[Choice of flaps for phalloplasty: what is the contemporary standard? Consensus Statement of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels]. / "Wahl der Lappenplastik zur Phalloplastik ­ was ist zeitgemäßer Standard" ­ Konsensus-Bericht der deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie der peripheren Nerven und Gefäße.

The ever-expanding number of transmen as well as their surgeons share an increasing interest in the construction of a neophallus. While the indication for surgery and the positive effect of a phalloplasty on the quality of life, mental health and sexual function has already been thoroughly analysed, there is a lack of data comparing and evaluating the surgical steps. During the consensus conference on the "choice of flaps for phalloplasty" at the annual meeting of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels, the current literature was discussed and a consensus on the surgical technique of a phalloplasty was reached. This manuscript publishes jointly developed recommendations on the following topics: choice of flaps for phalloplasty, preoperative diagnostic tests before phalloplasty, urethral construction in the radial forearm flap and anterior lateral thigh flap, preformation of the urethra at the forearm or thigh, venous drainage of the radial forearm flap, innervation of the phallus, staged phalloplasty, coronaplasty and managing the donor site of a radial forearm flap.

Measurement of Postoperative Quality of Pain in Abdominoplasty Patients-An Outcome Oriented Prospective Study.

(1) Background: Postoperative pain is a frequently underestimated complication significantly influencing surgical outcome and patient satisfaction. While abdominoplasty is one of the most commonly performed plastic surgery procedures, studies investigating postoperative pain are limited in current literature. (2) Methods: In this prospective study, 55 subjects who underwent horizontal abdominoplasty were included. Pain assessment was performed by using the standardized questionnaire of the Benchmark Quality Assurance in Postoperative Pain Management (QUIPS). Surgical, process and outcome parameters were then used for subgroup analysis. (3) Results: We found a significantly decreased minimal pain level in patients with high resection weight compared to the low resection weight group (p = 0.01 *). Additionally, Spearman correlation shows significant negative correlation between resection weight and the parameter "Minimal pain since surgery" (rs = -0.332; p = 0.013). Furthermore, average mood is impaired in the low weight resection group, indicating a statistical tendency (p = 0.06 and a Χ2 = 3.56). We found statistically significant higher maximum reported pain scores (rs = 0.271; p = 0.045) in elderly patients. Patients with shorter surgery showed a statistically significant (Χ2 = 4.61, p = 0.03) increased claim for painkillers. Moreover, "mood impairment after surgery" shows a dramatic trend to be enhanced in the group with shorter OP duration (Χ2 = 3.56, p = 0.06). (4) Conclusions: While QUIPS has proven to be a useful tool for the evaluation of postoperative pain therapy after abdominoplasty, only continuous re-evaluation of pain therapy is a prerequisite for constant improvement of postoperative pain management and may be the first approach to develop a procedure-specific pain guideline for abdominoplasty. Despite a high satisfaction score, we detected a subpopulation with inadequate pain management in elderly patients, patients with low resection weight and a short duration of surgery.

Tangential Excision of Rhinophyma with the Disposable Razor Blade: Simple and Cost Efficient with Aesthetically Good Results.

Medical therapies for rhinophyma have been described but these only delay progression. Therefore, surgery is the method of choice. Plenty of modalities have been described including cold-knife surgery, electrosurgery, hydrosurgery, laser-assisted treatments, and dermabrasion. SETTINGS AND DESIGN: In this two-center study, patients' charts and photodocumentation were analyzed retrospectively. MATERIALS AND METHODS: Surgery was performed under general anesthesia with an additional local anesthesia of the affected areas of the nose. We removed the hypertrophic tissue in thin layers with a sterile disposable razor blade under constant visual control of the underlying cartilage and adnexal structures. A dressing with Mepithel and gauzes was applied. Patients presented weekly to monitor the wounds. Follow-up was 1 year. RESULTS: From 2016 to 2019, nine male patients with rhinophyma underwent surgical therapy at AGAPLESION Markus Hospital, Frankfurt am Main, Germany and at the Department of Plastic, Reconstructive and Aesthetic Surgery, Innsbruck Medical University, Austria. The mean age of the patients was 66 years. Mean time to complete re-epithelization equaled 31.5 days. No recurrences were noted within the follow-up period of 1 year. Patients' satisfaction was very high. Only one patient had hypertrophic scars at the wing of the nose and another one developed a superficial fistula without connection to the nasal cavity. CONCLUSION: To the best of our knowledge, this is the first case series describing the use of a disposable razor blade for rhinophyma treatment supporting its efficiency described in previous anecdotal publications. We can highly recommend the technique, as it is cost-efficient and simple and provides excellent aesthetic results.

