Augmentation mastopexy using the "double inner bra technique" (DIB) in post-bariatric surgery.

BACKGROUND: Augmentation mastopexy has a 20-fold higher complication rate than primary augmentation. Performing augmentation mastopexy in post-bariatric patients poses an additional challenge owing to the reduced quality of the soft skin tissue. Therefore, it is technically complex and also fraught with complications. Implant dislocation, recurrent ptosis, wound healing problems with exposed implants, and the threat of implant loss are complications that must be prevented. METHODS: We present a case series study on our technique for stabilizing breast implants using the double inner bra technique (DIB) in which a laterobasal myofascial flap and an inferiorly based dermoglandular flap form a double inner bra for implant stabilization and protection. RESULTS: Thirty-seven cases were operated on using this technique from December 2020 to June 2023. No hematomas (0%), seromas (0%), infections (0%), and implant losses (0%) were recorded. Moreover, none of the patients had implant malposition (0%). With regard to recurrent ptosis mammae or waterfall deformity, 7 cases (2.6%) showed early ptosis within the first 3 months, and the number of ptosis decreased over time. Furthermore, 5 (1.81%) patients showed ptosis mammae after 6-12 months. Implant defect or rupture has not yet occurred (0%). CONCLUSION: The DIB is an easy-to-learn and versatile technique. It has low complication rates and can be used to achieve esthetically satisfactory mid- to long-term results.

[Role of Tranexamic Acid in Plastic Surgery: a Systematic Review] / Rolle der Tranexamsäure in der Plastischen Chirurgie: eine systematische ÜberprüfungRole of Tranexamic Acid in Plastic Surgery: a Systematic Review.

BACKGROUND: Bleeding events in surgery are a problem and can lead to revision surgery and bleeding anaemia, which sometimes must be treated by blood transfusion. Tranexamic acid is an antifibrinolytic agent and is already known for its role in the prevention and treatment of perioperative bleeding in the fields of orthopaedics, cardiovascular surgery and gynaecology. In plastic surgery, the use of tranexamic acid is increasing in popularity and has already been described in individual studies. METHODS: A literature search was performed using the database MEDLINE from the United States National Library of Medicine (NLM). The keywords "tranexamic acid in plastic surgery", "intravenous tranexamic acid in plastic surgery", "topical tranexamic acid in plastic surgery" and "subcutaneous tranexamic acid in plastic surgery" were used. The search was limited to the period from 2010 to 2023. The studies were analysed according to the level of evidence, validity and availability and divided into three groups for the topical, intravenous or subcutaneous application of tranexamic acid. Randomised controlled trials and non-randomised prospective and retrospective cohort studies were included in the systematic review. Studies from other disciplines, review articles, technical notes, experimental studies, letters to the editor, comments and case reports were excluded. RESULTS: The literature search resulted in a total of 135 papers. Of these, 56 papers were assessed as relevant to plastic surgery. After further analysis, 41 papers were excluded using the exclusion criteria described above. Fifteen studies were finally included in the present work and recommendations for possible applications such as intravenous, topical and subcutaneous application of tranexamic acid, including the indications, contraindications and dosage formulas were developed. DISCUSSION: Although the current study situation on the use of tranexamic acid is limited, the results show more advantages than disadvantages for perioperative use. Establishing the use of tranexamic acid in plastic surgery could facilitate the reduction of perioperative bleeding and lead to more precision in surgery, and it could enable a rapid removal of drains. However, following the analysis of benefit and risk factors, further randomised controlled trials are required for use in plastic surgery.

Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: Long Term Results. / Eigenfettinjektion bei Rhizarthrose: 5 Jahresergebnisse bei 42 Patienten.

BACKGROUND: Initial results after autologous fat transfer for treatment of thumb carpometacarpal joint osteoarthritis have been promising. But long-term results have not yet been available. METHODS: In a prospective study, 42 patients with thumb carpometacarpal joint osteoarthritis were observed for a mean time of 5 years after autologous fat transfer. Manual liposuction and centrifugation were performed. Pain rating according to numerous analogue pain scale; objective force of pinch grip and fist closure; and Disabilities of the Arm, Shoulder, and Hand questionnaire score (DASH score) before and after treatment were analysed. RESULTS: The average pain preoperatively was 8.0 ± 1.6 and 4.0 ± 3.0 after 5 years overall. Force and pinch force of the treated hand improved from 71% and 60% preoperative in comparison to the non-treated hand to 100% and 96%, respectively, 5 years after fat transplantation. There were similar improvements for the parameters strength and DASH score. All improvements were statistically significant. No serious adverse events were observed. CONCLUSIONS: Autologous fat transplantation is a real alternative to trapeziectomy even in the long term in basal joint osteoarthritis of the thumb. The low invasiveness of the procedure and early recovery of patients compared with classical procedures such as trapeziectomy, and the superior long-term results compared with classical injection therapy, make this approach feasible as a first-line therapy in basal joint osteoarthritis of the thumb as it offers stable results and warrants a high patient satisfaction rate.

