[Concept for a National Implant Registry to Improve Patient Safety]. / Konzept für ein nationales Implantatregister zur Verbesserung der Patientensicherheit.

Since the introduction of silicone implants, several events have led to considerable uncertainty among the patients, public, and users. So far, however, the necessary steps to significantly improving patient safety have not been taken in any of these cases. Requiring stricter approvals for medical devices, improving monitoring by the regulatory authorities and the revision of the Medical Devices Directive are all initial steps in the right direction towards a change in policy, but are insufficient as an early warning system. After the introduction of registers was announced in the coalition agreement, the German Society of Plastic, Aesthetic and Reconstructive Surgeons (DGPRÄC), in close consultation with the Ministry of Health, has developed a concept which is presented here. The need for a uniform and legally binding central register for breast implants is fully supported by the entire medical profession. According to the concept presented by the DGPRÄC, three data qualities would be applicable: Safety data (mandatory), physician information (voluntary) and research data (optional, except if safety related). The public authorities are creating a unified, secure entry portal for all professional associations concerned. This register is based with the professional associations, and from there the mandatory security data will be forwarded to the public authorities. Decoding of the identity of the patient and doctor would only occur in specifically defined emergency situations such as product recalls. Automated tools in the security database provide early detection of problems, so that rapid clarification is possible in consultation with the professional associations, manufacturers and possibly patients. This concept as proposed by the DGPRÄC has thus far been very positively received in all discussions between the various parties concerned.

Sexual reassignment surgery in female-to-male transsexuals: an algorithm for subcutaneous mastectomy.

INTRODUCTION: Subcutaneous mastectomy is one of the first steps in sexual reassignment in female-to-male transsexuals (FTMTS). The main goal is to masculinize the chest by removing the female contour. In this study, we introduce an algorithm to facilitate choosing the appropriate mastectomy technique depending on morphological aspects. PATIENTS AND METHODS: The records of 173 patients (346 mastectomies) from January 2008 to December 2013 were retrospectively reviewed. The authors conducted four different surgical techniques depending on breast volume, grade of ptosis and skin elasticity. The outcome parameters such as complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and surgical correction rate were obtained and related to the employed technique. RESULTS: From January 2008 to December 2013, we performed 346 mastectomies, of which 48 breasts (13.9%) were treated by a semicircular incision in combination with water-jet-assisted liposuction, 66 breasts (19.1%) by an additional circumferential mastopexy, 170 breasts (49.1%) by an inferior pedicled mammaplasty and 62 breasts (17.9%) by mastectomy with free nipple grafting. The mean operation time lasted 103.6 min. The overall complication rate was 11.8%. Secondary revisions were necessary in 9%. Of the patients, 88% rated the aesthetic results as "very good" or "good." Nipple sensitivity was rated as "very good" or "good" in 80.3% of the breasts. CONCLUSION: FTMTS are a well-informed patient population and therefore increasingly more demanding for aesthetic outcomes. If possible, the most scar-saving procedure should be preferred. With ascending degrees of ptosis, a larger skin envelope and lesser elastic skin, an extended-incision technique is required. The presented surgical algorithm facilitates the selection of the appropriate mastectomy technique and shows a high patient satisfaction with the aesthetic result, a preservation of nipple sensitivity and a low rate of complications and secondary aesthetic corrections.

[Surgical treatment of gynecomastia: an algorithm]. / Chirurgische Therapie der Gynäkomastie: Ein Algorithmus.

INTRODUCTIONS: Gynecomastia is a persistent benign uni- or bilateral enlargement of the male breast ranging from small to excessive findings with marked skin redundancy. In this paper we introduce an algorithm to facilitate the selection of the appropriate surgical technique according to the presented morphological aspects. PATIENTS AND METHODS: The records of 118 patients (217 breasts) with gynecomastia from 01/2009 to 08/2012 were retrospectively reviewed. The authors conducted three different surgical techniques depending on four severity grades. The outcome parameters complication rate, patient satisfaction with the aesthetic result, nipple sensitivity and the need to re-operate were observed and related to the employed technique. RESULTS: In 167 (77%) breasts with moderate breast enlargement without skin redundancy (Grade I-IIa by Simon's classification) a subcutaneous semicircular periareolar mastectomy was performed in combination with water-jet assisted liposuction. In 40 (18%) breasts with skin redundancy (Grade IIb) a circumferential mastopexy was performed additionally. An inferior pedicled mammaplasty was used in 10 (5%) severe cases (Grade III). Complication rate was 4.1%. Surgical corrections were necessary in 17 breasts (7.8%). The patient survey revealed a high satisfaction level: 88% of the patients rated the aesthetic results as "very good" or "good", nipple sensitivity was rated as "very good" or "good" by 83%. CONCLUSION: Surgical treatment of gynecomastia should ensure minimal scarring while respecting the aesthetic unit. The selection of the appropriate surgical method depends on the severity grade, the presence of skin redundancy and the volume of the male breast glandular tissue. The presented algorithm rarely leads to complications, is simple to perform and shows a high satisfaction rate and a preservation of the nipple sensitivity.

