Anatomy of the medial antebrachial cutaneous nerve and its significance in ulnar nerve surgery: An anatomical study.

BACKGROUND: During cubital tunnel surgery, the medial antebrachial cutaneous nerve (MACN) may be injured, causing painful scars, neuromas, hypaesthesia or hyperalgesia. As the literature on the anatomy of crossing branches in this area is contradictory, this study aimed to re-examine the anatomy of the MACN in this region. METHODS: Forty upper limbs were dissected. We looked specifically from 5 cm proximal to 6 cm distal to the medial epicondyle (ME) and documented the number of crossing branches and the distances between the crossing points and the ME; we also measured the length of each limb. RESULTS: The most common location for crossing branches was 2 cm distal to the ME. Twenty-seven branches (∼23%) were found proximal to or at the level of the ME, and 91 branches (∼77%) were distal to it. The average distance between the proximal crossing points and the ME was 1.7 cm, the mean number of crossing branches was 0.7 and at least one crossing branch per limb was found in 16/40 cases. For the distal crossing points, the average distance to the ME was 2.9 cm, the mean number of crossing branches was 2.3 and at least one crossing branch per limb was found in all cases. There was no correlation between the limb lengths and the number of crossing branches. CONCLUSION: Because the incidence of posterior branches of the MACN crossing the course of the ulnar nerve is 100%, it is important to take the anatomy of the MACN into consideration when undertaking ulnar nerve surgery.

A Multiple Regression Analysis of Postoperative Complications After Body-Contouring Surgery: a Retrospective Analysis of 205 Patients : Regression Analysis of Complications.

BACKGROUND: As bariatric surgery becomes ever more popular, so does body-contouring surgery to eliminate excess skin after radical weight loss. To date, the literature has described a number of risk factors affecting the postoperative outcome. Our study aimed to define those factors more closely, focusing on abdominoplasty ("tummy tuck") patients who suffered intra- and postoperative complications. METHODS: The study collective included 205 patients over 5 years (2001-2006) who underwent dermolipectomy at our department. The mean follow-up was 5.94 years. Every abdominoplasty was performed under general anesthesia with intraoperative one-dose antibiotic. The analysis included a complete review of all medical records. Statistical analysis was performed with the R-2.5.0 Software for Windows. RESULTS: The overall rate for major complications that required operative revision and/or antibiotics was 10.2 %, including 2.9 % cases of infections. Forty-one percent had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. The logistic regression models demonstrated that smoking combined with the age, a BMI higher than 30 kg/m(2), and the amount of removed tissue (measured in g) lead to significantly more wound healing problems in nearly all age groups. The probability of infections correlated with later drain removal. CONCLUSIONS: Regardless of the amount of tissue removed, no main risk factor for complications could be identified. A complication-free course and good outcome can be best achieved with careful patient selection and preoperative planning.

[Is there a psychological and physiological difference between DIEP- and free TRAM-flap? A retrospective patient survey]. / Besteht ein Unterschied zwischen DIEP- und freiem TRAM-Lappen aus physiologischer und psychologischer Sicht? Eine retrospektive Patientenbefragung.