[Deep sternal wound infection after sternotomy - Report of the consensus workshop of the German-Speaking Society for Microsurgery of Peripheral Nerves and Vessels (DAM)]. / Der tiefe sternale Wundinfekt nach Sternotomie.

Deep sternal wound infection (TSWI) is a potentially life-threatening complication that may occur after median sternotomy, contributing to prolonged hospital stay and increased health care costs. Bacterial infection is often characterized by biofilm formation on implant material and/or dead bone. Diagnosis is made upon clinical signs and symptoms of local and systemic infection. Early multidisciplinary decision making is needed for optimal patient care. Repeated surgical wound debridements accompanied by wound conditioning are performed until clean circumstances are achieved. Thereafter, wound closure and defect reconstruction are obtained using a variety of pedicled and microvascular flaps.

Occult Pathologic Findings in Reduction Mammaplasty in 5781 Patients-An International Multicenter Study.

Breast cancer is among the most commonly diagnosed cancers in the world, affecting one in eight women in their lifetimes. The disease places a substantial burden on healthcare systems in developed countries and often requires surgical correction. In spite of this, much of the breast cancer pathophysiology remains unknown, allowing for the cancer to develop to later stages prior to detection. Many women undergo reduction mammaplasties (RM) to adjust breast size, with over 500,000 operations being performed annually. Tissue samples from such procedures have drawn interest recently, with studies attempting to garner a better understanding of breast cancer's development. A number of samples have revealed nascent cancer developments that were previously undetected and unexpected. Investigating these so-called "occult" findings of cancer in otherwise healthy patients may provide further insight regarding risk factors and countermeasures. Here, we detail occult findings of cancer in reduction mammaplasty samples provided from a cohort of over 5000 patients from 16 different institutions in Europe. Although the majority of our resected breast tissue specimens were benign, our findings indicate that there is a continued need for histopathological examination. As a result, our study suggests that preoperative imaging should be routinely performed in patients scheduled for RM, especially those with risk factors of breast cancer, to identify and enable a primary oncologic approach.

Aesthetic outcomes after surgical repair of pectus excavatum in females: Differences between patients and professional evaluators.

BACKGROUND: Pectus excavatum is less common in females than in males, and it often aggravates a coexistent breast asymmetry. We conducted a study comparing female patients' versus medical professionals' evaluation of pectus excavatum repair to assess differences in aesthetic outcome ratings. Moreover, we evaluated the influence of surgical correction on patients' self-perception. METHODS: Of 30 female patients who were initially screened, 18 patients (mean age, 20 years) who underwent bar removal after surgical correction of pectus excavatum deformity participated in the survey (60%). They completed a questionnaire rating their appearance before and after surgery and responded to a psychological questionnaire about the changes that they had experienced. The mean interval between pectus bar removal and evaluation was 28 months. Standardized preoperative and postoperative patient photographs were evaluated using the same questionnaire by a panel of medical professionals and students (n=24) and the results were compared. RESULTS: Patients rated their preoperative deformity as more severe than the other evaluators, revealing the significant impact of the deformity on patients' self-perception. Postoperatively, patient and professional evaluations were much better than before and were very similar. The psychological evaluation showed a clear improvement in well-being. The ratings of the medical professionals were not influenced by their degree of medical education. CONCLUSIONS: Surgical correction of pectus excavatum in female patients positively influences body perception and psychological well-being. It should therefore not be considered as a merely aesthetic correction, but as an important procedure to restore a patient's self-perception.

