A.D. Niederbichler

Vergleichende In-vitro-Studie zur Zytotoxizität klinisch eingesetzter Antiseptika

ZusammenfassungHintergrundAntiseptika zur Behandlung chronischer und infizierter Wunden gehören zur Standardtherapie. Erkenntnisse über toxische Eigenschaften gegenüber dem Wund- und Hautgewebe sind jedoch kaum vorhanden. Diese Studie untersucht den Einfluss von Wundantiseptika auf die Vitalität und Proliferation humaner kutaner Zellen.Material und MethodenDie Antiseptika Lavasept (PHMB), Octenisept (Octenidin) und Betaisodona (PVP-Jod) wurden mittels MTT-Assay und BrDU-ELISA auf zytotoxische Effekte gegenüber der HaCaT-Zelllinie, primären humanen Keratinozyten und Fibroblasten untersucht.ErgebnisseLavasept besaß nur geringen Einfluss auf Vitalität und Zellproliferation. Betaisodona und Octenisept induzierten eine signifikante Reduktion der Zellvitalität (p<0,05) bis zu 0% überlebender Fibroblasten bei 7,5% (Betaisodona) bzw. 10% (Octenisept) sowie der Zellproliferation auf 0% bei Keratinozyten durch Konzentrationen von 7,5% (Betaisodona und Octenisept).SchlussfolgerungDie Studie zeigt, dass herkömmlich verwendete Wundantiseptika deutlich toxische Effekte besitzen. Sowohl antimikrobielle Potenz als auch toxische Eigenschaften der einzelnen Antiseptika müssen bei der Wundbehandlung berücksichtigt werden. Insgesamt zeigte die PHMB-Lösung (Lavasept) die geringste toxische Wirkung.AbstractPurposeLocal skin antiseptics are the standard of care for chronic and non-healing wounds. However, little is known about their potential toxic properties. This study investigates the impact of three commercially available and widely used antiseptics on vitality and proliferation of human cutaneous cells.Material and MethodsThree antiseptics, Lavasept (PHMB), Octenisept (octenidine) and Betaisodona (PVP-iodine) were tested for their cytotoxic effects towards HaCaT cells, primary human keratinocytes and fibroblasts using MTT assay and BrDU ELISA.ResultsLavasept showed only slight to moderate toxic effects on cellular vitality and proliferation. Ocentisept and Betaisodona induced severe reduction of cell vitality (p<0.05) to 0% surviving fibroblasts at 7.5% (Betaisodona) and 12.5% Octenisept, respectively. Furthermore, poliferative activity was reduced to 0% in keratinocytes at 7.5% concentration of Betaisodona and Ocentisept.ConclusionThis study shows that frequently used wound- and skin antiseptics show severe cytotoxic effects towards cutaneous cells. Furthermore, antimicrobial efficacy and toxic properties must be included in the clinical decision process for optimal therapy of chronic wounds. The PHMB solution Lavasept showed best results regarding toxicity in this study.PURPOSE Local skin antiseptics are the standard of care for chronic and non-healing wounds. However, little is known about their potential toxic properties. This study investigates the impact of three commercially available and widely used antiseptics on vitality and proliferation of human cutaneous cells. MATERIAL AND METHODS Three antiseptics, Lavasept (PHMB), Octenisept (octenidine) and Betaisodona (PVP-iodine) were tested for their cytotoxic effects towards HaCaT cells, primary human keratinocytes and fibroblasts using MTT assay and BrDU ELISA. RESULTS Lavasept showed only slight to moderate toxic effects on cellular vitality and proliferation. Ocentisept and Betaisodona induced severe reduction of cell vitality (p<0.05) to 0% surviving fibroblasts at 7.5% (Betaisodona) and 12.5% Octenisept, respectively. Furthermore, poliferative activity was reduced to 0% in keratinocytes at 7.5% concentration of Betaisodona and Ocentisept. CONCLUSION This study shows that frequently used wound- and skin antiseptics show severe cytotoxic effects towards cutaneous cells. Furthermore, antimicrobial efficacy and toxic properties must be included in the clinical decision process for optimal therapy of chronic wounds. The PHMB solution Lavasept showed best results regarding toxicity in this study.