BACKGROUND: The DIEP- (Deep Inferior Epigastric Perforator) flap and the free TRAM- (Transverser Rectus Abdominis Musculocutaneous) flap are common procedures for breast reconstruction. The aim of the study was to identify a difference in the psychological and physiological patient satisfaction between DIEP- and free TRAM-flap. MATERIAL AND METHODS: To provide a homogenous group, with a stable result of the reconstruction, the collective for questioning was picked out of the years 2009 and 2010. All patients included underwent a breast reconstruction with a DIEP-flap or free TRAM-flap at our division. For evaluation we formed 2 groups: DIEP-flap group (DLG) and TRAM-flap group (TLG). After preparing the questionnaire a telephone survey was performed. For the null hypothesis we postulated that there is no difference between DLG and TLG in the patient satisfaction. RESULTS: We contacted 44 patients, 30 of them took part in our survey (15 from the DLG and 15 from the TLG). The mean BMI in the questionnaire group was 26.9 kg/m² and the mean age was 48.3 years. 2 questions (lifting heavy loads (p=0.005) and performing sit-up's (p=0.001)) show a significant difference between DLG and TLG, a benefit of the DLG could be seen. Both questions had the physiology of the rectus abdominis muscle as background. The complication rate for partial flap loss or partial necrosis was one third lower (p=0.299) in the TLG than compared to the DLG. CONCLUSION: Up to now, physicians think that the DIEP-flap seems to be the best possible procedure for breast reconstruction with belly flaps. However, numerous studies disprove the superiority in the donor site morbidity. In the literature, an advantage of the TRAM-flap is clearly visible by comparing the complication rates. Our oral interviewing also states that there is no -difference in the psychological and physiological satisfaction of the patients. We can recommend a precise patient selection if a DIEP-flap for breast reconstruction should be performed. In case of comorbidities the possibility of the safer free TRAM-flap should be considered. In the future, a comparative analysis between the DIEP-flap, free TRAM-flap and pedicled TRAM-flap should be performed, by keeping the patients satisfaction, the complication rate and the cost effectiveness in mind.

Smartphones and burn size estimation: "Rapid Burn Assessor".

Estimation of the total body surface area burned (%TBSA) following a burn injury is used in determining whether to transfer the patient to a burn center and the required fluid resuscitation volumes. Unfortunately, the commonly applied methods of estimation have revealed inaccuracies, which are mostly related to human error. To calculate the %TBSA (quotient), it is necessary to divide the burned surface area (Burned BSA) (numerator in cm2) by the total body surface area (Total BSA) (denominator in cm2). By using everyday objects (eg. credit cards, smartphones) with well-defined surface areas as reference for estimations of Burned BSA on the one hand and established formulas for Total BSA calculation on the other (eg. Mosteller), we propose an approximation method to assess %TBSA more accurately than the established methods. To facilitate distribution, and respective user feedback, we have developed a smartphone app integrating all of the above parameters, available on popular mobile device platforms. This method represents a simple and ready-to-use clinical decision support system which addresses common errors associated with estimations of Burned BSA (=numerator). Following validation and respective user feedback, it could be deployed for testing in future clinical trials. This study has a level of evidence of IV and is a brief report based on clinical observation, which points to further study.

L'estimation de la totale de la surface corporelle brûlée (% de la SCT) à la suite d'une brûlure est importante en déterminant le transfert du patient vers un centre de brûlés et les volumes nécessaires des fluides de réanimation. Malheureusement, les méthodes d'estimation couramment appliquées ont révélé des inexactitudes, qui sont principalement liés à l'erreur humaine. Pour calculer le % de la SCT il faut diviser la surface brûlée (numérateur en cm2) de la surface corporelle totale (dénominateur en cm2). En utilisant des objets du quotidien (par exemple cartes de crédit et smartphones) avec des surfaces bien définies comme référence pour les estimations de la SC brûlée d'une part, et des formules établies pour le calcul de la SC totale sur l'autre (par exemple Mosteller), nous proposons une méthode d'approximation d'évaluer le % de la SCT brûlée plus de précision que les méthodes établies. Pour faciliter la distribution, et les commentaires des utilisateurs, nous avons développé une application intégrant tous les paramètres ci-dessus, disponibles sur les plates-formes d'appareils mobiles populaires. Cette méthode représente un système simple et prêt à l'emploi aide à la décision clinique qui traite les erreurs courantes associées aux estimations de BSA brûlé (= numérateur). Après la validation et la rétroaction des utilisateurs, il pourrait être déployé pour les tests dans les futurs essais cliniques. Cette étude a un niveau de preuve IV et elle présente un bref rapport basé sur l'observation clinique, qui pointe vers une étude plus approfondie.

The use of telemedicine in burn care: development of a mobile system for TBSA documentation and remote assessment.

