Quantification of Dermal Microcirculatory Changes after Topical Administration of Capsaicin: A Randomized Placebo-Controlled Study in 46 Subjects.

BACKGROUND: Dermal blood flow is crucial for wound healing and survival of flaps in dermatologic surgery. To improve flap viability in cases of compromised perfusion topical agents can easily be applied. The aim of this placebo-controlled study was to characterize changes of DBF in healthy subjects by quantitatively assessing perfusion dynamics after application of capsaicin to establish a reference for measurements at injured sites. METHODS: In 46 healthy subjects perfusion dynamics after local application with capsaicin and placebo was noninvasively assessed, determining cutaneous oxygen saturation, relative hemoglobin count and blood flow using an Oxygen-to-See device. RESULTS: A significant raise in superficial (162% p = 0.000) and deep (144%, p = 0.000) skin oxygenation after 30 min was provoked. A highly significant raise in measurements of flow and velocity was present in superficial (523%, p = 0.000) and deep (242%, p = 0.000) sites. CONCLUSION: With the introduced model applied to observe changes in parameters of dermal blood flow in healthy subjects the authors can reliably monitor effects of topically administered capsaicin. This baseline can be used as reference for further studies in the settings of endangered flap survival or critically perfused wounds as has been proven in animal studies.

The Influence of Topically Administered Heparin on Peripheral Microcirculation of the Skin: A Double-Blind, Randomized, Controlled Preliminary Study on 50 Healthy Subjects.

BACKGROUND: Venous thrombosis is the most common cause of flap failure in the first days after surgery. Although heparin is one of the most important antithrombotic substances and is implemented in the therapy of various diseases, there are only a few studies addressing its topical administration in the field of flap surgery. Especially, very little is known about the effects of topical heparin and its impact on microcirculation. In this study we evaluated to what extent topically administered heparin influences skin microcirculation (capillary venous oxygen saturation SO2, blood filling of microvessels, blood flow, and velocity) in healthy subjects. METHODS: Skin perfusion parameters on the forearm were measured with the O2C device in a double-blinded, controlled, and randomized study with 50 healthy subjects after administration of heparin ointment in three different concentrations and a control ointment (dexpanthenol). RESULTS: Topically administrated heparin slightly increased SO2 (max. 187 ± 285 SD or standard deviation % vs. 145 ± 129 SD %), flow (max. 264 ± 427 SD % vs. 151.74 ± 111 SD %), and velocity (max. 153 ± 149 SD % vs. 122 ± 56 SD %) after an incubation time of 60 minutes in comparison to control. No statistically significant difference could be detected regarding heparin concentration. CONCLUSION: As a first important step in possible future implementing of heparin as a topical administration in flap surgery, our data-although not statistically significant-indicate that heparin can improve microcirculation (SO2, flow) in healthy subjects. Nevertheless, further research in subjects with impaired microcirculation is necessary.

Autologous Unilateral Breast Reconstruction with Venous Supercharged IMAP-Flaps: A Step by Step Guide of the Split Breast Technique.

Various techniques for breast reconstruction ranging from reconstruction with implants to free tissue transfer, with the disadvantage of either carrying a foreign body or dealing with donor site morbidity, have been described. In patients who had a unilateral mastectomy and offer a contralateral mamma hypertrophy a breast reconstruction can be performed with the excess tissue from the hypertrophic side using the split breast technique. Here a local internal mammary artery perforator (IMAP) flap of the hypertrophic breast can be used for reconstruction avoiding the downsides of implants or a microsurgical reconstruction and simultaneously reducing the enlarged donor breast in order to achieve symmetry. METHODS: Between April 2010 and February 2019 the split breast technique was performed in five patients after mastectomy due to breast cancer. Operating time, length of stay, complications and the need for secondary operations were analyzed and the surgical technique including flap supercharging were described in detail. RESULTS: All five IMAP-flaps survived and an aesthetically pleasant result could be achieved using the split breast technique. An average of two secondary corrections to achieve better symmetry were necessary after each breast reconstruction. Complications included venous flap congestion, partial flap necrosis and asymmetry. No breast cancer recurrence was recorded. An overall approval of the surgical technique among patients was observed. CONCLUSIONS: The use of the contralateral breast for unilateral total breast reconstruction represents an additional highly useful technique for selected patients, is safe and reliable results can be achieved. Although this technique is carried out as a single-stage procedure, including breast reduction and reconstruction at the same time, secondary operations may be necessary to achieve superior symmetry and a satisfying aesthetic result. Survival of the IMAP-flaps can be improved by venous supercharging of the flaps onto the thoracoepigastric vein.

