Breaking the circle-effectiveness of liposuction in lipedema.

BACKGROUND: Lipedema is a common chronic fat distribution disorder often aligned with pain and reduced quality of life affecting 6-10% of the female population. Although lipedema has acquired more scientific attention in the last decade, validated diagnosis and treatment still remain challenging for specialists. PATIENTS AND METHODS: In this article we evaluate the effect of liposuction on appearance, pain and coexisting diseases of 860 patients with lipedema. Comparison among stages of lipedema pre- and post-liposuction was performed by using t-Tests for independent samples and Kruskal-Wallis-Tests. RESULTS: Our study demonstrates the positive effect on pain reduction in patients with lipedema after liposuction (NRS 2.24) compared with pre-liposuction pain perception (NRS 6.99) and pain perception of patients with conservative treatment (NRS 6.26). Significant differences were shown in the perception between the stages of lipedema and in the reduction of pain perception by liposuction. Furthermore we examined co-diseases in patients with lipedema, primarily menstruation complaints (43%), sleeplessness (36%) and migraine (35%). CONCLUSIONS: A progress of lipedema disease leads not only to a change of appearance and proportion but also to a progressive increase of pain. Liposuction shows a significant effect on pain reduction -independent of the patients' stage of lipedema.

Antibiotic prophylaxis for prevention of wound infections after soft tissue sarcoma resection: A retrospective cohort study.

BACKGROUND AND OBJECTIVES: The use of antibiotic prophylaxis for soft tissue sarcoma resection varies widely while little evidence on this topic exists. The aim of this study was to determine the impact of antibiotic prophylaxis on the occurrence of wound infections. METHODS: A single institutional retrospective cohort study was performed on patients who underwent truncal or extremity soft tissue sarcoma resection. The use of antibiotic prophylaxis was assessed and univariate and multivariate analysis of predictors of wound infections was performed. RESULTS: Nine hundred and fifty-eight patients could be included. Thirty-two percent of patients had no antibiotic prophylaxis, 44% of patients received single-shot prophylaxis, and 24% of patients received single-shot plus continued antibiotic treatment. Wound infections occurred in 140 patients (15%). Independent risk factors for wound infections upon multivariate analysis were obesity, high American Society of Anesthesiologists (ASA) status, high tumor size and grade, operation time over 120 minutes, and other complications. Antibiotic prophylaxis could not be identified as a protective factor in univariate or multivariate analysis. CONCLUSIONS: A favorable effect of antibiotic prophylaxis on the occurrence of wound infections could not be observed. Although more studies on this subject are needed, our data do not support the general use of antibiotic prophylaxis for soft tissue sarcoma resection.

Use of a self-contained vacuum-assisted biopsy system in the assessment of soft tissue tumors.

BACKGROUND AND OBJECTIVE: This is the first study to compare the safety and efficacy of vacuum-assisted biopsy (VAB) using a self-contained hand-held system compared to those of ultrasound-guided and computed tomography-guided core needle biopsy (US-CNB and CT-CNB) and to incisional biopsy (IB). METHODS: VAB was performed in an outpatient setting under local anesthesia. Safety, diagnostic accuracy, time, and cost expenditures of biopsy were compared between VAB, US-CNB, CT-CNB, and IB in 211 consecutive patients. RESULTS: VAB was applied in 78 patients, US-CNB in 51, CT-CNB in 45, and IB in 37. Patient characteristics did not differ between groups. Sample volume of VAB was 392.5 mm3 , 4062 mm 3 for IB, and 25.1 to 34.5 mm 3 for CNB, P < .001. VAB discriminated between malignant and benign lesions with the highest accuracy of 96% and determined sarcoma grading accurately in 95%. VAB and CNB had no complications vs 5% for IB. Duration of VAB was 5 ± 2 minutes, equal to US-CNB and shorter than CT-CNB and IB. Expenditures for VAB were higher than for US-CNB and lower than CT-CNB and IB. CONCLUSION: VAB is an accurate, safe, cost-effective, and time-saving outpatient diagnostic procedure for patients with soft-tissue tumors and presents a viable alternative to IB.

