[Diagnosis Related Groups in reconstructive plastic surgery of malignant head and neck skin tumours]. / Fallpauschalenabbildung plastischer Rekonstruktionen bei malignen Hauttumoren im Kopf-Hals-Bereich.

BACKGROUND: Diagnosis Related Groups (DRGs) were introduced in Germany as a medico-economic classification system 13 years ago. In this analysis, we looked into the compensation for reconstructive plastic surgery after the excision of malignant head and neck skin tumours by DRGs. MATERIAL AND METHODS: Four main diagnoses (malignant melanoma, basal cell carcinoma, squamous cell carcinoma, carcinoma in situ) at a maximum of 6 different locations in the head and neck were combined with the following procedures: excision and primary wound closure, excision with temporary soft tissue coverage, split-thickness or full-thickness skin grafting, local, free or regional pedicle flaps, distant flaps as well as combined procedures for coverage. RESULTS: We defined 10 different DRGs based on 5750 combinations of diagnoses and procedures. DRG J22Z (revenue: EUR 2817) predominated for large temporary soft tissue coverage and skin grafting techniques. In 2017, local flaps were devaluated and now lead to DRG J11D (revenue: EUR 1903) in most cases. In this context, an aggregation of cases by a two-stage approach (stage 1: excision, stage 2: reconstruction) is particularly important. Malignant tumours of the lips are inconsistently represented by DRGs with a lack of definite rules. The highly rated main group DRG J08 (including DRGs J08A, J08B and J08C) can be achieved almost invariably by addition of specific single procedures. CONCLUSION: The current representation of reconstructive surgery for malignant skin tumours by DRGs is associated with potential disincentive effects, which may have an impact on patient care. In search of a diversified portfolio, the main group DRG J08 should be considered in addition to the common practice of coding. The authors of this study think that this may be a possibility to compensate for the actual devaluation and to achieve resource-related reimbursement in high-cost cases. However, incorrect and inflationary use should be avoided due to the lack of long-term orientation caused by dilution of the DRGs.

The PAVE (peeling-assisted volume-enhancing) lift: A retrospective 6-year clinical analysis of a combined approach for facial rejuvenation.

The peeling-assisted volume-enhancing (PAVE) lift is a single-stage approach that combines superficial musculoaponeurotic system (SMAS) plication techniques with fat grafting and different peeling agents. To evaluate the safety of this approach, we analyzed the records of 159 patients who underwent surgery between 2008 and 2014. The percentage of complications observed was not higher than values reported in the literature for each treatment entity: surgical facelift: n=3 haematomas (1.89 %), n=2; temporary apraxia of the mandibular branch (1.26%); fat transfer: minor asymmetry in n = 5 cases (3.14%); peeling: temporary hyperpigmentation in trichloroacetic acid (n = 5; 3.8%) and phenol peels (n = 4; 3.1%), permanent hypopigmentation (n = 6; 5.6%), formation of skin miliae persisting longer than 2 to 3 months (n = 5; 4.6%) and prolonged erythema (n = 3; 0.28%) in phenol peels. The single-stage use of chemical peels, autologous fat transfer, and surgical rhytidectomy was safe.

Assessment of sural flap microcirculation: Which position maintains the optimal perfusion?

BACKGROUND: Limb elevation is a commonly used approach for reducing edema and increasing venous drainage. Considering the anatomy of the sural flap with retrograde perfusion and hence potentially difficult blood outflow, the best angle for positioning the leg following operation is not yet known. METHODS: A total of 14 patients undergoing sural flap lower limb reconstruction were enrolled in the study. We assessed the perfusion dynamics of the flaps using the oxygen-to-see (O2C) device that combines laser light, to determine blood flow, and white light to determine the relative amount of hemoglobin and oxygen saturation. Three different positions were evaluated: 45° angle downward, the horizontal position, and 45° angle upward. RESULTS: The blood flow was significantly higher in the 45° upward position compared to the 45° downward position. The relative amount of hemoglobin was significantly lower in the 45° upward position compared to the 45° downward position. No significant differences with regard to oxygen saturation were observed. CONCLUSION: The results of this study show a more precise pattern of perfusion due to different positioning. The 45° upward position of the leg generally maintains the best blood flow and venous drainage. However, compared to horizontal positioning, these differences were not statistically significant. As an elevation of 45° can be uncomfortable for patients, we recommend an elevation of the leg which approximates the 45° upward position but is still comfortable.

