Andreas Steiert

Outcome of simultaneous and staged microvascular free tissue transfer connected to arteriovenous loops in areas lacking recipient vessels.

Background: Arteriovenous loops are an indispensable tool in free flap surgery when appropriate recipient vessels are missing. In this study, the authors analyzed whether the outcome differs when flaps were transferred simultaneously or subsequently after construction of arteriovenous loops. Methods: Twenty-seven patients requiring free tissue transfer received arteriovenous loops by pedicled or free vein grafts because of inadequate local recipient vessels. In head and neck reconstruction, pedicled brachiocephalic or free saphenous vein grafts were anastomosed to cervical or axillary vessels. Pedicled major saphenous vein grafts were used in the pelvic area whereas, in lower leg and foot reconstruction, free saphenous or brachiocephalic veins were used. Flaps were transferred simultaneously (n = 10) or 4 to 17 days later (n = 17). Results: Thrombosis required revision in staged transfer (n = 3 patients) or in simultaneous flap transfer (n = 2). No free flap was lost. Fisher’s exact test did not indicate a significant difference between a simultaneous or staged flap transfer. Conclusions: Temporary arteriovenous loops provide adequate recipient vessels and flow to supply microvascular free flap tissue transfer in areas lacking recipient vessels and in which no other reconstructive options exists. No statistical differences in complications and overall outcome were found between immediate or secondary free tissue transfer. Meticulous monitoring of microvascular perfusion, however, is mandatory in both approaches and early intervention is necessary to ensure successful tissue transfer.

Capsular contracture by silicone breast implants: possible causes, biocompatibility, and prophylactic strategies.

The most common implanted material in the human body consists of silicone. Breast augmentation and breast reconstruction using silicone-based implants are procedures frequently performed by reconstructive and aesthetic surgeons. A main complication of this procedure continues to be the development of capsular contracture (CC), displaying the result of a fibrotic foreign body reaction after the implantation of silicone. For many years, experimental and clinical trials have attempted to analyze the problem of its etiology, treatment, and prophylaxis. Different theories of CC formation are known; however, the reason why different individuals develop CC in days or a month, or only after years, is unknown. Therefore, we hypothesize that CC formation, might primarily be induced by immunological mechanisms along with other reasons. This article attempts to review CC formation, with special attention paid to immunological and inflammatory reasons, as well as actual prophylactic strategies. In this context, the word “biocompatibility” has been frequently used to describe the overall biological innocuousness of silicone in the respective studies, although without clear-cut definitions of this important feature. We have therefore developed a new five-point scale with distinct key points of biocompatibility. Hence, this article might provide the basis for ongoing discussion in this field to reduce single-publication definitions as well as increase the understanding of biocompatibility.

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

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

Is there an association between comorbidities and the outcome of microvascular free tissue transfer

The aim of this study was to evaluate the relevant conditions for safe free flap transfers. The authors retrospectively studied the data from 150 patients who received free flaps at a single institution. Many parameters were analyzed to reveal if there was a correlation with respect to surgical or medical complications. Regarding safety of free tissue transfer, we found a worse prognosis in flaps where a revision of the microanastomosis had to be performed. Platelet count and leukocyte count had an impact on the prognosis. Patients older than 60 years did not have an increased rate of surgical complications. Apart from active osteomyelitis, the presence of comorbid conditions did not significantly impair the outcome of flap transfer, although smoking and diabetes correlated with minor surgical complications like wound breakdown or hematoma, respectively. Besides one case of lethal heart failure of an octogenarian patient, no severe medical complications occurred in this series of patients. Microvascular free tissue transfer is not significantly impaired by age and most comorbidities. Osteomyelitis as well as elevated leukocytes and lowered platelets may increase the complication rate and worsen the surgical prognosis. Smoking and diabetes might prolong the hospital course of the patients.