Soft Tissue Sarcomas of the Extremities: Surgical Margins Can Be Close as Long as the Resected Tumor Has No Ink on It.

BACKGROUND: Soft tissue sarcomas (STS) arising in the extremities pose a therapeutic challenge due to concerns of functional morbidity. Resections with negative margins are the mainstay of therapy, but the prognostic significance of surgical margins remains controversial. The purpose of this study was to determine the prognostic impact of surgical margins and clear margin widths in patients with STS of the extremities. MATERIALS AND METHODS: We assessed the relationship between local recurrence-free (LRFS), disease-specific (DSS), and metastasis-free survival (MFS) and potential prognostic factors retrospectively in a consecutive series of 643 patients treated at our institution between 1996 and 2016. Potential prognostic factors were assessed using univariate and multivariate analyses. RESULTS: The median follow-up time after primary diagnosis was 5.4 years (95% confidence interval [CI]: 4.8-6.0). The five-year estimates of the DSS, LRFS, and MFS rates in the entire cohort were 85.3% (95% CI: 81.6-88.3), 65.3% (95% CI: 60.8-69.5) and 78.0% (95% CI: 74.1-81.4), respectively. Histological grade and the quality of surgical margins were independent prognostic factors of all three survival endpoints (LRFS, DSS, MFS) in multivariate analyses. Within the R0 subgroup, univariate and multivariate analyses of categorized (≤1 mm vs. 1-5 mm vs. >5 mm) and non-categorized margin widths revealed that close and wide negative margins led to similar outcomes. Adjuvant radiation improved local control independently, but not DSS and MFS. CONCLUSION: Microscopically negative margins were associated with better LRFS, DSS, and MFS regardless of whether adjuvant radiation was applied. Here, surgical margins can be close as long as the resected tumor has no ink on it. IMPLICATIONS FOR PRACTICE: In the present retrospective analysis of 643 patients with primary soft issue sarcomas of the extremities, surgical margins could be identified as independent predictors of local recurrence-free, disease-specific, and metastasis-free survival. Given the diminished outcome of patients left with positive margins, surgical efforts should aim to achieve microscopically negative margins whenever feasible. It is noteworthy that only the quality of surgical margins, but not the negative margin width attained, had an influence on the prognosis. Our findings suggest that surgical margins can be close as long as the resected tumor has no ink on it.

Somatic Leiomyosarcoma of the Soft Tissues: A Single-Institutional Analysis of Factors Predictive of Survival in 164 Patients.

BACKGROUND: Somatic leiomyosarcoma (LMS) is an aggressive soft tissue sarcoma entity with a high metastatic potential. The purpose of this study was to identify prognostic indicators of survival in patients with somatic LMS of the soft tissues. METHODS: We retrospectively assessed the relationship between local recurrence-free survival (LRFS), disease-specific survival (DSS), overall survival (OS) and potential prognostic factors in 164 patients who were suitable for surgical treatment in curative intent. Patients with soft tissue LMS of the extremities, the truncal wall and the head and neck area were included. The median follow-up time was 4.9 years. RESULTS: In the entire cohort, the 5-year estimate of the DSS, OS and LRFS rate were 74.5% (95% confidence interval [CI] 65.0-81.8), 70.6% (95% CI: 60.9-78.3) and 63.4% (95% CI 53.4-71.9), respectively. Thirty-eight patients (23.2%) developed distant metastases with a median survival time of 1.5 years after diagnosis of metastasis. Surgical margins attained at the initial oncologic resection and eventual re-excisions did not influence DSS, OS and LRFS significantly. Within the R0 subgroup, close and wide negative margins led to similar outcomes. High histologic grade (P < 0.001), size >5 cm (P = 0.002) and subfascial localisation (P = 0.002) were associated with significantly diminished DSS in univariate analysis. In multivariate analysis, only histologic grade was found to be an independent prognostic factor of DSS. CONCLUSIONS: The data from this study could not determine a prognostic significance of surgical margins suggesting that tumour characteristics other than margin status are important. Tumour biology reflected by the histologic grade dictates the final outcome.