Reconstruction of scaphoid nonunion fractures of the proximal one third with a vascularized bone graft from the distal radius.

OBJECTIVE: The treatment of proximal located scaphoid nonunion is a well-known and common problem. For these patients, we used a vascular pedicled bone graft of the distal radius. METHODS: In the last 7 years, 75 patients were treated with the vascular pedicled bone graft. Retrospectively, patients' data, healing rates, and factors influencing scaphoid healing were analyzed. RESULTS: The overall healing rate in cases with proximal located nonunions (n = 54) was approximately 70%. Out of these 54 patients, 47 patients showed avascular proximal fragments. Multivariate analysis showed no significant impact for the factors age, smoking, duration of disease, or previous operation. CONCLUSIONS: In our negative selected patient group, we were able to achieve good results with the usage of a pedicled vascularized bone graft of the distal radius. Our results indicate a favorable outcome for the use of a pedicled vascularized distal radius bone graft in both scaphoid nonunion fractures of the proximal third, with or without an avascular proximal pole.

Evaluation of sensory recovery after reconstruction of digital nerves of the hand using muscle-in-vein conduits in comparison to nerve suture or nerve autografting.

BACKGROUND: Muscle-in-vein conduits are a good alternative solution to nerve autografts for bridging peripheral nerve defects since enough graft material is available and no loss of sensation at the harvesting area is expected. The purpose of this study was to compare regeneration results after digital nerve reconstruction with muscle-in-vein conduits, nerve autografts, or direct suture. PATIENTS AND METHODS: 46 patients with 53 digital nerve injuries of the hand subjected to direct suture (n = 22) or reconstruction of 1-6 cm long defects with either nerve autografts (n = 14) or muscle-in-vein conduits (n = 17) between 2008 and 2012, were examined using the two-point discrimination and Semmes-Weinstein Monofilaments. RESULTS: The follow-up examinations took place 12 to 58 months after surgery. A median reduction of sensibility of 2 Semmes-Weinstein monofilaments compared with intact digits was observed after direct suture (DS) and of 2.5 and 2 Semmes-Weinstein monofilaments after reconstruction with autologous nerve grafts (ANG) and muscle-in-vein conduits (MVC), respectively. No statistically significant differences between all three groups could be found with a significance level set by a P < 0.006 (PDS-ANG = 0.24, PDS-MVC = 0.03, PANG-MVC = 0.52). After harvesting a nerve graft, reduction of sensibility at the donor site occurred in 10 of 14 cases but only in one case after harvesting a muscle-in-vein conduit. CONCLUSIONS: Muscle-in-vein conduits may be a good alternative solution to autografts for the reconstruction of digital nerves, since no significant differences could be demonstrated between the two methods.

Evaluating the role of Netrin-1 during the early phase of peripheral nerve regeneration using the mouse median nerve model.

BACKGROUND: Less is known about the role of Netrin-1 in the peripheral nervous system. In this study, we evaluated the role of Netrin-1 using the mouse median nerve model for assessment of peripheral nerve regeneration. METHODS: Using real-time PCR and western blot analysis, we examined expression changes of netrin-1 mRNA and Netrin-1 protein after transection and repair of the mouse median nerve in Wild-type animals. We further evaluated histomorphometrical changes as well as the functional recovery of the grasping force after median nerve transection and repair in WT mice and Netrin-1(+/-) heterozygous mice. RESULTS: RT-PCR revealed a 1, 9 fold increase of Netrin-1 mRNA two weeks after nerve transection and repair in the nerve segment distal to the injury site. In Western blot analysis, we could show a high increase of Netrin-1 in the nerve segment distal to the injury site at day 14. Histomorphometrical analysis showed significantly higher cross sectional area and a lower fibre density in heterozygous Netrin-1(+/-) mice. Using the functional grasping test, we could show that peripheral nerve regeneration is significantly diminished in heterozygous Netrin-1(+/-) mice. CONCLUSIONS: Employing the mouse median nerve model in transgenic animals, we demonstrate that Netrin-1 plays an important role during peripheral nerve regeneration.

