[Subcutaneous Washout Procedure (SWOP) for Treating Severe Complications of an Aesthetic Gluteal Augmentation with a Copolyamide Filler]. / Subcutaneous Washout Procedure (SWOP) zur Behandlung schwerwiegender Komplikationen einer ästhetischen Glutealaugmentation durch Copolyamid-Filler.

BACKGROUND: Apart from surgical procedures for breast and buttock augmentation, copolyamide fillers can be locally injected for an increase in volume. This method is especially popular in Asia. PATIENT: A 39-year-old female patient had received a buttock augmentation by injection of a copolyamide filler. She presented with multiple abscesses six years after the augmentation. She had developed multiple fistulas and the filler had migrated down to the thigh muscles. RESULTS: In the presented case, the patient experienced multiple complications such as abscess formation, filler migration and chronic infection, with a significant time delay. Complete removal of the filler is only possible by removing surrounding tissue as well. Surgical treatment with repeated debridements and administration of an intravenous broad-spectrum antibiotic are the current standard of care. In contrast, the SWOP technique presented here appears to be less invasive and less likely for local recurrence. CONCLUSION: A breast or buttock augmentation with copolyamide fillers is associated with a high risk of abscess and fistula formation leading to a permanent disfigurement of the patient.

Outcome of Surgery as Part of Palliative Care of Patients with Symptomatic Advanced or Metastatic Extra-Abdominal High-Grade Soft Tissue Sarcoma.

Background: The modern multimodal treatment of malignant tumors has increased disease-specific survival and decreased the burden of tumor-associated complications. The main focus of palliative surgery is not based primarily on quantitative success parameters of tumor response but is instead mainly on the question of quality of life. Aim: The current study was conducted to analyze the clinical and oncological outcomes of palliative patients with soft tissue sarcoma. Design: Of 309 patients with extra-abdominal high-grade soft tissue sarcoma treated between August 2012 and December 2014, our retrospective analysis revealed 33 palliative patients for this study. All patients were evaluated and managed by a multidisciplinary team with expertise and experience in sarcoma treatment. The survival analysis was made using the Kaplan-Meier method. Results: The main sarcoma symptoms were pain (27.3%) and ulcerated tumors or shortly before ulceration (24.2%). Thirteen patients (39.4%) were operated on with negative margins, 15 (45.5%) with positive margins, 2 with tumor debulking (6.1%), and 3 patients (9.1%) were treated only with palliative hyperthermic isolated limb perfusion. Ten pedicle flaps were performed after sarcoma resection. The median operation time was 85 minutes (range, 37-216 minutes). The median hospitalization stay was 9.5 days (range, 3-27 days). No patients died during hospitalization. Twelve-month disease-free survival was 48.5% (95% confidence interval: 45.4-51.6). Conclusions: Palliative surgery of metastatic or advanced soft tissue sarcoma can improve the wound care and quality of life. Closed noninfected wounds enable further treatment options, such as chemotherapy, immunotherapy, and radiotherapy. This surgery should be considered during the discussion on interdisciplinary tumor boards.

[Reconstruction of posttraumatic soft tissue defects of the ankle using free fascial flaps from the anterolateral thigh]. / Rekonstruktion posttraumatischer sprunggelenknaher Weichteildefekte durch freie Faszienlappen aus dem anterolateralen Oberschenkel.

BACKGROUND: Free fascial flaps from the anterolateral thigh (ALT) were used to reconstruct soft tissue defects after trauma to the ankle. This modification was compared to the conventional fasciocutaneous method. MATERIAL AND METHODS: The defect size, the thickness of the subcutaneous fat layer on the thigh and the extent of the soft tissue covering the ankle were determined retrospectively. The evaluations were compared between fascial (Fo) and fasciocutaneous flaps (Fc). The foot and ankle outcome score (FAOS) was used. Esthetic outcome surveys were carried out. RESULTS: A total of 18 isolated fractures of the ankle were evaluated. In 94% of the cases a closed soft tissue damage predominated. After fracture fixation using a plate, soft tissue defects with a mean area of 40.4 ± 13.1 cm2 (28-76 cm2) developed. The thickness of the soft tissue covering over the affected malleoli increased significantly in both groups as a result of the flap surgery (4.5 ± 0.7 vs. 21.1 ± 6.4 mm, p < 0.05). A significant difference was found when comparing the body mass index (BMI) between the groups (Fc 26.3 ± 3.4 kg/m2 vs. Fo 30.1 ± 4.2 kg/m2, p < 0.05). For both groups there was a positive correlation (r = 0.843) between the BMI and the thickness of the epifascial fat layer of the thigh. The FOAS survey revealed 75.9 ± 28.9 and 47.9 ± 32.4 points, respectively, for "function in daily life" and "foot and ankle-related quality of life". The esthetic reconstruction result was rated as "acceptable" by 55% and as "good" by 45%. DISCUSSION: The modified method of a free fascial flap from the ALT can be useful in situations where a bulky flap makes it difficult to fit it into the defect.