A single-institutional review of 68 patients with dermatofibrosarcoma protuberans: wide re-excision after inadequate previous surgery results in a high rate of local control.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is a cutaneous soft tissue sarcoma characterized by an indolent but aggressive local growth. Unplanned excisions with positive margins are common, and the prognostic impact of radical re-excisions is still unclear. The aim of the present study was to identify prognostic indicators of recurrence-free survival (RFS) in patients with DFSP through a long-term follow-up. We tried particularly to determine the prognostic impact of surgical margins and re-excisions in patients after earlier inadequate surgery. METHODS: Seventy-five patients with DFSP were treated surgically at our institution between 1999 and 2015. Analyses were restricted to 68 participants with available information on surgical margins. The median follow-up was 5.4 years. RESULTS: Fifty-four patients (79.4%) had low-grade DFSP and 14 patients (20.6%) intermediate-grade FS-DFSP. The 5-year RFS rates were estimated to be 93.5% (95% CI 81.2-97.9) for low-grade DFSP and 39.7% (95% CI 13.0-65.8) for FS-DFSP (P < 0.0001). Re-excisions were performed in 55 patients (80.9%) following R1 or marginal R0 resections. Negative margins could be attained in a total of 65 patients (95.6%). Negative margin widths >1 cm led to the best local outcome within the R0 subgroup. Significant adverse prognostic features in the multivariate analysis included histologic grade and close margins. CONCLUSIONS: The data from this study underscore the long-term benefit of negative margins. In our analysis, re-excisions were an effective method to achieve a high rate of local control in patients who presented after R1 or marginal R0 resection. To ensure the best outcome, re-excisions should aim at negative margin widths of more than 1 cm in the histologic specimen.

Predictors of Intraoperative Blood Transfusion in Free Tissue Transfer.

Background Free tissue transfer has become a safe and reliable procedure and is routinely used in a variety of settings. However, it is associated with lengthy operating times and a high potential for blood loss and consecutive red blood cell transfusions (RBCTs). Methods To assess the risk for RBCTs, we retrospectively identified 398 patients undergoing free tissue transfer between 2005 and 2014. Based on a multivariate model of risk factors and their respective odds ratio, a risk score was developed to predict the likelihood of the need for intraoperative RBCT. Results The median age at the time of operation was 51.3 ± 15 years, and 278 (70%) patients were male. The average body mass index was 25.9 ± 4 and the median ASA score was 2 (range: 1-4). Mean duration of surgery was 319.8 ± 108 minutes and mean duration of hospital stay was 45.8 ± 40 days. A total of 231 patients (58%) required perioperative RBCTs, all of which were allogenic. RBCTs were performed 0 to 48 hours preoperatively in 36 patients (11.3%), intraoperatively in 166 patients (41.7%), and 0 to 48 hours postoperatively in 125 patients (31.4%). The mean amount of overall RBCTs given was 2.5 ± 3.7 units and 1.1 ± 1.9 units for intraoperative transfusions. The following risk factors were statistically significant in the multivariate regression analysis and included in the risk score: age >60 years; a preoperative hemoglobin concentration of <11 g/dL; a preoperative platelet count of >400/nL; history of renal (RI) and cardial insufficiency (CI); defect localization on the proximal extremities, head and neck, or trunk; and the use of myocutaneous flaps. This score assessed the risk for RBCTs with a sensitivity of 77%, a specificity of 81%, and an AUC of the ROC curve of 0.86. Conclusion We were able to develop a risk score that allows for the assessment of RBCT likelihood. While most of the identified risk factors cannot be prevented or corrected, it still allows for improved patient counseling and can potentially reduce the number of ordered but not transfused RBCTs.

Evaluation of angiogenesis, epithelialisation and microcirculation after application of polyhexanide, chitosan and sodium chloride in rodents.

