[Spinal cord injury: still an interdisciplinary challenge [corrected]]. / Querschnittläsion : Eine bleibende interdisziplinäre Herausforderung.

INTRODUCTION: Spinal cord injuries with symptoms of paraplegia remain incurable even 5000 years after the first description. However, the treatment of the residual paralysis and sensory deficits at the level of or below the spinal injury has made great progress. METHODS: This study involved a selective literature review with an emphasis on historical development, epidemiology, classification, acute and secondary rehabilitation after spinal cord injury with specific aspects of hand surgery in tetraplegia, decubitus treatment and urological specialist care, taking the experiences in a specialized center for spinal cord injuries into account. RESULTS: Modern comprehensive management started in the 1940s led by Sir Ludwig Guttmann. Early operative decompression and stabilization of spinal injuries is safe and can reduce secondary damage to the spinal cord but definitive evidence is lacking. Operative approaches provide advantages for the patient compared to conservative therapy, e.g. being able to be immediately transferred to a specialized center. Epidemiologically, the proportion of women and the average age has increased during the past decades, as well as the percentage of patients with tetraplegia. Common sequelae of spinal cord injuries include disorders of the digestive and urogenital system, autonomic regulation, chronic pain as well as swallowing and breathing restrictions. Frequent complications, such as thrombosis and pulmonary embolism, heterotopic ossification, decubitus ulcers, contractures, neuropathic pain and spasticity can impede rehabilitation. The general objective of rehabilitation and life-long care of patients with spinal cord injuries is to achieve the greatest possible autonomy, mobility, integration, employability and quality of life. A partial recovery of arm and grip function by surgical muscle or nerve transposition, joint stabilization and tenodesis can reliably support these goals in approximately 70 % of patients with tetraplegia. CONCLUSION: Spinal cord injuries require holistic interdisciplinary therapy from the beginning and regular life-long comprehensive and specific orthopedic examinations are also required to maintain the best possible level of independence.

Percutaneous collagen induction. Scarless skin rejuvenation: fact or fiction?

Photoageing is generally treated by ablative procedures that injure the epidermis and basement membrane, and lead to fibrosis of the dermis. Percutaneous collagen induction (PCI) therapy is an alternative treatment for photoaged skin that does not result in clinical signs of dermal fibrosis. In this study, the immediate effects of PCI on the skin were assessed, including the systemic inflammatory response and the production and gene expression of transforming growth factor (TGF) isoforms beta1, beta2 and beta3. Eighty rats were split into four groups: group 1 (n = 24; PCI plus skin care); group 2 (n = 24; skin care only); group 3 (n = 24; PCI only) and group 4 (n = 8; controls). Microarray analysis showed that TGF-beta3, an essential marker for preventing scarring, was upregulated and expressed for 2 weeks postoperatively. PCI might offer a regenerative therapy to improve skin appearance and quality and to improve or even prevent scarring.

Availability Of Covid-19 Information From National And International Burn Society Websites.

National and international burn society websites are an important source of information for patients and burn care professionals. The current COVID-19 pandemic represents an unprecedented global health crisis. The aim of this study was to assess the information available on national and international burns society websites on the current pandemic of COVID-19. National and international burns society websites were assessed with regard to COVID-19 information. Five percent of nations had a burn care society website. Forty percent of these national society websites mentioned COVID-19. None provided their state's guidelines, nor advised to provide only urgent or emergent care. None recommended following WHO guidelines. One-third (33%) of the international societies documented the decision to postpone its congress and provided links to two articles describing burn care during the COVID-19 pandemic. The availability of COVID-19 clinical guidelines and information on national and international burn care society websites is lacking. Burn care society websites must develop relevant COVID-19 information to support burn care professionals on the frontline of care.