The requirements for accurate documentation within the process of burn assessment have increased dramatically over the years. TBSA (total body surface area) and burn depth are commonly determined by visual inspection, especially in the emergency or acute care setting. However, inexperience often results in incorrect estimation of these factors. In 2001, BurnCase 3D was initiated in order to develop a tool for objective burn assessment and documentation on mobile devices (Apple iPhoneTM). The centerpiece is a 3D model representing the actual patient. At two international burn meetings, a survey containing three pictures of patients was conducted and this data was collected. A patient-specific 3D model adapted to the height and weight of the real patient was created and the digital picture was superimposed in the computer system. The burns were transferred to the model and the TBSA in % was calculated by the software BurnCase 3D. The preferred methods of the 80 respondents for burn extent estimation were: the Rule of Nines (38%), the Rule of Palm (37%) and the Lund-Browder chart (18%). Analysis showed very high deviations of TBSA within the participants, even among the group of experts. In comparison to a computer-aided method we found massive overestimation of up to 230%. The use of BurnCase 3D could have a true impact on the quality of treatment in burns. In the acute care setting for burn injuries, telemedicine has great potential to help guide decisions regarding triage and transfer based on TBSA, burn depth, patient age and injury mechanism.

Les exigences en matière de documentation précise dans le processus de l'évaluation des brûlures ont augmenté de façon spectaculaire au cours des années. La SCT (surface corporelle totale) et la profondeur de la brûlure sont généralement déterminées par inspection visuelle, en particulier dans le contexte d'urgence ou de soins aigus. Cependant, l'inexpérience se traduit souvent par une estimation incorrecte de ces facteurs. En 2001, BurnCase 3D a été lancé afin de développer un outil d'évaluation des brûlures objectif et de la documentation sur les appareils mobiles d'Apple (iPhone™). La pièce maîtresse est un modèle 3D représentant le patient réel. Sur deux réunions de brûlures internationales, une enquête contenant trois photos de patients a été réalisée. Ces données ont été collectées. Un modèle 3D spécifique au patient adapté à la taille et le poids du patient réel a été créé et l'image a été superposée dans le système informatique. Les brûlures ont été transférés dans le modèle et le % de la surface corporelle totale a été calculé par le logiciel BurnCase 3D. Les méthodes préférées des 80 répondants pour l'estimation de la taille de la brûlure étaient : la règle des neuf (38%), la règle des palm (37%) et les tables de Lund et Browder (18%). L'analyse montre des écarts très élevés de SCT dans les participants, même parmi le groupe d'experts. Par rapport à un procédé assisté par ordinateur, nous avons trouvé surestimation massive de jusqu'à 230%. L'utilisation de BurnCase 3D pourrait avoir un véritable impact sur la qualité du traitement des brûlures. Dans le cadre de soins de courte durée pour les brûlures, la télémédecine a un grand potentiel pour aider à guider les décisions concernant le triage et le transfert sur la base de la SCT et la profondeur de la brûlure, l'âge du patient et le mécanisme de blessure.

Skin graft fixation in severe burns: use of topical negative pressure.

Over the last 50 years, the evolution of burn care has led to a significant decrease in mortality. The biggest impact on survival has been the change in the approach to burn surgery. Early excision and grafting has become a standard of care for the majority of patients with deep burns; the survival of a given patient suffering from major burns is invariably linked to the take rate and survival of skin grafts. The application of topical negative pressure (TNP) therapy devices has demonstrated improved graft take in comparison to conventional dressing methods alone. The aim of this study was to analyze the impact of TNP therapy on skin graft fixation in large burns. In all patients, we applied TNP dressings covering a %TBSA of >25. The following parameters were recorded and documented using BurnCase 3D: age, gender, %TBSA, burn depth, hospital length-of-stay, Baux score, survival, as well as duration and incidence of TNP dressings. After a burn depth adapted wound debridement, coverage was simultaneously performed using split-thickness skin grafts, which were fixed with staples and covered with fatty gauzes and TNP foam. The TNP foam was again fixed with staples to prevent displacement and finally covered with the supplied transparent adhesive film. A continuous subatmospheric pressure between 75-120 mm Hg was applied (VAC®, KCI, Vienna, Austria). The first dressing change was performed on day 4. Thirty-six out of 37 patients, suffering from full thickness burns, were discharged with complete wound closure; only one patient succumbed to their injuries. The overall skin graft take rate was over 95%. In conclusion, we consider that split thickness skin graft fixation by TNP is an efficient method in major burns, notably in areas with irregular wound surfaces or subject to movement (e.g. joint proximity), and is worth considering for the treatment of aged patients.

