Measuring quality of care in autologous breast reconstruction: a Delphi consensus.

Measuring and benchmarking quality of care in surgical oncology has been gaining popularity. In autologous breast reconstruction (ABR), a standardized set of indicators to assess quality of care is lacking. In this study, we defined a set of evidence-based quality indicators for autologous breast reconstruction. First, we performed a systematic review to identify factors related to quality of care in ABR. Variables were categorized depending on their function: indicators related to outcome, indicators related to process and case-mix variables. The review was followed by a 3-round Delphi Consensus to determine which indicators and case-mix-variables were considered relevant and feasible for inclusion in an ABR standard set of indicators. 932 unique articles were identified, of which 110 papers were included in the study. Indicators were categorized by function: outcome, process and case-mix variables. In total, 8 process indicators and 41 outcome indicators were extracted. 30 case-mix-variables were included. Following 3 rounds of questioning in the Delphi Consensus, all respondents agreed on type of ABR, oncological outcomes and patient satisfaction for the standard set. Indicators related to complications were consistently ranked highly. Most process indicators were not chosen after 3 rounds of questioning. 11 case-mix-variables were included in the final set. Following the Delphi Consensus, it was possible to identify 33 process and outcome indicators and 11 case-mix-variables for inclusion for a standard set of quality indicators. With the inclusion of both objective and patient-reported outcome measures, this set of indicators provides a multidimensional measurement tool for quality assessment for ABR.

[Locoregional solutions for groin defects : Coverage after vascular surgery]. / Lokoregionale Lösungen bei Leistendefekten : Deckung nach gefäßchirurgischen Eingriffen.

INTRODUCTION: Vascular surgery through a groin incision may be associated with severe wound healing disorders in this sensitive area. There are many options to reconstruct the defect surgically. The choice of surgical reconstruction depends mainly on the individual status of vasculature, which is most often compromised in these patients. There are random pattern flaps, as well as perforator, pedicled flaps or microvascular flaps to choose from. AIM: We give an overview of plastic surgical solutions for groin defects, with a special focus on complex wounds after vascular surgical complications. We discuss advantages and disadvantages of different flaps with two case reports and also show alternatives. PATIENTS AND METHODS: We demonstrate in two cases how the reconstruction of the groin defect was planned, taking into account the vascular status, and why we chose an innovative and seldom-used option in each case. RESULTS: The selected flaps, a pedicled fasciocutaneous ALT propeller flap and a perforator-based, pedicled abdominal advancement flap reconstructed the defects successfully. DISCUSSION: The surgical therapy for the reconstruction of groin defects should be chosen according to the individual vascular status to ensure safe and reliable blood supply. To guarantee the best possible reconstruction and avoid postoperative healing disorders and infections, less common flaps should also be considered.

[Current Perceptions of Lipofilling on the Basis of the New Guideline on "Autologous Fat Grafting"]. / Aktuelle Erkenntnisse zur Eigenfett Transplantation anhand der neuen Leitlinie "Autologe Fetttransplantation".

Introduction: Autologous fat transfer has recently become an increasingly popular surgical procedure and comprises harvesting, processing and transplantation of adipose tissue, as well as professional follow-up care. This method, as a surgical procedure, can be utilised for trauma-, disease- or age-related soft tissue volume deficits and soft tissue augmentation. As usage is increasing, but the variables of fat harvest, specific indications and fashion of fat transfer are poorly defined, there is a great demand for development of a guideline in the field of reconstructive and aesthetic surgery. Methods: All relevant points were discussed within the scope of a consensus conference including a nominal group process of all societies involved in the procedure and ratified with a strong consensus (>95%). Literature from the standard medical databases over the last 10 years was retrieved, studied and specific guidelines were concluded. Results: Consensus was achieved among all professionals involved on the following points: 1. definition 2. indication/contraindication, 3. preoperative measures 4. donor sites 5. techniques of processing 6. transplantation 7. follow-up care 8. storage 9. efficacy 10. documentation 11. evaluation of patient safety. Conclusion: Definite indications and professional expertise are paramount for autologous fat tissue transfer. Successful transfers are based on the use of correct methods as well as specific instruments and materials. Autologous adipose tissue transplantation is considered to be a safe procedure in reconstructive and aesthetic surgery, due to the low rate of postoperative complications and sequelae.

