub and a disturbed consciousness. Therefore, the total burn surface area is often high. The initial clinical presentation displays a stark erythema of the skin, which frequently does not represent the true depth. The aim of this study was to characterize and assess medical features and outcome of scalds sustained in the bathtub. We conducted a retrospective study at a burn intensive care unit (BICU) between 2011 and 2018. Medical features as well as the treatment in these patients were statistically analyzed. We identified 16 patients and divided them into two groups regarding survival and lethality. The mean total burn surface area was 37.50 ± 19.47%. In 81.25% of the patients, we found a previous history of neurological or psychiatric disorders. Dementia and alcohol abuse were the most common triggers for the trauma. The statistical analysis showed a significant difference for the ABSI-score and the presence of multi organ failure (P-value .0462, respectively, .0004). Erythematous skin areas tended to progress into full thickness burns. We, therefore, coined the term "lobster redness" for these regions. Scalds sustained in the bathtub are devastating injuries. Initial assessment can be misleading and might delay early necrectomy. The wounds request even more attention, if the injuries occurred due to unconsciousness because of the longer exposure to heat. Early necrectomy should be considered. A biopsy with histological workup can be useful. Furthermore, we recommend special safety precautions for neurologically and psychiatrically affected patients.

Reconstruction of Basic Hand Function by a Free Osteocutaneous Spare-Part Flap From the Lower Leg After Septicemia: A Case Report.

Background: Spare-part surgery is widely accepted and offers an option in extremely traumatized patients for reconstructive maneuvers. Standardized techniques are lacking, and the therapy needs to fit the patient's clinic. Materials and Methods: In a woman with necrosis of almost all extremities due to septic infection, we used the lower leg as a free osteocutaneous flap to reconstruct a basic hand function after amputation. The fibula segment was buried alongside the remaining first metacarpal bone. On the hand stump, 2 short metacarpals were lengthened using the remaining 2 metacarpals as osteovascular on-top plasties. The flap was microsurgically anastomosed end-to-side to the ulnar artery. After 3 months, the buried fibula was trimmed to the necessary thumb length and fixed to the local metacarpal I stump. Secondary procedures were performed to deepen the first web space. Results: The patient is now able to manage her daily life. Also, she is able to put on her prosthesis on both legs and walk without aids. Conclusions: To our knowledge, this is the first description of successful microvascular transfer of an osteocutaneous free flap from an amputated lower leg of this size and could present a valuable technique for other cases.

Spread of Hand Infection According to the Site of Entry and Its Impact on Treatment Decisions.

Background: Hand infections can spread quickly and destroy functional structures. Early diagnosis and adequate therapy can prevent severe morbidities. The aim of this study was to evaluate systematically the spread of hand infections according to injury mechanism, pathogens, and entry site. Methods: The data and medical records of 425 patients were collected and analyzed retrospectively. Results: The entry site had a significant influence on the severity of hand infections. Especially finger lesions led to severe infections. Furthermore, a high C-reactive protein (CRP) concentration correlated with more involved compartments of the hand. Bacterial counts also correlated with the number of compartments involved. Conclusions: Compared with known factors for the severity of hand infections finger lesions lead to especially severe infections and should not be underestimated. If there is a higher CRP concentration or more than one bacterial species isolated, compartments adjacent to the site of injury should be checked intra-operatively.

How to become a medical professor - a comparative analysis of academic requirements in Germany and the United States.

BACKGROUND: The acquisition of a medical professorship represents a significant step in a physician's academic career. The responsibility as well as the honor and the associated obligations are significant; however, the requirements to become a medical professor vary in Germany. OBJECTIVE: We analyzed the variable requirements for prospective medical professors in Germany, with special focus on the tenure track concept and the U.S. system. METHODS: Based on an online research, we queried German medical faculty regulations to obtain a medical professorship within Germany. RESULTS: We analyzed 35 German universities. On average, 11 publications are required after "venia legendi" to meet professorship (apl) prerequisites (median x̅ = 10, max = 24, min = 6, n = 16), whereas 6 publications with first or last authorship are required on average (x̅ = 6, max = 16, min = 4, n = 26). In most German universities, it takes an average of 4 years after gaining habilitation to apply for a professorship (x̅ = 5 years, max = 6 years, min = 2 years). Candidates for university chair positions, however, can shorten this period by an average of 38%. DISCUSSION: In the German academic system, the prerequisites to gain a professorship differ among universities. Due to different scientific cooperation and exchange programs, research and academic activities have reached an intense international exchange level. Yet there is no international or even national standardization, quality assurance, and comparability to gain a medical professorship.