Au cours des 50 dernières années, l'évolution des soins de brûlure a conduit à une diminution significative de la mortalité. Le plus grand impact sur la survie a été le changement dans l'approche de la chirurgie. L'excision précoce et la greffe sont devenues une norme de soins pour la majorité des patients atteints de brûlures profondes; la survie chez les grands brûlés est invariablement liée à la taux de prise et à la survie des greffes de peau. L'application de la pression négative topique (PNT) a démontré une amélioration dans la prise des greffes par rapport aux méthodes conventionnelles. Le but de cette étude était d'analyser l'impact du traitement de PNT sur la prise des greffes de peau dans les grandes brûlures. Chez tous les patients, nous avons appliqué des pansements PNT, couvrant à moins 25% de la SCT. Les paramètres suivants ont été enregistrés et documentés via "BurnCase 3D" : âge, sexe, % de la SCT, profondeur de brûlure, durée de séjour à l'hôpital, le score Baux, survie, ainsi que la durée et la fréquence des pansements PNT. Après le débridement des plaies, la couverture était simultanément réalisée à l'aide de greffes de peau de demi-épaisseur, qui ont été fixées avec des agrafes et couvertes de toiles gras et de mousse de PNT. La mousse PNT a été de nouveau fixée avec des agrafes pour empêcher le déplacement et finalement recouverte avec le film adhésif transparent. Une pression atmosphérique continue entre 75 à 120 mm Hg a été appliquée (VAC®, KCI, Vienne, Autriche). Le premier changement de pansement a été effectué pendant le quatrième jour. Trente-six des 37 patients, souffrant de brûlures au troisième degré, ont obtenu leur congé avec la fermeture complète de la plaie ; un seul patient a succombé à ses blessures. Le taux de la prise des greffes de peau était supérieur à 95%. La greffe de peau mince par PNT est une méthode efficace dans les grandes brûlures, notamment dans les zones avec des surfaces irrégulières et des zones soumises à un mouvement (par exemple, de proximité joint), et est à considérer pour le traitement des patients âgés.

The real expansion rate of meshers and micrografts: things we should keep in mind.

Skin graft expansion techniques (mesh and micrograft) are widely used, but there is ample evidence that skin graft meshers do not provide their claimed expansion rates. Although this finding might not be new for the majority of surgeons, less is known about surgeons' actual knowledge of expansion rates. The aim of this study was to evaluate the true expansion rates of commonly used expansion techniques with regard to claimed, achieved, and polled results. In the first part of the study, 54 surgeons were polled during an annual burns meeting regarding the most commonly used expansion techniques and expansion ratios; in the second step the true (achievable) expansion rates of the most widely used meshers and micrografts were analysed; and in third step, a poll involving 40 surgeons was conducted to estimate the true expansion rates of the most frequently used skin expansion techniques. The skin meshers (1:1.5 / 1:3) did not achieve their claimed values: (1:1.5) 84.7% of the claimed expansion (mean ± SD: 1:1.27 ± 0.15) and (1:3) 53.1% of the 1:3 (1:1.59 ± 0.15) mesher. The use of the micrografting technique resulted in 99.8% of the 1:3 (1:2.99 ± 0.09), 93.6% of the 1:4 (1:3.74 ± 0.12) and 93.8% of the 1:6 (1:5.63 ± 0.12) claimed expansion rates, respectively. In general the surgeons overestimated the achievable expansion rates. In general the achieved expansion rate was lower than the estimated and claimed expansion rates. The micrografting technique provided reliable and valid expansion rates compared to the skin meshers. We recommend using the micrograft technique when large expansion ratios are required, for example in severe extensive burns.

