[The complexity of hand-surgical procedures in the context of cross-sector care concepts: a consensus recommendation of the German Society of Hand Surgery] / Die Komplexität handchirurgischer Therapien im Kontext sektorenübergreifender Versorgungskonzepte: Konsensusempfehlung der Deutschen Gesellschaft für Handchirurgie.

Overboarding politcal influence in Germany concerning medical issues has come to a new peak. The report by the IGES Institute published in 2022 made an important contribution in this regard. Unfortunately, only that part of the recommendations of this report were implemented in a new version of the contract for outpatient surgery according to Section 115b SGB V (AOP contract), that called for an expansion of outpatient surgery. In particular, those aspects that are important from a medical point of view for a patient-specific adjustment of outpatient surgery (e. g. old age, frailty, comorbidities) as well as the important structural requirements for outpatient postoperative care were included in the new AOP contract at best in a rudimentary manner. For this reason, the German Society for Hand Surgery felt compelled to give its members a recommendation as to which medical aspects must be taken into account, especially when performing hand surgery operations, in order to ensure the highest level of safety for the patients entrusted to us while performing outpatient surgery. An expert group of experienced hand surgeons and hand therapists who work in hospitals of all levels of care as well as resident surgeons was formed in order to formulate mutually agreed recommendations for action.

[Case report of frontobasal reconstruction and volume augmentation using a free gracilis muscle flap and autologous fat grafting: utilising the free flap as a scaffold for fat transplantation]. / Fallbericht einer Frontobasisrekonstruktion und Volumenkorrektur durch freie M. gracilis-Lappenplastik und autologe Fett-Transplantation ­ Die Lappenplastik als Scaffold für eine Fettgewebe-Transplantation.

This case report shows the interdisciplinary treatment of a 28-year-old woman suffering from a pronounced frontal volume defect after severe craniocerebral trauma. The combination of cranioplasty using a polymethylmethacrylate (PMMA) implant, free gracilis muscle flap transfer for soft tissue coverage and serial autologous fat grafting into the muscle flap for subsequent contouring enabled both an adequate and aesthetic reconstruction. This example demonstrates the feasibility of treating increasingly complex composite defects in a multidisciplinary setting, when plastic surgeons are involved.

The versatility of the medial thigh lift for defect coverage in the genito-perineal region.

Soft tissue defects in the genito-perineal region are predominantly because of trauma, infections, neoplasms or iatrogenic causes. As a result of the region's urological, reproductive and gastrointestinal function, defects in this area may cause devastating physical and psychological consequences as well as diminished sexual functioning. The purpose of this study was to examine the efficacy of implementing a medial thigh lift for defect coverage in the perineal region. A retrospective analysis of all medial thigh lift procedures for defect coverage in the genito-perineal region between November 2010 and March 2015 was conducted at three institutions. Ten consecutive patients underwent a medial thigh lift for defect coverage in the genito-perineal region. Nine patients were male, and one was female. The causative factors were Fournier's gangrene in eight patients, one patient had a straddle injury, and one suffered from extramammary Paget's disease. The mean follow-up time was 19·8 months. The average total defect size was 11·1 × 11 cm (length × width). The medial thigh lift procedure is a safe, technically easy and reliable technique with discrete scars. Outstanding aesthetic and functional outcomes result in a high rate of patient satisfaction. Through immediate wound closure, a reduction of recovery time can be achieved.

Occult moyamoya disease causing fulminant infarction after septorhinoplasty.

Moyamoya disease is an extremely rare cerebrovascular condition that predisposes affected patients to stroke in association with progressive stenosis of the intracranial internal carotid arteries and their proximal branches. To our knowledge, this is the first report of a lethal complication due to moyamoya disease after septorhinoplasty. A 25-year-old female Caucasian patient presented to our outpatient clinic with impaired nasal breathing for septorhinoplasty. Regrettably the patient died 6 days postoperatively due to progressive infarct series affecting all major cerebral vessels. Despite a thorough knowledge of possible local complications after septorhinoplasty, it is of utmost importance to consider rare general complications like moyamoya disease. Although cerebral infarctions are very rare in young people, it is crucial to identify and correctly interpret underlying typical symptoms.

Instep split skin grafts on muscle flaps to reconstruct pressure exposed soft tissue parts at the lower extremity.