Classic Type of Epithelioid Sarcoma of the Distal Upper Extremity: Clinical and Oncological Characteristics.

BACKGROUND: The classic type of epithelioid sarcoma (ES) is a rare, aggressive soft tissue neoplasm that most commonly affects the distal upper extremities of young patients. This study aimed to assess clinical features and provide a long-term report of the oncological outcome. METHODS: We retrospectively analyzed our clinical database for patients with ES of the distal upper extremities. RESULTS: Twenty-three patients with ES of the distal upper extremity were treated surgically between January 1990 and August 2018. ES affected most commonly the palmar side of young patients. The most common site affected by a sarcoma was the wrist in 47.8% of cases, followed by metacarpals and fingers with 34.8% and 17.4%, respectively. Most of the patients were treated according to the protocols of interdisciplinary tumor boards with multimodal therapy. A local recurrence was observed in 7 patients (30.4%). The 5 - and 10-year recurrence-free survival was 80.4% (95% confidence interval [CI]: 68.6-76.8) and 60.9% (95% CI: 53.5-68.3), respectively. The 5- and 10-years disease-specific survival was 89.9% (95% CI: 87-92.8) and 61.9% (95% CI: 56.5-67.3), respectively. Five patients (21.7%) had metastasis in regional lymph nodes. CONCLUSION: The classic type of ES represents a group of high-grade sarcomas, which affect the dominantly distal upper extremity. Specific clinical, diagnostic, and oncological characteristics make it difficult to diagnose and therapy. Wide tumor resection as a part of multimodal therapy remains a more viable and common treatment option for patients with ES on distal extremities. High rates of lymph node metastasis are typical for ES.

[Turbo-propeller flap for elbow reconstruction under regional anesthesia]. / Turbopropellerlappen zur Rekonstruktion eines Ellenbogendefektes in Regionalanästhesie.

A method for the reconstruction of an extensive soft tissue defect after a complicating olecranon fracture is presented. A perforator-based retrograde pedicled propeller flap was used from the lateral upper arm with additive microvascular "turbo"-anastomosis to the radial artery and vein. The turbo-flap was performed under regional anesthesia.

Improving Vascularization of Biomaterials for Skin and Bone Regeneration by Surface Modification: A Narrative Review on Experimental Research.

Artificial tissue substitutes are of great interest for the reconstruction of destroyed and non-functional skin or bone tissue due to its scarcity. Biomaterials used as scaffolds for tissue regeneration are non-vascularized synthetic tissues and often based on polymers, which need ingrowth of new blood vessels to ensure nutrition and metabolism. This review summarizes previous approaches and highlights advances in vascularization strategies after implantation of surface-modified biomaterials for skin and bone tissue regeneration. The efficient integration of biomaterial, bioactive coating with endogenous degradable matrix proteins, physiochemical modifications, or surface geometry changes represents promising approaches. The results show that the induction of angiogenesis in the implant site as well as the vascularization of biomaterials can be influenced by specific surface modifications. The neovascularization of a biomaterial can be supported by the application of pro-angiogenic substances as well as by biomimetic surface coatings and physical or chemical surface activations. Furthermore, it was confirmed that the geometric properties of the three-dimensional biomaterial matrix play a central role, as they guide or even enable the ingrowth of blood vessels into a biomaterial.

[Perforator-based keystone flap in the reconstruction of extensive tissue defects after lumbosacral spondylodesis]. / Perforatorbasierte Keystone-Lappenplastik in der Rekonstruktion ausgedehnter Gewebedefekte nach lumbosakraler Spondylodese.