Burn-induced organ dysfunction: Vagus nerve stimulation attenuates organ and serum cytokine levels

INTRODUCTION The interaction of the CNS and the immune system is well known. A parasympathetic anti-inflammatory pathway has recently been described. Both electrical and pharmacological parasympathetic stimulation attenuate proinflammatory mediator generation. Burn induces abacterial cytokine generation and we sought to evaluate whether parasympathetic stimulation after experimental burn decreases cardiodepressive mediator generation. MATERIAL AND METHODS A 30% TBSA full-thickness rat burn model was used. After microsurgical preparation of the cervical portion of the vagus nerve, we performed electric vagus nerve stimulation. Serum was harvested and organ samples of heart and liver were homogenized. Samples were subjected to sandwich-ELISA specific for TNF-alpha, IL-1beta and IL-6. Heart rate measurements were done using left ventricular microcatheterization. Statistical analysis was done using Students t-tests and analysis of variance (ANOVA). RESULTS Burn induced a significant rise of TNF-alpha, IL-1beta and IL-6 in organ homogenates and serum. After cervical vagal electrostimulation, serum and organ homogenate levels of proinflammatory cytokines were markedly reduced compared to burn controls. Left ventricular microcatheter assessment demonstrated no cardiodepressive effect of the vagal stimulation itself. CONCLUSION Our results encourage further research regarding the neuroimmunologic background of burn, possibly leading to the development of a novel therapeutic approach to burn-induced organ dysfunction and immunodysregulation.

Innovative Wundtherapie und Hautersatz bei Verbrennungen

ZusammenfassungDie Erfolgsbilanz der modernen Verbrennungstherapie in Spezialzentren beruht neben einer spezialisierten Intensivtherapie vor allem auf einer frühen Hautexzision mit autologem Hautersatz. Die Möglichkeiten der konservativen Wundtherapie haben sich vor allem durch den Einsatz innovativer Externa und des Hautersatzes durch bioartifizielle Hautanaloga beträchtlich erweitert. In diesem Beitrag sollen daher aktuelle und innovative Verfahren der konservativen Wundtherapie sowie des Hautersatzes bei Verbrennungen dargestellt werden.AbstractThe success of modern burn therapy is based mainly on special burn intensive care, topical treatment, early eschar excision, and wound closure by immediate skin grafting or skin substitutes. This paper describes the current state of wound care and skin substitutes in burn therapy.

A comparative in vitro study of cell toxicity of clinically used antiseptics

ZusammenfassungHintergrundAntiseptika zur Behandlung chronischer und infizierter Wunden gehören zur Standardtherapie. Erkenntnisse über toxische Eigenschaften gegenüber dem Wund- und Hautgewebe sind jedoch kaum vorhanden. Diese Studie untersucht den Einfluss von Wundantiseptika auf die Vitalität und Proliferation humaner kutaner Zellen.Material und MethodenDie Antiseptika Lavasept (PHMB), Octenisept (Octenidin) und Betaisodona (PVP-Jod) wurden mittels MTT-Assay und BrDU-ELISA auf zytotoxische Effekte gegenüber der HaCaT-Zelllinie, primären humanen Keratinozyten und Fibroblasten untersucht.ErgebnisseLavasept besaß nur geringen Einfluss auf Vitalität und Zellproliferation. Betaisodona und Octenisept induzierten eine signifikante Reduktion der Zellvitalität (p<0,05) bis zu 0% überlebender Fibroblasten bei 7,5% (Betaisodona) bzw. 10% (Octenisept) sowie der Zellproliferation auf 0% bei Keratinozyten durch Konzentrationen von 7,5% (Betaisodona und Octenisept).SchlussfolgerungDie Studie zeigt, dass herkömmlich verwendete Wundantiseptika deutlich toxische Effekte besitzen. Sowohl antimikrobielle Potenz als auch toxische Eigenschaften der einzelnen Antiseptika müssen bei der Wundbehandlung berücksichtigt werden. Insgesamt zeigte die PHMB-Lösung (Lavasept) die geringste toxische Wirkung.AbstractPurposeLocal skin antiseptics are the standard of care for chronic and non-healing wounds. However, little is known about their potential toxic properties. This study investigates the impact of three commercially available and widely used antiseptics on vitality and proliferation of human cutaneous cells.Material and MethodsThree antiseptics, Lavasept (PHMB), Octenisept (octenidine) and Betaisodona (PVP-iodine) were tested for their cytotoxic effects towards HaCaT cells, primary human keratinocytes and fibroblasts using MTT assay and BrDU ELISA.ResultsLavasept showed only slight to moderate toxic effects on cellular vitality and proliferation. Ocentisept and Betaisodona induced severe reduction of cell vitality (p<0.05) to 0% surviving fibroblasts at 7.5% (Betaisodona) and 12.5% Octenisept, respectively. Furthermore, poliferative activity was reduced to 0% in keratinocytes at 7.5% concentration of Betaisodona and Ocentisept.ConclusionThis study shows that frequently used wound- and skin antiseptics show severe cytotoxic effects towards cutaneous cells. Furthermore, antimicrobial efficacy and toxic properties must be included in the clinical decision process for optimal therapy of chronic wounds. The PHMB solution Lavasept showed best results regarding toxicity in this study.PURPOSE Local skin antiseptics are the standard of care for chronic and non-healing wounds. However, little is known about their potential toxic properties. This study investigates the impact of three commercially available and widely used antiseptics on vitality and proliferation of human cutaneous cells. MATERIAL AND METHODS Three antiseptics, Lavasept (PHMB), Octenisept (octenidine) and Betaisodona (PVP-iodine) were tested for their cytotoxic effects towards HaCaT cells, primary human keratinocytes and fibroblasts using MTT assay and BrDU ELISA. RESULTS Lavasept showed only slight to moderate toxic effects on cellular vitality and proliferation. Ocentisept and Betaisodona induced severe reduction of cell vitality (p<0.05) to 0% surviving fibroblasts at 7.5% (Betaisodona) and 12.5% Octenisept, respectively. Furthermore, poliferative activity was reduced to 0% in keratinocytes at 7.5% concentration of Betaisodona and Ocentisept. CONCLUSION This study shows that frequently used wound- and skin antiseptics show severe cytotoxic effects towards cutaneous cells. Furthermore, antimicrobial efficacy and toxic properties must be included in the clinical decision process for optimal therapy of chronic wounds. The PHMB solution Lavasept showed best results regarding toxicity in this study.

