The lipo-facelift: merging the face-lift and liposculpture: eight years experience and a preliminary observational study.

BACKGROUND: Since the introduction of the classic submucosal aponeurotic system (SMAS) face-lift, the surgical approach to improve the changes of an aging face has evolved, and significant technical improvements have been made. However, several problems still have not been solved satisfactorily. These problems include facial lipodystrophy and changes in skin and skin texture. METHODS: The Lipo-Facelift procedure consists of facial liposculpturing performed simultaneously with a biplanar, bivectorial SMAS face-lift procedure. The authors analyzed pre- and postsurgical photographs of 12 patients with a Lipo-Facelift after 3 and 12 months and analyzed their charts for complications. Furthermore, O2C measurement was performed to assess improved microcirculation. The longest follow-up period was 8 years. RESULTS: The Lipo-Facelift demonstrated very satisfying results. Initial swelling and bruising were seen as well as two cases of wound-healing disorders, but no surgical intervention or revision was needed. The findings show lasting improvement of skin quality and a youthful appearance. CONCLUSION: The Lipo-Facelift corrects age-related skin and SMAS changes as well as age-related lipodystrophy, improves skin circulation and skin revitalization, and provides a lasting and natural result. The skin quality resulting from simultaneous lipofilling can be explained by improved angiogenesis due to transferred growth factors in the lipoaspirate. Also, differentiation of progenitor cells to fibroblasts and increased production of collagen contribute to firmer skin. LEVEL OF EVIDENCE IV: 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 .

Randomised, controlled pilot to compare collagen and foam in stagnating pressure ulcers.

OBJECTIVE: To compare the clinical efficacy of a collagen dressing covered with a foam dressing with the same foam used as a primary dressing in stagnating granulating pressure ulcer patients. METHOD: Patients were randomised to receive either a foam dressing (Suprasorb P; Lohmann & Rauscher) as a primary dressing (group A), or a combination of a collagen dressing (Suprasorb C; Lohmann & Rauscher) covered with the same foam dressing (group B).Wound fluid was collected and evaluated prior to treatment (day 0), and on days 3,7, 14 and 21 .The level and expression of matrix metalloproteinases (MMPs) MMP-2 and MMP-9, and tissue inhibitors of metalloproteinases (TIMPs) TIMP- I and TIMP-2,as well as elastase content in wound fluid and angiogenesis,were evaluated, comparing results on day 0 and day 2 I.Time to ulcer healing, reduction in ulcer area, safety of treatment, patient-reported ulcer pain and comfort of the dressing regimen were evaluated as secondary outcomes. Patients received standard preventive measures, in line with the pressure ulcer prevention guidelines. RESULTS: Ten patients were included in the pilot; five were treated with the foam dressing (group A) and five patients received the collagen dressing, using the foam as a secondary dressing (group B).Wound fluid from group B displayed a significant positive effect on angiogenesis (p < 0.05) compared with group A. In the collagen and foam groupTIMP- I and -2 increased faster and levels were higher than in group A. Furthermore, MMP-2, MMP-9 (p < 0.04) and elastase in group B showed faster and greater decrease in levels, compared with group A, indicating a faster and superior reduction of inflammation. In both groups the ulcers started to heal, with a faster onset of healing for group B. CONCLUSION: The results of this pilot support published data on the use of collagen dressings compared with foam for stagnating wounds, shown in clinical studies. DECLARATION OF INTEREST: This study was supported with an educational grant by Lohmann & Rauscher GmbH.Apart from DrAbel, the sponsors had no role in the design or conduct of the study, in the collection, analysis and interpretation of the data, or in the preparation, review or approval of the manuscript. DrAbel gave input to the study design from a scientific perspective. None of the authors received administrative, technical or material support for the conduct of this study.The authors have no other relevant financial interests to declare.

[Extensive fibromata pendulantia. Hydrosurgery as a therapy option using the Versajet technique]. / Flächenhafte Fibromata pendulantia. Hydrochirurgie als Therapieoption mittels Versajet-Technik.

Fibromata pendulantia often appear as small filiform skin tags with a narrow pedicle in the neck, axilla and groin areas. Hitherto, extensive fibromata pendulantia were resected either surgically (curette, scissors, scalpel) or by laser. The present case study of an adipose patient with disseminated fibromata pendulantia in the axillary region in the setting of pseudoacanthosis nigricans introduces the Versajet hydrosurgery technique as an alternative method. It is able to remove tissue and rinse the wound simultaneously by means of a high-pressure water jet.