Les techniques pour l'extension des greffes cutanées (en filet ou microgreffes) sont largement utilisées, mais il est amplement prouvé que les greffes cutanées en filet ne correspondent aux taux d'expansion réclamés. Il est bien possible que cette constatation ne constitue pas rien de nouveau pour les chirurgiens, mais nous savons encore moins des connaissances réelles des chirurgiens pour ce qui concerne cette matière. Le but de cette étude était d'évaluer l'exact taux d'expansion des techniques d'expansion couramment utilisées à l'égard des résultats revendiqués, réalisés et soumis à sondage. Dans la première partie de l'étude, 54 chirurgiens ont été interrogés lors d'une réunion annuelle des brûlologues sur les techniques d'expansion les plus utilisées et les rapports d'expansion. Dans la deuxième étape, les taux effectifs d'extension (possibles) des greffes en filet et les microgreffes les plus utilisés ont été analysés. Dans la troisième étape, un sondage auprès de 40 chirurgiens a été réalisé pour évaluer les taux effectifs des techniques d'expansion cutanée les plus utilisées. Les greffes en filet évaluées (1 : 1,5 / 1:3) en effet n'atteignaient pas les valeurs revendiquées: 1:1,5 = 84,7% de l'expansion revendiquée (moyenne ± écart-type = 1:1.27 ± 0,15) et 1:3 = 53,1% du mesher 1:3 (1:1.59 ± 0,15). L'utilisation de la technique de la microgreffe a produit des taux revendiqués d'expansion de 99,8% dans le cas de 1:3 (1:2,99 ± 0,09), de 93,6% dans le cas de 1:4 (1:3,74 ± 0,12) et de 93,8% dans le cas de 1:6 (1:5.63 ± 0,12). En général, les chirurgiens ont surestimé les taux d'expansion réalisables. Ainsi, toutes choses considérées, le taux d'expansion effectivement réalisé était inférieur aux divers taux d'expansion estimés et revendiqués. Les microgreffes montraient des taux d'expansion fiables et valides par rapport aux greffes en filet. Les Auteurs recommandent l'utilisation de la technique de la microgreffe quand il faut obtenir un rapport d'expansion élevé, par exemple dans le cas de brûlures graves de grande extension.

Use of 2-octyl cyanoacrylate together with a self-adhering mesh (Dermabond™ Prineo™) for skin closure following abdominoplasty: an open, prospective, controlled, randomized, clinical study.

BACKGROUND: Abdominoplasty is one of the most commonly performed procedures in plastic surgery. The appearance of the scar is a major factor that contributes to the aesthetic outcome of the procedure and depends largely on the technique of wound closure. The new Prineo™ wound closure system was introduced to combine the effectiveness of 2-octyl cyanoacrylate (Dermabond™) together with a self-adhering mesh. METHODS: Fifty-two women and eight men aged between 21 and 65 years who were scheduled for abdominoplasty were included in the study. The total operating times after abdominoplasty of the traditional wound closure technique and the Prineo™-type wound closure technique were compared. Furthermore, an analysis comparing the cost of the two methods was performed. Two weeks after surgery the wounds were examined and graded using the Hollander Cosmesis Scale. At the 6- and 12-month follow-ups, the aesthetic outcome of the abdominal scar was evaluated using the Vancouver Scar Scale. Twelve months after surgery, the patients were asked to answer their part of the Patient Scar Assessment Scale. RESULTS: The mean total operating time for the new skin closure system was statistically significantly shorter than that of intradermal sutures. The mean price difference per patient was 104.27 (134.79$) in favor of Prineo™. The Hollander Cosmesis Scale indicated a significantly more favorable overall result with Prineo™ at 2 weeks after surgery. The Vancouver Scar Scale demonstrated a better cosmetic outcome in favor of Prineo™ 6 and 12 months after surgery. The Patient Scar Assessment Scale scores 12 months after surgery indicated that the patients noted significantly less pain, thickness, and irregularity with Prineo™. CONCLUSION: Based on our results, we conclude that Prineo™ is a safe and effective substitute for superficial skin closure, with good cosmetic results and no increase in wound complications. The use of Prineo™ decreases operative time and cost and enhances the patient's postoperative comfort. LEVEL OF EVIDENCE I: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The properties of the "ideal" donor site dressing: results of a worldwide online survey.