Bronchopleural fistula after pneumonectomy: interdisciplinary surgical closure by an ipsilateral pedicled latissimus dorsi flap supported by video-assisted thoracoscopy.

Post-pneumonectomy bronchopleural fistula (BPF) remains a rare but often life-threatening complication and therapeutic challenge. Traditional surgical procedures include chronic open drainage, attempts at direct stump closure, thoracoplasty with or without chest wall muscle transposition and trans-sternal bronchial closure. We describe a case with successful closure of a chronic BPF after pneumonectomy by intrathoracic transposition of a pedicled latissimus dorsi muscle flap circumferentially fixed on the surrounding pleural tissue under continuous video-assisted thoracoscopic overview. The postoperative course was without complications; no tumour, empyema or fistula re-occurred. In this article we want to present the potential advantages of video-assisted thoracoscopic support and interdisciplinary teamwork to improve the outcome of patients with BPFs after pneumonectomy.

[Cost analysis of conservative versus operative therapy of macromastia]. / Kostenanalyse der konservativen versus operativen therapie der makromastie.

Macromastia causes back and neck pain, scaphodynia, intertrigo of the inframammary crease up to dysaesthesia. Typical complaints of patients with macromastia are physical burden, psychological irritation and aesthetic deformity, often resulting in social isolation. Despite the demonstrable success of reduction mammaplasty to eliminate not only the symptoms of macromastia but the cause of the ailment, conservative therapy is still favoured by insurance companies and bearing of costs for surgical therapy therefore is rejected. Expenses of conservative treatment as well as costs related to appeal and lawsuits against insurance decisions exceed the case-based lump sum of reduction mammaplasty manifold. Conservative treatments do not eliminate the causes of the illness. Therefore the rejection of a medically indicated reduction mammaplasty has to be regarded as unfavourable and economically inefficient.

Depot-specific regulation of glucose uptake and insulin sensitivity in HIV-lipodystrophy.

Altered fat distribution is associated with insulin resistance in HIV, but little is known about regional glucose metabolism in fat and muscle depots in this patient population. The aim of the present study was to quantify regional fat, muscle, and whole body glucose disposal in HIV-infected men with lipoatrophy. Whole body glucose disposal was determined by hyperinsulinemic clamp technique (80 mU x m(-2) x min(-1)) in 6 HIV-infected men and 5 age/weight-matched healthy volunteers. Regional glucose uptake in muscle and subcutaneous (SAT) and visceral adipose tissue (VAT) was quantified in fasting and insulin-stimulated states using 2-deoxy-[18F]fluoro-D-glucose positron emission tomography. HIV-infected subjects with lipoatrophy had significantly increased glucose uptake into SAT (3.8 +/- 0.4 vs. 2.3 +/- 0.5 micromol x kg tissue(-1) x min(-1), P < 0.05) in the fasted state. Glucose uptake into VAT did not differ between groups. VAT area was inversely related with whole body glucose disposal, insulin sensitivity, and muscle glucose uptake during insulin stimulation. VAT area was highly predictive of whole body glucose disposal (r2 = 0.94, P < 0.0001). This may be mediated by adiponectin, which was significantly associated with VAT area (r = -0.75, P = 0.008), and whole body glucose disposal (r = 0.80, P = 0.003). This is the first study to directly demonstrate increased glucose uptake in subcutaneous fat of lipoatrophic patients, which may partially compensate for loss of SAT. Furthermore, we demonstrate a clear relationship between VAT and glucose metabolism in multiple fat and muscle depots, suggesting the critical importance of this depot in the regulation of glucose and highlighting the significant potential role of adiponectin in this process.