[Training in aesthetic surgery at a university clinic - the "Munich model"]. / Weiterbildung in der ästhetischen Chirurgie an einer Universitätsklinik - Das "Münchner Modell"

BACKGROUND: Aesthetic surgery is regarded as one of the 4 pillars of plastic surgery. To assure safety in this field of surgery, a structured and well guided surgical training is indispensable. However, during the specialist training for plastic and aesthetic surgery, plastic aesthetic interventions are often carried out in low numbers only. Objective of the present study was the development, implementation and evaluation of a new training concept in aesthetic surgery. PATIENTS: Over a period of 2 years, 304 aesthetic operations were performed in the fields of body contouring, breast surgery and facial surgery as an "educational surgery". Educational surgeries were performed by resident surgeons under the guidance of experienced specialists and under favourable financial conditions. As indicator for safety of the interventions, the incidence of complications was recorded and assessed. RESULTS: Out of a total of 304 operations included in the study 47.7% were performed as an educational surgery. In the fields of body contouring and breast surgery, the majority of interventions (51.3% and, respectively, 53%) were carried out as educational surgeries. In aesthetic surgeries of the face only 28.4% were educational surgeries. In 4.9% of all cases complications occurred. The incidences of complications were approximately the same in the educational surgeries (5.5%) and in the surgeries carried out by experienced specialists (4.4%), showing no significant difference. CONCLUSION: The presented training concept aims at ensuring high quality in patient care by structure and quality of surgical training. Our data give evidence that a structured training of residents in the field of aesthetic surgery is possible without loss in quality. We expect that -sufficient surgical education and the associated quality will consequently contribute to keep aesthetic surgeries a domain of plastic surgery and to prevent these procedures from being taken over by other surgical disciplines.

[Erythropoietin in plastic surgery]. / Erythropoetin in der Plastischen Chirurgie.

EPO is an autologous hormone, which is known to regulate erythropoiesis. For 30 years it has been used for the therapy of diverse forms of anaemia, such as renal anaemia, tumour-related anaemias, etc. Meanwhile, a multitude of scientific publications were able to demonstrate its pro-regenerative effects after trauma. These include short-term effects such as the inhibition of the "primary injury response" or apoptosis, and mid- and long-term effects for example the stimulation of stem cell recruitment, growth factor production, angiogenesis and re-epithelialisation. Known adverse reactions are increases of thromboembolic events and blood pressure, as well as a higher mortality in patients with tumour anaemias treated with EPO. Scientific investigations of EPO in the field of plastic surgery included: free and local flaps, nerve regeneration, wound healing enhancement after dermal thermal injuries and in chronic wounds.Acute evidence for the clinical use of EPO in the field of plastic surgery is still not satisfactory, due to the insufficient number of Good Clinical Practice (GCP)-conform clinical trials. Thus, the initiation of more scientifically sound trials is indicated.

First-aid with warm water delays burn progression and increases skin survival.

INTRODUCTION: First aid treatment for thermal injuries with cold water removes heat and decreases inflammation. However, perfusion in the ischemic zone surrounding the coagulated core can be compromised by cold-induced vasoconstriction and favor burn progression. The aim of this study is to evaluate the effect of local warming on burn progression in the rat comb burn model. METHODS: 24 male Wistar rats were randomly assigned to either no treatment (control) or application of cold (17 °C) or warm (37 °C) water applied for 20 min. Evolution of burn depth, interspace necrosis, and microcirculatory perfusion were assessed with histology, planimetry, respectively with Laser Doppler flowmetry after 1 h, as well as 1, 4, and 7 days. RESULTS: Consistent conversion from a superficial to a deep dermal burn within 24 h was obtained in control animals. Warm and cold water significantly delayed burn depth progression, however after 4 days the burn depth was similar in all groups. Interspace necrosis was significantly reduced by warm water treatment (62±4% vs. 69±5% (cold water) and 82±3% (control); p<0.05). This was attributed to the significantly improved perfusion after warming, which was present 1 h after burn induction and was maintained thereafter (103±4% of baseline vs. 91±3% for cold water and 80±2% for control, p<0.05). CONCLUSION: In order to limit damage after burn injury, burn progression has to be prevented. Besides delaying burn progression, the application of warm water provided an additional benefit by improving the microcirculatory perfusion, which translated into increased tissue survival.