[Fistula prophylaxis with muscle-sparing, myofascial pectoralis major lobe in salvage laryngectomy]. / Fistelprophylaxe mit muskelsparendem, myofaszialem Pectoralis-major-Lappen bei Salvage-Laryngektomie.

BACKGROUND: In recurrent hypopharyngeal/laryngeal squamous cell carcinoma after radiation salvage-laryngectomy (salvage-LE) represents the best curative treatment option. Pre-irradiation promotes development of pharyngocutaneous fistulas (pc-fistula). Transfer of unirradiated tissue to the surgical site reduces fistula rate. Frequently, a myocutaneous Pectoralis-major-flap (PMF) is applied. We describe a muscle sparing, myofascial PMF (ms-PMF) and its functional & aesthetic results. METHODS: For the ms-PMF, the pectoralis major is exposed via two 8 cm long subclavicular & submammary horizontal incisions. The pectoral branch of the thoracoacromial artery, which represents the blood supply for the ms-PMF, is identified between the clavicular and sternocostal aspect of the muscle. A craniocaudal stripe of the pectoralis major is recovered and supraclaviculary transposed towards the pharynx. The clavicular and sternocostal part of the muscle remain untouched.The clear-margin resection rate (CMRR), mean overall survival (OS), complications, median length of hospital stay, & functional & aesthetic outcome were assessed. RESULTS: In 25 patients, salvage-LE with ms-PMF was performed. The CMRR was 100 %, median OS 1.3 (follow-up 2.8) years, complications rate 16 % (4 complete lobe necroses, 3 pc-fistulas) and median inpatient stay 20 (11-78) days. Good functional outcome were observed: limitations of oral food intake occurred in 2-, limitations in voice rehabilitation in 3 patients. Wound healing disorders without lobe necrosis were not observed. The aesthetic results were appealing. CONCLUSION: The ms-PMF is a less invasive & safe procedure for fistula prophylaxis in salvage-LE with favorable functional & aesthetic results.

The Pectoralis Major Island Flap: Short Scar Modified Muscle-Sparing Harvesting Technique Improves Aesthetic Outcome in Reconstructive Head and Neck Surgery.

BACKGROUND: Pectoralis major flap reconstruction is often associated with large unappealing scars in head-neck surgery. We recently established an alternative harvesting technique that improves aesthetic outcome. OBJECTIVES: The objective of this study was to demonstrate a modified surgical technique that harvests the pectoralis major muscle as an island flap and focuses on minimizing incision lines and applying a muscle-sparing approach. METHODS: A retrospective analysis covering the period 2008-2018 was conducted. Patients who underwent pectoralis major island flap reconstruction for fistula prophylaxis after salvage laryngectomy at the Medical University of Innsbruck were included. Flap harvesting was performed subcutaneously using two small incision lines, thereby sparing the clavicular and upper sternocostal aspects of the pectoralis muscle. RESULTS: Twenty-three patients with squamous cell carcinoma of the larynx (n = 19) or pharynx (n = 4) underwent salvage laryngectomy and consecutive reconstruction using a pectoralis major island flap and our muscle-sparing technique. Mean overall operation time was 147 ± 48.6 min. The majority (70%) of patients had an uneventful course of recovery and showed satisfying aesthetic results and low donor site morbidity as compared to traditional harvesting techniques. Six (26%) patients had major complications that required surgical revision. Three (13%) cases were complicated with fistulas. CONCLUSION: The pectoralis major island flap is shown to be reliable in otolaryngeal surgery. This surgical technique minimizes scarring and preserves thoracic wall architecture by taking a less invasive approach, thereby improving aesthetic outcome and reducing overall patient morbidity.