[Sentinel lymph node dissection in patients with malignant melanoma. Diagnostic and therapeutic standards]. / Sentinel-Lymphknoten-Dissektion beim malignen Melanom. Ein diagnostischer und therapeutischer Standard.

INTRODUCTION: In patients with cutaneous malignant melanoma, the sentinel lymph node (SLN) reflects the histopathological features of the lymphatic basin with high accuracy. MATERIAL AND METHODS: Three hundred eighty-one melanoma patients at the Hornheide clinic with an overall follow-up of 36 months (November 1998 to October 2001) underwent sentinel lymph node dissection (SLND). RESULTS: The SLNs were successfully found in 93% of truncal melanoma ( n=136), 97% of melanoma of the extremities ( n=184), and 86% of melanoma of the head and neck region ( n=61). Of truncal midline melanomas, 84% ( n=43) showed two or more regional basins, in contrast to 18% of nonmidline melanoma ( n=93). Histopathological analysis revealed occult nodal disease in 25% of all patients. Completion lymphadenectomy revealed residual nodal disease in 8% of all patients with low risk melanoma with a tumor thickness of 0-1.5 mm (two of 26 patients with positive SLN) and in 11% of all patients with high risk melanoma with tumor thickness above 1.5 mm (eight of 70 patients with positive SLN). Tumor relapse was noted in 5% of negative SLN patients and 14% of positive SLN patients. The results of the method were false negative in 2% with a sensitivity of 98%. CONCLUSION: Sentinel lymph node dissection is a reliable and accurate method of staging regional lymph nodes for all primary tumor sites. It can localize occult metastases in unexpected lymphatic basins and provides critical indications for completion lymphadenectomy. It represents an essential method of establishing stratification criteria for future adjuvant trials. Further long-term follow-up is needed to investigate its prognostic relevance to recurrence and overall survival.

[Administration of Integra on primary burn wounds and unstable secondary scars]. / Der Einsatz von Integra bei primären Verbrennungswunden und instabilen sekundären Narben.

We report on our experience with Integra application in 22 patients treated from February 1996 through April 1999. Nine patients suffered a primary burn injury and 13 patients had secondary unstable scars. Integra is artificial skin that consists of a collagen/glycosaminoglycane matrix and a silicon layer. It was first used by Burke and Yannas in 1980 in the USA. The mechanical and biological features of Integra protect the tissue from fluid loss and bacterial invasion in the acutely burned patient. The integra-induced formation of a neodermis leads to functionally and aesthetically highly acceptable scar formation. We present our clinical experience with Integra in long-term follow-up.

Gynecomastia of the male nipple.

Diseases of the male nipple can be responsible for severe problems for the patient. The location of gynecomastia can be restricted to the nipple. Carcinoma should also be considered. The therapy of choice is operative treatment. A subtle microsurgical procedure is helpful to achieve a good functional and cosmetic result.

Persistence of pedicle blood flow up to 10 years after free musculocutaneous tissue transfer.

The hypothesis of whether or not flap perfusion remains persistent through its vascular pedicle up to 10 years after free tissue transfer was tested. Since 1982, more than 1,000 free tissue transfers have been performed at this institution. Of these, 40 patients were selected with comparable posttraumatic soft-tissue defects of the lower leg and surgical repair by a latissimus dorsi myocutaneous free flap. All patients had a postoperative course free of complications. Measurements of flap perfusion were started in groups 1 through 4 (each 10 patients) 3 to 5 weeks, 5 to 7 months, 4 to 6 years, and 8 to 10 years after free tissue transfer, respectively. Quantitative measurements of local flap perfusion were performed by means of the hydrogen clearance technique (Ameda, Switzerland) at definite sites intracutaneously and subcutaneously within the flap's skin paddle as well as in the adjacent intracutaneous and subcutaneous skin of the surrounding soft tissue. Simultaneously, the vascular pedicle of the flap was visualized by a duplex scanner (Toshiba, Japan). In each group nine measurements were performed before (phase A), during (phase B), and after closing the pedicle (phase C) by manual compression. Each measurement took about 10 minutes. Statistical evaluation of the obtained values was achieved by the Mann-Whitney U test and the Wilcoxon signed rank test. Local flap perfusion showed no statistical differences for phase A and C in all four groups of patients. In phase B, however, a statistically highly significant (p < 0.01) absence of local flap perfusion was registered in all four groups at the site of the flap's skin paddle. No statistically significant alterations of intracutaneous and subcutaneous blood flow was found in the surrounding soft tissue. In our clinical-experimental setting, flap perfusion persisted by means of its vascular pedicle even 10 years after free tissue transfer. Our findings support the importance of an intact vascular pedicle for permanent flap survival after free tissue transfer.