In vivo evaluation of histomorphological alterations in first-degree burn injuries by means of confocal-laser-scanning microscopy-more than "virtual histology?".

There are various approaches to the treatment of superficial burns. No modality exists to date for determining treatment efficiency on morphological features. We review the first application of high-resolution in vivo confocal-laser-scanning microscopy (CLSM) to the evaluation of superficial burns on a histomorphological level. Sixteen patients (6 women, 10 men; 34.5 ± 16.2 years) with first-degree thermal contact injuries to a maximum extent of 1% of the body surface were enrolled into the study. CLSM was performed with the Vivascope 1500 (Lucid Inc., Rochester, NY) 24 hours after injury. The following parameters were assessed: cell size of the granular layer, thickness of the basal layer, minimal thickness of the epidermis, and diameter of capillary loops. Compared with the control sites 24 hours postburn, the minimal thickness of the epidermis increased on average by approximately 11% (P = .01; t-test); the thickness of the basal layer increased about 7% (P = .008; t-test); the diameter of capillary loops increased approximately by 17% (P = 0.003; t-test); and the cell size of the granular layer increased about 8% (P = .009; Wilcoxon’s test). In vivo CLSM allows characterizing and quantifying histomorphological alterations in superficial burns. CLSM could be helpful in assessing the effects of various treatment approaches for superficial burns on a histomorphological level.

Innovative wound therapy and skin substitutes for burns

ZusammenfassungDie Erfolgsbilanz der modernen Verbrennungstherapie in Spezialzentren beruht neben einer spezialisierten Intensivtherapie vor allem auf einer frühen Hautexzision mit autologem Hautersatz. Die Möglichkeiten der konservativen Wundtherapie haben sich vor allem durch den Einsatz innovativer Externa und des Hautersatzes durch bioartifizielle Hautanaloga beträchtlich erweitert. In diesem Beitrag sollen daher aktuelle und innovative Verfahren der konservativen Wundtherapie sowie des Hautersatzes bei Verbrennungen dargestellt werden.AbstractThe success of modern burn therapy is based mainly on special burn intensive care, topical treatment, early eschar excision, and wound closure by immediate skin grafting or skin substitutes. This paper describes the current state of wound care and skin substitutes in burn therapy.

