The acute impact of local cooling versus local heating on human skin microcirculation using laser Doppler flowmetry and tissue spectrophotometry.

INTRODUCTION: Knowledge of thermally induced skin injury has increased, but its pathophysiology remains unclear. Although it is assumed that local cooling may protect tissue, little is known about the impact of local heating on human skin. This study aimed to evaluate acute skin perfusion dynamics following thermal stimuli in healthy human volunteers. MATERIAL AND METHODS: In 54 subjects, a TSA-II-NeuroSensory Analyzer was used to induce local hypothermia (15 °C and 5 °C) and local hyperthermia (40 °C and 45 °C) at the palmar forearm of healthy volunteers. Changes in tissue microcirculation were assessed using an O2C device before and after each temperature change. RESULTS: Blood flow and velocity values showed a continuous decrease with decreasing skin temperature, whereas haemoglobin oxygen saturation (SO2) showed a continuous increase in superficial (2 mm) and deep layers (8 mm). With increasing skin temperature, flow, SO2 and velocity increased in the superficial and deep layers. The relative amount of haemoglobin (rHB) did not show a continuous alteration. DISCUSSION: Local cooling may protect damaged tissue due to increased SO2 (lower oxygen consumption). However, reduced blood flow and velocity in response to local cooling limit nutrient requirements and the transport of metabolites. Despite higher oxygen consumption of tissue at higher temperatures, both blood flow and SO2 increase. Thus, we hypothesize that not only hypothermia but also hyperthermia may provide tissue protection.

Healing Time Correlates With the Quality of Scaring: Results From a Prospective Randomized Control Donor Site Trial.

BACKGROUND: Scar formation remains a potential problem after surgery or trauma. Factors influencing scar tissue have been recognized, most notably healing time and wound depth. OBJECTIVE: To examine the association between healing time and the quality of scar tissue formation. MATERIALS AND METHODS: Scarring was assessed at 3 and 12 months after treatment in an RCT of 219 patients and consecutive 438 split-thickness skin graft donor sites. The primary end point of the study was healing time and the quality of scar tissue, which was scored by a validated scar scale evaluating scar height, surface, and color. RESULTS: The mean time of wound healing was 15.8 days, with a mean scar score of 6.89 at 3 months and 4.66 at 12 months. There was a significant (p < .000001) and linear correlation between healing time and scar quality. Of particular note, at 12 months, all subparameters of the score demonstrated worsening with prolonged time to heal. CONCLUSION: The authors could objectively demonstrate that epithelialization time is an important factor influencing scar quality. In contrast to previous assumptions, this correlation follows linearly. It is reasonable then to assume that treatment strategies expediting healing will also improve scar outcome.

[Plastic surgery treatment techniques for interdisciplinary therapy of pressure sores]. / Plastisch-chirurgische Behandlungstechniken in der interdisziplinären Therapie des Dekubitalulkus.

Pressure sores in geriatric patients represent a challenge for all disciplines involved in the treatment process; however, the prerequisite for successful treatment is the elaboration of an interdisciplinary treatment concept. The treatment goals should be adapted to the individual needs of the patients including the life situation, general condition and local findings. In addition to general basic operative techniques, such as wound cleansing and conditioning, plastic and reconstructive surgery provides a wide range of highly specialized operative techniques for the treatment of these patients by which a definitive defect coverage can be achieved. The aim of this article is to raise awareness for these complex and highly specialized procedures for all disciplines participating in the treatment in order to improve the interdisciplinary cooperation and ultimately the quality of treatment.

Double transverse myocutaneous gracilis free flaps for unilateral breast reconstruction.

BACKGROUND: In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. PATIENTS AND METHODS: Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. RESULTS: The average operating time was 6 hours 55 minutes (295 - 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. CONCLUSION: Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This method further expands the range of options with autologous tissue in reconstructive breast surgery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:539-545, 2016.

Localized lipomatosis of the perineum in a 58-year-old male patient - case report.

Lipomatosis of the perineum is an extremely rare condition. We report a localized hypertrophy of adipose tissue of the perineum in a 58-year-old man. The cause of enlargement could not be revealed. Nonetheless, preoperative workup and exclusion of possible malign tumors is essential.

Reconstruction of scaphoid nonunion fractures of the proximal one third with a vascularized bone graft from the distal radius.

