S3 guidelines for the management of anticoagulation in cutaneous surgery.

BACKGROUND: An increasing number of patients are being treated with anticoagulants and platelet inhibitors. Whenever surgical procedures of the skin are required, questions arise regarding the perioperative management of anticoagulation. METHODS: Development of S3 guidelines following the requirements of the Association of Scientific Medical Societies, systematic literature search and analysis, use of GRADE methodology, structured consensus conference using a nominal group process. RESULTS: During cutaneous surgery, treatment with acetylsalicylic acid (ASA) should be continued if medically necessary. In procedures with a higher risk of bleeding and a positive bleeding history, INR should be determined preoperatively. Surgical procedures of the skin with a higher risk of bleeding should not be performed if the INR is above therapeutic range. Bridging from vitamin K antagonists (VKA) to heparin should not be performed just because of the surgery of the skin. As to direct-acting oral anticoagulants, the last dose should be taken 24 h preoperatively. CONCLUSIONS: The recommendations issued by the German guidelines group are mostly in line with recommendations provided by other guidelines. The American ìChest-Guidelineì recommends continuing VKAs and acetylsalicylic acid during minor dermatologic procedures. In their guidelines, the German College of General Practitioners and Family Physicians considers an INR of 2 to be adequate in surgical procedures on the skin.

Computed tomographic angiography imaging and clinical implications of internal mammary artery perforator vessels as recipient vessels in autologous breast reconstruction.

The internal mammary artery (IMA) is the standard recipient vessel for autologous breast reconstruction. To save the IMA for bypass surgery, to keep flap pedicles short, and to allow better flap positioning, the IMA perforators were used. Forty-six flaps for immediate breast reconstructions were performed in 39 patients. In the first 22 patients, the decision to use the perforators was clinically based. In the second group of 17 patients, all patients received a thoracic computed tomographic angiography (CTA) to determine the perforators. In 13 flaps (6 deep inferior epigastric artery perforator, 3 superficial inferior epigastric artery, and 4 transverse myocutaneous gracilis), the perforators were used as recipient vessels. Of these flaps, 5 were anastomosed to perforators before the CTA was applied and 8 after the CTA was established. The CTA revealed the IMA and the perforators in detail. In immediate reconstructions, the IMA perforators can be used as recipient vessels. They allow better flap positioning for superficial inferior epigastric artery and transverse myocutaneous gracilis flaps in particular; moreover, it decreases donor site and recipient site morbidity. After introducing the CTA, the perforators were used more frequently for anastomosis.

Vascular surgery, microsurgery and supramicrosurgery for treatment of chronic diabetic foot ulcers to prevent amputations.

INTRODUCTION: Diabetic foot ulcers occur in approximately 2,5% of patients suffering from diabetes and may lead to major infections and amputation. Such ulcers are responsible for a prolonged period of hospitalization and co- morbidities caused by infected diabetic foot ulcers. Small, superficial ulcers can be treated by special conservative means. However, exposed bones or tendons require surgical intervention in order to prevent osteomyelitis. In many cases reconstructive surgery is necessary, sometimes in combination with revascularization of the foot. There are studies on non surgical treatment of the diabetic foot ulcer. Most of them include patients, classified Wagner 1-2 without infection. Patients presenting Wagner 3D and 4D however are at a higher risk of amputation. The evolution of microsurgery has extended the possibilities of limb salvage. Perforator based flaps can minimize the donorsite morbidity. PATIENTS AND METHODS: 41 patients were treated with free tissue transfer for diabetic foot syndrome and chronic defects. 44 microvascular flaps were needed. The average age of patients was 64.3 years. 18 patients needed revascularization. 3 patients needed 2 microvascular flaps. In 6 cases supramicrosurgical technique was used. RESULTS: There were 2 flap losses leading to amputation. 4 other patients required amputation within 6 months postoperatively due to severe infection or bypass failure. Another 4 patients died within one year after reconstruction. The remaining patients were ambulated. DISCUSSION: Large defects of the foot can be treated by free microvascular myocutaneous or fasciocutaneous tissue transfer. If however, small defects, exposing bones or tendons, are not eligible for local flaps, small free microvascular flaps can be applied. These flaps cause a very low donor site morbidity. Arterialized venous flaps are another option for defect closure. Amputation means reduction of quality of life and can lead to an increased mortality postoperatively.

The transverse myocutaneous gracilis muscle flap: a fast and reliable method for breast reconstruction.

BACKGROUND: Autologous breast reconstruction is predominantly performed using free transverse rectus abdominis musculocutaneous or deep inferior epigastric perforator flaps. However, some patients are not suitable candidates for flaps from the lower abdomen. The transverse skin island of the gracilis muscle presents an additional option, as it includes tissue from the posterior upper thigh/lower buttock and thus delivers the amount of tissue necessary for breast reconstruction. METHODS: In 2007, the authors' unit performed 73 free flaps for breast reconstruction subsequent to carcinoma, implant-related capsular fibrosis, and breast asymmetry. The transverse myocutaneous gracilis flap was used 32 times. The ventral margin was the greater saphenous vein, and the posterior margin was the midline of the inferior gluteal fold. The skin island could be harvested to a width of up to 30 cm and a height of up to 10 cm. The donor site was closed primarily. RESULTS: Thirty-two flaps were performed in 20 patients. Mean follow-up was 6 months. Mean operating time was 220 minutes for unilateral and 325 minutes for bilateral cases. All flaps and donor sites healed uneventfully. An initially described "tight feeling" at the thigh ceased after 2 to 3 weeks. Persistent hypesthesia of the dorsal thigh was not noted. A major asymmetry of the thigh in unilateral transplantations was not apparent. After 6 months, all flaps were soft. CONCLUSIONS: The transverse myocutaneous gracilis flap is a safe, fast flap for reconstruction after benign and malignant breast disease. It combines a constant vascular pedicle with soft subcutaneous tissue that has breast-like characteristics.