Monitoring of microcirculation in free transferred musculocutaneous latissimus dorsi flaps by confocal laser scanning microscopy – a promising non-invasive methodical approach

INTRODUCTION For the survival of a microvascular tissue transfer, early detection of vascular complications is crucial. In vivo confocal laser scanning microscopy allows real-time, non-invasive evaluation of tissue microcirculation with a high cellular resolution. The aim of this study was to evaluate confocal laser scanning microscopy for early recognition of flap failure. METHODS Fourteen patients (ages: 40.2+/-12.4 years) were monitored postoperatively for a period of 24h following free microvascular M. latissimus dorsi transfer to the lower extremity using confocal laser scanning microscopy (Vivascope1500; Rochester; New York; USA). The following parameters were evaluated: quantitative blood-cell flow, diameter of capillary loops and minimal thickness of the epidermis. RESULTS Venous congestion was characterised by a decrease in blood-cell flow of up to 41%, accompanied by an increase of the diameter of capillary loops of up to 22% and the minimal thickness of the epidermis up to 32%. By contrast, arterial occlusion was clearly verified by a decrease in blood flow of up to 90%, accompanied by an insignificant change of both capillary loop size and epidermal thickness. CONCLUSION Confocal laser scanning microscopy appears to be a useful non-invasive tool for early recognition of flap failure during the monitoring of microsurgical tissue transfer prior to its clinical manifestation.