Les sites des sociétés savantes brûlologiques sont une source importante d'information pour le grand public et les professionnels. La pandémie actuelle à COVID- 19 est une crise sanitaire sans précédent. Le but de cette étude était d'évaluer les informations concernant cette épidémie disponibles sur les sites des sociétés savantes, tant nationales qu'internationales. Seuls 5% des pays ont des sites émanant des sociétés savantes brûlologiques, 40% de ces sites dispensant des informations sur la pandémie. Aucun ne relayait les recommandations de leur état, pas plus qu'il ne conseillait de ne pratiquer que des soins urgents ni de suivre les recommandations de l'OMS. Le tiers des sociétés y a fait apparaître la décision de repousser leur congrès, le tiers aussi insérant un lien vers 2 articles décrivant la prise en charge des brûlés en période pandémique. Les informations concernant la pandémie COVID-19 manquent donc sur les sites des sociétés savantes brûlologiques. Elles doivent les afficher, afin d'aider les professionnels dans la prise en charge des brûlés pendant cette période.

[Organ transplantation, composite tissue allotransplantation, and plastic surgery]. / Organtransplantation, Gewebetransplantation und plastische Chirurgie.

Transplantations play an increasing role for plastic reconstructive surgeons. The increasing number of solid organ transplantations and the improved long-term survival rates lead to increased numbers of these patients also undergoing plastic and reconstructive procedures. Free flap transfer in solid organ transplant patients is feasible with no higher risk to both transplant function and postoperative complications than for nontransplant patients, even during immune suppression. Composite tissue allotransplantation (CTA) is an evolving field in plastic reconstructive surgery with hands, arms, partial faces, abdominal walls, and knee joints being transferred in clinical settings. However only an interdisciplinary approach using all available resources in highly selected patients after exhausting all other plastic reconstructive procedures is able to achieve reasonable results. The potential complications of long-term immune suppression and patient compliance have to be balanced with the expected and achieved functional result of CTA, whose procedures must be discussed as a potential tissue or organ transplantation, given the legal and logistic implications. The interdisciplinary cooperation of transplant surgeons, microsurgeons, psychologists, and ergo- and physiotherapists is mandatory to achieve successful CTA results.

Toxic epidermal necrolysis: use of Biobrane or skin coverage reduces pain, improves mobilisation and decreases infection in elderly patients.

INTRODUCTION: Toxic epidermal necrolysis is a rare disease with high mortality due to generalised infection, sepsis or lung involvement, and requires discontinuation of all potentially triggering medications and intensive care in a specialised burn centre. Apart from wound care with antiseptics, wound coverage may be achieved with a skin substitute; treatments are compared with regard to infection, protein loss, re-epithelialisation and mortality. PATIENTS AND METHODS: Of 14 people with toxic epidermal necrolysis affecting >30% body surface area, eight received daily dressing changes using Lavasept nd six received wound coverage with Biobrane. Demographic data, SCORTEN score, mortality, visual-analog pain scale, mobilisation, time to re-epithelialisation, serum protein, albumin, C-reactive protein and leukocytes, and body temperature were evaluated in all cases. RESULTS: Mean age of patients was 68.0+/-14.8 years, mean body surface area affected was 66.4%, median SCORTEN score was three and overall mortality was 36%. In the Biobrane ompared with the Lavasept control) group, mean pain was significantly reduced (2.9 versus 5.5 on the scale, p<0.05), mobilisation was significantly earlier (walking at 3 days versus 7 days, p=0.003), re-epithelialisation was complete in 12.5 days versus 16 days, and at 9 days there was reduced decrease of serum proteins and significantly lower levels of C-reactive protein and white cells (p<0.05). CONCLUSION: Early wound coverage with synthetic skin substitute such as Biobrane s beneficial compared with conservative antiseptic wound treatment, but mortality rate is not significantly different.

[Nicotine in plastic surgery : a review]. / Nikotinkonsum und plastische Chirurgie : Eine aktuelle Ubersicht.