Covalent vectored binding of functional proteins by bifunctional crosslinking at silicone interfaces

In the daily clinical routine, numerous synthetic medical devices are implanted in the human body, either temporarily or permanently. The synthetic material most often implanted is polydimethylsiloxane (silicone). Numerous studies have demonstrated that silicone is encompassed in a connective tissue capsule by the body, preventing integration into the surrounding tissue. This can result in complications. The aim of our study was to develop a simple procedure to functionalize the silicone surface, thereby positively affecting the materials biocompatibility. By combining a silanization with the use of ester activation, a reactive amino group is generated, which can bind any free carboxyl group. Directional crosslinking of a near-infrared-conjugated fluorophore antibody to the activated silicone surface could be demonstrated on a dose-dependent basis. The redox reaction at a silicone surface coated with an HRP-conjugated antibody caused by the addition of NBT/BCIP could be shown. Covering the silicone discs with an anti-FAS-antibody coating followed by a coincubation with FAS-sensitive T-cells allowed highly significant detection of caspase-3. In summary, our crosslinking procedure enables the stable binding of proteins without the loss of biological function. Through this process, silicones could be endowed with new functions which could improve their biocompatibility.

Coating of an anti-Fas antibody on silicone: first in vivo results.

BACKGROUND Although the etiology of capsular contracture after breast augmentation has not yet been definitively clarified, the literature contains numerous reports placing the blame on a foreign body reaction. We have developed a procedure for covalently activating a silicone surface with an anti-Fas antibody, which might suppress the foreign body reaction on the silicone surface. OBJECTIVES The authors evaluate whether surrounding tissue might be influenced by anti-Fas antibody coating on silicone disks in comparison to untreated silicone disks in an in vivo model. METHODS During this study, 4-mm anti-Fas-coated silicone disks were implanted subcutaneously in the paravertebral region of mice (C57/BL6). Silicone disks passing the activation coating process without anti-Fas antibody incubation were defined as the control group. Twelve weeks after implantation, the disks were removed and the surrounding tissue examined. RESULTS The tissue surrounding the silicone disks in the experimental group showed significantly increased levels of collagen type 3, elevated levels of matrix metalloproteinase 9, markedly decreased levels of transforming growth factor β2, and a reduced CD68 expression in the pericapsular tissue. CONCLUSIONS The first in vivo data reveal that the tissue surrounding a silicone surface can be influenced by the vectored binding of an anti-Fas antibody.

Rekonstruktion der aktiven Ellbogenbeugung durch bipolare Transposition des Musculus latissimus dorsi

ZusammenfassungOperationszielWiederherstellung der aktiven Ellbogenbeugung gegen Eigenschwere (Kraftgrad ≥M3) und Verbesserung der Gebrauchsfähigkeit der gesamten oberen Extremität durch bipolare Transposition des intakten Musculus latissimus dorsi.IndikationenIrreparable Läsion des Nervus musculocutaneus (C5/6). Unvollständige Regeneration nach konservativer Behandlung oder nach Eingriff am verletzten Nerv (Neurolyse, Nervennaht, Nervenrekonstruktion). Verletzung des oberen Anteils des Plexus brachialis (C5/6). Funktionsverlust des Musculus biceps durch Poliomyelitis. Muskelschaden (Endorganinsuffizienz) durch Trauma, Ischämie oder Tumor.KontraindikationenMögliche Besserung der Lähmung durch weitere Re-innervation, spontan oder nach neurochirurgischem Eingriff. Ungenügende Funktion des Musculus latissimus dorsi (Kraftgrad < M4). Eingeschränkte passive Beweglichkeit des Ellbogengelenks (Arthrose, Kontraktur). Fehlende Motivation, Einsichtsfähigkeit und Kooperation des Patienten bei der Nachbehandlung.OperationstechnikDer Musculus latissimus dorsi wird als Ersatz des Musculus biceps brachii nach ventral zum Oberarm verlagert. Dort wird der ehemalige Ursprung des Muskels mit seiner Aponeurose mit der Sehne des Musculus biceps vereinigt, der Ansatz wird am Processus coracoideus fixiert.WeiterbehandlungPostoperative Immobilisation im Gilchrist-Verband in 100° Beugung und Supination oder Neutralstellung über 6 Wochen, dann zunächst zunehmende aktive Streckung des Ellbogens mit völliger Freigabe und Üben der aktiven Flexion nach 8–10 Wochen. Um einer Überdehnung des Muskels und der Sehnennaht vorzubeugen, wird eine Orthose zur nächtlichen Ruhigstellung des Ellbogens in 90° Beugung für weitere 6 Monate verwendet.ErgebnisseDer Vergleich der eigenen Ergebnisse von drei operierten Patienten mit den in der Literatur beschriebenen Fallserien zeigt, dass durch diese Methode zuverlässig eine funktionell wertvolle Ellbogenbeugung im Hinblick auf Bewegungsausmaß (> 90° Ellbogenflexion) und Kraftleistung (Unterarmbeugung gegen Eigenschwere, Kraftgrad ≥M3) zu erwarten ist, wobei der Hebedefekt und die Komplikationsrate gering sind.AbstractObjectiveReconstruction of active elbow flexion against gravity (strength grade ≥M3) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity.IndicationsIrreparable lesions of the musculocutaneous nerve (C5/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C5/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor.ContraindicationsPossible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M4). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program.Surgical TechniqueThe intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor.Postoperative ManagementFollowing postoperative immobilization in an upper-arm Gilchrist bandage at 100° flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8–10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90° for 6 months.ResultsAccording to the authors’ experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90° elbow flexion) and strength (at least antigravity strength, ≥M3) with acceptable donor morbidity and complication rate.