Wireless microcurrent stimulation improves blood flow in burn wounds.

RATIONALE: Skin breakdown, as in wounds, leads to an electric potential, defined as current of injury with the intent of wound closure. Burn wounds are defined by different zones of perfusion having a direct influence on further therapy (e.g. conservative management or skin grafting). We studied immediate, quantifiable effects of electric stimulation on skin perfusion in burn wounds. METHOD: Wireless Microcurrent Stimulation (WMCS) was utilised as an adjunct therapeutic modality in 10 patients with partial thickness burn wounds. Microcirculation in the skin was quantified with a Laser Doppler (LDI) before and after WMCS treatment. We included a control group of 10 healthy individuals. RESULTS: A single application of WMCS significantly increased mean flow, velocity and subsequently, haemoglobin and oxygen saturation in partial thickness burn wounds. In healthy skin these parameters increased, but were far less pronounced than in thermally injured skin. CONCLUSION: This study revealed, for the first time that non-contact WMCS improves blood flow in critically perfused partial thickness burn wounds without disturbing the wound or systemically affecting the patient and may represent a promising adjunct tool in burn treatment, with the potential of faster healing by enhanced perfusion of burn wounds and reduction of the zone of stasis. LEVEL OF EVIDENCE: III.

Tissue substitutes with improved angiogenic capabilities: an in vitro investigation with endothelial cells and endothelial progenitor cells.

The use of implantable biomaterials, such as artificial skin substitutes used for dermal defects, remains limited by the low angiogenic potential of these products. The rapid in vivo degradation of growth factors contributes to the limiting of angiogenesis in biomaterials. Here, we report on collagen sponges in which vascular endothelial growth factor (VEGF) was immobilized through physical binding to heparin, covalently incorporated in the matrix via cross-linking with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC) and N-hydroxysuccinimide. The in vitro release of VEGF over time and endothelial cell proliferation were investigated in matrices modified at varying heparin to EDC ratios either nonloaded or loaded with VEGF. ELISA demonstrated a significantly slower in vitro release of VEGF over a period of 5 days from heparinized matrices as compared to their unmodified and cross-linked counterparts. The effects of these modifications on the proliferation of endothelial cells and endothelial progenitor cells were evaluated after 1, 3 and 5 days either according to the bromodeoxyuridine assay or total cell counting with a Neubauer chamber. The endothelial and endothelial progenitor cells cultured in contact with heparinized matrices loaded with VEGF revealed both the highest rate of DNA synthesis and the highest total cell count. Furthermore, these results show that the cross-linking of collagen matrices - both in the presence and absence of heparin - leads to increases of the proliferative activities. We can assume that these changes lead to matrices with increased angiogenic capabilities.

Modified technique for thoracomyoplasty after posterolateral thoracotomy.

OBJECTIVE: Thoracomyoplasty after prior posterolateral thoracotomy (PLT) remains a challenge for the thoracic surgeon. Thoracodorsal artery division after PLT impairs the vascularization supply of the latissimus dorsi muscle (LDM) resulting in muscle mass reduction due to distal atrophy. This makes adequate filling of residual empyema space and/or surgical closure of bronchial stump insufficiency more difficult, and they require alternative surgical procedures. We present an alternative approach using a four-muscle flap technique to include the infraspinatus, the subscapularis and the teres major muscle group, all pedicled from the subscapular artery as a part of a modified thoracomyoplasty technique for closing residual empyema space and bronchial stump insufficiency. METHODS: Between 2002 and 2008 we performed the technique in 7 patients with residual empyema space. Three patients had post-tuberculosis syndrome, 2 had postpneumectomy empyema, and 2 had chronic parapneumonic empyema. Three cases were combined with a bronchopleural fistula. All patients underwent a two-stage procedure. First, open window thoracostomy was performed followed by definitive surgical treatment after 3-6 months. In all cases with bronchial insufficiency the stump was covered with a subscapularis muscle flap. The infraspinatus and the teres muscle group were used in combination with a local thoracoplasty. RESULTS: Mean age was 68 +/- 7.9 years. Time from open window thoracostomy to thoracomyoplasty averaged 4 +/- 1.3 months. The number of resected ribs ranged between 4 and 8. Mean postoperative stay in the ICU was 3 +/- 2.9 days. The thoracic drains were removed after 5 +/- 2.3 days. Total hospital stay was 15 +/- 7.6 days. No hospital mortality was noted. Minor postoperative complications occurred in 2 cases. Shoulder function without pain allowed abduction up to 90 degrees. Function was decreased by 16 +/- 9 degrees compared to preoperative evaluation. No severe progressive scoliosis was noted. CONCLUSIONS: Division of the LDM and its vascular supply after posterolateral thoracotomy results in a reduction of muscle mass. The shoulder girdle muscles offer an adequate alternative to fill residual empyema space with acceptable long-term results and restriction in shoulder motion. In all cases with bronchial fistula, bronchial stump closure with a pedicled subscapular muscle was an effective alternative operative technique.