BACKGROUND: The surgical complication rate is significantly increased in active smoking patients. However there are no evidence-based recommendations regarding smoking among patients seeking plastic surgical procedures. METHODS: MEDLINE analysis was performed of all relevant clinical and experimental papers from 1965 to 2008. RESULTS: In face-lift operations smokers present a 13-fold risk of skin necrosis. In mamma reduction procedures the risk among smokers is doubled for number of complications, with T-incision site necrosis (odds ratio 3.1) and infection rate (OR 3.3) significantly elevated among active smokers. Transverse rectus abdominis myocutaneous flaps for breast reconstruction are associated with significantly higher flap necrosis rates for smokers than nonsmokers (19% vs 9%, P=0.005). The smoking history can be indicative, but usually the number of cigarettes is drastically underestimated. Cotinine testing is a method of determining smoking quantitatively up to 4 days before testing. CONCLUSION: Four weeks of abstinence from smoking reduces smoking-associated complications. Despite the published evidence, smoking is no longer relevant in the German 2008 Disease-Related Group for plastic surgical procedures.

[Gynecomastia, its etiologies and its surgical management: a difference between the bilateral and unilateral cases?]. / La gynécomastie, ses étiologies et sa prise en charge chirurgicale: y a-t-il une différence entre les cas bilatéraux et unilatéraux?

Numerous excision and liposuction techniques have been described to correct bilateral male breast enlargement. Yet little attention has been directed towards the rare cases of unilateral gynecomastia which have frequently been suspected to be malignant. The purpose of this study was to investigate the results of surgical gynecomastia management and the roles of different treatment modalities in a large patient cohort with special attention to etiology, treatment and outcome in the cases of unilateral involvement.

[Vascular interventions and reconstructive plastic surgery. Optimizing the treatment of chronic wounds]. / Gefässchirurgische Interventionen und plastisch-rekonstruktive Chirurgie. Ergebnisoptimierung in der Behandlung chronischer Wunden.

Despite the high prevalence of arterial occlusive disease, only a few studies have investigated the benefit of interventions to recanalize extremity arteries prior to plastic operations to close chronic wounds. The purpose of this study was to investigate the correlation of simple clinical examinations and apparative diagnostics of arterial occlusive disease of the lower extremity in patients with chronic wounds and to evaluate the benefit of vascular procedures to optimize wound perfusion before surgical closure. A total of 150 individuals with chronic wounds were included in this retrospective study. All patients underwent palpation of their foot pulses, Doppler sonography, and measurement of occlusive pressure. Positive results were tested by angiography. All patients with peripheral extremity vessel occlusion underwent vascular interventions prior to plastic operations for definitive wound closure. In all 34 patients with missing foot pulses, the clinical diagnosis of arterial occlusion could be confirmed by angiography. Peripheral recanalization and improved wound perfusion could be achieved in all patients. Arterial insufficiency could be diagnosed rapidly and safely using simple clinical examination such as palpation of foot pulses or measurement of occlusive pressures combined with Doppler sonography. Thus this simple and straightforward algorithm helped to secure the success of surgical therapy by shortening the time until wound-healing and reducing the psychosocial burden on the patient and financial costs to the health care system.

[Hirudo medicinalis-leech applications in plastic and reconstructive microsurgery--a literature review]. / Hirudo medicinalis-Anwendungen in der plastischen und rekonstruktiven Mikrochirurgie--eine Literaturübersicht.

Medical leech therapy has enjoyed a renaissance in the world of reconstructive microsurgery during recent years. Especially venous congestion is decreased using hirudo medicinalis application such as following replantation of amputated fingers or congested flaps. They provide a temporary relief to venous engorgement whilst venous drainage is re-established. Living in symbiosis with Aeromonas hydrophila, who can digest the sixfold blood meal related to their body weight, and a broad number of anticoagulant agents such as the thrombin inhibitor hirudin, apyrase as well as collagenase, hyaluronidase, Factor Xa inhibitor and fibrinase I and II, leeches decrease venous congestion. Laser Doppler flowmetry could demonstrate a significant increase in superficial skin perfusion following leech application 16 mm around the biting zone. Following the initial blood meal accounting for about 2.5 ml, the anticoagulant effect of the various leeches enzymes follows within the next 5-6 hours, which both account for the beneficial effects. Infection associated with leech therapy is a documented complication of leech application, with reported incidences ranging from 2.4 to 20 % and a chinolone antibiotic is currently recommended to face the potential Aeromonas hydrophila infection. Anemia is a second adverse effect during medicinal leech application which has to be taken account with repetitive blood samples. Besides the successful applications of leeches in various applications in plastic and reconstructive microsurgery, randomized-controlled trials are pending to elucidate the value of hirudo medicinalis according to evidence-based criteria above from case series and case studies.