[Settlement of the surgical treatment of lipoedema]. / Abrechnung der chirurgischen Therapie des Lipödems.

The billing of lipoedema treatment in Germany has come to be heterogeneous. This is due to the decision of the Federal Joint Committee ("Gemeinsamer Bundesausschuss", G-BA) to acknowledge lipoedema stage III as a treatment to be paid by the statutory health insurance funds ("Gesetzliche Krankenversicherung", GKV) until the completion of the trial study "LipLeg" at the end of 2024. Based on this decision, inpatient and outpatient surgical treatment of stage III lipoedema can be billed to the GKV, while the reimbursement of costs for surgical treatment of the other two stages remains a case-by-case decision of the GKV and is currently often rejected. Therefore, treatment costs are often paid by patients themselves. The question of the correct settlement of lipoedema treatment repeatedly arises in the context of legal disputes, which, in turn, repeatedly faces experts and courts with a major challenge. In the following article, the Task Force Lipoedema of the German Society for Plastic, Reconstructive and Aesthetic Surgery presents an overview of the various billing modalities and presents a proposal for the correct billing of lipoedema within the framework of the German medical fee schedule ("Gebührenordnung für Ärzte", GOÄ).

Zur medizinischen Indikation bei ästhetisch-plastischen Operationen.

The concept of indication is used in many ways in medicine and in the healthcare industry. In connection with "medical" and/or "physician-based", it is often used to describe the path that a doctor and a patient take - after weighing up all available information - to describe a common treatment goal and to define measures derived from that goal. From today's perspective, however, there is a third factor that plays a role: the healthcare industry, here in particular in the form of health insurance (both statutory health insurance and private health insurance), but more recently also in the form of financial administration. Plastic surgery is faced with the dilemma that, although there is a medically proven indication in many cases, neither the payers nor the financial courts or offices are willing to follow the medical assessment and reject the indication (usually without justification). This article offers support in defining an indication for aesthetic plastic surgery.

[Lipoabdominoplasty in post-bariatric Surgery: a relevant Alternative to Fleur-de-Lis abdominoplasty?] / Lipoabdominoplastik in der postbariatrischen Chirurgie: eine relevante Alternative zur Fleur-de-Lis-Abdominoplastik?

BACKGROUND: The number of bariatric procedures, and thus also the number of post-bariatric operations, has increased dramatically in recent years. Although long scars are common in post-bariatric surgery and accepted in favour of body shape reconstruction, we increasingly notice the wish for aesthetically pleasing results in addition to the desire for body contouring. In particular, Fleur-de-Lis abdominoplasty (FdL) is viewed critically by younger patients after massive weight loss due to the visible vertical scar. Surgeons are also often bothered by the unsatisfying aesthetic outcome as well as the higher rate of complications. METHODS: Retrospective analysis of 20 female patients with massive weight loss following bariatric surgery, who received lipoabdominoplasty instead of Fleur-de-Lis abdominoplasty in the period from January 2019 to June 2020. Data analysis was based on measurements of preoperative vertical and horizontal excess skin and fat (Pittsburgh Rating Scale), Body Mass Index, surgical technique and final result. RESULTS: Twenty female patients with an indication for FdL abdominoplasty underwent radical liposuction of the abdomen combined with abdominoplasty. The original weight before massive weight reduction ranged between 100 and 168 kg. Average weight reduction was 56.5 kg. The mean BMI was 27.3 kg/m². The average age of our cohort was 40 years. One patient (5 %) had a major complication. This was an infected seroma which could be treated conservatively. Two other patients (10 %) developed an uninfected seroma as a minor complication. CONCLUSION: Our work shows that lipoabdominoplasty can be performed safely and well even in patients after massive weight loss. It is possible to achieve good body contours without vertical incisions and with a high degree of patient satisfaction. The number of patients who have to undergo FdL abdominoplasty can be successfully reduced by this technique.

[Liposuctions in the ambulatory setting]. / Fettabsaugungen im ambulanten Setting.