Restoration of active elbow flexion by muscle transfer of the latissimus dorsi

ZusammenfassungOperationszielWiederherstellung der aktiven Ellbogenbeugung gegen Eigenschwere (Kraftgrad ≥M3) und Verbesserung der Gebrauchsfähigkeit der gesamten oberen Extremität durch bipolare Transposition des intakten Musculus latissimus dorsi.IndikationenIrreparable Läsion des Nervus musculocutaneus (C5/6). Unvollständige Regeneration nach konservativer Behandlung oder nach Eingriff am verletzten Nerv (Neurolyse, Nervennaht, Nervenrekonstruktion). Verletzung des oberen Anteils des Plexus brachialis (C5/6). Funktionsverlust des Musculus biceps durch Poliomyelitis. Muskelschaden (Endorganinsuffizienz) durch Trauma, Ischämie oder Tumor.KontraindikationenMögliche Besserung der Lähmung durch weitere Re-innervation, spontan oder nach neurochirurgischem Eingriff. Ungenügende Funktion des Musculus latissimus dorsi (Kraftgrad < M4). Eingeschränkte passive Beweglichkeit des Ellbogengelenks (Arthrose, Kontraktur). Fehlende Motivation, Einsichtsfähigkeit und Kooperation des Patienten bei der Nachbehandlung.OperationstechnikDer Musculus latissimus dorsi wird als Ersatz des Musculus biceps brachii nach ventral zum Oberarm verlagert. Dort wird der ehemalige Ursprung des Muskels mit seiner Aponeurose mit der Sehne des Musculus biceps vereinigt, der Ansatz wird am Processus coracoideus fixiert.WeiterbehandlungPostoperative Immobilisation im Gilchrist-Verband in 100° Beugung und Supination oder Neutralstellung über 6 Wochen, dann zunächst zunehmende aktive Streckung des Ellbogens mit völliger Freigabe und Üben der aktiven Flexion nach 8–10 Wochen. Um einer Überdehnung des Muskels und der Sehnennaht vorzubeugen, wird eine Orthose zur nächtlichen Ruhigstellung des Ellbogens in 90° Beugung für weitere 6 Monate verwendet.ErgebnisseDer Vergleich der eigenen Ergebnisse von drei operierten Patienten mit den in der Literatur beschriebenen Fallserien zeigt, dass durch diese Methode zuverlässig eine funktionell wertvolle Ellbogenbeugung im Hinblick auf Bewegungsausmaß (> 90° Ellbogenflexion) und Kraftleistung (Unterarmbeugung gegen Eigenschwere, Kraftgrad ≥M3) zu erwarten ist, wobei der Hebedefekt und die Komplikationsrate gering sind.AbstractObjectiveReconstruction of active elbow flexion against gravity (strength grade ≥M3) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity.IndicationsIrreparable lesions of the musculocutaneous nerve (C5/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C5/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor.ContraindicationsPossible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M4). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program.Surgical TechniqueThe intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor.Postoperative ManagementFollowing postoperative immobilization in an upper-arm Gilchrist bandage at 100° flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8–10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90° for 6 months.ResultsAccording to the authors’ experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90° elbow flexion) and strength (at least antigravity strength, ≥M3) with acceptable donor morbidity and complication rate.