Der gestielte Leistenlappen zur Defektdeckung an der Hand

ZusammenfassungOperationszielDefektdeckung des beuge- und streckseitigen Hand- und Unterarmbereichs bis zu einer maximalen Defektgröße von 10 × 25 cm.IndikationenWeichteildefekte des beuge- und streckseitigen Hand- und Unterarmbereichs bis zu einer maximalen Defektgröße von 10 × 25 cm.KontraindikationenPolytraumatisierte Patienten mit lebensbedrohlichen Begleitverletzungen. In diesen Fällen sollte die definitive Weichteildeckung spätprimär oder sekundär nach Kreislaufstabilisierung erfolgen. Schlecht vaskularisiertes Empfängergebiet (z.B. nach Radiatio). Floride Infekte im Empfänger- und/oder Spendergebiet sowie Nekrosen. Voroperationen der Leistenregion mit Kompromittierung der Gefäße. Nicht kooperativer Patient.OperationstechnikOrientierungspunkte zur Lappenumschneidung sind der tastbare Puls der Arteria femoralis, das Leistenband, die Spina iliaca anterior superior und der Musculus sartorius. Einzeichnung des Lappenober- und -unterrandes parallel zum Leistenband, wobei die Längsachse des Lappens dem Verlauf der Arteria circumflexa ilium superficialis entspricht, die anteilig oberhalb des Leistenbandes verläuft. Ein Drittel des Lappens sollte oberhalb und zwei Drittel sollten unterhalb des Leistenbandes zu liegen kommen. Die Lappenpräparation beginnt im lateralen Abschnitt ohne Einschluss der Faszie. Um eine Verletzung des Gefäßstiels zu vermeiden, erfolgt die vorsichtige Identifikation des lateralen Sartoriusrandes, dessen Faszie eingeschnitten und in den Lappen miteinbezogen wird. Ein langer Rundstiel erfordert unter Umständen, die Präparation der A. circumflexa ilium superficialis bis zu ihrem Ursprung fortzusetzen. Nach Hebung des Lappens Einschwenken des Lappens in den Defektbereich und Einnaht mit Rundstielbildung. Der Rundstiel schützt die Lappengefäße und erleichtert die ischämische Konditionierung des Lappens in der postoperativen Phase. Je nach Lappengröße spannungsfreier Primärverschluss des Hebedefekts oder Spalthautdeckung. Die durchschnittliche Operationszeit in einer Ausbildungsklinik beträgt 120 min (Daten aus dem eigenen Pa-tientengut).Weiterbehandlung3-wöchige Stielung des Lappentransplantats und sofortige Mobilisierung des Patienten. Vermeidung von Abknickungen des Lappenstiels; hierzu ggf. Unterpolsterung des Arms und Lagerung in angepasster Schulterabduktion. Tägliche Verbandswechsel und Lappenmonitoring zur Vitalitätsprüfung. Ab dem 10.–14. postoperativen Tag Lappentraining mit Abklemmen des Lappenstiels mit einer Darmklemme. Steigerung der Abklemmzeit um täglich 5–10 min von initial 3 × 5 min/d auf 3 × 1 h/d. Lappenstieldurchtrennung nach Erreichen der maximalen Abklemmzeit nach 3 Wochen unter Belassung eines ausreichend langen Lappenstiels im Empfängergebiet und Sekundärverschluss der Leiste. Nach Demarkierung des Lappenstielendes endgültige Einpassung des Leistenlappens.ErgebnisseIn einem 3-Jahres-Zeitraum wurde bei insgesamt 14 Patienten eine Defektdeckung mit dem gestielten Leistenlappen durchgeführt. Indikationen für das Verfahren waren die Daumenrekonstruktion nach Avulsionsamputation zum Längenerhalt und zur Defektdeckung, die spätsekundäre Wiederherstellung der Daumenlänge durch eine Beckenkammspaninterposition, die Rekonstruktion der Daumenweichteile nach radikalem Débridement einer tiefen zweitgradigen Verbrennung, Hautweichteildefekte im Bereich des Handrückens nach traumatischer Kontusion und Infekt, ausgedehnte Hautweichteildefekte nach Kombinationsverletzung des distalen Unterarms, Handgelenks und der Hohlhand sowie ein plastisch-rekonstruktiver Langfingererhalt mit nachfolgender Phalangealisierung bzw. Syndaktylietrennung. Die Anwendung des Leistenlappens führte in allen Fällen zur vollständigen Defektdeckung. In keinem der Fälle kam es zu einem Lappenverlust, und bei sämtlichen Patienten konnte ein zufriedenstellendes funktionelles und ästhetisches Ergebnis erzielt werden.AbstractObjectiveSoft-tissue defect closure of the volar and dorsal aspect of the hand and lower arm with a maximum defect size of 10 × 25 cm.IndicationsSoft-tissue defects of the entire palm and dorsum of the hand and lower arm with a maximum defect size of 10 × 25 cm.ContraindicationsPolytraumatized patients presenting with concomitant life-threatening injuries. In these cases one should perform the definite defect closure secondary after cardiovascular stabilization. Scars and vascular injury at the donor site. Lack of vascularity and necrosis of implantation site. Poorly vascularized recipient site (e.g. after radiation) Infection and necrosis at the donor and/or recipient site. Prior operations of the groin with impairment of the vasculature. Noncompliant patient.Surgical TechniqueLandmarks are the femoral artery, inguinal ligament, anterior superior iliac spine, and sartorius muscle. The superior and inferior border of the flap should be orientated parallel to the inguinal ligament. The longitudinal axis of the flap is parallel to the superficial circumflex iliac artery, which is partially located superior to the inguinal ligament. One third of the flap is located superior, and two thirds inferior, to the inguinal ligament. Flap dissection starts at the lateral border without including the fascia. Identification of the lateral border of the sartorius muscle, incision of its