[Profitability of reconstructive microsurgery: position paper of the German-Speaking Group for Microsurgery of Peripheral Nerves and Vessels]. / Wirtschaftlichkeit der rekonstruktiven Mikrochirurgie: Positionspapier der Deutschsprachigen Arbeitsgemeinschaft für Mikrochirurgie ­ (DAM).

The profitability of medical treatment has gained increasing importance in health politics and likewise has become a considerable part of a microsurgeon's daily practice. The resulting cost pressure leads to microsurgeons having to justify their often complex and expensive treatments against hospital providers and health insurances. In this position paper of the German Speaking Group for Microsurgery of Peripheral Nerves and Vessels, we analyze the current status of profitability of microsurgical extremity and breast reconstruction, and its impact on choice of therapy and residency training. We specifically highlight the available literature, that shows often reduced long-term treatment costs after microsurgical reconstruction in comparison to cheaper initial treatments. The statements are based on a consensus workshop on the 40th meeting of the DAM in Lugano, Switzerland.

Mastectomy in female-to-male transgender patients: A single-center 24-year retrospective analysis.

BACKGROUND: Mastectomy in male transgender patients is an important (and often the first) step toward physical manhood. At our department, mastectomies in transgender patients have been performed for several decades. METHODS: Recorded data were collected and analyzed for all male transgender patients undergoing mastectomy over a period of 24 years at our department. RESULTS: In total, 268 gender-reassigning mastectomies were performed. Several different mastectomy techniques (areolar incision, n=172; sub-mammary incision, n=96) were used according to patients' habitus and breast features. Corresponding to algorithms presented in the current literature, certain breast qualities were matched with a particular mastectomy technique. Overall, small breasts with marginal ptosis and good skin elasticity allowed small areolar incisions as a method of access for glandular removal. In contrast, large breasts and those with heavy ptosis or poor skin elasticity often required larger incisions for breast amputation. The secondary correction rate (38%) was high for gender reassignment mastectomy, as is also reflected by data in the current literature. Secondary correction frequently involved revision of chest wall recontouring, suggesting inadequate removal of the mammary tissue, as well as scar revision, which may reflect intense traction during wound healing (36%). Secondary corrections were performed more often after using small areolar incision techniques (48%) than after using large sub-mammary incisions (21%). CONCLUSIONS: Choosing the suitable mastectomy technique for each patient requires careful individual evaluation of breast features such as size, degree of ptosis, and skin elasticity in order to maximize patient satisfaction and minimize secondary revisions.

Skin grafting after paediatric palmar burns: an analysis of 82 patients.

Contact burn injuries to the palm are common in toddlers. We report a case series of 82 paediatric patients (age 7-48 months) with contact burn injury of the palm. We share our experience and outcomes of using plantar split-thickness skin grafts for resurfacing of the paediatric palm. We found that despite the excellent colour and texture match, split-thickness skin grafts from glabrous skin during growth are prone to motion-limiting scare contracture. From this series, we conclude that full-thickness skin grafts remain the reference standard of care in paediatric patients' hands. We recommend that children with burn scars should have regular check-up examinations until they are fully grown. Level of evidence: IV.

Comparative analysis on the effect of low-thermal plasma dissection device (PEAK PlasmaBlade) versus conventional electro surgery in post-bariatric body-contouring procedures: A retrospective randomised clinical study.