[Emergencies in Plastic Surgery: Analysis of Emergency Presentation within a University Department for Plastic and Hand Surgery]. / Notfallaufkommen in der Plastischen Chirurgie - Auswertung der Notfallvorstellungen einer Universitätsklinik für Plastische Chirurgie und Handchirurgie.

BACKGROUND: Interdisciplinary emergency departments in Germany are seeing an increasing inflow of patients for several reasons. Since the number of patients in the emergency room cannot be planned, there may be a lack of capacity with prolonged waiting periods and delays. In particular, a significant amount of capacities is consumed by hand injuries. Also it is suspected for the discipline of plastic surgery that the majority of emergency presentations are unjustified. We provide a collection of data followed by an analysis of emergencies to better understand the increased number of patients with the aim of identifying possible solutions for the relief of emergency care. METHODS: We performed a retrospective analysis of documented patient cases seen in the interdisciplinary emergency room of the Department of Plastic, Aesthetic, Hand and Reconstructive Surgery of a university hospital. Over the span of one year, we evaluated the diagnosis, waiting time and distribution of patients over 24 hours at 7 weekdays. Furthermore, we evaluated the justification of emergency presentation and the necessity of inpatient admission. RESULTS: We assessed a total of 2768 patients with an average age of 40 years (median = 37 years, male 59 %/ female 41 %) within one year (2016-2017). Of 2450 patients, 69 % were legitimate emergencies, defined by severity of trauma or disease. Proportionally, the most common cause of presentation for 2768 cases was upper extremity injury with cut and saw injuries amounting to 25 % (n = 697), followed by lacerations/bite injuries with 22 % (n = 611) and burns with 17 % (n = 477). Most services were performed between 09:00 a.m. and 01:00 p.m. There were no significant differences regarding the distribution over different weekdays. In 24 % (n = 583) of these cases, the patient was hospitalised for inpatient treatment. In 45 % of cases, there was no indication for hospitalisation after treatment. The waiting time for 2450 patients averaged 2:23 h (median = 01:43 h) until treatment. DISCUSSION: In face of these results it may be argued, that a majority of emergency cases could be selected through filter structures to be distributed to suitable facilities. This could cover a large proportion of the 45 % legitimate, but ambulatory emergencies. Furthermore a concentration of emergency departments should take place with a simultaneous supply of financial resources to expanding emergency departments with high patient flow.

Quality of life and reconstructive surgery efforts in severe hand injuries.

INTRODUCTION: Severe hand trauma, leading to extensive skeletal and tissue defects, requires plastic surgical reconstruction of the highest level aiming at maximizing function and aesthetics. The intention of this study was to investigate clinical parameters and resource consumption connected with severe hand injuries, with specific emphasis on a follow-up evaluation of quality of life after the reconstruction process. MATERIALS AND METHODS: In this retrospective study, we evaluated patients with severe hand injuries from 2013 to 2016 who had completed surgical and non-surgical treatment. Measures included total period of therapy (TPT) in days, total duration of operations including anesthesia (TOA), total duration of all operations (TO), and total number of operations (TNO). We also determined total inpatient stay (TIS), total number of clinic presentations with interventions (TNPI), initial hand injury severity score (iHISS), and inpatient proceeds (IPP) in Euros (€). Correlation was assessed between iHISS and TOA, TNO, and TIS. Finally, these patients were reexamined in a follow-up inquiry and the life quality was assessed with the five-level version of the EuroQol five-dimensional (EQ-5D) descriptive system (EQ-5D-5L). RESULTS: We analyzed 12 patients with an average age of 44 years (min. 24 years, max. 75 years). Patients receiving reconstructive surgery experienced median ( x ˜ ) TPT of 175 days [interquartile range (IQR), 51-499], TOA of 13 h (IQR, 6-37), TO of 9 h (IQR, 4-25), and TNO of 5 (IQR, 3-11). Further, the patients' median TIS was 22 days (IQR, 9-86), TNPI was 4 (IQR, 2-8), and iHISS was 77 (IQR, 44-162). The median IPP was 14.595 € (IQR, 5.541-33.709 €). IHISS was positively correlated with Pearson's r for TIS (0.817), TOA (0.857), and TNO (0.871). The EQ-5D-5L index value resulted in a high level of life quality with a median of 0.898 (min. 0.8, max. 1). CONCLUSION: Severe hand injuries are related to high efforts for surgical and functional reconstructions, which result in high quality of life measured with the EQ-5D-5L assessment. However, for a defined collective of patients, myoelectric prosthetic functional replacement should be considered. Further studies are necessary to examine functional outcomes and quality of life after bionic prosthetic replacement. Also, a bionic reconstruction score to define hard criteria for taking an acute treatment decision is necessary.