fascia and inclusion of the fascia into flap dissection in order to preserve the vessel. If a long flap pedicle is favored, flap dissection is continued to the source of the superficial circumflex iliac artery. Primary closure of the donor site and, finally, inset of the flap. A tubed pedicle protects the vessels and simplifies the ischemic preconditioning during the postoperative phase. According to the flap size, the donor site closure is either primary or split-thickness skin grafting is necessary at the lateral aspect of the donor site. The mean duration of the procedure is 120 min in a teaching hospital (own data).Postoperative ManagementThe patient should be mobilized as early as possible. Dressings and flap monitoring should be performed daily. Ischemic preconditioning by applying a tourniquet starts after 10–14 days. The ischemic period is increased continuously from 3 × 5 min/d in the beginning to 3 × 1 h/d before flap dissection. Flap dissection of the pedicle is performed after 3 weeks. The residual donor site is closed, while the distal pedicle is left untrimmed and closed secondarily a few days later to allow for sufficient venous drainage. Finally, defect closure can be completed after demarcation of the pedicle.ResultsIn a 3-year period, defect closure with a pedicled groin flap was performed in 14 patients. Indications for this procedure were the following: thumb reconstruction for lengthening and defect closure after amputation and burn injury, soft-tissue reconstruction of the dorsum of the hand after decollement and infection, soft-tissue reconstruction of the distal part of the lower arm, wrist and palm after complex and combined trauma, and plastic reconstructive preservation of multiple fingers with subsequent phalangealization and syndactyly release, respectively. In all patients, complete soft-tissue coverage and flap survival could be achieved. The functional and aesthetic result was satisfactory in all cases.OBJECTIVE Soft-tissue defect closure of the volar and dorsal aspect of the hand and lower arm with a maximum defect size of 10 × 25 cm. INDICATIONS Soft-tissue defects of the entire palm and dorsum of the hand and lower arm with a maximum defect size of 10 × 25 cm. CONTRAINDICATIONS Polytraumatized patients presenting with concomitant life-threatening injuries. In these cases one should perform the definite defect closure secondary after cardiovascular stabilization. Scars and vascular injury at the donor site. Lack of vascularity and necrosis of implantation site. Poorly vascularized recipient site (e.g. after radiation) Infection and necrosis at the donor and/or recipient site. Prior operations of the groin with impairment of the vasculature. Noncompliant patient. SURGICAL TECHNIQUE Landmarks are the femoral artery, inguinal ligament, anterior superior iliac spine, and sartorius muscle. The superior and inferior border of the flap should be orientated parallel to the inguinal ligament. The longitudinal axis of the flap is parallel to the superficial circumflex iliac artery, which is partially located superior to the inguinal ligament. One third of the flap is located superior, and two thirds inferior, to the inguinal ligament. Flap dissection starts at the lateral border without including the fascia. Identification of the lateral border of the sartorius muscle, incision of its fascia and inclusion of the fascia into flap dissection in order to preserve the vessel. If a long flap pedicle is favored, flap dissection is continued to the source of the superficial circumflex iliac artery. Primary closure of the donor site and, finally, inset of the flap. A tubed pedicle protects the vessels and simplifies the ischemic preconditioning during the postoperative phase. According to the flap size, the donor site closure is either primary or split-thickness skin grafting is necessary at the lateral aspect of the donor site. The mean duration of the procedure is 120 min in a teaching hospital (own data). POSTOPERATIVE MANAGEMENT The patient should be mobilized as early as possible. Dressings and flap monitoring should be performed daily. Ischemic preconditioning by applying a tourniquet starts after 10-14 days. The ischemic period is increased continuously from 3 × 5 min/d in the beginning to 3 × 1 h/d before flap dissection. Flap dissection of the pedicle is performed after 3 weeks. The residual donor site is closed, while the distal pedicle is left untrimmed and closed secondarily a few days later to allow for sufficient venous drainage. Finally, defect closure can be completed after demarcation of the pedicle. RESULTS In a 3-year period, defect closure with a pedicled groin flap was performed in 14 patients. Indications for this procedure were the following: thumb reconstruction for lengthening and defect closure after amputation and burn injury, soft-tissue reconstruction of the dorsum of the hand after decollement and infection, soft-tissue reconstruction of the distal part of the lower arm, wrist and palm after complex and combined trauma, and plastic reconstructive preservation of multiple fingers with subsequent phalangealization and syndactyly release, respectively. In all patients, complete soft-tissue coverage and flap survival could be achieved. The functional and aesthetic result was satisfactory in all cases.