The Impact of Age on Perioperative Complications after Extremity Reconstruction with the Free Gracilis Flap: A Retrospective Cohort Study Involving 153 Patients.

BACKGROUND: The need for plastic and reconstructive surgery on elderly patients has been on the rise due to an increase in life expectancy in the past decades. Therefore, a study was conducted on young and elderly patients following microsurgical extremity reconstructions with free gracilis muscle flaps with the primary aim to investigate the influence of age and the American Society of Anesthesiologists (ASA) score on the general outcome, as well as surgical and medical complications. METHODS: A retrospective analysis of 153 patients receiving free gracilis muscle flaps for extremity reconstructions between November 2009 and January 2018 was performed at two partner institutions specialized in microsurgical reconstructions. A logistic regression analysis was performed to correlate age and the ASA score with postoperative complication probability. Patients younger than 70 years were directly compared with elderly patients with respect to age, gender, ASA score, preexisting comorbidities, localization, and postoperative medical and surgical complications. RESULTS: Age turned out to be not significantly associated with major flap complications (p = 0.925) but with higher ASA scores (p = 0.016). However, an age-related significant increase in minor flap complications could be observed in the elderly (p = 0.008). A significant correlation between minor medical complications and age could be observed (p = 0.001) in contrast to ASA score (p = 0.912). CONCLUSION: An increased minor flap, as well as minor and major medical complications, must be expected in extremity reconstructions with free gracilis flaps in elderly patients. Higher ASA scores correlate with a higher incidence of major flap complications. Septuagenarians are more prone to develop perioperative major medical complications than patients younger than 70 years. Age and general medical condition, coupled with the performance of each patient, should be thoroughly assessed individually to facilitate a tailored reconstructive approach using risk assessment tools and established scoring systems.

A rare approach? Microsurgical breast reconstruction after severe burns.

Breast deformity, in post-burn patients, is a common problem leading to lower self-esteem and reclusive behavior that impairs quality of life. The authors present the course of treatment of an 18-year-old immigrant girl who suffered second- to third-degree burns over approximately 20% of her total body surface area in her early childhood. The second- to third-degree burns were located on her right trunk and abdomen, as well as her right shoulder, neck, and right groin area. Since it was not offered in her home country, reconstructive surgery, including microsurgical breast reconstruction, was sought abroad. Due to the lack of available skin and soft tissue, a bilateral breast reconstruction with free transverse myocutaneous gracilis flaps was offered. This case illustrates one method of using microsurgery to address post-burn breast deformities in order to alleviate psychological suffering and improve quality of life.

Skin Perfusion Changes within 12 h after Axillary Plexus Block.

BACKGROUND/PURPOSE: An improvement of the blood flow would be beneficial in microvascular upper-extremity reconstruction and in digit replantation. In the present work, skin perfusion changes and their duration due to axillary plexus block were quantified. METHODS: The peripheral blood flow of the upper extremities in 20 patients undergoing trapeziectomy under axillary plexus block was analyzed. RESULTS: Laser Doppler spectrophotometry was used to measure perfusion factors over a 12-h period, with the contralateral hand acting as the control. Axillary plexus block produced a significant increase of peripheral oxygen saturation (117 ± 35% vs. control 93 ± 22%, p = 0.019), peripheral blood flow (220 ± 166% vs. 130 ± 77%, p = 0.037), and velocity (164 ± 58% vs. 117 ± 45%, p = 0.011). CONCLUSION: Axillary plexus block produces an improvement of peripheral tissue oxygen saturation of the upper extremities over the first 6 h after the inception of anesthesia. This suggests a potential benefit especially for critically perfused tissues.

Double transverse myocutaneous gracilis free flaps for unilateral breast reconstruction.