OBJECTIVE: The treatment of proximal located scaphoid nonunion is a well-known and common problem. For these patients, we used a vascular pedicled bone graft of the distal radius. METHODS: In the last 7 years, 75 patients were treated with the vascular pedicled bone graft. Retrospectively, patients' data, healing rates, and factors influencing scaphoid healing were analyzed. RESULTS: The overall healing rate in cases with proximal located nonunions (n = 54) was approximately 70%. Out of these 54 patients, 47 patients showed avascular proximal fragments. Multivariate analysis showed no significant impact for the factors age, smoking, duration of disease, or previous operation. CONCLUSIONS: In our negative selected patient group, we were able to achieve good results with the usage of a pedicled vascularized bone graft of the distal radius. Our results indicate a favorable outcome for the use of a pedicled vascularized distal radius bone graft in both scaphoid nonunion fractures of the proximal third, with or without an avascular proximal pole.

Correlation analysis of histomorphometry and motor neurography in the median nerve rat model.

OBJECTIVE: Standard methods to evaluate the functional regeneration after injury of the rat median nerve are insufficient to identify any further differences of axonal nerve regeneration after restitution of motor recovery is completed. An important complementary method for assessing such differences is a histomorphometric analysis of the distal to lesion nerve fibers. Recently, an electrophysiological method has been proposed as a sensitive method to examine the quality of axonal nerve regeneration. METHODS: A linear regression analysis has been performed to correlate histomorphometric and neurographic data originating from 31 rats subjected to neurotmesis and immediate reconstruction of their right median nerve. RESULTS: A significant linear correlation between the velocity of neuromuscular conduction and the total number of nerve fibers (P = .037) as well as between the amplitude of compound muscle action potential and the total number of nerve fibers (P = .026) has been identified. Interestingly, a significant correlation between the velocity of neuromuscular conduction and the square root of the cross-sectional area of the nerve could be found (P = .008). This corresponds to a linear correlation between the velocity of neuromuscular conduction and the radius of the nerve. CONCLUSION: These results contribute in a better interpretation of morphological predictors of nerve regeneration and verify the previously described electrophysiological assessment in the median nerve rat model as a valid method.

Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities.

There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves "untreated". Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.

Bioartificial reconstruction of peripheral nerves using the rat median nerve model.

Different bioartificial tubes were recommended for peripheral nerve reconstruction in the past. In order to replace autologous nerve grafts this materials are still under review in different animal studies. Most of them are dealing with the rodent peripheral nerves. One very popular animal model to study different materials is the rat median nerve model. With its easy excess, simple behavioral tests and reliable long term results it is attractive to many scientists in this field. This review gives an overview about the past, current and future options in this model for bioartificial nerve tubes. It summarizes the evolution of successful implantation of different materials across short nerve gaps and demonstrates the obstacles arising from long nerve gaps and the problems associated to them.

Application of two different hemostatic procedures during microsurgical median nerve reconstruction in the rat does not hinder axonal regeneration.

BACKGROUND: Hemostatic procedures by means of electrical coagulation or application of topical agents are widely used to avoid postoperative bleeding during microsurgical reconstruction of peripheral nerves. It is speculated, however, that extensive hemostasis could provoke significant nerve damage. OBJECTIVE: To examine the effects of 2 intraoperative hemostatic procedures on peripheral nerve regeneration. METHODS: In 36 adult rats divided into 3 groups, the median nerve was transected and repaired by end-to-end neurorrhaphy. During surgery, bleeding was treated in groups 2 and 3 by application of either the topical hemostatic agent Floseal or routine bipolar coagulation. The degree of nerve regeneration was assessed in terms of motor function recovery using weekly grasping test evaluation for 3 months, muscle mass recovery of flexor digitorum sublimis, and stereological assessment of myelinated axon regeneration. RESULTS: Neither of the 2 applied hemostatic methods induced any negative effects on nerve regeneration as defined by grip strength, muscle mass recovery, and morphology of myelinated nerve fibers. In contrast, Floseal-treated animals showed a faster progression of motor function recovery, and animals subjected to bipolar coagulation revealed a higher muscle mass recovery compared with the control group. CONCLUSION: Controlled application of bipolar coagulation or Floseal does not exert a negative effect on the nerve regeneration outcome in rats. We propose that these methods can be applied safely to patients.

The sGAP flap: rare exception or second choice in autologous breast reconstruction?

Various flaps are available for autologous breast reconstruction. However, there is no accepted standard. The superior gluteal artery perforator (sGAP) flap is one possible option for autologous breast reconstruction. Eighty-one sGAP flaps were performed for breast reconstruction. Patient data regarding age, body mass index, medical history, timing of reconstruction, operating time, success of the operation, and complications were retrospectively analyzed. The success rate was 93% ( N = 75). Thrombosis occurred in nine flaps, and three revisions were successful. There was no partial necrosis. All but one bilateral breast reconstruction was performed in two stages. The average time between the reconstructions was 3 and 5 months (2 to 6). The average operating time was 7 hours 36 minutes (5'45 to 9'33). For autologous breast reconstruction, there is no universally accepted standard and no flap meets all the requirements. The deep inferior epigastric perforator flap is our first choice. We favor the sGAP as a second choice particularly for larger breast sizes. For a staged bilateral reconstruction, the sGAP flap advances to be our first choice. The sGAP flap is a safe and reliable perforator flap providing a good breast projection, cosmetically pleasing outcome on the breast, and an acceptable outcome on the buttock with the disadvantage of a demanding dissection.