The pedicled groin flap for defect closure of the hand

ZusammenfassungOperationszielDefektdeckung des beuge- und streckseitigen Hand- und Unterarmbereichs bis zu einer maximalen Defektgröße von 10 × 25 cm.IndikationenWeichteildefekte des beuge- und streckseitigen Hand- und Unterarmbereichs bis zu einer maximalen Defektgröße von 10 × 25 cm.KontraindikationenPolytraumatisierte Patienten mit lebensbedrohlichen Begleitverletzungen. In diesen Fällen sollte die definitive Weichteildeckung spätprimär oder sekundär nach Kreislaufstabilisierung erfolgen. Schlecht vaskularisiertes Empfängergebiet (z.B. nach Radiatio). Floride Infekte im Empfänger- und/oder Spendergebiet sowie Nekrosen. Voroperationen der Leistenregion mit Kompromittierung der Gefäße. Nicht kooperativer Patient.OperationstechnikOrientierungspunkte zur Lappenumschneidung sind der tastbare Puls der Arteria femoralis, das Leistenband, die Spina iliaca anterior superior und der Musculus sartorius. Einzeichnung des Lappenober- und -unterrandes parallel zum Leistenband, wobei die Längsachse des Lappens dem Verlauf der Arteria circumflexa ilium superficialis entspricht, die anteilig oberhalb des Leistenbandes verläuft. Ein Drittel des Lappens sollte oberhalb und zwei Drittel sollten unterhalb des Leistenbandes zu liegen kommen. Die Lappenpräparation beginnt im lateralen Abschnitt ohne Einschluss der Faszie. Um eine Verletzung des Gefäßstiels zu vermeiden, erfolgt die vorsichtige Identifikation des lateralen Sartoriusrandes, dessen Faszie eingeschnitten und in den Lappen miteinbezogen wird. Ein langer Rundstiel erfordert unter Umständen, die Präparation der A. circumflexa ilium superficialis bis zu ihrem Ursprung fortzusetzen. Nach Hebung des Lappens Einschwenken des Lappens in den Defektbereich und Einnaht mit Rundstielbildung. Der Rundstiel schützt die Lappengefäße und erleichtert die ischämische Konditionierung des Lappens in der postoperativen Phase. Je nach Lappengröße spannungsfreier Primärverschluss des Hebedefekts oder Spalthautdeckung. Die durchschnittliche Operationszeit in einer Ausbildungsklinik beträgt 120 min (Daten aus dem eigenen Pa-tientengut).Weiterbehandlung3-wöchige Stielung des Lappentransplantats und sofortige Mobilisierung des Patienten. Vermeidung von Abknickungen des Lappenstiels; hierzu ggf. Unterpolsterung des Arms und Lagerung in angepasster Schulterabduktion. Tägliche Verbandswechsel und Lappenmonitoring zur Vitalitätsprüfung. Ab dem 10.–14. postoperativen Tag Lappentraining mit Abklemmen des Lappenstiels mit einer Darmklemme. Steigerung der Abklemmzeit um täglich 5–10 min von initial 3 × 5 min/d auf 3 × 1 h/d. Lappenstieldurchtrennung nach Erreichen der maximalen Abklemmzeit nach 3 Wochen unter Belassung eines ausreichend langen Lappenstiels im Empfängergebiet und Sekundärverschluss der Leiste. Nach Demarkierung des Lappenstielendes endgültige Einpassung des Leistenlappens.ErgebnisseIn einem 3-Jahres-Zeitraum wurde bei insgesamt 14 Patienten eine Defektdeckung mit dem gestielten Leistenlappen durchgeführt. Indikationen für das Verfahren waren die Daumenrekonstruktion nach Avulsionsamputation zum Längenerhalt und zur Defektdeckung, die spätsekundäre Wiederherstellung der Daumenlänge durch eine Beckenkammspaninterposition, die Rekonstruktion der Daumenweichteile nach radikalem Débridement einer tiefen zweitgradigen Verbrennung, Hautweichteildefekte im Bereich des Handrückens nach traumatischer Kontusion und Infekt, ausgedehnte Hautweichteildefekte nach Kombinationsverletzung des distalen Unterarms, Handgelenks und der Hohlhand sowie ein plastisch-rekonstruktiver Langfingererhalt mit nachfolgender Phalangealisierung bzw. Syndaktylietrennung. Die Anwendung des Leistenlappens führte in allen Fällen zur vollständigen Defektdeckung. In keinem der Fälle kam es zu einem Lappenverlust, und bei sämtlichen Patienten konnte ein zufriedenstellendes funktionelles und ästhetisches Ergebnis erzielt werden.AbstractObjectiveSoft-tissue defect closure of the volar and dorsal aspect of the hand and lower arm with a maximum defect size of 10 × 25 cm.IndicationsSoft-tissue defects of the entire palm and dorsum of the hand and lower arm with a maximum defect size of 10 × 25 cm.ContraindicationsPolytraumatized patients presenting with concomitant life-threatening injuries. In these cases one should perform the definite defect closure secondary after cardiovascular stabilization. Scars and vascular injury at the donor site. Lack of vascularity and necrosis of implantation site. Poorly vascularized recipient site (e.g. after radiation) Infection and necrosis at the donor and/or recipient site. Prior operations of the groin with impairment of the vasculature. Noncompliant patient.Surgical TechniqueLandmarks are the femoral artery, inguinal ligament, anterior superior iliac spine, and sartorius muscle. The superior and inferior border of the flap should be orientated parallel to the inguinal ligament. The longitudinal axis of the flap is parallel to the superficial circumflex iliac artery, which is partially located superior to the inguinal ligament. One third of the flap is located superior, and two thirds inferior, to the inguinal ligament. Flap dissection starts at the lateral border without including the fascia. Identification of the lateral border of the sartorius muscle, incision of its fascia and inclusion of the fascia into flap dissection in order to preserve the vessel. If a long flap pedicle is favored, flap dissection is continued to the source of the superficial circumflex iliac artery. Primary closure of the donor site