Erythropoietin in the prevention of experimental burn progression.

BACKGROUND: Damage control is essential in first aid of burn lesions. The aim of the present study was to investigate whether systemic erythropoietin (EPO) administration could prevent secondary burn progression in an experimental model. METHODS: The burn comb model creates four rectangular burn surfaces intercalated by three unburned zones prone to progression. Twenty-one Wistar rats were randomized to a control group or to receive intraperitoneal EPO (500 units per kg) once a day for 5 days starting 45 min (EPO45min) or 6 h (EPO6h) after burn injury. Histological analyses assessing burn depth, inflammation and neoangiogenesis, planimetric evaluation of burn progression, and laser Doppler flowmetry to assess perfusion were performed after 1, 4 and 7 days. Final scarring time and contracture rate were assessed once a week. RESULTS: Burn progression was decreased significantly with EPO45min but not EPO6h; progression of burn depth stopped in the intermediate dermis (mean(s.e.m.) burn depth score 3·3(0·6) for EPO45min versus 4·7(0·3) and 5·0(0·0) for EPO6h and control respectively on day 7; P = 0·026) and the surface extension was significantly reduced (45(8), 65(4) and 78(4) respectively on day 7; P = 0·017). This was paralleled by faster re-establishment of perfusion with EPO45min (114(5) per cent on day 4 versus 85(6) and 91(3) per cent for EPO6h and control respectively; P = 0·096). The reduction in progression resulted in a decreased healing time (7·3(0·7) weeks for EPO45min versus 11·5(1·0) and 10·8(0·5) weeks for EPO6h and control; P = 0·020) and contracture rate (P = 0·024). CONCLUSION: Early EPO prevented burn progression, mainly by improved vascular perfusion.

Ghrelin protects musculocutaneous tissue from ischemic necrosis by improving microvascular perfusion.

Persistent ischemia in musculocutaneous tissue may lead to wound breakdown and necrosis. The objective of this experimental study was to analyze, whether the gastric peptide ghrelin prevents musculocutaneous tissue from necrosis and to elucidate underlying mechanisms. Thirty-two C57BL/6 mice equipped with a dorsal skinfold chamber containing ischemic musculocutaneous tissue were allocated to four groups: 1) ghrelin; 2) N(ω)-nitro-l-arginine methyl ester (l-NAME); 3) ghrelin and l-NAME; and 4) control. Microcirculation, inflammation, angiogenesis, and tissue survival were assessed by fluorescence microscopy. Inducible and endothelial nitric oxide synthase (iNOS I and eNOS), vascular endothelial growth factor (VEGF), as well as nuclear factor κB (NF-κB) were assessed by Western blot analysis. Ghrelin-treated animals showed an increased expression of iNOS and eNOS in critically perfused tissue compared with controls. This was associated with arteriolar dilation, increased arteriolar perfusion, and a sustained functional capillary density. Ghrelin further upregulated NF-κB and VEGF and induced angiogenesis. Finally, ghrelin reduced microvascular leukocyte-endothelial cell interactions, apoptosis, and overall tissue necrosis (P < 0.05 vs. control). Inhibition of nitric oxide by l-NAME did not affect the anti-inflammatory and angiogenic action of ghrelin but completely blunted the ghrelin-induced tissue protection by abrogating the arteriolar dilation, the improved capillary perfusion, and the increased tissue survival. Ghrelin prevents critically perfused tissue from ischemic necrosis. Tissue protection is the result of a nitric oxide synthase-mediated improvement of the microcirculation but not due to induction of angiogenesis or attenuation of inflammation. This might represent a promising, noninvasive, and clinically applicable approach to protect musculocutaneous tissue from ischemia.

[Perioperative coagulation management in microsurgery: report of the consensus workshops in the course of the 31st and 32nd Annual Meeting of the German-language Working Group for microsurgery of the peripheral nerves and vessels (DAM) November 2009 in Erlangen and November 2010 in Basel]. / Perioperatives Gerinnungsmanagement in der Mikrochirurgie - Bericht der Konsensus-Workshops im Rahmen der 31. und 32. Jahrestagung der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße (DAM) im November 2009 in Erlangen und November 2010 in Basel.