[Does tissue perfusion after free microvascular tissue transplantation stay autonomous?]. / Bleibt die Gewebeperfusion nach freier mikrovaskulärer Gewebetransplantation autonom?

In a prospective study including 60 patients after free latissimus dorsi transfer (FLDT) to the lower leg, we found persistence of pedicle blood flow up to 10 years postoperatively. After uncomplicated FLDT the pedicle supported the flap in all cases, whereas after complicated FLDT (hematoma, thrombosis, infection) we found only 50% of all flaps autonomously perfused by the vascular pedicle.

[Analysis of cost measures in treatment of severely burned patients]. / Analyse der Kostenbereiche in der Behandlung Schwerbrandverletzter.

An analysis of costs and profit and an evaluation of the different cost parameters was performed in our burn centre, which treated 50-80 patients per year between 1991 and 1995. The cost-profit relationship (costs 3.7-4.6 million DM/year, profit 3.8-5.0 million DM/year) is balanced. The main cost parameters are staff costs (1.3-1.9 million DM/year), costs for medical treatment (1.5-1.8 million DM/year), and costs for internal services (0.6-0.9 million DM/year).

[Budget analysis in a burn center for severely burned patients]. / Budgetanalyse in einem Schwerverbranntenzentrum.

The treatment of patients with severe burn injuries is expensive and belongs in the hands of specialized burn centres. In our burn centre 257 patients were treated from 1991 to June 1995 (between 50 and 60 patients per year except for 1993 with 77 patients). Patients were evaluated according to the ABSI score (mean 7) and had mortality of around 15%. The costs range between 3.7 and 4.8 million DM per year, the profit lies in the same range. The costs are divided into staff costs (1.4-1.8 million DM per year), costs for medical treatment (1.5-1.9 million DM per year) and costs for internal services (600,000-900,000 DM per year) such as laboratory examinations (247,000-386,000 DM per year) and blood bank (100,000-215,000 DM per year), the main factors in this category. The different fields of costs and profit are compared in this analysis. Possible ways of reducing costs are pointed out, and the question of effectiveness of therapy is discussed. Conclusions from this analysis are limited by the individuality of each case with different clinical courses, the great number of influencing factors and the comparably small numbers of patients.

[Treatment of mentosternal contractures by flap-plasty]. / Behandlung mentosternaler Kontrakturen durch Lappenplastiken.

Mentosternal contractures still represent a surgical challenge due to their exposed location. They require early operative treatment for both functional as well as aesthetic reasons. Careful clinical examination of scar location and traction forces both in the resting and functional, moving state including proper evaluation of the surrounding soft tissue is mandatory for exact preoperative planning of the reconstructive surgical procedure required. In general, the technically most feasible operation is favoured, if functional and aesthetic results are good and the postoperative risk of recurrent mentosternal contractures is low. Between 1987 and 1994, 21 patients with cervical, mentosternal and mentothoracic contractures underwent operative procedures at our clinic. Eight patients underwent a surgical reconstruction with local flaps and 13 patients received a free microvascularized flap.

[Scar carcinoma as a late complication after burns]. / Narbenkarzinom als Spätkomplikation nach Verbrennung.

Carcinomas, mainly of the squamous cell type, may occur in burn scars from 3 months to 75 years after the burn injury, and they have a poor prognosis. Therefore, unstable scars, chronic ulcers and tumors must be subjected to histological examination as soon as possible. If a malignant tumor is present, the therapy of choice is wide local excision, though in the event of progressive tumor development an ablative procedure may be necessary. Early radical surgery is important. Unstable scars should be investigated to allow prophylactic surgery to be performed if appropriate [4]. Early mobilization of the (mostly elderly) patients is important. Three case reports of patients with burn scar carcinoma are presented.

[Results of the Maquet/Bandi tibial tuberosity ventralization]. / Ergebnisse der Tuberositas-tibiae-Ventralisation nach Maquet/Bandi.

From 1975 to summer 1980, 87 patients suffering from chondropathy of the patella underwent 95 operations according to the method of Maquet-Bandi. 79 patients could be followed up 1,5 year after the operation. Additional procedures for restoring the knee joint had to be performed in 54 cases. The results obtained were good in 83%.