The effect of repetitive intraperitoneal anesthesia by application of fentanyl-medetomidine and midazolam in laboratory rats.

BACKGROUND: Literature reviews show numerous options for anesthesia in the small laboratory animals. Many methods are associated with complications, such as high technical effort, difficult monitoring, respiratory and cardiovascular depression, and prolonged sedation. In the present study, we report first time results after repeated use of an intraperitoneal combined anesthesia with a high tolerability. METHODS: Three hundred and seventy-four anesthesias were performed on 38 adult male Lewis rats (280-460 g). Each animal was anesthetized repeatedly over a period of three months, using an intraperitoneal combination of Fentanyl-Medetomidine and Midazolam (FMM). The time required for the animals to lose ear pinch response and the ability to perform a righting and pedal withdrawal reflex was measured. For evaluation of the clinical state, a four-point vitality scale was developed. The anesthesia was antagonized with Naloxone, Flumazenil, and Atipamezole (s.c.). RESULTS: The animals lost all three reflex responses within 5 (± 2.4) min of injection. Without antagonism of anesthesia, the ear pinch response returned on average within 125 (± 21.5) min. After antagonism of anesthesia, the rats needed 5 (± 2.9) min to regain all three reflex responses. No significant differences of vitality-index were measured after repeated use of FMM during the investigation period. CONCLUSIONS: A repeatable and secure anesthesia is indispensable for any experimental studies that require multiple anesthesia of a single animal. Intraperitoneal combination of FMM provides an adequate procedure to induce a well tolerable, repeatable state of anesthesia, which conforms to all the necessary requirements for laboratory rats.

Fibulo-scapho-lunate arthrodesis after resection of the distal radius for giant-cell tumor of the bone.

BACKGROUND: Giant-cell tumors of the distal radius are rare. They have a high-risk of local recurrence and a risk of pulmonary metastasis. Curettage alone or combined with adjunctive agents is often associated with local recurrence. METHODS: Three patients with giant-cell tumor of the distal radius are presented. All patients showed Campanacci grade 3 lesions. All patients underwent complete distal radius resection and reconstruction with a vascularized fibular graft distally fused with the scaphoid and the lunate, allowing midcarpal motion. RESULTS: The follow-up period ranged from 6 to 60 months. For all three patients, emotional acceptance was excellent. The postoperative motion of the wrist was good, with a range of motion of 30-0-30°, 40-0-0°, and 30-0-10° (extension-flexion). There was neither tumor recurrence nor pulmonary metastasis. CONCLUSION: Fibulo-scapho-lunate fusion is an elegant method of distal radius reconstruction with good functional outcome and low risk of pulmonary metastasis.

A postoperative analysis of perfusion dynamics in deep inferior epigastric perforator flap breast reconstruction: a noninvasive quantitative measurement of flap oxygen saturation and blood flow.