BACKGROUND: Prolonged surgical site infections after spinal fusion surgery may lead to exposure of the implant due to the formation of extensive tissue defects and endanger the clinical outcome. OBJECTIVE: This study aims to enlighten the role of the keystone perforator flap method in the reconstruction of lumbar soft tissue defects. MATERIAL AND METHODS: The retrospective study included 11 consecutive patients with a wound dehiscence of over 6â€¯× 6 cm defect area persisting for 2 weeks after spinal fusion. The keystone perforator flap was applied for the reconstruction of tissue defects, whereas the arterial blood supply of the flaps was based on the intramuscular and intermuscular perforating branches of the dorsal branches of the lumbar arteries. RESULTS: The median age of our cohort was 58 years. The median body mass index (BMI) and Charlson comorbidity index (CCI) were 29.9 and 3.4, respectively. In eight cases a lumbosacral was carried out whereas in the remaining series a lumbar fusion was performed. In the course of the subsequent wound revision, on average 4 applications of negative pressure wound therapy (NPWT) were performed. The average defect size was 7.5 cm in width and 16.5 cm in length. The microbiological analysis of the tissue samples obtained intraoperatively after repeated NPWT revealed positive evidence of pathogenic bacteria in all cases. The average duration of inpatient treatment after flap surgery was 15 days, which was significantly shorter than the NPWT management of the open defect wounds (15.5 ± 2.5 vs. 37 ± 16.5, p < 0.05). CONCLUSION: The keystone perforator flap offers a stable coverage for soft tissue defects and supports infection control after spinal fusion.

Intra-abdominal lymph node flaps in lymphedema therapy: An anatomical guide to donor site selection.

BACKGROUND: Secondary lymphedema is a leading sequela of cancer surgery and radiotherapy. The microsurgical transfer of lymph node flaps (LNFs) to affected limbs can improve the symptoms. The intra-abdominal cavity contains an abundant heterogenic source. The aim of this study is to aid selection among intra-abdominal LNFs. METHODS: Eight LNFs were harvested in a microsurgical fashion at five sites in 16 cadavers: gastroepiploic, jejunal, ileal, ileocolic, and appendicular. These flaps were compared regarding size, weight, arterial diameter, and lymph node (LN) count after histologic verification. RESULTS: One hundred and sixteen flaps were harvested. The exposed area correlated with the flap weight and volume (r2 = 0.86, r = 0.9). While gastroepiploic LNFs (geLNFs) showed the highest median weight of 99 ml, the jejunal LNFs (jLNFs) had the highest density with 3.8 LNs per 10 ml. The most reliable jLNF was 60 cm from the ligament of Treitz. Three or more LNs were contained in 94% of the jejunal, 88% of the ileal/ileocolic, and 63% of the omental LNs. The ileocolic LNF had the largest arterial diameter of 3 mm, yet the smallest volume. CONCLUSIONS: jLNF and ileal LNF provide a reliable, high LN density for simultaneous, smaller recipient sites. geLNFs are more suitable for larger recipient sites.

An Extraordinary Reconstruction of a Postoperative Defect after Metatarsophalangeal Joint Arthrodesis of the Big Toe Using the "Chinese Forearm Flap". / Eine außergewöhnliche Rekonstruktion eines postoperativen Defektes nach Grundgelenksarthrodese der Großzehe mithilfe des "Chinesischen Unterarmlappens".

BACKGROUND: We present an unusual technique for reconstruction of a postoperative tissue defect following hallux rigidus surgery. METHODS: A complicated course after left big toe arthrodesis resulted in a soft tissue defect with bone exposure of the first ray. Amputation of the big toe was categorically rejected by the patient. There was advanced arteriosclerosis with single-vessel supply to the foot via the posterior tibial artery. OUTCOME: To preserve the big toe, the defect was covered by a fasciocutaneous radial free flap with a 15 cm long vascular pedicle which was microanastomosed to the posterior tibial artery and its accompanying vein at the level of the medial malleolus. CONCLUSION: In certain extreme situations, the free "Chinese" radial flap can be quite effective in covering forefoot defects and allowing satisfactory and aesthetically pleasing soft tissue reconstruction.

Angle-stable polyaxial locked plating with and without polymethylmethacrylate cement augmentation for proximal humeral fractures in elderly.