The purpose of this study was to investigate the effect of polyhexanide and a new developed chitin-based wound dressing on skin microcirculation, epithelialisation and angiogenesis. A full-thickness dermal layer extending to the underlying cartilage was excised on the dorsal side of hairless mice (n = 27; 2·3 ± 0·3 mm2 ). A polyhexanide ointment, a chitosan solution and a sodium chloride group as control were analysed using intravital fluorescence microscopy. Angiogenesis, epithelialisation and microcirculatory standard parameters were measured over a time period of 20 days. The non-perfused area is regarded as a parameter for angiogenesis and showed the following results: on days 12, 16 and 20, the sodium chloride group was significantly superior to chitosan solution (P < 0·05) and, on days 8, 12, 16 and 20, the polyhexanide group was superior to chitosan solution (P < 0·05). The epithelialisation was measured significantly faster in the polyhexanide and control group on day 8 versus chitosan solution. Whereas polyhexanide and sodium chloride were nearly completely epithelialised, treatment with chitosan solution showed still an open wound of 11% of the initial wound size. Altogether, we could demonstrate the advantageous effects of a polyhexanide ointment on microcirculation, angiogenesis and epithelialisation. Chitosan solution appears to inhibit angiogenesis and delays epithelialisation. Further studies in different models would be worthwhile to confirm these results.

Advanced Microcirculatory Parameters of Lower Extremity Free Flaps during Dangling and Their Influencing Factors.

BACKGROUND: Dangling of the leg to habituate a free flap to the lower extremity is common practice. However, little is known about the microcirculatory changes in free flaps and the influence of comorbidities. METHODS: Tissue oxygen saturation (StO2) and hemoglobin content (tissue hemoglobin index [THI]) of 39 lower extremity free flaps was measured during dangling on postoperative days (PODs) 6 to 9. We assessed the maximal desaturation during dangling and re-elevation and the maximal increase in THI as well as the time required to reach a stable plateau during dangling, among others. RESULTS: All parameters showed significant changes during dangling (desaturation during dangling: 0.23 ± 10.7 vs. - 4.66 ± 12.6%, p = 0.001 for POD 6 vs. 7; further desaturation after re-elevation: - 11.1 ± 7.4 versus - 14.5 ± 7.8%, p = 0.001 for POD 6 vs. 9; THI increase during dangling: from 3.4 ± 1.6 to 4.2 ± 1.8 AU, p = 0.008, time to THI plateau: 1.7 ± 1.2 vs. 2.5 ± 1.7 minutes, p = 0.004 for POD 6 vs. 7). Age, gender, and smoking did not influence the mentioned parameters. Nondiabetic patients showed a significant increase of baseline StO2, whereas diabetic patients did not (p = 0.009 vs. 0.11). For THI, both diabetic and hypertensive patients showed a lower increase in THI on the first day of dangling (p = 0.056; p = 0.009) and significantly lower baseline values on the last day (0.046 for both). CONCLUSION: Duration of dependency seems to have the greatest impact on microcirculation during dangling, although comorbidities may interfere with the adaptive processes. An earlier start of dangling could safely be applied in most patients. Special care needs to be taken in diabetic and hypertensive patients.

[Aggressive Fibromatosis: Retrospective Analysis of 110 Patients]. / Die Aggressive Fibromatose. Eine retrospektive Analyse von 110 Patienten.

Aggressive fibromatosis, histologically classified as benign due to the absence of metastasis, is characterised by locally invasive and destructive growth with high recurrence rates after resection. For this reason, prognostic recurrence factors, in particular the extent of resection, are much debated, and treatment decisions seem challenging for interdisciplinary tumour conferences. Between the years 2000 and 2020, 110 patients with aggressive fibromatosis of the extremities or trunk received surgical treatment at BG University Hospital Bergmannsheil (Bochum, Germany). Univariate analyses were performed to detect any potential prognosis factors. The median follow-up time was 5.9 years. A total of 57 (51.8%) of these patients developed recurrence during this period. The 5-year recurrence-free survival was 52.9% (95% CI: 42.4-62.3) in the entire cohort. In R0-resected patients, the 5-year recurrence-free survival (RFS) was significantly better (p<0.001) at 69.2% compared with patients with R1 or R2-resected tumours (32.6%). Beyond that, no other significant influencing factors were identified. The results of this study indicate that R0 resection or R0 resectability were associated with a significantly better local control. The therapeutic recommendation for resection should be made individually by an interdisciplinary tumour board in due consideration of tumour progression, possible therapeutic alternatives, and foreseeable functional impairment.