BACKGROUND: In cases were the deep inferior epigastric perforator flap (DIEP flap) is not available and unilateral transverse myocutaneous gracilis flap (TMG flap) is not sufficient for breast reconstruction, we perform double TMG flaps as a reconstructive method. In this report, we present our results of the use of double TMG free-flap-transfer for unilateral breast reconstruction. PATIENTS AND METHODS: Between August 2004 and June 2012 we performed 58 TMG flaps in 29 patients for unilateral breast reconstruction. Patient data were analyzed and operative outcome (operation time, complication rate and aesthetic results) were investigated. Aesthetic outcome was evaluated retrospectively via photo documentation by an independent plastic surgeon. The results were classified in;unsatisfactory, satisfactory, good and very good. RESULTS: The average operating time was 6 hours 55 minutes (295 - 650 minutes). Of 58 TMG flaps, 57 (98.3%) were successful. Thrombosis occurred in seven (12%) cases (1 arterial, 6 venous). Flap salvage was successful in six cases and flap failure occurred in one (1.7%) case. The results of 25 patients were graded as good and very good. Three patients showed satisfying and one patient unsatisfying results. CONCLUSION: Double TMG flaps in unilateral breast reconstruction could lead to good operative results. This method further expands the range of options with autologous tissue in reconstructive breast surgery. © 2015 Wiley Periodicals, Inc. Microsurgery 36:539-545, 2016.

Localized lipomatosis of the perineum in a 58-year-old male patient - case report.

Lipomatosis of the perineum is an extremely rare condition. We report a localized hypertrophy of adipose tissue of the perineum in a 58-year-old man. The cause of enlargement could not be revealed. Nonetheless, preoperative workup and exclusion of possible malign tumors is essential.

One-stage nasal soft tissue reconstruction with local flaps.

Because of better public education and earlier diagnosis of skin tumors, the number of soft tissue defects of the nose with limited size and depth after tumor resection is increasing. A variety of surgical methods such as skin grafts, regional flaps such as forehead flap, and local flaps have been described. The method of choice is dependent on the defect size, localization, skin structure and the wishes and expectations, and general condition of the patient. Nasal reconstruction for soft tissue defects in the supratip area, dorsum, and sidewalls using local rotation and/or advancement flaps is our primary option. But achieving supreme results with these non-subunit-based techniques is still a challenge. Showing schematic figures and case studies, this article is aimed at assisting surgeons in the planning and decision making of which flap is appropriate for the reconstruction of soft tissue defects of the nose.

Tracheocutaneous fistula closure using a Cartilo-musculo-cutaneous bilobed flap.

In general, the development of a tracheocutaneous fistula (TCF) after tracheotomy is a seldom but recurrent clinical problem in long-term ventilated patients. In cases of prolonged wound healing with no spontaneous wound closure or insufficient later closure by secondary suture, different surgical procedures have been previously described for the closure of TCFs. Nonetheless, each procedure has its individually associated complications so that definite closure of TCFs still remains a challenge. The purpose of this case report is to present a unique case of a patient with a persistent TCF that was successfully closed using a local cartilo-musculo-cutaneous bilobed flap.

Evaluation of a non-invasive monitoring method for free flap breast reconstruction using laser doppler flowmetrie and tissue spectrophotometry.

BACKGROUND: Despite advances in the monitoring of free flaps, there is still a demand for new technology to detect ischemic complications at an early stage. The aim of the present study was to evaluate the reliability of the O2C-device in terms of detecting flap failure in commonly used perforator flaps for breast reconstruction. METHODS: A total of 34 patients undergoing breast reconstruction were involved in this study. The perfusion dynamics of 23 deep inferior epigastric perforator flaps and 11 superior gluteal arterial perforator flaps were assessed using the O2C-device, which combines a laser light, to determine blood flow (flow), velocity, and white light to determine hemoglobin oxygenation (SO(2)) and relative amount of hemoglobin (rHB). Measurements were carried out intra-operatively after clamping and declamping the perforator vessels. In the post-operative period measurements were carried out every hour for the first 48 hours and from 3rd to 7th for every 2 hours. These dates were compared to findings of clinical assessment. RESULTS: Several intra-operative measurements, during the clamping and declamping the different perforator vessels, revealed a high correlation for all parameters: Flow (r = 0.89, P < 0. 05), Velo (r = 0.92, P < 0. 05), SO2 (r =0.84, P <0. 05), and rHB (r =0.83 P < 0.05). Vessel occlusion was detected in five cases, of which three were due to arterial thrombosis and two further cases were due to venous occlusion. Of the five cases, one flap loss caused by venous occlusion was noted. CONCLUSION: The O2C-device seems to be a reliable, objective, and non-invasive device for the monitoring of free flaps. Thus, it may improve flap survival rates by detecting vascular compromise at an early stage.