BACKGROUND: The blood supply of microvascular free flaps is rated as very critical, particularly in the first postoperative days. Only a timely recognition of a complication and its treatment can ensure the survival of the flap. To quantify the postoperative perfusion dynamics, we measured the oxygen supply and blood flow of the deep inferior epigastric perforator (DIEP) flaps. METHOD: A total of 23 patients undergoing DIEP flap breast reconstruction were involved in this study. Noninvasive measurements were performed with the O2C-device, which combines the determination of hemoglobin oxygenation and blood flow using white light and laser light. The first measurement was performed immediately after the flap anastomosis. Further measurements were carried out on the first, third, fifth, and seventh postoperative days. RESULTS: The preoperative value represents our baseline. With the exception of the third day, all postoperative measurements were above the baseline. On the third postoperative day, there was a decrease in the cutaneous oxygen saturation of 22% and a decrease in blood flow of 18% on average, regardless of the individual fluctuations of patient's blood pressure. CONCLUSIONS: The postoperative perfusion characteristics of the DIEP flap showed a critical drop in the cutaneous oxygen supply and blood flow on the third postoperative day. This represents a potential risk and should be considered in the postoperative management of the DIEP flap.

Application of two different hemostatic procedures during microsurgical median nerve reconstruction in the rat does not hinder axonal regeneration.

BACKGROUND: Hemostatic procedures by means of electrical coagulation or application of topical agents are widely used to avoid postoperative bleeding during microsurgical reconstruction of peripheral nerves. It is speculated, however, that extensive hemostasis could provoke significant nerve damage. OBJECTIVE: To examine the effects of 2 intraoperative hemostatic procedures on peripheral nerve regeneration. METHODS: In 36 adult rats divided into 3 groups, the median nerve was transected and repaired by end-to-end neurorrhaphy. During surgery, bleeding was treated in groups 2 and 3 by application of either the topical hemostatic agent Floseal or routine bipolar coagulation. The degree of nerve regeneration was assessed in terms of motor function recovery using weekly grasping test evaluation for 3 months, muscle mass recovery of flexor digitorum sublimis, and stereological assessment of myelinated axon regeneration. RESULTS: Neither of the 2 applied hemostatic methods induced any negative effects on nerve regeneration as defined by grip strength, muscle mass recovery, and morphology of myelinated nerve fibers. In contrast, Floseal-treated animals showed a faster progression of motor function recovery, and animals subjected to bipolar coagulation revealed a higher muscle mass recovery compared with the control group. CONCLUSION: Controlled application of bipolar coagulation or Floseal does not exert a negative effect on the nerve regeneration outcome in rats. We propose that these methods can be applied safely to patients.

Fibrin-targeted direct factor Xa inhibition: construction and characterization of a recombinant factor Xa inhibitor composed of an anti-fibrin single-chain antibody and tick anticoagulant peptide.

We investigated whether the direct fXa inhibitor tick anticoagulant peptide (TAP) can be N-terminally coupled to a clot-targeting, single-chain antibody specific for fibrin (scFv(59D8)). Due to its unique position at the convergence point of the intrinsic and extrinsic pathways early in the coagulation cascade, factor Xa (fXa) represents an attractive therapeutic target. In contrast to indirect inhibitors, direct fXa inhibitors effectively inhibit clot-bound and prothrombinase-associated fXa. Targeting of direct fXa inhibitors to clots promises to enhance local anticoagulative potency and to reduce systemic anticoagulation which potentially results in less bleeding complications.TAP is a highly potent fXa inhibitor. Since its N-terminus is essential for anti-fXa activity, it was a challenging question, whether TAP will be active as a N-terminally coupled fusion molecule. Two step affinity chromatography with Ni(2+) and beta(15-22)-peptide of human fibrin results in a pure 36 kDa protein, which was tested for its targeting function and anti-fXa activity. The recombinant fusion did not destroy the function of the fusion partners. Antibody binding function was on a par with the parent molecule. TAP activity was partially reduced, arguing that a free N-terminus is not required for anti-fXa activity, but is important for maximal potency. In human whole blood clots, scFv(59D8)-TAP revealed anticoagulative properties at concentrations (200 to 500 nM) where non-targeted TAP did not reveal anticoagulative activity at all. In summary, scFv(59D8)-TAP constitutes a promising new anticoagulant with fibrin-targeted factor Xa inhibition. The production in E. coli and the established purification methods are a solid basis for a modern, large scale production at low cost and reproducible activity.