and, finally, inset of the flap. A tubed pedicle protects the vessels and simplifies the ischemic preconditioning during the postoperative phase. According to the flap size, the donor site closure is either primary or split-thickness skin grafting is necessary at the lateral aspect of the donor site. The mean duration of the procedure is 120 min in a teaching hospital (own data).Postoperative ManagementThe patient should be mobilized as early as possible. Dressings and flap monitoring should be performed daily. Ischemic preconditioning by applying a tourniquet starts after 10–14 days. The ischemic period is increased continuously from 3 × 5 min/d in the beginning to 3 × 1 h/d before flap dissection. Flap dissection of the pedicle is performed after 3 weeks. The residual donor site is closed, while the distal pedicle is left untrimmed and closed secondarily a few days later to allow for sufficient venous drainage. Finally, defect closure can be completed after demarcation of the pedicle.ResultsIn a 3-year period, defect closure with a pedicled groin flap was performed in 14 patients. Indications for this procedure were the following: thumb reconstruction for lengthening and defect closure after amputation and burn injury, soft-tissue reconstruction of the dorsum of the hand after decollement and infection, soft-tissue reconstruction of the distal part of the lower arm, wrist and palm after complex and combined trauma, and plastic reconstructive preservation of multiple fingers with subsequent phalangealization and syndactyly release, respectively. In all patients, complete soft-tissue coverage and flap survival could be achieved. The functional and aesthetic result was satisfactory in all cases.OBJECTIVE Soft-tissue defect closure of the volar and dorsal aspect of the hand and lower arm with a maximum defect size of 10 × 25 cm. INDICATIONS Soft-tissue defects of the entire palm and dorsum of the hand and lower arm with a maximum defect size of 10 × 25 cm. CONTRAINDICATIONS Polytraumatized patients presenting with concomitant life-threatening injuries. In these cases one should perform the definite defect closure secondary after cardiovascular stabilization. Scars and vascular injury at the donor site. Lack of vascularity and necrosis of implantation site. Poorly vascularized recipient site (e.g. after radiation) Infection and necrosis at the donor and/or recipient site. Prior operations of the groin with impairment of the vasculature. Noncompliant patient. SURGICAL TECHNIQUE Landmarks are the femoral artery, inguinal ligament, anterior superior iliac spine, and sartorius muscle. The superior and inferior border of the flap should be orientated parallel to the inguinal ligament. The longitudinal axis of the flap is parallel to the superficial circumflex iliac artery, which is partially located superior to the inguinal ligament. One third of the flap is located superior, and two thirds inferior, to the inguinal ligament. Flap dissection starts at the lateral border without including the fascia. Identification of the lateral border of the sartorius muscle, incision of its fascia and inclusion of the fascia into flap dissection in order to preserve the vessel. If a long flap pedicle is favored, flap dissection is continued to the source of the superficial circumflex iliac artery. Primary closure of the donor site and, finally, inset of the flap. A tubed pedicle protects the vessels and simplifies the ischemic preconditioning during the postoperative phase. According to the flap size, the donor site closure is either primary or split-thickness skin grafting is necessary at the lateral aspect of the donor site. The mean duration of the procedure is 120 min in a teaching hospital (own data). POSTOPERATIVE MANAGEMENT The patient should be mobilized as early as possible. Dressings and flap monitoring should be performed daily. Ischemic preconditioning by applying a tourniquet starts after 10-14 days. The ischemic period is increased continuously from 3 × 5 min/d in the beginning to 3 × 1 h/d before flap dissection. Flap dissection of the pedicle is performed after 3 weeks. The residual donor site is closed, while the distal pedicle is left untrimmed and closed secondarily a few days later to allow for sufficient venous drainage. Finally, defect closure can be completed after demarcation of the pedicle. RESULTS In a 3-year period, defect closure with a pedicled groin flap was performed in 14 patients. Indications for this procedure were the following: thumb reconstruction for lengthening and defect closure after amputation and burn injury, soft-tissue reconstruction of the dorsum of the hand after decollement and infection, soft-tissue reconstruction of the distal part of the lower arm, wrist and palm after complex and combined trauma, and plastic reconstructive preservation of multiple fingers with subsequent phalangealization and syndactyly release, respectively. In all patients, complete soft-tissue coverage and flap survival could be achieved. The functional and aesthetic result was satisfactory in all cases.

Is superficial burn caused by ultraviolet radiation (sunburn) comparable to superficial burn caused by heat – a histomorphological comparison by in vivo Reflectance-Mode-Confocal Microscopy

Background  Regardless of the underlying cause, both sunburn and superficial thermal injuries are classified as first‐degree burns, since data on morphological differences are scarce. Reflectance‐Mode‐Confocal Microscopy (RMCM) enables high‐resolution non‐invasive investigation of the human skin.