OBJECTIVES: This study aims to evaluate the outcomes of proximal humeral fracture (PHF) fixation with a polyaxial locking plate (PLP) osteosynthesis alone versus cement-augmented PLP (PLP-CA) in an elderly population. PATIENTS AND METHODS: Between May 2015 and June 2018, a total of 101 patients (17 males, 84 females; mean age: 74.5±8.1 years; range, 60 to 94 years) aged ≥60 years with an acute PHF who underwent osteosynthesis with PLP or PLP-CA were retrospectively analyzed. The patients were divided into two groups as the PLP (n=53) and PLP-CA (n=48). Clinical outcomes, Constant-Murley Scores (CMS), Disabilities of the Arm, Shoulder and Hand (DASH) scores, and Short Form-12 (SF-12) scores were compared between the groups. RESULTS: The overall mean follow-up was 28.1±11.1 months. No clinically relevant differences in the mean duration of surgery, mean intraoperative X-ray image intensifier time or postoperative in-hospital stay were found between the groups. A higher complication rate was observed in the PLP group (20.8% in PLP vs. 10.4% in PLP-CA; p<0.05). There was no statistically significant difference for this (t-test, p=0.08848). The CMS for the operated side did not show any significant differences between the groups. Also, no statically significant difference was seen in the SF-12. A slightly improved DASH score was found for the PLP group (p=0.02908). CONCLUSION: During follow-up PLP-CA osteosynthesis yielded nearly similar functional outcomes to PLP fracture fixation, despite with an overall lower rate of complication regarding secondary loss of reduction and screw cut-out. The polymethylmethacrylate cement augmentation can decrease morbidity in this patient group.

Effects of Extracorporeal Shock Waves on Microcirculation and Angiogenesis in the in vivo Wound Model of the Diver Box.

INTRODUCTION: Extracorporeal shock waves (ESWs) have been shown to have a positive effect on skin wound healing; however, little is known on the regeneration of the microcirculation and angiogenesis as well as the different application modes. METHODS: A total of 40 BALB/c mice were provided with dorsal skin fold chambers and were divided into 3 therapy groups (n = 30) and one control group (n = 10). The 3 therapy groups were treated with shock waves at different pulse rates (500-1,000 pulses/min) and application frequencies (day 0 and day 6 or day 0 only). Photographic documentation and intravital microscopy were carried out on day 1, 2, 4, and 6 after wounding. RESULTS: Using the newly developed Diver Box, shock waves could be applied in vivo without mechanical tissue damage. Shock wave therapy to skin wounds demonstrated to induce faster wound closure rates in the beginning than controls in groups with higher pulse rates and frequencies of the shock waves. Furthermore, the regeneration of microcirculation and perfusion in the healing skin was significantly improved after the application of, in particular, higher pulse rates as given by increased numbers of perfused capillaries and functional vessel density. The study of inflammation showed, especially in high-pulse ESW groups, higher leukocyte counts, and rolling leukocytes over time until day 6 as a response to the induction of inflammatory reaction after ESW application. Angiogenesis showed a marked increase in positive areas as given by sprouts, coils, and recruitments in all ESW groups, especially between days 4 and 6. CONCLUSION: The major findings of this trial demonstrate that ESW therapy to skin wounds is effective and safe. This is demonstrated by the initially faster wound closure rate, but later the same wound closure rate in the treatment groups than in controls. Furthermore, during the regeneration of microcirculation and perfusion in the healing skin, a significant improvement was observed after the application of, in particular, higher ESW pulse rates, suggesting an ESW-related increase in nutrient and oxygen supply in the wound tissue.

[Fluorescence lymphangiography in the diagnosis and navigated microsurgical treatment of iatrogenic lymph vessel lesion]. / Fluoreszenzlymphangiographie in Diagnostik und navigierter mikrochirurgischer Therapie iatrogener Lymphgefäßläsionen.

Injuries of lymph vessels can occur due to trauma or surgery and may result in significant difficulties for patients. Wound healing is often severely impaired and patients may need extensive surgical treatment. A case of iatrogenic lymph vessel injury after excision of a skin tumor in the axillary region is reported, as is the reconstructive procedure by lymphaticovenous anastomosis.

[Microvascular reconstruction of foot defects using a free femoral periostal flap]. / Mikrovaskuläre Rekonstruktion von Defekten am Fuß durch freien Femur-Periostlappen.