Revision surgery after carpal tunnel release--analysis of the pathology in 200 cases during a 2 year period.

Carpal tunnel release (CTR) is regarded as a common and successful operative procedure in hand surgery. However, an increasing number of patients with complications have been referred to our hospital. This retrospective investigation was undertaken to clarify the reasons for persisting or recurrent symptoms in 200 patients who underwent secondary exploration during a 26 month period at a single institution. In 108 cases, the flexor retinaculum was found to have been released incompletely. In 12 patients, a nerve laceration had occurred during the primary intervention. In 46 patients, symptoms were due to the nerve being tethered in scar tissue. The re-exploration revealed circumferential fibrosis around and within the median nerve in 17 patients and a tumour in the carpal tunnel in four patients. In 13 patients, no specific reason was found for recurrence of symptoms. We conclude that CTR seems to be a widely underestimated procedure and revision surgery could be largely avoided by reducing technical errors during the primary operation.

[Long-term results after resection arthroplasty in patients with arthrosis of the thumb carpometacarpal joint: comparison of abductor pollicis longus and flexor carpi radialis tendon suspension]. / Ergebnisse nach Resektions-Suspensions-Arthroplastik bei Rhizarthrose: Vergleich der Abductor pollicis longus- mit der Flexor carpi radialis-Sehnensuspension.

PURPOSE/BACKGROUND: This retrospective analysis focused on a comparison of long-term results in patients who underwent resection of the trapezium with subsequent arthroplasty and tendon suspension using either the abductor pollicis longus (APL) or the flexor carpi radialis (FCR) tendon. METHOD AND MATERIAL: Based upon a positive history along with a clinical and radiological examination, 20 patients underwent suspension arthroplasty using the APL tendon (APL group) and 21 patients suspension arthroplasty using the FCR tendon (FCR group) after trapeziectomy. In both groups mean age (APL group: 60.4 +/- 5.3; FCR group: 61.7 +/- 6.8 years), pain severity according to the Visual Analogue Scale (VAS; APL group: 6.7 +/- 1.9; FCR group: 6.9 +/- 1.7), severity of arthrosis in the thumb carpometacarpal joint according to the Eaton-Littler classification (APL group: 3 +/- 0.7; FCR group: 3.2 +/- 0.6) and time interval from onset of symptoms to surgery (APL group: 27 +/- 8.1; FCR group: 41.5 +/- 14.1 months) did not significantly differ. Each patient of both groups was treated surgically and reviewed by one experienced hand surgeon. Both groups received the same standardized postoperative treatment. RESULTS: In the APL group the mean operative time was significantly shorter (31.7 +/- 9.5 min) than in the FCR group (48.7 +/- 7.9 min). The follow-up period from surgery to the final examination was similar in both groups (APL group: 23.1 +/- 12.2; FCR group: 31 +/- 17.6 months). At the time of the final examinations, no statistically significant differences were found when analyzing the results of the DASH score (APL group: 20.1 +/- 15.1; FCR group: 29.3 +/- 15.7), the self-administered hand ability score (APL group: 1.7 +/- 0.6; FCR group: 2.1 +/- 0.6) and the VAS (APL group: 1.1 +/- 1.6; FCR group: 0.8 +/- 1.5). The time period from surgery to the offset of postoperative pain was also comparable in both groups (APL group: 5 +/- 1.8; FCR group: 5.3 +/- 2.5 months). The range of abduction in the first carpometacarpal joint after arthroplasty, parallel and perpendicular to the dorsum of the hand, was also similar in both groups (APL group: 63.4 +/- 14.3 degrees /62.1 +/- 11 degrees ; FCR group: 67.8 +/- 12.7 degrees /66 +/- 12.1 degrees ). However, patients enrolled in the APL group revealed significantly better results compared to patients in the FCR group regarding grip-strength, key and pinch grip (APL group: 23.9 +/- 9.7/6.6 +/- 2.4/6.2 +/- 2.8 kg; FCR group: 17 +/- 7.2/4.5 +/- 1.5/3.6 +/- 1.5 kg). CONCLUSION: Both techniques led to highly satisfactory results as seen in DASH and VAS data together with a near normal range of abduction in the first carpometacarpal joint in all enrolled patients. However, in direct comparison the APL procedure is technically easier to perform with significantly shorter surgery time recorded and significantly higher values in all force parameters compared to the FCR procedure.