Microsurgery is a very relevant component of reconstructive surgery. In this context anticoagulation plays an increasing role. At the moment there are no unanimously accepted prospective studies or generally accepted regimes available that could serve as evidence-based guidelines for the prevention of thrombosis in microsurgery. With regard to this problem the aim of a series of workshops during the annual meetings of the German-speaking group for microsurgery in 2009 and 2010 was to establish a first possible consensus. This article reflects the main aspects of the ongoing development of a generally acceptable guideline for anticoagulation in microsurgery as interim report of these consensus workshops. Basically there are 3 main agents in thromboprophylaxis available: antiplatelet drugs, dextran and heparin. In the course of the workshops no general use of aspirin or dextran for anticoagulation in microsurgery was recommended. The use of heparin as anticoagulation agent is advisable for different indications. Low molecular heparins (LMH) have certain advantages in comparison to unfractionated heparins (UFH) and are therefore preferred by most participants. Indications for UFH are still complex microsurgical revisions, renal failure and some specific constellations in patients undergoing reconstruction of the lower extremity, where the continuous administration of heparin is recommended. At the moment of clamp release a single-shot of UFH is still given by many microsurgeons, despite a lack of scientific evidence. Future prospective clinical trials and the establishment of a generally accepted evidence-based guideline regarding anticoagulation treatment in microsurgery are deemed necessary.

N-acetylcysteine attenuates leukocytic inflammation and microvascular perfusion failure in critically ischemic random pattern flaps.

INTRODUCTION: Microcirculatory dysfunction causes ischemia resulting in tissue necrosis. N-acetylcysteine (NAC) has been shown capable of protecting tissue from ischemic necrosis. However, the mechanism of action of NAC is yet not fully understood. OBJECTIVE: Herein, we studied whether NAC is capable of attenuating microvascular perfusion failure in critically ischemic musculo-cutaneous tissue. MATERIAL AND METHODS: A laterally based skin flap was elevated in the dorsum of C57BL/6 mice and fixed into a dorsal skinfold chamber. Arteriolar perfusion, functional capillary density, leukocytic inflammation, apoptotic cell death, and non-perfused tissue area were repetitively analyzed over 10 days by intravital fluorescence microscopy. Treatment with either 100mg/kg NAC or saline (control) was started 30 min before surgery and was continued until day 10 after flap elevation. RESULTS: Surgery induced leukocytic inflammation, microvascular perfusion failure, apoptosis, and tissue perfusion failure. NAC was capable of significantly attenuating the area of non-perfused tissue. This was associated by a marked arteriolar dilation and an increased capillary perfusion. NAC further reduced the ischemia-associated leukocytic response and significantly attenuated apoptotic cell death in all areas of the flap. CONCLUSION: NAC is effective to attenuate leukocytic inflammation and microvascular perfusion failure in critically ischemic tissue. Thus, NAC treatment may represent a promising approach to improve the outcome of ischemically endangered flap tissue.

[The role of erythropoietin in improvement of wound healing]. / Die Rolle von Erythropoietin bei der Verbesserung der Wundheilung.

Pleiotropic substances are characterized by their versatile and complex range of actions which makes them potential new active agents for the therapy of wounds. Besides its known effect to increase red blood cell production, the glycoprotein hormone erythropoietin (EPO) has been found to demonstrate a tissue protective effect in several other organs. The administration of EPO during skin wound healing is most likely essentially based on its cytopotective, proangiogenic, antiapoptotic and antiinflammatory effects. Herein EPO stimulates a coordinated interaction of different types of cells at a low or only a single dose. This review article aims to present the advantages and disadvantages of EPO administration in different experimental models to study the healing and regeneration processes of the skin and discusses possible clinical applications.

An old dream revitalised: preconditioning strategies to protect surgical flaps from critical ischaemia and ischaemia-reperfusion injury.