Rekonstruktion der aktiven Ellbogenbeugung durch bipolare Transposition des Musculus latissimus dorsi@@@Restoration of Active Elbow Flexion by Muscle Transfer of the Latissimus Dorsi

ZusammenfassungOperationszielWiederherstellung der aktiven Ellbogenbeugung gegen Eigenschwere (Kraftgrad ≥M3) und Verbesserung der Gebrauchsfähigkeit der gesamten oberen Extremität durch bipolare Transposition des intakten Musculus latissimus dorsi.IndikationenIrreparable Läsion des Nervus musculocutaneus (C5/6). Unvollständige Regeneration nach konservativer Behandlung oder nach Eingriff am verletzten Nerv (Neurolyse, Nervennaht, Nervenrekonstruktion). Verletzung des oberen Anteils des Plexus brachialis (C5/6). Funktionsverlust des Musculus biceps durch Poliomyelitis. Muskelschaden (Endorganinsuffizienz) durch Trauma, Ischämie oder Tumor.KontraindikationenMögliche Besserung der Lähmung durch weitere Re-innervation, spontan oder nach neurochirurgischem Eingriff. Ungenügende Funktion des Musculus latissimus dorsi (Kraftgrad < M4). Eingeschränkte passive Beweglichkeit des Ellbogengelenks (Arthrose, Kontraktur). Fehlende Motivation, Einsichtsfähigkeit und Kooperation des Patienten bei der Nachbehandlung.OperationstechnikDer Musculus latissimus dorsi wird als Ersatz des Musculus biceps brachii nach ventral zum Oberarm verlagert. Dort wird der ehemalige Ursprung des Muskels mit seiner Aponeurose mit der Sehne des Musculus biceps vereinigt, der Ansatz wird am Processus coracoideus fixiert.WeiterbehandlungPostoperative Immobilisation im Gilchrist-Verband in 100° Beugung und Supination oder Neutralstellung über 6 Wochen, dann zunächst zunehmende aktive Streckung des Ellbogens mit völliger Freigabe und Üben der aktiven Flexion nach 8–10 Wochen. Um einer Überdehnung des Muskels und der Sehnennaht vorzubeugen, wird eine Orthose zur nächtlichen Ruhigstellung des Ellbogens in 90° Beugung für weitere 6 Monate verwendet.ErgebnisseDer Vergleich der eigenen Ergebnisse von drei operierten Patienten mit den in der Literatur beschriebenen Fallserien zeigt, dass durch diese Methode zuverlässig eine funktionell wertvolle Ellbogenbeugung im Hinblick auf Bewegungsausmaß (> 90° Ellbogenflexion) und Kraftleistung (Unterarmbeugung gegen Eigenschwere, Kraftgrad ≥M3) zu erwarten ist, wobei der Hebedefekt und die Komplikationsrate gering sind.AbstractObjectiveReconstruction of active elbow flexion against gravity (strength grade ≥M3) by transfer of the latissimus dorsi muscle in order to improve the functionality of the upper extremity.IndicationsIrreparable lesions of the musculocutaneous nerve (C5/6). Failure of regeneration after peripheral nerve reconstruction for the musculocutaneous nerve (neurolysis, suture, nerve grafting). Brachial plexus injury (lesions to the upper part, C5/6). Loss of biceps function due to trauma, ischemia, poliomyelitis or tumor.ContraindicationsPossible recovery of biceps function by reinnervation, spontaneously or after nerve reconstruction. Weakness of the latissimus dorsi muscle (strength grade < M4). Insufficient passive range of motion of the elbow joint (osteoarthritis, contracture). Lack of motivation, reliability, and cooperation of the patient in postoperative rehabilitation program.Surgical TechniqueThe intact latissimus dorsi muscle is transferred with its origin and insertion ventrally and sutured with its thoracic aponeurosis into the insertion of the biceps tendon in order to act as an elbow flexor.Postoperative ManagementFollowing postoperative immobilization in an upper-arm Gilchrist bandage at 100° flexion and supination (or neutral position, but not pronation) of the forearm for 6 weeks, passive motion exercises of the elbow are started. Active flexion and extension exercises begin at 8–10 weeks postoperatively. To prevent the deleterious effect of muscle and tendon elongation, an orthosis is used during the night to keep the elbow flexed at 90° for 6 months.ResultsAccording to the authors’ experience and the results reported in the literature, bipolar latissimus dorsi muscle transfer is a reliable method to restore functional elbow flexion regarding range of motion (> 90° elbow flexion) and strength (at least antigravity strength, ≥M3) with acceptable donor morbidity and complication rate.