Factors Influencing Quality of Life after Massive Weight Loss-What Makes the Difference?

Although weight reduction in obesity and morbid obesity has been shown to improve associated comorbidities, there is currently no information on what influences quality of life after a large reduction in body weight. The present study looks at differences in patients' quality of life classified by mode and amount of weight loss. MATERIAL AND METHODS: A cross-sectional study was designed using a validated German version of the BODY-Q questionnaire. The internet-based questionnaire was distributed to patients via social media. RESULTS: 460 patients (443 female, 17 male) were interviewed for this study via "Surveymonkey". The comparison of conservative and surgical weight loss showed no significant difference in the patients' quality of life (p > 0.05). A high BMI correlates negatively with body image (p = 0.023 *), as does the specific assessment of most body regions. For example, a negative correlation was found between a high BMI and satisfaction with skin appearance (p < 0.001 *) and satisfaction with the inner thigh (p = 0.011 *). CONCLUSION: Increased weight loss is associated with a greater ability to maximise quality of life. The type of weight loss, whether conservative or surgical, can be neglected based on the present study. Bariatric surgery cannot be considered a universal solution to obesity. Body contouring interventions should also become a focus of therapy.

After weight loss, what skin removal procedure has the most effect using Body Q metrics?

BACKGROUND: Although postbariatric body contouring procedures have the ultimate goal of restoring quality of life, there currently exist minimal data assessing the effect of these procedures. OBJECTIVES: To identify the most important body contouring procedure for quality of life (QoL). SETTING: University Hospital, Online Questionnaire, Germany. METHODS: A cross-sectional study was designed using a validated version of the internet-based Body Q questionnaire, which was distributed among patients using social media and patient events. RESULTS: A total of 460 patients (443 female, 17 male) participated and fulfilled inclusion criteria. Of those patients, 191 (41.5%) had already undergone surgery, and the rest served as the control group. Patients in a postoperative status had a significantly (P < .05) higher QoL regarding all body regions. Additionally, patients who underwent body contouring surgery showed significantly higher QoL in regard to sexuality, society, body image, and psychosocial metrics. Abdominoplasty represents the most important procedure for QoL. The control group showed the greatest dissatisfaction in the area of the inner thighs. CONCLUSION: Body contouring procedures have been shown to significantly restore and enhance a patient's QoL. Conducting contouring surgeries is specifically associated with an increase in body image satisfaction as well as patient acceptance of certain body regions.

Initial experience with the superficial circumflex iliac artery perforator (SCIP) flap for extremity reconstruction in Caucasians.

BACKGROUND: The superficial circumflex iliac artery perforator (SCIP) flap has been established in Asia to provide an excellent option for soft tissue defect coverage. The main advantage of this delicate flap is its very thin design. However, the adoption of this technique in other parts of the world has been rarely reported. METHODS: In this retrospective study, we analyzed outcomes of 32 SCIP flaps in a Caucasian patient population. The procedures were performed at our institution between March 2019 and August 2020. We present patient characteristics, surgical technique, perioperative care, and flap applications as compared to the Asian approaches. RESULTS: Patients' average BMI was 28.7. Flap anatomy and flap thickness at the superficial fascial plane differed significantly within our population. With 1.7 mm on average, the arterial diameter was higher than reported in the literature. Flaps were based on an axial perforator in 52% of cases. The SCIP flap was performed safely in the majority of cases. The surgical flap elevation approach was modified toward speedy perforator identification. CONCLUSIONS: The SCIP flap offers superior opportunities for thin soft tissue defect coverage with excellent functional outcomes in Caucasian patients. Based on higher BMI and anatomical differences as compared to Asian patient populations, modifications of flap elevation were necessary to increase reliability. More outcome reports from outside Asia need to become available to advance SCIP flap application internationally.

Closed-Incision Negative-Pressure Wound Therapy after Resection of Soft-Tissue Tumors Reduces Wound Complications: Results of a Randomized Trial.