The prevention of ischaemia and the adequate restitution of blood flow to ischaemic tissue are pivotal to halt the progression of cellular injury associated with decreased oxygen and nutrient supply. Accordingly, the search for novel strategies which aim at preventing ischaemia-reperfusion-induced tissue damage is still of major interest in flap surgery. Preconditioning represents an elegant approach to render the tissue more resistant against deleterious ischaemic insults. For many decades, 'surgical delay' has been the standard method of tissue preconditioning. During the last 10 years, ischaemic preconditioning was added to the repertoire of plastic surgeons to protect flaps from ischaemic necrosis. The invasiveness and expenditure of time of these procedures, however, have always been major drawbacks, hindering a wide distribution in clinical practice. Consequently, the motivation has all along been to further refine and simplify protective strategies. Recent experimental studies have now shown that efficient protection from ischaemic necrosis can also be achieved by remote preconditioning or pretreatment with chemical agents and growth factors, which mimic the action of surgical delay and ischaemic preconditioning. In addition, the local application of unspecific stressors, including both heating and cooling, have been shown to effectively improve flap microcirculation and, thus, tissue survival. In view of successful translational research, it is now time that the efficacy of these novel preconditioning procedures is proven in prospective randomised clinical trials.

[Pain therapy--legal reference points and stumbling blocks]. / Schmerztherapie.

In this day and age expertise in pain therapy is required in all fields of medicine. Unfortunately pain therapy has become a recurrent focus of forensic considerations. Legal experience shows that preliminary criminal proceedings and civil liability suits also involve pain specialists and palliative physicians, but not inordinately; in fact, most cases concern other medical disciplines such as a general medicine, internal medicine, surgical specialties, and the field of patient care. From the legal point of view, it should be taken into account that every patient is entitled to receive adequate pain therapy. This should be ensured in both private practice and the inpatient setting, if necessary by calling in a pain specialist. If the patient s incapable of giving consent, in emergency situations the assumption can be made that the patient desires optimal pain control. If the circumstances are not urgent, the decision is made by the Guardianship Court or a representative empowered by the patient while still capacitated. All measures for pain management including information given to the patient should be precisely documented by the physician.

[Pain therapy--legal reference points and stumbling blocks]. / Schmerztherapie--rechtliche Eckpunkte und Stolpersteine.

Pain therapy and palliative medicine have gained new importance in medical treatment in recent years. Pain is no longer considered an acceptable evil; in fact, awareness has increased that even in tumor patients and those with chronic pain the available options for special pain therapy can provide long-term pain relief. Pain therapy is not limited to these fields but applies to all areas of medicine. Unfortunately though, pain therapy has become the focus of forensic considerations, illustrated by the current case of an internist in Hannover who has to answer for eight counts of manslaughter this year. She is charged with ordering inappropriately high doses of morphine and in part excessive administration of diazepam. Legal practice shows however that the predominant number of preliminary criminal proceedings and civil liability lawsuits do not involve pain specialists and palliative physicians, but rather other specialties such as the surgical disciplines and patient care. This is not surprising since good pain therapy is at present expected in all branches of medicine but obviously those fields not specialized in this subject lag further behind in these expectations than those already dedicated to pain therapy or palliative medicine.

The influence of local and systemic preconditioning on oxygenation, metabolism and survival in critically ischaemic skin flaps in pigs.