Improvement of clinical outcome and shortening of hospital days with decreased risk following application of Integra and subatmospheric pressure

To the Editor: It is with interest that I read the article by Kreymerman et al, published in the April issue of Annals. The authors do a good job of discussing some aspects of methods used to evaluate implant rupture. As the authors pointed out, comprehensive clinical and radiologic assessment for patients with implants frequently becomes complicated. Thus, a management algorithm is useful to help determine which imaging modality is appropriate and, particularly, when to use magnetic resonance imaging (MRI). Nonetheless, I must point out that there is another side to this equation that is not examined in the present article: costs and technical limitations related to MRI accuracy. MRI is generally accepted as the technique of choice for evaluating implant integrity, with a sensitivity of 70% to 94% and a specificity of 85% to 100%, depending on the applied MRI protocol and on the diagnostic criteria used for the definition of implant status. In recent years, there has been a resurgence of interest in the implant imaging techniques, as well as the lack of logic of the US Food and Drug Administration recommendation for post–silicone implant MRI study. This article again illustrates the value of the MRI to evaluate implant integrity and an algorithm to consider when evaluating these patients. In my experience, frequently implant rupture is asymptomatic because the free silicone remains within the capsule. Therefore, the identification of rupture is based on the use of imaging techniques and MRI has the potential to address questions raised or unanswered with traditional imaging methods. However, implant integrity depend on multiple technical factors and implant factors (ie, capsule contracture, implant position, implant type). In addition, individual investigative imaging methods are diverse, causing difficulty in protocol development for the radiologist. Thus, MRI can present some limitations and as with any other test, there is an inherent false-negative and false-positive rate. It has been suggested that detection of an extracapsular rupture or silicone leakage is relatively easy on silicone-specific MRI images, however in my experience, detection of an intracapsular rupture can be challenging. An intracapsular rupture can be a total collapse of the inner capsule, creating a “lumen within a lumen” appearance, or it can be a focal collapse with multiple intraluminal linear hypointense structures within the silicone-filled lumen (linguine sign) or a focal silicone collection in radial folds (“keyhole” sign). In some situations, a false-negative rupture diagnose can be observed. In these cases, the envelope adherence to the fibrous capsule justified the linguine sign absence and the homogeneous high signal intensity inside the ruptured implant. As described by Berg et al, the term “rupture without collapse” can explain the envelope adherence to the capsule phenomenon and the gel homogeneity that are found in some ruptured implants. Another potential and “cost” problem is related to the false-positive cases. In some situations, the presence of atypical radial folds simulated a “linguine” appearance of a ruptured wavy elastomer. According to some authors, the presence of complex radial folds is one of the principal reasons of false-positive on MRI mimicking the total collapse of the implant shell. In addition, the “linguine sign” can be detected in bleeding implants. In this last situation, the false-positives are due to the presence of atypical folds that mimicked ruptured wavy elastomer. To resolve this problem is important to use orthogonal planes with lesser slice thickness, or volumetric acquisition with volumetric reformatting. In the last 5 years, 7 patients with positive MRI presented without a history or physical examination suggesting a rupture. Based only on the MRI result, all implants were removed and none were ruptured, resulting in unnecessary expense and risk. In conclusion, awareness of potential pitfalls is important if MRI is to maximize its potential in breast imaging. Some pitfalls that may arise in relation to MRI of the breast can readily be avoided by attention to technique and care with interpretation of imaging. On the other hand, screening of asymptomatic breast augmentation patients, and in particular with MRI, remains controversial, and sound scientific studies in this area are scarce. Again, I congratulate the authors on their results.