BACKGROUND: Liposuctions are among the most frequently performed operations in plastic surgery worldwide. They are offered as inpatient as well as outpatient procedures. In the outpatient setting, tumescent anaesthesia is used in various forms. There is ambiguity about the amount of lipoaspirate that can be removed safely in an outpatient setting, and also about the monitoring of parameters and the duration of postoperative care. MATERIAL AND METHODS: A systematic literature review was conducted with the help of the MEDLINE data base of the U. S. National Library of Medicine (NLM) and the bibliographic search engine Google Scholar (https://scholar.google.com) of Google LLC. The key words "Liposuction Anesthesia" and "Liposuction Guidelines" were used. All items resulting from the search were checked for thematic concordance and further analysed by their level of evidence, significance and availability. RESULTS: After the literature review, a total of 197 items were identified for further analysis. The analysis of the international and German literature yielded a systematic overview of recommendations. CONCLUSIONS: Tumescence anaesthesia in an outpatient setting has various advantages, e. g. cost reduction for provider and patient as well as avoidance of the risk profile of general anaesthesia. Also patients can change their position autonomously, which can be beneficial for surgery. However, there are limitations in terms of the lipoaspirate volume that can be removed safely. With increasing lipoaspirate volumes, more local anaesthetic is needed, which also increases the postoperative monitoring time. In the authors view, tumescent anaesthesia should only be used for small-volume and localised liposuctions. Liposuction in general anaesthesia offers more advantages, especially with increasing lipoaspirate volumes.

[Complex microsurgical reconstructions: relevant billing in an outdated CPT system]. / Komplexe mikrochirurgische Rekonstruktionen und ihre gebührenrechtliche Abbildung im antiquierten Vergütungssystem der GOÄ.

The German equivalent of the USA CPT Code dates in his surgical parts back to 1996. This implies that modern surgical procedures cannot be adequately coded.This article discusses the codes that are frequently challenged by insurance companies and justifies their application with relevant judicial decisions.

[Current aspects regarding the documentation and publication of photos in plastic surgery]. / Aktuelle Aspekte zur Fotodokumentation in der Plastischen Chirurgie und deren Veröffentlichung.

When using photos of patients for the purpose of documentation, their distribution or publication various legal obligations are to be considered. It is essential to know in which cases a written consent of the patient is mandatory and when it is not necessary. Moreover, it is decisive to note that even if a written consent of the patient exists, there are laws in the German legal system that regulate the publication of photo documentations. This is a difficult-to-read legal issue that unsettles many medical colleagues. In the following review we have tried to put the most important parts of the relevant legislation into an easier-to-read context.

[Medical malpractice in the treatment of carpometacarpal osteoarthritis of the thumb - An analysis of data provided by the Arbitration Board for Medical Liability Issues of North Germany]. / Behandlungsfehler bei der Therapie der Rhizarthrose ­ Eine Analyse der Daten der Norddeutschen Schlichtungsstelle für Arzthaftpflichtfragen.

BACKGROUND: Osteoarthritis of the first carpometacarpal (CMC) joint, also known as rhizarthrosis, is one of the most common diseases of the hand. Multiple medical and paramedical disciplines can be involved in the treatment. Interventional and surgical treatments may have a risk of complications and thus also of medical malpractice. In this paper, cases of medical malpractice in treatments of rhizarthrosis were analysed, in order to evaluate the quality of medical care. PATIENTS AND METHODS: Cases of medical malpractice with the diagnosis "Rhizarthrosis" (ICD-10 M18) from 2010 until 2018 were provided by the Arbitration Board for Medical Liability Issues of the Medical Associations of North Germany. The cases were allocated according to the medical specialty of the attending physician. Cases with verified medical malpractice were further evaluated and statistically analysed. RESULTS: 44 cases with purported medical malpractice were found over a period of 9 years. In 16 of these cases, medical malpractice was verified (36.4 %): hand surgeons 8 of 24 (30.0 %), trauma and orthopaedic surgeons 6 of 14 (42.9 %), plastic surgeons 1 of 2 (50.0 %), general surgeons 1 of 1 (100.0 %) and 0 of 1 (0.0 %) each in the specialties of diagnostic radiology, radiation therapy and anaesthesiology. Surgeons with specialisation in hand surgery were responsible for 30.0 % (8 of 24) cases of verified malpractice, compared to 47.1 % (8 of 17) cases in other surgeons without this specialisation (p = 0.286). CONCLUSIONS: As surgical procedures for the treatment of rhizarthrosis are among the most common hand surgeries, the data shows that the treatment of rhizarthrosis in Germany is safe and has a very low rate of medical errors. Furthermore, medical malpractice in these cases is less frequent in surgeons with a specialisation in hand surgery compared to surgeons without this specialisation.