Stress proteins represent a group of highly conserved intracellular proteins that provide adaptation against cellular stress. The present study aims to elucidate the stress protein-mediated effects of local hyperthermia and systemic administration of monophosphoryl lipid A (MPL) on oxygenation, metabolism and survival in bilateral porcine random pattern buttock flaps. Preconditioning was achieved 24h prior to surgery by applying a heating blanket on the operative site (n = 5), by intravenous administration of MPL at a dosage of 35 microg/kg body weight (n = 5) or by combining the two (n = 5). The flaps were monitored with laser Doppler flowmetry, polarographic microprobes and microdialysis until 5h postoperatively. Semiquantitative immunohistochemistry was performed for heat shock protein 70 (HSP70), heat shock protein 32 (also termed haem oxygenase-1, HO-1), and inducible nitrc oxide synthase (iNOS). The administration of MPL increased the impaired microcirculatory blood flow in the proximal part of the flap and partial oxygen tension in the the distal part by approximately 100% each (both P<0.05), whereas both variables remained virtually unaffected by local heat preconditioning. Lactate/pyruvate (L/P) ratio and glycerol concentration (representing cell membrane disintegration) in the distal part of the flap gradually increased to values of approximately 500 mmol/l and approximately 350 micromol/l, respectively (both P<0.01), which was substantially attenuated by heat application (P<0.01 for L/P ratio and P<0.05 for glycerol) and combined preconditioning (P<0.01 for both variables), whereas the effect of MPL was less marked (not significant). Flap survival was increased from 56% (untreated animals) to 65% after MPL (not significant), 71% after heat application (P<0.05) and 78% after both methods of preconditioning (P<0.01). iNOS and HO-1 were upregulated after each method of preconditioning (P<0.05), whereas augmented HSP70 staining was only observed after heat application (P<0.05). We conclude that local hyperthermia is more effective in preventing flap necrosis than systemic MPL administration because of enhancing the cellular tolerance to hypoxic stress, which is possibly mediated by HSP70, whereas some benefit may be obtained with MPL due to iNOS and HO-1-mediated improvement in tissue oxygenation.

Heparin-protamine does not aggravate local LPS-provoked leukocytic inflammation in vivo.

OBJECTIVE: Secondary complications involving inflammation limit postoperative results in cardiac surgery. Because heparin-protamine can elicit inflammatory reactions, this study evaluates in vivo whether treatment with heparin-protamine aggravates local endotoxin-induced injury. METHODS: Mice received intravenous injections of either heparin-protamine, protamine alone or PBS for controls, before local air pouch challenge with LPS. Leukocytes recruited within the air pouches were collected and analyzed by flow cytometry. RESULTS: LPS provoked a local leukocytic infiltration in a dose- and time-dependent manner with significantly elevated numbers of 1.75 +/- 0.29 x 10 (6) cells after four hours compared to non-LPS-stimulated controls (0.55 +/- 0.08 x 10 (6) cells). Recruited cells comprised of 74 +/- 4 % PMNLs and 26 +/- 4 % MNLs. The largest fraction of MNLs was positive for the T cell-specific marker CD90.2 (59 +/- 6 %). B cells were only rarely observed (4 +/- 1 %). In non-LPS-challenged air pouches, heparin-protamine provoked a leukocytic infiltration, which was comparable to that observed after LPS (1.51 +/- 0.22 x 10 (6) cells). However, neither heparin-protamine nor protamine alone aggravated the LPS-mediated leukocyte recruitment (2.25 +/- 0.25 x 10 (6) and 1.77 +/- 0.23 x 10 (6) cells). Neither treatment influenced the distribution of leukocyte subpopulations compared to PBS-treated controls. Furthermore, surface expression of CD11a and CD11b on blood leukocytes did not differ between the groups, indicating that protamine does not increase the activation of circulating leukocytes during LPS-induced local inflammation. CONCLUSIONS: Our data indicate that heparin-protamine, although pro-inflammatory in nature, does not aggravate local inflammation provoked by LPS. Thus, enhanced inflammation during the perioperative course of cardiac surgery patients seems not to be attributable to the intraoperative use of heparin-protamine.

The cervical lymph node preparation: a novel approach to study lymphocyte homing by intravital microscopy.

OBJECTIVE: Lymphocyte recirculation constitutes an integral part of the adaptive immune system. Blood-borne lymphocytes migrate into secondary lymphoid organs, crossing the vascular wall of site-specific high endothelial venules (HEVs). We created a preparation of the cervical lymph node in mice to study lymphocyte homing in vivo. METHODS AND RESULTS: Our novel approach allowed the detailed analysis of hemodynamics and lymphocyte-HEV endothelium interactions by means of intravital fluorescence microscopy. We confirm the key roles of L-selectin and LFA-1 for lymphocyte homing. Blockade of L-selectin function inhibited lymphocyte rolling and firm adhesion by 92% and 66%. In LFA-1-deficient mice, lymphocyte firm adhesion was reduced by 70%. In addition to the microcirculation studies, the cervical lymph node preparation allowed for visualization of afferent lymphatic transport, which is mainly derived from the oral mucosa. CONCLUSION: This study reports a novel technical tool for the detailed in vivo analysis of adaptive immune responses.