[The impact of silicone spray on scar formation. A single-center placebo-controlled double-blind trial]. / Einfluss eines Silikonsprays auf die Narbenbildung. Doppelblinde, placebokontrollierte, unizentrische Studie.

For more than two decades silicone has successfully been employed in the treatment and prevention of hypertrophic scars and keloids as a painless noninvasive modality with few side effects. In the present trial, after 3 months of treatment the Patient Scar Assessment Scale demonstrated that patient satisfaction with the silicone application was significantly higher compared to placebo. When treatment was stopped after 3 months, the topical silicone spray did not exhibit any lasting long-term impact on the objective results of scar formation. Due to the significant differences in patient satisfaction once treatment has ended and since the administration is safe and simple, any final decision on treatment indication should be tailored to the patient and include the psychological well-being of the patient as well as the temporary improvement in scar formation during treatment.

A new tool for the early diagnosis of carbon monoxide intoxication.

Invasive measurement of carboxyhemoglobin (COHb) by blood gas analysis (BGA) is accepted as the standard diagnostic procedure in diagnosis of inhalation injury and carbon monoxide (CO) intoxications. The main disadvantage of BGA with COHb testing is the unavailability in pre-hospital rescue conditions. The non-invasive SpCO analysis using pulse CO oximetry (Rad57, Masimo Corp., USA) represents an easy-to-handle device to facilitate the diagnosis of CO intoxication. Between January 2006 and August 2008, 20 patients who were admitted with CO intoxication to our burn centre were included in this study. Blood gas analysis including COHb testing was performed on the first day, hourly. At the same time, SpCO was determined using the Rad57 pulse CO oximeter. Patients received inhalative oxygen according to the parameters of blood gas analysis or hyperbaric oxygenation if COHb > 10%. Five young healthy volunteers served as control group. The SpCO of the volunteers was cross-checked against their COHb levels, which were measured by blood gas analysis. Results of pulse CO oximetry revealed a mean error of approximately 3.15% from the results achieved by blood gas analysis. If COHb resulted in values higher than 10%, the bias remained approximately the same (3.43%/precision 2.362%). When different blood gas analyzers in our department were tested with the same patient sample, a mean error of 2.4% was found. This is only 1% lower compared to the mean error of pulse CO oximetry. Therefore, pulse CO oximetry represents a reliable measurement technique that is easy to handle and could facilitate the early diagnosis of CO intoxication in pre-hospital rescue conditions.

[Possibilities and limitations of plastic surgery]. / Möglichkeiten und Grenzen der Plastischen Chirurgie.

Demographic changes of the industrialised modern society can be recognised throughout every medical specialisation. In the past plastic surgery had a main focus in the reconstruction of posttraumatic disorders but nowadays the typical disorders of the elderly and "civilization diseases" became a major part of reconstructive surgery. In this context the preservation of the lower extremity is a major concern of the plastic surgeon. Especially in patients with diabetes and its typical peripheral atherosclerosis we have to treat peripheral ulcers in an interdisciplinary setting including diabetologist, vascular and plastic surgeon to preserve the endangered extremity.

[Merkel cell carcinoma]. / Merkel-Zell-Karzinom des Handrückens.

A 67-year old patient developed multiple flesh-colored nodules on the back of his left hand. Histological examination led to the diagnosis of a Merkel cell carcinoma (MCC). This highly aggressive primary cutaneous tumor is classified as a neuroendocrine carcinoma. It affects mostly elderly and immunosuppressed patients. Recently, a new polyomavirus (MCPyV) has been detected in about 75-85% of MCC and seems to play an important role in their pathogenesis. This new finding may help to develop new therapeutic options for MCC.

CatWalk gait analysis in assessment of functional recovery after sciatic nerve injury.