[The Humboldtian model in Plastic and Reconstructive Surgery - a student survey on teaching and venia legendi]. / Das Humboldt'sche Bildungsideal in der Plastischen Chirurgie ­ Studentenumfrage zur Lehre und Venia Legendi.

BACKGROUND: The workload of university hospitals and hospitals with university association includes clinical patient care as well as teaching and research in particular. The current development with focus on financial issues leads to a reduction of teaching and research capacities. Economic focus in university medicine changes priorities of academic surgery. METHODS: An online survey questioned medical students with regard to subjective assessment of quality of the academic body of university hospitals and current teaching quality. Students evaluated the current quality of teaching of postdoctoral lecturers in relation to their career stage and made suggestions for quality of teaching improvement. RESULTS: A total of 166 students participated in the survey. Of 123 students, about 78 % stated that the reputation of postdoctoral lecturers increases with the habilitation but about 85 % stated that professional expectations also rise. About 43 % of the students aim to achieve a postdoctoral lecture qualification. DISCUSSION: Among students academic career is still attractive, but restructuring and modernization of established working models is an essential prerequisite.

[Careers in plastic and aesthetic surgery: a review of habilitation and professorship of members of the DGPRAEC]. / Karriere in der Plastischen und Ästhetischen Chirurgie ­ Untersuchung zur Habilitation und Professur der Mitglieder der DGPRÄC.

Background Over the last few decades plastic and aesthetic surgery careers aimed at holding a chair as head of the department or clinical director. The current career trend shows a drain of academic teaching staff to peripheral hospitals with sole clinical focus. The achievement of a doctorate in German university medicine or obtaining the venia legendi appears to be the termination of academic careers. This brain drain with loss of expertise and scientific output imposes a problem to future progress in clinical and scientific plastic and reconstructive surgery. The causative role of our present work profile, workload and financial compensation will be discussed in this paper. Methods In order to understand this brain drain, the scientific and clinical developments of all habilitands, Assistant Professors and University Directors enlisted in our specialist society (DGPRAEC) were analyzed. The evaluation included the duration of the residency, the time span from being a specialist physician to habilitation, as well as gaining a leadership position after habilitation. Finally, the current activity of the members at university and non-university institutions was evaluated. Results A total of 1238 members were analyzed. Among these, 177 (14.3 %) members had completed the habilitation. In total, 114 (9.21 %) were included based on full available CVs. Of the listed members, 80 members (6,5 %) had an APL professorship/university professorship in April 2017. 88 CVs showed an average time span of 4.2 years from specialization to habilitation. 80 CVs revealed a 5 year time span to achieve an APL professorship/university professorship. After an average of 4.2 years, leadership positions were held. Of the analyzed habilitations, 60 % were active in peripheral hospitals at the time April 2017. Discussion The loss of scientific and clinical expertise should be prevented in order to preserve academic plastic surgery with focus on patient care, academic education and research. This could be achieved by creating more attractive working conditions.

Is tamoxifen associated with an increased risk for thromboembolic complications in patients undergoing microvascular breast reconstruction?