Postoperative wound-healing problems are relatively high in post-bariatric body-contouring procedures, partly because of electrosurgery and the associated thermal tissue damage. This study is a retrospective randomised evaluation of the effect of a low-thermal plasma dissection device (PEAK PlasmaBlade, Medtronic, Minneapolis, Minnesota) in comparison with conventional electrosurgery. A total of 24 patients undergoing upper arm or medial thigh lifting were randomised to PEAK PlasmaBlade on one side and to monopolar electrosurgery on the other side of the same patient. Wounds of 10 patients were examined histologically for acute thermal injury depth. Significantly lower total volume of drain output (61,1 ± 70,2 mL versus 95,1 ± 176,0 mL; P = .04) was found on the PEAK PlasmaBlade side compared with the electrosurgery side. Furthermore, the PEAK PlasmaBlade side showed fewer seromas (no case of seroma versus three seromas in the electrosurgery group) and less thermal damage (40% versus 70%; P = .26). Acute thermal injury depth from the PEAK PlasmaBlade was less than from monopolar electrosurgery (425 ± 171 µm versus 686 ± 1037 µm; P = .631). PEAK PlasmaBlade appears to be superior to traditional monopolar electrosurgery for post-bariatric body-contouring procedures because it demonstrated less tissue damage, lower total volume of drain output, and fewer postoperative seromas resulting in faster wound healing.

Outcome, Complications, and Body Mass Index Correlation of Horizontal and Combined Horizontal and Vertical Thigh Lift: A 16-year Single-center Experience.

BACKGROUND: Thigh lift is a procedure used within the aesthetic as well as the post-bariatric field of surgery as it focuses on reducing excess lipodermal tissue within the medial thigh area. Depending on the specific area of excess tissue, common thigh lifting procedures include horizontal (H) and combined horizontal and vertical (HV) tissue reduction. AIMS AND OBJECTIVES: The aim of this study was the analysis of outcome of H and HV thigh lift procedures, including evaluation of comorbidities and complications. SUBJECTS AND METHODS: Over a 16-year period, all thigh lift procedures performed at our department were assessed for comorbidities and outcome through our hospital documentation system. RESULTS: A total of 151 thigh lifts have been performed over 16 years. Of which, 124 were performed using the HV technique and 27 thigh lifts were performed using H tissue excision only. Of all the patients, 9 of 10 were female, the overall average age was 43 years. Approximately 48% of the HV group of patients had previously undergone bariatric surgery, the mean body mass index (BMI) was 29.3 kg/m2 for this group. Around 19% of the H patient population had previously undergone bariatric surgery. This group had a mean BMI of 25.1kg/m2. Wound-associated problems occurred in 48%, for these patients, surgical revision was necessary for 12%. Remaining excess tissue was an issue for 20% of all patients, for this reason, 14% needed revision surgery. Age was found to be a significant cofactor for wound-associated complications (P = 0.02) and nicotine abuse for scar-related problems (P = 0.032). CONCLUSION: The rate of overall complication for thigh lifts is high, although surgical revision rate is low. Remaining excess tissue and wound-associated problems are most common, possibly reflecting a too restrictive and radical surgical approach, respectively. Increasing BMI increases the risk for development of complications.

Safety of long-term subcutaneous free flap skin banking after skin-sparing mastectomy.

BACKGROUND: A persistent problem in autologous breast reconstruction in skin-sparing mastectomies is skin restoration after skin necrosis or secondary oncological resection. As a solution to facilitate reconstruction, skin banking of free-flap skin has been proposed in cases where the overlying skin envelope must be resected, as this technique spares the patient an additional donor site. Herein, we present the largest series to date in which this method was used. We investigated its safety and the possibility of skin banking for prolonged periods of time. METHODS: All skin-sparing mastectomies and immediate autologous breast reconstructions from December 2009 until June 2013 at our institution were analysed. RESULTS: We identified 31 patients who underwent 33 free flap reconstructions in which skin banking was performed. Our median skin banking period was 7 days, with a maximum duration of 171 days. In 22.5% of cases, the banked skin was used to reconstruct overlying skin defects, and in 9.6% of cases to reconstruct the nipple-areolar complex. Microbiological and histological investigations of the banked skin revealed neither clinical infections nor malignancies. CONCLUSIONS: In situ skin banking, even for prolonged periods of time, is a safe and cost-effective method to ensure that skin defects due to necrosis or secondary oncological resection can be easily reconstructed.