Split skin grafting is a widely used technique for reconstructing skin defects. Although a vast number of different coverage options for donor sites have become available in daily clinical practice, no optimum dressing material has been found to date. For this reason, we conducted a globally-distributed online survey to poll for the properties of such an "ideal" donor site dressing, possibly leading to an improved clinically-driven direction of future wound dressing developments. A total of 69 respondents from 34 countries took part in the questionnaire, resulting in a response rate of 13.8% (69/500) over a 1-month period. The majority of respondents rated the characteristics of an "ideal" donor site dressing to be either "essential" or "desirable" as follows: lack of adhesion to the wound bed ("essential": 31/69, 44.9%; "desirable": 30/69, 43.5%); pain-free dressing changes ("essential": 38/69, 55.1%; "desirable": 30/69, 43.5%); absorbency ("essential": 27/69, 39.1%; "desirable": 33/69, 47.8%); ease of removal ("essential": 37/69, 53.6%; "desirable": 27/69, 39.13%). With regard to the desired frequency of dressing changes, respondents preferred "no dressing change until the donor site has healed" (51/69, 73.9%) in the majority of cases, followed by "twice weekly" (10/69, 14.5%), "alternate days" (5/69, 7.2%) and "daily" (3/69, 4.3%). With regard to the design of the dressing material, the majority of participants preferred a one-piece (composite) dressing product (44/69, 63.8%). The majority of respondents also denied the current availability of an "ideal" donor site dressing (49/69, 71%). The strength of this study was the remarkable geographic distribution of responses; all parts of the world were included and participated. We believe that this globally conducted online survey has polled for the properties of the "ideal" donor site dressing and possibly will lead to an improved clinically-driven direction of future wound dressing development.

Les greffes de peau mince sont largement utilisées pour reconstruire les défauts de la peau. Même si un grand nombre de différentes options de couverture des sites donneurs sont devenus disponibles dans la pratique clinique quotidienne, à ce jour, aucun matériel de pansement optimum n'a été trouvé. Pour cette raison, nous avons mené un sondage en ligne mondialement distribué à scrutin pour les propriétés d'un tel pansement de site donneur «idéal¼, qui peut conduire à une meilleure direction en ce qui concerne des futurs développements de pansement. Un total de 69 répondants de 34 pays ont été inclus dans le questionnaire, soit un taux de réponse de 13,8% (69/500) sur une période de 1 mois. La majorité des répondants ont évalué les caractéristiques d'un pansement «idéal¼ pour les sites donneurs d'être «essentiel¼ ou «souhaitable¼ comme suit: le manque d'adhérence au lit de la plaie («essentiel¼: 31/69, 44,9%; «souhaitable¼ : 30/69, 43,5%), le changement de pansement sans douleur («essentiel¼: 38/69, 55,1%; «souhaitable¼: 30/69, 43,5%); l'absorption («essentiel¼: 27/69, 39,1% ; «souhaitable¼: 33/69, 47,8%), la facilité de retrait («essentiel¼: 37/69, 53,6%; «souhaitable¼: 27/69, 39.13%), par rapport à la fréquence souhaitée des changements de pansements, les répondants préféraient «aucun changement de pansement jusqu'à ce que le site donneur est guéri¼ (51/69, 73,9%) dans la majorité des cas, suivi par «deux fois par semaine¼ (10/69, 14,5%), «deux jours¼ (5/69 , 7,2%) et «quotidienne¼ (3/69, 4,3%). En ce qui concerne la conception du matériel de pansement, la majorité des participants ont préféré une seule pièce (composite) (44/69, 63,8%). La majorité des répondants a également nié l'existence actuelle d'un pansement au site donneur «idéal¼ (49/69, 71%). La force de cette étude est la répartition géographique remarquable de réponses ; toutes les parties du monde ont été inclus et ont participé. Nous croyons que cette enquête en ligne, menée au niveau mondial, concernant les propriétés du pansement «idéal¼ pour les sites donneurs se traduira, éventuellement, par une amélioration future dans le développement des pansements.