INTRODUCTION: Tamoxifen is associated with a twofold increased risk of thromboembolic events. Third generation aromatase inhibitors (AIs), such as letrozole, anastrozole, and exemestane have therefore replaced tamoxifen in the adjuvant therapy of hormone receptor-positive breast cancer. A retrospective review was performed in patients who underwent delayed microvascular breast reconstruction and received tamoxifen at the time of surgery in order to assess the risk of both minor and major flap complications including thromboembolic events. PATIENTS AND METHODS: Twenty-nine patients who underwent delayed microsurgical breast reconstruction with autologous tissue between 2006 and 2012 were included in the study. The overall complication rates were compared between patients who did versus those who did not receive tamoxifen at the time of microsurgical breast reconstruction. RESULTS: Breast reconstruction was performed with a DIEP flap in 25 patients and with a TRAM flap in 4 patients. Overall, the complication rate was 37.9% (n=11) consisting of 5 major (including one total flap loss) and 6 minor complications. In patients receiving tamoxifen (n=5), we observed one minor complication and one major complication with a total flap loss due to thrombus formation at the anastomosis site. In one patient pulmonary embolism occurred without association to tamoxifen. The number of thromboembolic events was equivalent in both groups (p=0.642). No increase of major (p=0.858) or minor (p=0.967) complications in the tamoxifen group could be observed. Taking the overall complication rate into account there was no statistically difference between the two groups (p=0.917). CONCLUSION: In our study we could not observe an increased risk for thromobembolic events in patients receiving tamoxifen while undergoing autologous microvascular breast reconstruction.

Impact of diabetes and peripheral arterial occlusive disease on the functional microcirculation at the plantar foot.

BACKGROUND: Plastic and reconstructive surgeons are commonly faced with chronic ulcerations and consecutive wound infections of the feet as complications in patients with diabetes and/or peripheral arterial occlusive disease (PAOD). Microcirculatory changes seem to play an important role. However, the evaluation of functional changes in the soft tissue microcirculation at the plantar foot using combined Laser-Doppler and Photospectrometry System has not yet been performed in patients with DM or PAOD. METHODS: A prospective, controlled cohort study was designed consisting of a total of 107 subjects allocated to 1 of 3 groups-group A: healthy subjects (57% males, 63.3 y); group B: patients with diabetes mellitus (DM) (53% males, 59.4 y); and group C: patients with PAOD (81% males, 66.1 y). Microcirculatory data were assessed using a combined Laser-Doppler and Photospectrometry System. RESULTS: Global cutaneous oxygen saturation microcirculation at the plantar foot of healthy individuals was 8.4% higher than in patients with DM and 8.1% higher than in patients with PAOD (both P = 0.033). Patients with diabetes did not show significant differences in global cutaneous blood flow when compared with either healthy subjects or patients suffering from PAOD. CONCLUSIONS: Functional microcirculation at the plantar foot differs between healthy subjects and patients suffering from diabetes or PAOD of the same age. Patients with either diabetes or PAOD demonstrate deteriorated cutaneous oxygen saturation with equivalent blood perfusion at the plantar foot. More clinical studies have to be conducted to evaluate therapeutical methods that might ameliorate cutaneous oxygen saturation within diabetic foot disease and PAOD.

Anticoagulative strategies in reconstructive surgery--clinical significance and applicability.

Advanced strategies in reconstructive microsurgery and especially free tissue transfer with advanced microvascular techniques have been routinely applied and continuously refined for more than three decades in day-to-day clinical work. Bearing in mind the success rates of more than 95%, the value of these techniques in patient care and comfort (one-step reconstruction of even the most complex tissue defects) cannot be underestimated. However, anticoagulative protocols and practices are far from general acceptance and - most importantly - lack the benchmark of evidence basis while the reconstructive and microsurgical methods are mostly standardized. Therefore, the aim of our work was to review the actual literature and synoptically lay out the mechanisms of action of the plethora of anticoagulative substances. The pharmacologic prevention and the surgical intervention of thrombembolic events represent an established and essential part of microsurgery. The high success rates of microvascular free tissue transfer as of today are due to treatment of patients in reconstructive centers where proper patient selection, excellent microsurgical technique, tissue transfer to adequate recipient vessels, and early anastomotic revision in case of thrombosis is provided. Whether the choice of antithrombotic agents is a factor of success remains still unclear. Undoubtedly however the lack of microsurgical experience and bad technique can never be compensated by any regimen of antithrombotic therapy. All the more, the development of consistent standards and algorithms in reconstructive microsurgery is absolutely essential to optimize clinical outcomes and increase multicentric and international comparability of postoperative results and complications.

Is there an association between comorbidities and the outcome of microvascular free tissue transfer?

The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.