Following peripheral nerve injury repair, improved behavioural outcome may be the most important evidence of functionality of axon regeneration after any repair strategy. A range of behavioural testing paradigms have been developed for peripheral nerve injury research. Complete injury of the adult rat sciatic nerve is frequently used in combination with walking track analysis. Despite its wide-spread use, these walking track analyses are unsuitable for the simultaneous assessment of both dynamic and static gait parameters. Conversely, a novel automated gait analysis system, i.e. CatWalk can simultaneously measure dynamic as well as static gait parameters and, importantly, it's easy to control for the speed of locomotion which can strongly affect gait parameters. In a previous study, CatWalk was already successfully used to examine deficits in both dynamic and static gait parameters using the sciatic nerve lesion model with a 1cm gap characterized by absence of recovery [Deumens R, Jaken RJ, Marcus MA, Joosten EA. The CatWalk gait analysis in assessment of both dynamic and static gait changes after adult rat sciatic nerve resection. J Neurosci Methods 2007;164:120-30]. Using the sciatic nerve crush injury model (validated with the static sciatic index) and a follow-up period of 12 weeks, we now show that CatWalk can also measure behavioural recovery. In particular dynamic gait parameters, coordination measures, and the intensity of paw prints are of interest in detecting recovery as far as these parameters completely return to pre-operative values after crush injury. We conclude that CatWalk can be used as a complementary approach to other behavioural testing paradigms to assess clinically relevant behavioural benefits, with a main advantage that CatWalk demonstrates both static and dynamic gait parameters at the same time.

[Eccrine adenocarcinoma in a patient with familial breast carcinoma]. / Ekkrines Adenokarzinom bei einer Patientin mit familiärem Mammakarzinom.

A 67-year-old patient developed a subcutaneous, non-tender nodule in her left groin over a period of about seven years. The patient underwent surgery and 4 procedures were required to obtain complete excision. The histopathologic findings showed eccrine adenocarcinoma, a member of the heterogeneous group of sweat gland tumors which occur primarily in adults with a peak of 50-60 years of age. Sweat gland carcinomas are extremely rare neoplasms of the skin and exhibit a slow growth rate with a rather high local recurrence rate. The tumor has a disposition to metastasize and shows a poor response rate to adjuvant therapy regimens. Therefore wide, deep surgical excision with an excision margin of 2-3 cm is the treatment of choice. Nevertheless there are some case reports on successful therapy of a metastasized sweat gland carcinoma with 5-fluorouracil and tamoxifen. Here further studies are needed to achieve a better survival rate for patients with metastatic disease.

[Postbariatric plastic surgery]. / Postbariatrische Plastische Chirurgie.

Approximately 1.7 billion people around the world are defined as being overweight or obese. Various surgical options to treat obesity have quite recently been developed. Following efficient and lasting weight loss, up to one-third of the patients will require plastic and reconstructive surgery. Plastic surgery will thus be the final part of a modern bariatric treatment plan. Postbariatric plastic surgery interventions do not treat obesity but rather remove excess skin and restore the normal body contour and function of the bariatric patient. The presented work summarizes current concepts and limitations in modern plastic and reconstructive surgery of the bariatric patient population.

[Merkel cell carcinoma and immunosuppression: report of three cases and review of therapeutic options]. / Das Merkel-Zell-Karzinom und immunsuppression: drei fallberichte und uberblick der therapeutischen optionen.

Merkel cell carcinoma (MCC) is a cutaneous, neuroendocrine tumour of high malignancy that is described as a firm, purple tumour localised in the dermal layer. Due to its high progression rate, the 5-year survival rate is quoted as between 30 and 74 %. The course of disease is characterised by high relapse rate (30 - 77 %) and lymph node metastases (ca. 50 %). Therapy of MCC is based on a radical surgical excision combined with sentinel lymph node biopsy (stadium I), lymph node dissection (stadium II) and postoperative radiotherapy. We report three cases of MCC under immunosuppression and present therapeutic options of MCC in overview.

Impact of scapholunate dissociation on human wrist kinematics.

Neither the complex motions of the scapholunate joint, nor the kinematic changes that occur as a result of injury to it, are fully understood. We used electromagnetic tracking within affected bones to evaluate the physiologic motions in the planes of flexion and extension, and of radial and ulnar deviation of human cadaver wrists, before and after complete transection of the scapholunate ligaments. Despite individual variance between each wrist, we were able to establish a pattern in the changes that occurred after scapholunate ligament injury. During the motions examined, the scaphoid showed an increase in translational deviation in almost all motion axes. In contrast, the movement of the lunate seemed to be impaired, especially in radial-ulnar deviation.

