Plastic Surgery Reconstruction of Chronic/Non-Healing Wounds.

In western countries, approximately 1 % of individuals are affected by chronic wounds during their lifetime. Due to changing demographics, this incidence will likely increase in the future. Additionally, the high prevalence is accompanied by substantial treatment expenditures. Therefore, it is of global interest to find effective treatment algorithms. In this article, we present up-to-date solutions for treating chronic / difficult to heal and complex wounds by means of plastic and reconstructive surgery. We outline the principles of chronic wounds and how to perform an appropriate diagnosis. Close cooperation and interdisciplinary exchange are important for optimizing treatment. We report the principles of wound debridement and the role of negative pressure wound therapy. Moreover, we discuss the state of the art of defect reconstruction by means of skin grafting, with or without acellular dermal matrices, local tissue transfers and free tissue transfers. In very complex cases, the local macrovascular blood flow is greatly reduced and there are few, if any, recipient vessels for free flap reconstruction. We discuss the role of arteriovenous loops to overcome this problem.

Free Latissimus Dorsi Myocutaneous Flap in a 6-Month-Old Child for Reconstruction of a Temporal Fossa Defect After Teratoma Resection.

Although free flap reconstruction has already gained widespread acceptance in pediatric patients, little is known about the outcome of free tissue transfer in head and neck reconstruction in pediatric patients. We present a case of a 6-month-old boy with a large volume deficit in the right temporal fossa after resection of a teratoma. This led to a large volume deficit with widely undermined skin margins. Therefore, we provided volume augmentation by microsurgical free latissimus dorsi myocutaneous flap transplantation. Intraoperative use of laser-assisted indocyanine green angiography indicated excellent flap perfusion. Postoperative magnetic resonance imaging showed adequate flap perfusion with no signs of flap necrosis. To our best knowledge, this case presents the youngest patient who underwent free flap transplantation in the head and neck region. Our case demonstrates that microvascular surgery can play an important role in particular cases in pediatric oncology, even in very young patients.

New aspects on efficient anticoagulation and antiplatelet strategies in sheep.

BACKGROUND: After addressing fundamental questions in preclinical models in vitro or in small animals in vivo, the translation into large animal models has become a prerequisite before transferring new findings to human medicine. Especially in cardiovascular, orthopaedic and reconstructive surgery, the sheep is an important in vivo model for testing innovative therapies or medical devices prior to clinical application. For a wide variety of sheep model based research projects, an optimal anticoagulation and antiplatelet therapy is mandatory. However, no standardised scheme for this model has been developed so far. Thus the efficacy of antiplatelet (acetylsalicylic acid, clopidogrel, ticagrelor) and anticoagulant (sodium enoxaparin, dabigatran etexilate) strategies was evaluated through aggregometry, anti-factor Xa activity and plasma thrombin inhibitor levels in sheep of different ages. RESULTS: Responses to antiplatelet and anticoagulant drugs in different concentrations were studied in the sheep. First, a baseline for the measurement of platelet aggregation was assessed in 20 sheep. The effectiveness of 225 mg clopidogrel twice daily (bid) in 2/5 sheep and 150 mg bid in 3/5 lambs could be demonstrated, while clopidogrel and its metabolite carboxylic acid were detected in every plasma sample. High dose ticagrelor (375 mg bid) resulted in sufficient inhibition of platelet aggregation in 1/5 sheep, while acetylsalicylic acid did not show any antiplatelet effect. Therapeutic anti-factor Xa levels were achieved with age-dependent dosages of sodium enoxaparin (sheep 3 mg/kg bid, lambs 5 mg/kg bid). Administration of dabigatran etexilate resulted in plasma concentrations similar to human ranges in 2/5 sheep, despite receiving quadruple dosages (600 mg bid). CONCLUSION: High dosages of clopidogrel inhibited platelet aggregation merely in a low number of sheep despite sufficient absorption. Ticagrelor and acetylsalicylic acid cannot be recommended for platelet inhibition in sheep. Efficient anticoagulation can be ensured using sodium enoxaparin rather than dabigatran etexilate in age-dependent dosages. The findings of this study significantly contribute to the improvement of a safe and reliable prophylaxis for thromboembolic events in sheep. Applying these results in future translational experimental studies may help to avoid early dropouts due to thromboembolic events and associated unnecessary high animal numbers.

Aesthetic correction of tuberous breast deformity: lessons learned with a single-stage procedure.

Tuberous breast deformity is a pathologic condition of the breast affecting teenage women. The aberration of breast shape in tuberous breast deformity consisting of a constricting ring at the breast base, breast tissue deficiency, and herniation of breast tissue into the nipple-areola-complex with areola enlargement and additional asymmetry makes the surgical correction challenging. In the present study, 15 patients were operated using a surgical procedure, which addresses all aspects of the deformity at a one-stage operation. The described technique results in a periareolar scar only, and the use of tissue expanders or skin flaps is unnecessary. Minor periareolar scar revision surgery was necessary in eight of 15 patients (53%) because of hypertrophic or expanded scarring. In two patients, implant dislocation occurred and therefore surgical revision was necessary. In all cases, an excellent final aesthetic result with a high patient satisfaction was achieved.

Comparison between distally based peroneus brevis and sural flaps for reconstruction of foot, ankle and distal lower leg: an analysis of donor-site morbidity and clinical outcome.

BACKGROUND: Skin defects of the foot, ankle and distal lower leg often require coverage by local or distant flaps. We aimed to compare functional outcome and donor-site morbidity following transfer of distally based delayed sural (DSFs) or peroneus brevis flaps (PBFs). METHODS: Between 2003 and 2006, 52 patients (24 DSFs and 28 PBFs) were included. For increased reliability, all extended sural flaps were delayed for 3-15 days. At the end of the follow-up period (minimum 12 months), patients were asked to fill out a modified foot and ankle score (Foot and Ankle Outcome Score (FAOS)) questionnaire. In addition, a chart review and a physical examination were performed. RESULTS: Total hospital stay and total number of operations were significantly lower in the PBF group. Minor flap necrosis (<10%) was observed in 21% of the DSF and 7% of the PBF group, and partial (>10%) or total flap loss occurred in one and three patients from the DSF group, respectively. Patient satisfaction, FAOS results and range of motion were comparable in both groups. Defect aetiology and patient age did not influence surgical outcome. CONCLUSION: Donor-site morbidity and functional outcome after DSF and PBF are comparable. A higher rate of complications was observed in the DSF group. Based on our findings, the PBF is recommended as first-line procedure for reconstruction of small- to medium-sized defects at the distal tibia, fibula, ankle and heel. The sural flap might be chosen for extended skin defects especially when a larger arc of rotation is required.