[Conservative versus surgical therapy of perilunar dislocation and dislocation fractures]. / Konservative versus operative Therapie der perilunären Luxation und Luxationsfrakturen.

18 perilunate dislocations and fracture-dislocations were treated at the Trauma Center of the Vienna General Hospital during the period from 1992 to 1995. Only five cases were treated without surgery. 15 of these 18 patients returned for follow-up after an average of 16 months. In ten cases good results were achieved. Radiologically, eight patients were classified as good. Overall better results were seen after surgical treatment.

[Restoration of knee extension with biceps femoris muscle transfer after resection of the quadriceps femoris muscle]. / Die Transposition des Musculus biceps femoris zum Ersatz des Kniegelenkstreckers nach Resektion des Musculus quadriceps.

OBJECTIVE: Improvement of gait and ability to stand by reconstruction of functional knee extension. INDICATIONS: Loss of function of the quadriceps femoris muscle due to tumour resection or traumatic damage of the muscle with loss of active knee extension. CONTRAINDICATIONS: Inadequate strength of the biceps femoris muscle. Recurrent tumour or ankylosis of the knee joint. SURGICAL TECHNIQUE: The tendon of the biceps femoris is dissected near the knee at the head of the fibula and is mobilized proximally. The underlying common peroneal nerve and the neurovascular supply of the biceps muscle must be spared. Through a ventral approach at the thigh the lateral intermuscular septum is opened and the biceps tendon is pulled through and sutured to the quadriceps tendon and periost of the patella. POSTOPERATIVE MANAGEMENT: The knee is immobilized in extension with a cast followed by a knee orthosis for 6 weeks, which is followed by intensive physiotherapy; however, the patient should not be forced to flex the knee extensively. The orthosis can be worn for another 3-4 weeks to stabilize the knee joint, while the muscles are intensively trained. RESULTS: Reliable reconstruction of functionally useful, active knee extension without an orthosis of a previously unstable knee joint in the sagittal plane, even if full extension is not to be expected.

Carpal tunnel syndrome caused by supernumerous lumbrical muscle in hemihyperplasia of the upper extremity.

INTRODUCTION: Hemihyperplasia of the upper extremity is a rare pathology that occurs in 1/86,000 births. Carpal tunnel syndrome may be associated with this disease. CLINICAL PRESENTATION: We describe the case of a 74-year-old male who has hemihyperplasia of both upper extremities since birth. At the age of 73, he started experiencing continuous, progressive and high intensity pain that occurred more frequently at night and was localized in the right hand. It was associated with paresthesia and hypoesthesia predominantly of the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to diagnosis of carpal tunnel syndrome. RESULTS: The patient underwent surgical carpal tunnel release to treat the disease. The enlarged nerve was compressed by a supernumerous lumbrical muscle, which was resected intraoperatively. After six months of follow-up the patient has normal sensitivity and grip strength in the right hand. CONCLUSION: Hemihyperplasia should be clearly distinguished from other complex pathologies that may also entail CTS. Since significant variation in the anatomy of the hemihyperplasic extremities is the rule rather than the exception, a conventional open approach should be taken to localize and treat the compression.