Beneficial effect of corticosteroids in catecholamine-dependent septic burn patients.

Recent studies indicated the benefit of hydrocortisone in septic patients based on the significant reduction of catecholamines and improved outcome in common intensive care patients. The treatment of intensive care burn patients with corticosteroids was discussed with great caution due to the especially compromised immune status of severely burned patients. The purpose of this study was to investigate the influence of corticosteroids in burn patients during septic shock. In our burn unit, we started with the administration of cortisol in 2001. In this retrospective study, 10 severely burned patients received, > or = 24h after norepinephrine dependency, hydrocortisone infusions of 200 mg/24 h. The course of norepinephrine dose, hemodynamic measurements (Swan-Ganz-Catheter) and daily Sequential Organ Failure Assessment (SOFA-Score) were analyzed and compared to nine (catecholamine-dependent) burn patients without cortisol therapy. Statistical analysis by means of Fisher's Exact Test revealed beneficial effects (morbidity and mortality) of low dose cortisol therapy compared to control patients. However, the results of this study must be interpreted with caution because of its limited number of patients and its retrospective character. Further randomized prospective controlled studies are necessary to determine the efficacy and safety of cortisol therapy in burn patients.

[Perineal approach to repair rectal and cutaneous fistulas involving the urethra and bladder]. / Perinealer Zugang zur Korrektur von rektalen und kutanen Fisteln zu Urethra und Blase.

The perineal approach was used in ten patients for the repair of fistulas involving the bladder or prostatic urethra. In the case of radiotherapy-induced (n=2) or recurrent fistulas (n=4) fecal diversion and interposition of the gracilis muscle was performed. In addition in three patients prostatectomy was performed. All fistulas were repaired successfully with minimal morbidity.

Necrotizing fasciitis resulting in fatal lung aspergillosis: Uncommon pathogenesis. A case report.

We present a fatal case of Aspergillus-associated lung failure in a patient with necrotizing fasciitis. The cause of the fasciitis was a retroperitoneal perforation of a colon carcinoma. Being already a rare condition, the fasciitis did not manifest as Fournier's gangrene like similar described cases illustrate, but instead travelled along the fasciae and subcutaneous fat tissue cranially into the thoracic cavity, ultimately leading to a disseminated infection of the lungs. The lethal outcome was thus caused by respiratory failure at a time when the primary focus was already successfully treated, contrary to typical cases of necrotizing fasciitis. This case report depicts the importance of acknowledging opportunistic fungal infections in the practice of emergency surgery. Contributing factors, pathogenesis and possible prevention measures are discussed.

Evaluation of facial blood flow using three-dimensional scanning.

The Vectra X3 3-dimensional face scanner allows us to visualise the erythema of superficial layers of skin in addition to its regular scanning functions. The aim of our study was to find out whether changes we provoked in the circulation of the skin would be registered and displayed by the face scanner. We measured the circulation in the skin of the cheeks of 20 volunteers with a face scanner, a laser Doppler device, and a skin pigmentation analyser before and after the application of a nitric oxide cream. The results were compared in terms of grey tones, local concentrations of haemoglobin, and erythema. All methods showed significant changes (p<0.001) before and after application of the cream. The study proved that the Vectra X3 recognises changes in skin circulation and displays them in a simple and evident way.

Two-component collagen nerve guides support axonal regeneration in the rat peripheral nerve injury model.

Progress in material development has enabled the production of nerve guides that increasingly resemble the characteristics of an autologous nerve graft. In the present study, 20 mm adult rat sciatic nerve defects were bridged with the collagen-based, two-component nerve guide 'Neuromaix', the commercially available NeuraGen® nerve tube or an autologous nerve graft. Neuromaix was able to support structural as well as functional regeneration across this gap. The majority of the axons grew across the scaffold into the distal nerve segment and retrograde tracing confirmed that these axons were of somatosensory and motor origin. Histomorphology revealed that axons regenerating through Neuromaix exhibited reduced myelin sheath thickness, whereas axon diameter and axon density were comparable to those of the autograft. Neuromaix implantation resulted in reinnervation of the gastrocnemius muscle to a level that was not significantly different from that supported by the autograft, as demonstrated by electrophysiology. Our findings show that the use of the Neuromaix scaffold not only allowed axonal regeneration across large nerve gaps, but that the regenerating axons were also able to functionally reinnervate the muscles. These data provide a promising perspective for the first in human application of the materials. Copyright © 2016 John Wiley & Sons, Ltd.