BACKGROUND: Wound healing after resection of large soft-tissue tumors is often impaired by large dead space and fluid collection. Recently, the authors were able to show an association of wound complications with worse oncologic outcome in soft-tissue sarcomas. The aim of the study was to examine the value of closed-incision negative pressure wound therapy on postoperative wound drainage and wound complications after soft-tissue tumor resection. METHODS: Patients for whom resection is planned of a soft-tissue tumor larger than 10 cm in diameter of the extremities or the trunk were allocated randomly to one of two groups. After wound closure, patients in the study group received closed-incision negative-pressure wound therapy for a duration of 5 days, whereas those in the control group received regular dressings. The amount of drainage fluid, course of wound healing, length of hospital stay, and wound edge perfusion at postoperative day 5 measured by white-light infrared spectroscopy were compared. RESULTS: Sixty patients could be included in the study with even distribution to both study arms, meeting the goal. The postoperative course of wound drainage volume was significantly lower in the study group, and hospital stay was significantly shorter, with 9.1 ± 3.8 days versus 13.9 ± 11.8 days. The occurrence of wound complications was significantly lower in the study group on time-to-event analysis (one versus six). Tissue spectroscopy revealed a significantly higher oxygen saturation increase in the wound edge for the study group versus the control group. CONCLUSION: Closed-incision negative-pressure wound therapy should be considered for patients undergoing resection of large soft-tissue tumors. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Microvascular tissue transfer after the resection of soft tissue sarcomas.

BACKGROUND: Microvascular tissue transfer enables the oncological resection of soft tissue sarcomas of the extremities and the trunk by covering the resulting tissue defects that are often extensive. This study was performed to investigate the long-term survival and functional outcome of patients treated with free flaps after sarcoma resection. METHODS: A total of 78 sarcoma patients received microvascular tissue transfer in our institution between March 2003 and January 2013. In a retrospective analysis, we investigated data such as tumor characteristics as well as survival time and disease-free survival. In a prospective analysis, we assessed the functional outcome and the health-associated quality of life with the TESS and SF-36 questionnaire, respectively. RESULTS: Seventy patients qualified for disease-free survival after tumor resection, 41 patients remained disease free for over 5 years. Forty-five patients reached a survival time of more than 5 years. The functional results experienced by our patients were good with a mean score of 82.6% in the TESS. The physical health-related quality was lower than in the German norm sample and patients suffering from chronical illnesses or cancer, whereas the mental health was only slightly lower than in the norm sample and higher than in the groups with chronic illnesses or cancer (SF-36). CONCLUSION: Microvascular tissue transfer enables tumor resection and limb salvage through the coverage of the resulting defects without impairing patients' prognosis. The long survival times after tumor resection emphasizes the need for good functional results as well as quality of life.

Gene expression analysis of cell death induction by taurolidine in different malignant cell lines.

BACKGROUND: The anti-infective agent Taurolidine (TRD) has been shown to have cell death inducing properties, but the mechanism of its action is largely unknown. The aim of this study was to identify potential common target genes modulated at the transcriptional level following TRD treatment in tumour cell lines originating from different cancer types. METHODS: Five different malignant cell lines (HT29, Chang Liver, HT1080, AsPC-1 and BxPC-3) were incubated with TRD (100 µM, 250 µM and 1000 µM). Proliferation after 8 h and cell viability after 24 h were analyzed by BrdU assay and FACS analysis, respectively. Gene expression analyses were carried out using the Agilent-microarray platform to identify genes which displayed conjoint regulation following the addition of TRD in all cell lines. Candidate genes were subjected to Ingenuity Pathways Analysis and selected genes were validated by qRT-PCR and Western Blot. RESULTS: TRD 250 µM caused a significant inhibition of proliferation as well as apoptotic cell death in all cell lines. Among cell death associated genes with the strongest regulation in gene expression, we identified pro-apoptotic transcription factors (EGR1, ATF3) as well as genes involved in the ER stress response (PPP1R15A), in ubiquitination (TRAF6) and mitochondrial apoptotic pathways (PMAIP1). CONCLUSIONS: This is the first conjoint analysis of potential target genes of TRD which was performed simultaneously in different malignant cell lines. The results indicate that TRD might be involved in different signal transduction pathways leading to apoptosis.