Restoration of active palmar abduction of the thumb in tetraplegia by tendon transfer of the extensor digiti minimi to abductor pollicis brevis.

We describe a method to restore active palmar abduction of the thumb and report its functional impact in tetraplegia. At 54.2 (SD 42.8) months after cervical spinal cord injury (12 traumatic, 3 nontraumatic), the extensor digiti minimi (EDM) tendon was transferred to the abductor pollicis brevis (APB) through the interosseous membrane in 15 tetraplegic patients (age range 19-70 years) in addition to a mean 3.2 procedures to restore key pinch. According to International Classification, the operated upper extremities were in the OCu4 to OCu8 (1 patient X) group. The maximum distance between thumb and index finger tips during active or passive opening of the hand, maximum angle of palmar abduction, grip and key pinch strength, and active finger range of motion were measured. All patients were re-examined after 38.4 (SD 22.7) months. The active thumb-index opening increased significantly from 2.5 (SEM 1.0) cm before to 9.0 (SEM 0.8) cm after surgery. Nine patients without previous active opening of the first web space recovered a mean thumb-index opening of 9.1 (SEM 1.7) cm, whereas this distance increased by an average of 2.9 (SEM 0.8) cm in six patients who had active thumb index distance of 6.3 (SEM 1.6) cm before surgery. All but one patient were able to direct and coordinate key pinch and perform tasks using the restored APB function, including five patients whose EDM strength was rated as grade 3 before transfer. This EDM-to-APB transfer meets the theoretical requirements of architecture matching between donor and recipient muscles, the principles of tendon transfer, and our surgical expectations. We strongly recommend that an active EDM is transferred to the APB to restore opening of the hand and help in key pinch control in patients with tetraplegia.

Otto Hilgenfeldt (1900-1983): tribute to an important pioneer of European hand surgery.

The German surgeon Otto Hilgenfeldt (1900-1983) was a great innovator in European hand surgery in the 20th century, particularly in respect of the tactile (sensate) thumb and grip reconstruction in amputation injuries. His experience, beginning in the 1930s, helped him to treat hundreds of soldiers with mutilating hand injuries from 1941 to 1945 during World War II. While totally isolated and without any access to international publications, he devised many innovative ideas such as a neurovascular middle finger transposition for pollicization (first case done in July 1943) and a sensory dorsoradial first metacarpal flap for thumb resurfacing. His book Operative thumb replacement and substitution of finger losses published in 1950 is regarded as one of the most important German contributions to modern hand surgery. Hilgenfeldt's life and work remain fascinating and exemplary from a historical and surgical point of view. Many of his pragmatic surgical solutions remain valid despite the advent of microsurgery.

Simultaneous powering of forearm pronation and key pinch in tetraplegia using a single muscle-tendon unit.

This study clinically assessed the concept that both thumb flexion and forearm pronation can be restored by brachioradialis (BR)-to-flexor pollicis longus (FPL) tendon transfer if the BR is passed dorsal to the radius. Six patients [two women and four men, mean age 32.3 years (SD 4.9, range 23-56)] underwent BR-to-FPL transfer dorsal to the radius and through the interosseous membrane (IOM). Lateral key pinch strength and pronation range of motion (ROM) were measured 1 year after surgery. A group of six patients [two women and four men, mean age 31.2 years (SD 5.0, range 19-52)] who underwent traditional palmar BR-to-FPL was included for comparison. Postoperative active pronation was significantly greater in the dorsal transfer group compared to the palmar group [149 (SD 6) and 75 (SD 3), respectively] and pinch strength was similar in the two groups [1.28 (SD 0.16) kg and 1.20 (SD0.21) kg, respectively]. We conclude that it is feasible to reconstruct lateral key pinch and forearm pronation simultaneously using only the BR motor.

Subcutaneous wash-out procedure (SWOP) for the treatment of chemotherapeutic extravasations.