One-stage ear reconstruction after avulsion injury, using the amputated cartilage and a retroauricular transposition flap.

INTRODUCTION: Auricular reattachment or reconstruction after traumatic ear loss remains a challenge for the plastic reconstructive surgeon. Because of the diverse accident mechanisms, no standard algorithms exist and several modalities have been proposed in the literature. METHODS: A case of an innovative ear reconstruction of a partially avulsed ear is presented. The amputated cartilage was reattached after being deepithelized from the anterior skin. A transauricular-retroauricular random pattern flap was then harvested and used for anterior skin coverage. RESULTS: The described technique provided a nice final result without the need of any further operations. CONCLUSION: In general, a microsurgical replantation should be applied when the circumstances allow. In other cases, especially in partial upper-ear amputations with severe skin contusions, the described technique should be considered as a safe, single-step approach with good final results.

Non-viral genetic transfection of rat Schwann cells with FuGENE HD© lipofection and AMAXA© nucleofection is feasible but impairs cell viability.

PURPOSE: To determine transfection efficiency of FuGENE HD© lipofection and AMAXA© nucleofection on rat Schwann cells (SC). METHODS: The ischiadic and median nerves of 6-8 week old Lewis rats were cultured in modified melanocyte-growth medium. SCs were genetically transfected with green fluorescent protein (GFP) as reporter gene using FuGENE HD© lipofection and AMAXA© nucleofection. Transfection rates were determined by visualization of GFP fluorescence under fluorescence microscopy and cell counting. Transfected cell to non-transfected cell relation was determined. RESULTS: Purity of Schwann cell culture was 88% as determined by immunohistologic staining. Transfection rate of FuGENE HD© lipofection was 2%, transfection rate of AMAXA© nucleofection was 10%. With both methods, Schwann cells showed pronounced aggregation behavior which made them unfeasible for further cultivation. Settling of Schwann cells on laminin and poly-L-ornithine coated plates was compromised by either method. CONCLUSION: Non-viral transfection of rat SC with FuGENE HD© lipofection and AMAXA© nucleofection is basically possible with a higher transfection rate for nucleofection than for lipofection. As cell viability is compromised by either method however, viral transfection is to be considered if higher efficiency is required.

Superior gluteal artery perforator flap in bilateral breast reconstruction.

The incidence of bilateral breast reconstruction is increasing particularly due to genetic counseling and the option for bilateral prophylactic mastectomies. The decision to undergo a prophylactic mastectomy depends on the achievable outcomes of breast reconstruction. The free superior gluteal artery perforator flap (sGAP) flap is one option for autologous bilateral reconstruction which has rarely been reported.All bilateral sGAP flaps performed in the department of plastic surgery at the Behandlungszentrum Vogtareuth over a period of 4.5 years were retrospectively analyzed for indication, success rate, and complications.Thirty sGAP flaps were performed for bilateral breast reconstruction. The average age of the 15 women was 42 years and the average body mass index was 20.8. Indications for breast reconstruction were predominantly prophylactic mastectomies (60%). Indication for a sGAP flap was either a thin patient with insufficient abdominal tissue or a 2-staged bilateral reconstruction. 83% of the breast reconstructions were performed secondarily and 93% in 2 stages. The average operating time was 7 hours 12 minutes. Twenty-nine flaps (97%) were successful. Complications were fat necrosis (n = 3), hematoma (n = 3), and breast seroma (n = 1). Donor site complications were seroma (n = 8), infection (n = 1), and wound dehiscence (n = 1).Our results with bilateral breast reconstruction with the sGAP flap show cosmetically appealing results with high success and low complication rates on the breast. However, seromas on the donor site occurred in 27%. In addition, the sGAP flap is a technically demanding and time consuming operation. We recommend the sGAP flap when the abdomen has not enough tissue bulk to perform a deep inferior epigastric perforator flap or for a 2-staged bilateral reconstruction. This is often the case in women with a hereditary high risk of breast cancer who often present as young and slim patients.

Efficacy of various durations of in vitro predegeneration on the cell count and purity of rat Schwann-cell cultures.