Super obesity is not necessarily a contraindication to deep inferior epigastric perforator flap breast reconstruction.

The deep inferior epigastric perforator (DIEP) flap is widely recognised as a safe and reliable flap for use as a first-choice option in autologous tissue breast reconstruction. Patients with obesity represent a challenging group for autologous breast reconstruction, as they are at increased risk of developing major and minor complications in comparison with patients with normal weight. We report a 59-year-old woman with super obesity, who presented to our department with right breast skin necrosis after implant reconstruction following mastectomy for right breast cancer. After implant removal and local treatment with both surgical debridement and negative pressure wound therapy, the patient successfully underwent a DIEP flap breast reconstruction. We conclude that super obesity should not be a contraindication to DIEP flap breast reconstruction.

Bilateral sagittal split osteotomy-parameters and correlations of postoperative pain management.

OBJECTIVES: Postoperative pain management is of utmost interest for patients undergoing orthognathic surgery. Currently, there is a lack of information regarding process and outcome parameters of postoperative pain management after bilateral sagittal split osteotomy. MATERIALS AND METHODS: In a prospective clinical study, 31 adults were evaluated on the first postoperative day following bilateral sagittal split osteotomy using the standardized questionnaire of the Germany-wide project Quality Improvement in Postoperative Pain Management (QUIPS). It allows a standardized assessment of patients' characteristics, pain parameters, outcome, and pain therapy process parameters. RESULTS: Pain management consisted mainly of premedication with midazolam, sufentanil, and metamizol intraoperatively; piritramide in the recovery room; and metamizol and tramadol on ward. Twenty patients (64.5%) showed inadequate pain management with pain levels ≥4. Patients receiving tramadol as opioid on ward presented significantly higher maximum pain levels (p = .037). Significantly lower satisfaction with postoperative pain intensity (p > .001) and significantly higher desire for additional pain medication (p = .023) were detected, when duration of surgery was above the median of 107.5 min. CONCLUSIONS: Inadequate pain management on the first postoperative day following bilateral sagittal split osteotomy was widespread on our ward. QUIPS helped us to identify it and thereby gave us the possibility to improve the situation. Prolonged duration of surgery seems to be a predictor of an elevated postoperative pain medication demand. CLINICAL RELEVANCE: Only the establishment of an ongoing monitoring of postoperative pain management can help to reduce or even avoid inadequate postoperative pain management. In accordance to the existing literature, we found inadequate postoperative pain management more widespread than thought.

Aseptic surgical preparation for upper eyelid blepharoplasty via full-face octenidine antiseptic without antibiotic medication shows effective prophylaxis against post-surgical wound infection.

Blepharoplasty is the third most common plastic surgical procedure in the USA. Due to the emergence of multiresistant bacteria, optimising the antiseptic procedure is crucial. Choice of antiseptics plays an important role as they may cause skin irritation and colouring of disinfected areas. In this study, the use of the aqueous antiseptic octenisept® (octenidine) was evaluated in the outcome of blepharoplasties: incidence of wound dehiscence; haematoma; and infection in correlation with gender, medication, smoking habits and time of year. This retrospective surveillance study included 352 patients (median age 58·3 years). Skin disinfection was performed thrice prior to blepharoplasty. Sutures were removed on day 6. None of the patients suffered from wound infection. The total rate of wound dehiscence was 6·3%, with a higher ratio among male patients. Smokers and patients on anticoagulant medication showed a significantly higher incidence of wound dehiscence. Throughout the year, rates of wound dehiscence were highest in summer. Aseptic surgical preparation for blepharoplasty via full-face scrub with octenisept® without oral antibiotic prophylaxis is well tolerated, with no report of wound infection, which may improve antibiotic stewardship as well as patient comfort. Elective upper eyelid blepharoplasty may ideally be performed in winter.