INTRODUCTION: Extravasations of chemotherapeutic drugs may lead to tissue necrosis and subsequent tissue defects, sometimes resulting in loss of function. In the absence of therapy, approximately one-third of vesicant extravasations will result in ulcerations, some of which necessitate plastic microsurgery to cover the soft tissue defects. The aim of this study was to describe the surgical technique itself and to present clinical results of the procedure in a clinical series of chemotherapeutic extravasation injuries that benefitted from a subcutaneous wash-out procedure (SWOP) by minimisation of serious complications. PATIENTS AND METHODS: Over a time period of 3 years, we treated 13 female patients following chemotherapeutic extravasation injury. Nine of the cases involved a high vesicant chemotherapy agent, and four patients involved chemotherapy with low vesicant potential. The therapeutic approach was performed using SWOP exclusively without the application of specific antidotes. RESULTS: The mean time interval between the extravasation injury and the SWOP was 345min (140-795min). In none of the cases was there a tissue breakdown, but there was a steady decrease in the inflammatory reaction of the cutaneous and subcutaneous soft tissues without additional complications over a 3-month follow-up period. CONCLUSION: The results of the study suggest that SWOP is a minimally invasive, safe and effective emergency treatment for chemotherapeutic extravasation injury. Based on the absence of comparative studies with regard to the efficacy of conservative therapy, SWOP should be offered as a therapeutic option for chemotherapeutic extravasations, especially in cases of medical malpractice and also as a defence in case of a legal conflict.

[A survey of preoperative perforator mapping in perforator flap surgery]. / Umfrage zu Methoden der präoperativen Lokalisation von Perforans-Gefässen zur erleichterten Planung von Perforans-Lappenplastiken.

INTRODUCTION: The frequency of perforator flap surgery is increasing. As such, the claim to identify and localize the perforators is closely related to preoperative perforator imaging. Starting with Doppler sonography magnetic resonance imaging (MRI) followed early in the 90s. Recently, three- and four-dimensional computer tomographic angiography and venography present impressive preoperative illustrations of perforators. HYPOTHESIS: Duplex ultrasound dominates in clinical practice for perforator imaging. METHODS: We performed a survey using a multiple choice questionnaire which was distributed among consultants of the German plastic surgery society (DGPRAC). Response rate was 46% with 132 institutions responding. RESULTS: Preoperative perforator imaging is applied in 77%. Duplex sonography is predominant with 70%, followed by colour Doppler ultrasound (42%). CT angiography (7%) and MRI angiography (8%) are currently underutilized. The amount of perforator flaps performed did not favor any preoperative perforator diagnostic. However, among those performing more than 30 perforator flaps per year, only 2% did not perform any perforator diagnostic at all. CONCLUSION: Preoperative perforator imaging is applied in 3/4 of all perforator flaps with duplex ultrasound dominating. Angio-CT and Angio-MRI are currently infrequently used for preoperative perforator imaging in Germany to date.

In vivo reflectance-mode confocal microscopy provides insights in human skin microcirculation and histomorphology.

PURPOSE: Various approaches are used to study microcirculation, however, no modality evaluates microcirculation and histomorphology on cellular levels. We hypothesized that reflectance-mode confocal microscopy (RCM) enables simultaneous evaluation in vivo of both microcirculation and histomorphology. PRINCIPALS: The forearm of 20 volunteers was exposed to either local heat stress (HS-group), or to local cold stress (CS-group). RCM was performed prior and after temperature stress to evaluate quantitative blood-cell flow, capillary loop diameter, granular cell size, and basal layer thickness. RESULTS: In the HS-group, we observed significant increase in capillary loop diameter and increased blood-cell flow after heat stress. In the CS-group, significant decreases of capillary loop diameter and in blood-cell flow were determined following cold stress. Granular cell size and basal layer thickness differed insignificantly prior and after local temperature stress. CONCLUSIONS: RCM provides real-time and in vivo high resolution imaging of temperature-dependent changes in the human skin microcirculation and histomorphology on cellular levels.