Limb preserving surgery for soft-tissue sarcoma in the hand: a retrospective study of 51 cases.

Our retrospective study analysed the long-term results of a conservative limb-preserving surgical strategy in 51 patients with soft-tissue sarcoma of the hand from a single institution. We assessed survival and prognostic factors, including the surgical margins. No transradial amputations were performed. Microscopically free resection margins were obtained in 45 of the patients. The remaining six patients had microscopically incomplete resection. Forty-four surviving patients had a median follow-up of 6.5 years (range 12-307), and one patient had no follow-up beyond 3 months following surgery. Among those patients, 29 had more than 5 years of follow-up. Five-year local-recurrence-free survival was 65%, metastasis-free survival was 84%, and disease-specific survival was 91%. Tumour size was predictive of all outcome parameters, but positive resection margins adversely affected local recurrence only. Survival was similar to the survival after a more radical surgical approach reported in the literature. Level of evidence: IV.

Enzymatic debridement of hands with deep burns: a single center experience in the treatment of 52 hands.

Background: Bromelain-based enzymatic debridement has been introduced as an alternative to surgical excision in deep partial thickness and full thickness burns. We aimed to analyze effectiveness and predictors of spontaneous epithelialization after enzymatic debridement of deep hand burns.Methods: All patients who received enzymatic debridement for deep partial thickness or full thickness burns of the hands at our institution in the last 5 years were identified. Demographic, clinical and outcome data were collected and analyzed. For patients with deep partial thickness burns, Kaplan-Meier log-rank and subsequent multivariate Cox-regression analysis were performed to identify predictors of spontaneous epithelialization.Results: 44 patients and 52 hands were treated in the observation period. Among these, 14 had full thickness burns and received split thickness skin grafts. In the 38 hands with deep partial thickness burns, predictors of 28-day epithelialization were total burn extent and mechanism of burn injury. During the first 3 years, 8 out of 13 treated deep partial thickness burns received split thickness skin grafts after a median of 3 days. The following 3 years, 5 out of 25 deep partial thickness burns received surgery after a median of 14 days.Conclusions: Enzymatic debridement is a useful tool in the treatment of burned hands but the decision-making and correct timing of operative intervention in deep partial thickness burns after debridement requires experience. In our cohort, spontaneous healing of deep partial thickness burns was best in patients with contact burns and less than 15% burn TBSA.

Predictors of oncologic outcome in patients with and without flap reconstruction after extremity and truncal soft tissue sarcomas.

BACKGROUND: Soft tissue sarcomas (STS) of the extremities or trunk often require plastic reconstructive transfer of vital tissue for wound closure after resection. Literature on the oncologic outcome of patients receiving flap closure in comparison with patients receiving primary wound closure is very limited. METHODS: Patients who underwent resection of a primary extremity or truncal STS without dissemination at our institution between January 2000 until December 2015 were eligible for the study. Patients were divided into two groups based on type of soft tissue closure (primary or flap) while patients receiving skin grafting were excluded. Characteristics, oncologic outcome and prognostic factors of both groups were compared. RESULTS: 781 patients could be included, of these 200 had received flap closure and 581 primary wound closure. Tumors receiving flap closure were significantly smaller but were located in distal extremities and showed a trend towards prior neoadjuvant radiotherapy. Incidence of wound and general complications was similar in both groups. 5-year local recurrence free survival (LRFS, 71% vs. 69%) and 5-year disease specific survival (DSS, 84% vs. 88%) did not differ significantly between patients with primary closure and flap closure. Most important predictors in both groups were tumor size and grading with no major differences in analysis of predictors for both endpoints. CONCLUSION: Plastic reconstructive surgery plays an important role in limb-conserving STS treatment. Complication rates of patients with flap coverage are not higher than of patients with primary wound closure and oncologic outcome is similar with no major differences in predictors of LRFS and DSS.