The efficacy of Schwann-cell cultivation can be enhanced by in vitro predegeneration of the harvested cells compared to immediate culture. The aim of this study was to improve Schwann-cell culture efficacy by comparing three different durations of predegeneration. The sciatic and median nerves of 6-8-week-old Lewis rats were harvested and subjected to either 2-day, 7-day, or 14-day predegeneration in Dulbecco's Modified Eagle's Medium supplemented with 10% fetal calf serum and 1% Penicillin/Streptomycin. Afterward, tissue was enzymatically dissociated and placed in a modified melanocyte growth medium. The cell count was determined immediately after dissociation while the cell purity was determined one subculture/trypsinization cycle later after cell attachment to the culture plate by means of optical microscopy and immunocytochemistry. Particular attention was then paid to the Schwann-cell-to-fibroblast relation. The cumulative cell count in the culture was 5.8 x 10(5) for 2-day, 1.12 x 10(6) for 7-day, and 1.48 x 10(6) for 14-day predegeneration. The culture purity was approximately equal for 2- and 7-day predegeneration (88% Schwann cells, 12% fibroblasts after 2 days; 85% Schwann cells, 15% fibroblasts after 7 days). After 14 days, however, cell cultures were significantly debased by fibroblast proliferation (57% Schwann cells, 43% fibroblasts). In vitro predegeneration is a particularly suitable procedural method to increase the cultural Schwann-cell yield. The number of cultivated rat Schwann cells is doubled by 7-day in vitro predegeneration in comparison to 2-day predegeneration. After 14-day predegeneration, however, the culture is significantly debased by fibroblasts. Therefore, 7-day in vitro predegeneration is an advisable predegeneration period.

Functional recovery after implantation of artificial nerve grafts in the rat- a systematic review.

PURPOSE: The aim of this study was to compare functional data of different nerve-gap bridging materials evaluated in rat experiments by means of a systematic review. MATERIALS AND METHODS: A systematic review was conducted, searching MEDLINE, HTS and CENTRAL to identify all trials evaluating functional recovery of artificial nerve conduits in the rat model. RESULTS: There was a trend towards a favourable outcome of conduits coated with Schwann-cells compared to the plain synthetics. Histomorphometry, electrophysiology and muscle-weight correlated poorly with functional outcome. CONCLUSION: Schwann-cell coated conduits showed promising results concerning functional recovery. Further standardization in outcome reporting is encouraged.

Chapter 23: Manual stimulation of target muscles has different impact on functional recovery after injury of pure motor or mixed nerves.

Direct coaptation and interpositional nerve grafting (IPNG) of an injured peripheral nerve is still associated with poor functional recovery. Main reasons for that are thought to be an extensive collateral axonal branching at the site of transection and the polyinnervation of motor endplates due to terminal axonal and intramuscular sprouting. Moreover, severe changes occurring within the muscle after long-term denervation, like loss of muscle bulk and circulation as well as progressive fibrosis, have a negative effect on the quality of functional recovery after reinnervation. We have recently shown that manual stimulation (MS) of paralyzed vibrissal muscles in rat promotes full recovery after facial nerve coaptation. Furthermore, MS improved functional recovery after hypoglossal nerve repair, hypoglossal-facial IPNG of the facial nerve in rat. In contrary, MS did not improve recovery after injury of the median nerve in rat, which is however a mixed peripheral nerve comparing to the facial nerve. It is speculated that manually stimulated recovery of motor function requires an intact sensory input, which is affected in case of mixed peripheral nerves but not in case of pure motor nerves. In this article, we summarize our results of MS in several peripheral nerve injury models in order to illustrate the application potential of this method and to give insights into further investigations on that field.

Evidence-based management strategies for treatment of chronic wounds.

The care and management of patients with chronic wounds and their far-reaching effects challenge both the patient and the practitioner. Further complicating this situation is the paucity of evidence-based treatment strategies for chronic wound care. After searching both MEDLINE and Cochrane databases, we reviewed currently available articles concerning chronic wound care. Utilizing this information, we have outlined a review of current, evidence-based concepts as they pertain to the treatment of chronic wounds, focusing on fundamental treatment principles for the management of venous, arterial, diabetic, and pressure ulcers. Individualized treatment options as well as general wound management principles applicable to all varieties of chronic wounds are described. Classification and treatment guidelines as well as the adoption of the TIME acronym facilitate an organized conceptional approach to wound care. In so doing, individual aspects of generalized wound care such as debridement, infection, and moisture control as well as attention to the qualities of the wound edge are comprehensively evaluated, communicated, and addressed. Effective adjuvant agents for the therapy of chronic wounds including nutritional and social support measures are listed, as is a brief review of strategies helpful for preventing recurrence. An appreciation of evidence-based treatment pathways and an understanding of the pathophysiology of chronic wounds are important elements in the management of patients with chronic wounds. To achieve effective and long-lasting results, a multidisciplinary approach to patient care, focused on the education and coordination of patient, family as well as medical and support staff can prove invaluable.