[Prior cost approval for treatment of lipoedema: things to consider]. / Kostenübernahmen beim Lipödem ­ was ist zu beachten?

Lipoedema used to be a rather unknown disease. In the past five years, it has gained increasing awareness, especially through media attention. Besides non-surgical treatment by complex conservative decongestion, there are an increasing number of studies pointing out the potential of liposuction for a successful treatment of lipoedema. As a result, an increasing number of affected patients present to plastic surgeons and request correction and pain relief.As the German Federal Joint Committee (Gemeinsamer Bundesausschuss (G-BA)) has not positively acknowledged liposuction as a treatment for lipoedema so far, coverage of the procedure by the statutory health insurance is still a decision on a by-case basis. Therefore, patients seeking liposuction treatment must apply for prior cost approval from the statutory health insurance in cooperation with their plastic surgeon. The review at hand provides a summary of the current prevailing legal norms and gives advice on how to apply for prior cost approval.

[Arbitration proceedings caused by communication problems]. / Die ärztliche Kommunikation als Auslöser von Schlichtungsverfahren.

INTRODUCTION: Functioning communication is one of the basic elements of a trusting doctor-patient relationship. Good medical communication is more important than ever in times of increasing personnel and time constraints. The aim of this study was to examine to what extent medical communication has an influence on the initiation of arbitration procedures. MATERIAL AND METHODS: The analysis was based on arbitration cases of plastic surgery, which were processed and completed by the Arbitration Board for Medical Liability Issues of North Germany between 2005 and 2015. After eliminating cases with incomplete data, 280 cases were evaluated. The documents were examined for possible communication errors and other triggers of the proceedings. If communication errors were present, these were analysed more closely. Furthermore, it was verified if treatment errors were suggested to patients, e. g. by physicians in charge of aftercare. RESULTS: 53.6 % of all cases emerged from communication errors in primary care, mainly caused by the attending surgeon (93.7 %). The outpatient follow-up treatment was identified as the most critical period (48.7 %). The most common problem was that patients felt they were not taken seriously (30.9 %). Further aspects were non-availability of the treating doctor (12.2 %), insults or disrespect (8.5 %), inadequate provision of information (8.5 %), and a lack of therapeutic enlightenment (8.1 %). In 43.9 % of the cases, treatment errors were suggested to patients, primarily by the after-treatment physician (70.3 %). DISCUSSION: The results show that inadequate medical communication has a considerable influence on the overall satisfaction of patients. Statements that appear normal to the surgeon may cause significant emotional reactions in patients. This study shows that arbitration procedures are not only triggered by "real" treatment errors and damage, but also by communication problems. Good communication and empathy help to reduce dissatisfaction and the risk of possible legal disputes.

[Conciliatory proceedings of a German mediation center after breast augmentations]. / Schlichtungsverfahren nach Mammaaugmentationen ­ eine Analyse der Eingriffe mit Behandlungsfehler und Haftungsanspruch der Norddeutschen Schlichtungsstelle.

Introduction The requested by the "Norddeutsche Schlichtungsstelle ["North German Mediation Centre"] reveal the complications and problems of breast augmentation. The North German Mediation Centre is responsible for ten federal states in Germany (Berlin, Brandenburg, Bremen, Hamburg, Mecklenburg-Western Pomerania, Lower Saxony, Saarland, Saxony-Anhalt, Schleswig-Holstein and Thuringia) and is thus the largest mediation centre in Germany Material and Methods We analysed requests from patients, expert reports ordered by the North German Mediation Centre and the final verdicts of mediations after breast augmentations between 2000 and 2007. This approach has the advantage that it addresses the topic from different viewpoints. Furthermore we analysed the statistical data provided by the mediation centre. Results In 44 % of the patient´s requests, a causal relationship was confirmed between the damage caused to the patient's health and malpractice. This is much greater than the overall figure for the mediation centre, which is that a causal relationship was confirmed in only 24 % of cases. The 66 patient requests after breast augmentations included 29 cases with liability. In 86 % of the cases, the expert opinions concluded that mistakes were made during planning (72 %). Most frequently, surgical incisions were incorrect (45 %), followed by the preparation of the pocket (28 %), the surgical approach (31 %) and the implant size (17 %). The patients mainly complained about asymmetry (79 %) and the position of the implants (62 %) or the size of the breasts after surgery (38 %). Discussion The greater frequency of a causal relationship between the damage caused to patient health and malpractice - in comparison to the general statistics - may be due to the greater complexity of breast augmentation than generally expected. Not only the surgery itself, but - to an even greater extent - adequate planning and aftercare are of predominant importance in satisfying the patient. All these factors and the high expectations of the patients lead to a higher request rate.

Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study.

BACKGROUND: Most operations for carpometacarpal joint osteoarthritis of the thumb irreversibly alter or destroy the anatomy. There is a high demand for minimally invasive alternatives. The authors report the results of autologous fat transfer for treatment of thumb carpometacarpal joint osteoarthritis. METHODS: In a prospective study, 50 patients with thumb carpometacarpal joint osteoarthritis were observed for 1 year after autologous fat transfer. Manual liposuction and centrifugation were performed. Pain rating according to visual analogue pain scale; objective force of pinch grip and fist closure; and Disabilities of the Arm, Shoulder, and Hand questionnaire scores before and after treatment were analyzed. RESULTS: The average pain in stage 2 patients preoperatively was 7.7 ± 1.3; it was 1.8 ± 1.9 after 6 months and 2.4 ± 3.1 after 12 months. Patients with stage 2 osteoarthritis demonstrated a superior benefit from this treatment compared with patients with either stage 3 or stage 4 thumb carpometacarpal joint osteoarthritis. There were similar improvements for the parameters strength and Disabilities of the Arm, Shoulder, and Hand questionnaire score. No serious adverse events were observed. CONCLUSIONS: Autologous fat transplantation is an appealing alternative, especially in early-stage basal joint osteoarthritis of the thumb. The low invasiveness of the procedure and early recovery of patients compared with classical procedures such as trapeziectomy, and the superior long-term results compared with classical injection therapy, make this approach feasible as a first-line therapy in early-stage basal joint osteoarthritis of the thumb. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

[Does the hand solely belong in the hands of a qualified hand surgeon?] / Gehört die Hand alleine in die Hand des Handchirurgen?

Background In Germany, Hand Surgery is an additional qualification that can only be obtained by a three-year training after a completed residency in General Surgery, Plastic Surgery or Trauma and Orthopaedic Surgery. Nevertheless, injuries and diseases of the hand are also treated by physicians without this particular qualification. It is questionable whether these treatments more often lead to medical malpractice. Material and Methods 376 charges of medical malpractice in surgical treatments of the hand and forearm that were closed in 2014 and 2015 were collected by the Arbitration Board for Medical Liability Issues of the Medical Association of North Germany.Cases with proven medical malpractice were classified by the qualification of the physician in charge and analysed. A statistical analysis was performed with the use of the program SPSS (IBM). Results Medical malpractice was proven in 42 of 113 cases with an attending physician who held the additional qualification for Hand Surgery (37.2 %). For physicians without this qualification, the figures were 79 out of 155 (51.0 %) in the group of trauma and orthopaedic surgeons and 54 out of 108 (50.0 %) in the group of general surgeons. The differences between the hand surgeons and the trauma and orthopaedic surgeons (p = 0.017) and between hand surgeons and general surgeons were significant (p = 0.037). Conclusions It was shown that physicians with an additional qualification in hand surgery had signifcantly fewer proven medical malpratice cases than physicians without this qualification. The following trends were observed in the cases of the physicians without the additional qualification in hand surgery: underestimation of the severity of trauma to soft tissues and infections of the hand, errors in the surgical examination of the hand, including functional tests of tendons and nerves, as well as in diagnostic findings after X-ray studies of the hand.

G-spot augmentation with autologous fat transplantation.

Lipofilling for G-spot augmentation is appealing because long-term persistence of the fat is expected to be very good. We report the case of a 29-year-old patient who requested G-spot augmentation to enhance sexual sensation. Autologous fat (8 cc) that was harvested from the trochanteric area was injected. Although there are few published data acknowledging the presence of the G-spot, the patient was satisfied with the procedure and no side effects occurred. Nevertheless, evaluation with standard questionnaires, such as Fragebogen zur Lebenszufriedenheit (FLZ) and Kurzfragebogen für sexuelle Probleme (KFSP-F), did not indicate the positive effects on subjective well-being and sexual parameters of a surgical G-spot augmentation. Studies comprising a larger series of patients are required before substantiated recommendations regarding the benefits and risks of this procedure will be possible.