A quantitative analysis of the venous outflow of the deep inferior epigastric flap (DIEP) based on the perforator veins and the efficiency of superficial inferior epigastric vein (SIEV) supercharging.

BACKGROUND: While the arterial perfusion of the anterior abdominal wall has been extensively described in the literature, little has been published on the venous drainage of the deep inferior epigastric flap (DIEP). The present study was performed to further clarify the venous drainage of DIEP flap, which remains a common vascular complication of this flap. METHODS: We assessed the efficiency of venous outflow on 19 patients undergoing DIEP flap breast reconstruction, determining relative haemoglobin concentration (rHB) as an indicator of venous congestion. After the flap had been isolated on the perforator vessels, a selective clamping and declamping of the single lateral and medial perforator was performed and several measurements were carried out using a micro-lightguide spectrophotometer device (O2C: Oxygen to See; LEA Medizintechnik, Gießen, Germany). In addition, the efficacy of venous supercharging with ipsilateral and contralateral superficial inferior epigastric veins (SIEVs) was quantified. RESULTS: For the sake of simplicity, we applied the classic perfusion zones of the lower abdomen as suggested by Hartrampf (1983). Regardless of lateral or medial DIEP perforator veins, zone IV showed the least venous outflow, while we observed the highest drainage in zone I. There was no significant difference between the venous drainage of the two immediately adjacent zones II and III. Supercharging with the contralateral SIEV showed a significantly better venous drainage in the contralateral zones II and IV, whereas the ipsilateral SIEV did not present any significant improvement in the venous drainage of any zone. CONCLUSION: This study evaluated the characteristics of the venous outflow of the DIEP flap, based on the single perforator and the SIEVs. Our findings revealed that zones II and III have a similar venous drainage regardless of the perforator veins used. The supercharging of the contralateral SIEV leads to an improved venous outflow compared to the ipsilateral SIEV. This may support surgeons in minimising venous complications and may improve the degree of DIEP flap survival.

Diagnosis-Related Groups in Hand Surgery--a comparison of six European countries.

Diagnosis-Related Group (DRG) is a classification system, which groups patients according to their diagnosis and resource consumption. Common hand surgical diagnoses and procedures were processed using national DRG-groupers of six European countries. The upper thresholds of length of stay (LoS) are indicated for every country with the exception of Spain. The mean value in the series was 9.9 days for Germany, 4.5 days for Austria, 10.7 days for Italy, 9.7 days for Sweden and 9.4 days for the United Kingdom (UK). Germany and Austria also have lower thresholds of LoS and the average LoS.Multiple finger replantation presented the highest single case reimbursement in Germany, Austria and the UK (13,825 €, 10,576 € and 9,198 €). Scaphoid non-union had the highest single case reimbursement in Italy (2,676 €), flap coverage of wounds in Spain (5,506 €) and trapeziometacarpal arthritis in Sweden (5,350 €). The mean values for single case reimbursement were as follows: Germany 3,211 €, Austria 2,821 €, Italy 1,947 €, Spain 3,594 €, Sweden 2,403 € and the UK 3,253 €. Ten out of 19 cases showed the highest reimbursement in Spain, followed by the UK (5 cases), Sweden (2 cases), Germany and Austria (1 case each). Applying the case numbers of our clinic to the reimbursement system of each country, total proceeds would be 2.25 million € in Spain, 1.79 million € in Germany as well as the UK, 1.75 million € in Austria, 1.63 million € in Sweden and 1.22 million € in Italy. The consequences of international differences in efficiency and reimbursement are hard to assess as they are influenced by multiple factors that are seldom purely market-driven. However, the consideration of international data for benchmarking and refinement of national compensation systems should be a useful instrument.