BACKGROUND: Reconstructed mechanically stressed zones of the lower extremity frequently suffer from problems such as hyperkeratotic edges or chronic ulcerations in the transition zone between conventional thigh skin grafts and normal skin. Defect coverage with skin grafts harvested from the instep region and placed on muscle flaps is not yet an established alternative. METHODS: This is a retrospective study of a series of 12 clinical applications of soft tissue reconstruction at mechanically exposed zones of the lower extremity. Locally transposed or transplanted muscle flaps were covered with meshed instep skin instead of meshed thigh skin for the purpose to gain a superior stable skin surface and transition zones adjacent to normal skin. RESULTS: There is no ulceration found at follow-up from 6 to 72 months. Only one case presented with delayed graft take. Different thicknesses of the corneal layers of the healed instep versus thigh skin grafts were verified histologically. Instep skin grafts showed substantial durability as well as advantageous aesthetic appearance with respect to texture and coloring. All donor sites healed without notable scars or sensitivity disorders. CONCLUSIONS: The instep split skin graft is particularly well suited for defect coverage of muscle flaps transposed or transplanted to mechanically stressed zones of the foot or lower leg. The paramount advantage of transplanted instep skin as compared to thigh skin is given by the feasibility to create a durable graft with a thick horny layer and a stable transition zone at its periphery that is bordering normal skin.

The psychological assessment of candidates for reconstructive hand transplantation.

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at-risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the 'Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT-PSP)' which utilizes a semi-structured interview and standardized psychological screening procedures and continuous follow-up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT-PSP. Psychological impairments including social withdrawal, embarrassment, reduced self-esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi- or unilateral impairment, native or accidental loss of hand, and social integration.

Abdominal wall reconstruction after extensive abdominal wall necrosis resulting from chevron incision for liver transplant and subsequent Y-shaped incision for re-transplantation--clinical experience and literature review.

Extensive Abdominal wall necrosis is a devastating complication. In visceral transplant patients a quick and easy to perform reconstructive technique may be crucial for patient survival. Based on a clinical case a literature review is performed including a thorough analysis of abdominal wall perfusion and surgical options for defect closure are presented and critically appraised.

World experience after more than a decade of clinical hand transplantation: update on the Innsbruck program.

Patients who have lost a hand or upper extremity face many challenges in everyday life. For some patients, reconstructive hand transplantation represents a reasonable option for anatomic reconstruction, restoring prehensile function with sensation and allowing them to regain daily living independence. The first clinical case of bilateral hand transplantation at University Hospital Innsbruck was realized on March 17th, 2000. A decade later, a total of 7 hands and forearms were transplanted in 4 patients. This article review the clinical courses of 3 bilateral hand transplant recipients and highlights psychological aspects on reconstructive hand transplantation with special regard to unilateral/bilateral transplantation.

Adipokine profile and insulin sensitivity in formerly obese women subjected to bariatric surgery or diet-induced long-term caloric restriction.

To better understand the contribution of the fat mass to the effects of long-term caloric restriction in humans, we compared adipokine profile and insulin sensitivity in long-term calorically restricted formerly obese women (CRW) subjected to different interventions, bariatric surgery, or reducing diet, with age- and BMI-matched obese (OW) and normal-weight women (NW) eating ad libitum. Our key findings are that despite a considerably stronger weight loss induced by bariatric surgery, both long-term caloric restriction interventions improved insulin sensitivity to the same degree and led to significantly lower retinol-binding protein-4 and interleukin-6 serum levels than in OW, suggesting that lowering of these two adipokines contributes to the improved insulin sensitivity. Moreover, serum leptin was considerably lower in CRW than in OW as well as in NW, suggesting that CRW develop hypoleptinemia.

Familial congenital symmastia: ultrastructurally abnormal breast tissue.

Reports about congenital symmastia and its surgical treatment are few. We report two patients - a mother and daughter - with congenital symmastia in whom breast and fatty tissue was found to be mobile adhering poorly to the chest wall. Although histological examination showed no abnormality of the tissue bridge between the breasts, ultrastructural investigation of breast tissue (including Cooper's ligaments) showed an abnormal arrangement of collagen fibres. Satisfying aesthetic results were achieved by resection of excess soft tissue in the cleavage area through a submammary incision and fixation of the skin with subcutaneous interrupted sutures to the sternal periosteum.

Stabilization of microvascular pedicles in intricate locations using fibrin glue.

In reconstructive microsurgery, it is occasionally advantageous to use long recipient or donor vessels for optimal flap inset. These long vessels are prone to kinking or torsion along their longitudinal axis from vessel distension during blood inflow and rising blood pressure. More often than arteries, the veins can also be compressed by overlying tissue sutured under tension or by developing edema. Reanastomosis can no longer be feasible or desirable for several reasons, and the elongated vessels may have to be shifted to a curved course. To avoid detrimental kinking or torsion, fibrin glue can be administered along this new vessel course in order to ensure stabilization. In 20 such cases, we successfully avoided complications when the danger of kinking, torsion, or vein compression was evident after successful anastomosis. On the basis of this experience, we recommend the use of fibrin glue in microsurgical procedures, especially for vessels in intricate geometrical locations.