BACKGROUND: The reconstruction of defects in the foot region is a challenge due to the anatomical peculiarities of the soft tissue covering. OBJECTIVE: This article presents the results of the reconstruction of postoperative foot defects using the free femoral periosteal flap (FFPF). MATERIAL AND METHODS: In a patient collective (n = 10) with postoperative wound healing disorders of the foot, the defect zone was covered using a vascularized FFPF from the distal femoral region. The wound healing process was retrospectively analyzed. RESULTS: The mean follow-up time was 20.2 ± 8.22 months (7-35 months). All patients had a soft tissue defect in the foot region with a mean area of 17.9 ± 3.72 cm2 (12-24 cm2). On average, a wound healing disorder occurred 2 weeks after the primary surgery. In the group of patients followed up the vascularized FFPF enabled a stable, definitive and aesthetically pleasing reconstruction and contributed to the bony consolidation. The duration of inpatient care after defect closure was 8-10 days and was significantly less than the duration of wound management prior to transplantation of the FFPF. CONCLUSION: The FFPF is an effective and elegant method for the regenerative reconstruction of defects with accompanying osseous components in the foot region. The FFPF has the advantage of instant thin and pliable tissue coverage in contrast to many other reconstructive methods. The FFPF can promote wound consolidation through the regenerative properties of a vascularized periosteal sheath in the context of a one-step and permanent infection control.

A Novel Technique for the Standardized Application of Shock Waves in Experimental Research: The Diver Box.

The Diver Box is designed to prevent impedance differences, energy loss or damage to neighboring structures caused by the use of shock waves with application gels. The Diver Box is an acrylic glass container filled with tempered water and includes a coupling membrane to prevent the impedance jump from air to water and to avoid the continuous propagation of shock waves into the tissue, maintaining wave dynamics. Different modes of extracorporeal shock waves can be applied to a mouse skin wound without energy loss and protected from harmful phase-reversed waves. Macroscopic changes were seen in only 5% to 12% of tested specimens. Hazardous phase reversal, back reflection and mechanical tissue damage can be avoided by use of the Diver Box, ensuring standardized extracorporeal shock wave application.

In-vivo monitoring of infection via implantable microsensors: a pilot study.

The most common complication after implantation of foreign material is infection, leading to implant failure and severe patient discomfort. Smoldering-infections proceed inapparently and might not get verified by radiological diagnostics. Early identification of this type of infection might significantly reduce the rate of complications. Therefore, we manufactured a microsensor strip in a hybrid of thin-film and laminate technology in a wafer-level process. It comprises electrochemical, amperometric microsensors for glucose, oxygen and lactate as well as an integrated reference electrode. Microsensors have been implanted in the mouse dorsal skin fold chamber, which got inoculated with a human-pathogen bacterial strain. A selective signal could be measured for all parameters and time points. The infection led to measurable changes of the wound environment as given by a decrease of the oxygen- as well as the glucose-concentration while the lactate concentration increased markedly over time. The given results in this study are the first hints on a promising new tool and should therefore be interpreted as a proof of the principle to show the functionality of the microsensors in an in vivo setting. These microsensors could be used to monitor smoldering infections of implantable foreign materials reducing foreign implant associated complications.

Soft tissue sarcomas of the distal lower extremities: A single-institutional analysis of the prognostic significance of surgical margins in 120 patients.

Soft tissue sarcomas (STS) arising in the distal lower extremities pose a therapeutic challenge due to concerns of functional morbidity. The impact of surgical margins on local recurrence­free survival (LRFS) and overall survival (OS) still remains controversial. The aim of this study was to identify prognostic indicators of survival and functional outcome in patients with STS of the distal lower extremities through a long­term follow­up. Between 1999 and 2014, 120 patients with STS of the foot, ankle and lower leg were treated surgically at our institution. The median follow­up was 6.3 years. The results reveal that the 5­year estimate of the OS rate was 80.0% [95% confidence interval (CI): 69.6­87.1] for the entire series. Surgical margins attained at the resection of the primary tumor did not influence OS significantly [5­year OS: R0 80.5% (69.7­87.9) vs. R1 74.1% (28.9­93.0); P=0.318]. Within the R0 subgroup, negative surgical margin widths ≤1 and >1 mm led to similar outcomes, as well as ≤5 and >5 mm, respectively. In the multivariate analysis, significant adverse prognostic features included male gender and age >60 years at the time point of primary diagnosis. In conclusion, the data from this study could not underscore the long­term benefit of negative margins achieved at the resection of the primary tumor. Surgical efforts should aim at function­sparing resections when feasible with negative margins. Here, close negative margins seem to be adequate.