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

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

Vascularized tendon incorporated in reverse homodigital and heterodigital island flaps for the reconstruction of dorsal digital defects.

BACKGROUND: An adequate range of motion (ROM) of the distal interphalangeal (DIP) joint is indispensable for fine motor skills of the hand. Reconstruction of extended skin and tendon loss of the distal phalanx is often challenging for surgeons and may lead to functional impairment of the injured finger. This article presents an option for a one-step functional and esthetical reconstruction of dorsal digital defects using combined island flaps. METHODS: Vascularized tendons were harvested incorporated in reverse homodigital and heterodigital island flaps to treat skin and extensor tendon loss of patients over their DIP joints. In a 6-month follow-up, we evaluated the active ROM and fine motor skills of the involved fingers as well as the patients' satisfaction. RESULTS: Six months postoperatively satisfactory functional and sensory results of the donor site finger have been reported. The mean ROM for the recipient finger was 0°/25° for the DIP joint. All flaps remained viable and full finger length was preserved. Patients stated adequate till high satisfaction with respect to operation time, pain, and finger appearance. CONCLUSION: The vascularized tendon incorporated in reverse island flaps provides a sufficient method to restore function of the DIP joint after complex injury and prevents finger deformity, arthrodesis, or amputation.

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

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

Thermoregulatory response of anterolateral thigh flap compared with latissimus dorsi myocutaneous flap: an evaluation of flaps cutaneous flow and velocity due to thermal stress.

INTRODUCTION: Although, the success of free flaps has increased in the last years, more details about its characteristics might improve the clinical outcome of the flaps. This study examined the thermoregulatory ability as a sign of neural re-innervation of two different types of microsurgical free flaps in the postoperative course. METHODS: A total of 22 patients were examined after grafting two different flap types: The latissimus dorsi myocutaneous (LDM) flap (n = 11) and the anterolateral thigh (ALT) flap (n = 11). Patients were examined 6 and 9 months postoperatively. After exposure to cold and warm water (10°C and 35°C), multiple measurements were performed with the focus on blood velocity and flow using the "O2C" device. RESULTS: Both examined flaps showed a tendency for improvement in local blood flow and velocity due to thermal stress. We recorded a more physiological thermoregulation during thermal stress for the LDM flap, when compared with the ALT flap over a measured period of time. CONCLUSION: We believe that the presence of the muscle portion in the LDM flap may offer better conditions for thermoregulation based on the improvement of neural and vascular regeneration. However, further studies should clarify the pathophysiological backgrounds, to make these interesting results clinically applicable.

A clinical evaluation of Biobrane(®) and Suprathel(®) in acute burns and reconstructive surgery.

BACKGROUND: In the treatment of superficial partial-thickness burns, various skin substitutes and temporary dressings offer potential advantages over traditional treatments. Nonetheless, the search for an ideal temporary skin substitute or biosynthetic wound dressing is still a continuous quest. This research aimed to provide objective data on the long-term outcome of Biobrane(®) and Suprathel(®). METHODS: Eight months after the initial burn treatment of Biobrane(®) and Suprathel(®), skin elasticity was measured objectively using a Cutometer(®) and the scarring process was quantified using the Vancouver Scar Scale (VSS). RESULTS: The median healing time for patients treated with Biobrane(®) was up to 1.8 days shorter then the Suprathel(®) group. Regarding the Vancouver Scar Scale (VSS), neither the single parameter, nor the total score were significantly different in both groups. In comparison, the Biobrane(®) group demonstrated superior Cutometer(®) parameters in regards to maximal extension, elasticity, retraction and pliability. Despite higher levels of Biobrane(®) group, the differences in the viscoelastic analysis of both substitutes did not vary significantly. CONCLUSION: Using both substitutes, we observed satisfying results in superficial partial-thickness burn treatment, without any significant differences. Since the treatment of burned patients is associated with high socioeconomic load, the cost factor should be one of the most important criteria in dermal substitute selection.