Dirk Hermes

Superficial ulnar artery: Curse or blessing in harvesting fasciocutaneous forearm flaps

Superficial ulnar artery is a well‐known vascular anomaly that may cause special risks because of possible impairment of the vessel by mistake during harvesting fasciocutaneous forearm flaps.

Rare facial clefts : Treatment during charity missions in developing countries

During 10 charity missions in developing countries, 14 patients of a total of 374 children with cleft lip and palate deformities were treated for rare facial clefts. There were three midline clefts (Tessier no. 0 cleft, n = 1; Tessier no. 14 cleft, n = 2), four oblique facial clefts (Tessier no. 3 cleft, n = 2; Tessier no. 5 cleft, n = 2), and seven lateral facial clefts (Tessier no. 7 cleft). Surgical treatment focused on cleft repair by soft-tissue reconstruction apart from two Tessier no. 14 clefts, in which the bony gap was also closed using bone grafts from the iliac crest. The postoperative course was uneventful except for one local wound infection that was treated successfully using oral antibiotics. This article summarizes the authors’ experience with the surgical management of these malformations and considers the limitations under conditions of charity missions in developing countries. Furthermore, some rare forms of cleft formation are added to the existing literature.

Early and late immunohistochemical and ultrastructural changes associated with functional impairment of the lachrymal gland following external beam radiation

The aim of this study was to investigate scintigraphic, immunohistological and ultrastructural changes associated with radiation‐induced dysfunction of the lachrymal gland in an established experimental animal model. Ten rabbits were randomized into two groups and used for the study; in the control as well as experimental group, the Schirmer‐test, lachrymal gland scintigraphy, and immunohistological and ultrastructural investigations were carried out prior to irradiation and 72 h as well as 1 month after single‐dose irradiation with 15 Gy. Seventy‐two hours after irradiation, secretion reduction evaluated by the Schirmer‐test was evident. At this phase, we could observe a decrease in the expression of α‐SMA and a re‐distribution of tenascin‐C matrix. Ultrastructural changes of acinar and myoepithelial cells were noticed; simultaneously, disturbance in the primary 99mTcO4– uptake as well as significant reduction of the lachrymal ejection fraction was assessed scintigraphically. These changes were still evident 1 month following irradiation but became less intensive. Single‐dose irradiation with 15 Gy implicates a functional impairment of the lachrymal gland, which is associated with early immunohistological and ultrastructural alterations. These changes may represent objective surrogate parameters for radiogenic dysfunction and prerequisites for further investigations on radioprotection of lachrymal glands during radiotherapy of the periorbital region.

Acceptance of medical hypnosis by oral and maxillofacial patients.

Prognosis in surgical treatment of diseases of the oral and maxillofacial region under local anesthesia is quite commonly restricted by compliance by the patient. An alternative approach, medical hypnosis, has not been used in oral and maxillofacial surgery to any significant degree. As such, hypnosis treatment also depends to a great extent on the cooperation of the patient, and it would seem advisable to collect information concerning the individual motivation for accepting such a treatment option. The questionnaire consisted of 21 questions and was handed out to patients of the department. A total of 310 questionnaires were evaluated statistically, and the result shows a high level of acceptance of medical hypnosis by patients being treated surgically in the oral and maxillofacial region. The authors conclude that the effectiveness of this treatment option should be examined in clinical studies.

Evaluation des intraoperativen Einsatzes standardisierter Hypnose mit State-Trait-Angst-Inventar (STAI)

Chirurgische Eingriffe unter Lokalanästhesie finden nicht selten ihre Limitationen in der individuellen Compliance und Belastbarkeit des Patienten. Eine Alternative zur Behandlung unter Sedierung oder Allgemeinnarkose könnte die Anwendung von Hypnose darstellen. Nachdem ein einjähriger klinischer Einsatz des Verfahrens in unserer Klinik interessante Perspektiven aufgezeigt hat, werden die beobachteten hypnoseinduzierten Effekte durch klinische Studien evaluiert. In die prospektive Studie wurden 50 zu chirurgischen Zahnsanierungen überwiesene Patienten aufgenommen. In der Verumgruppe (n=25) wurde zusätzlich zur Standardbehandlung (Lokalanästhesie) eine intraoperative Hypnose angewandt. Die Quantifizierung der individuellen und situativen Ausprägungen von Behandlungsangst erfolgte mit dem State-Trait-Angst-Inventar (STAI). Bei gleichsinnig ansteigender direkt präoperativer Behandlungsangst wiesen die Patienten der Hypnosegruppe eine signifikante intraoperative Reduktion bis zum Baseline-Niveau auf. In der Kontrollgruppe (n=25) verblieb das Angstniveau auf stabil hohem präoperativem Niveau. Hypnose senkt die intraoperative Behandlungsangst mund-, kiefer- und gesichtschirurgischer Patienten signifikant. Weitere klinische Studien zu den Einsatzmöglichkeiten von Hypnose in diesem Fachgebiet erscheinen sinnvoll. Surgical treatment under local anesthesia is commonly restricted by limited compliance of patients. Hypnosis may represent an alternative to sedation or general anesthesia. As the procedure demonstrated promising prospects during 1-year experience, the observed hypnosis-induced effects are now being evaluated in clinical studies. The prospective study included 50 patients scheduled for dental surgery. All procedures were performed under standardized surgical conditions. The experimental group (n=25) received supplementary standardized tape hypnosis, whereas the control group received standard treatment (only local anesthesia). Individual and situative anxiety levels were determined by the State-Trait Anxiety Inventory (STAI). After simultaneous increase of preoperative state anxiety, anxiety levels in the hypnosis group showed a significant intraoperative reduction to baseline level, whereas intraoperative anxiety of the control group (n=25) remained unchanged. Hypnosis reduces intraoperative anxiety of oral and maxillofacial patients significantly. Further clinical studies on the use of hypnosis are considered useful.

Inkorporation multipler Fremdkörper bei Borderlinepersönlichkeitsstörung

Selbst schädigende Verhaltensmuster stellen ein pathognomonisches Merkmal der Borderlinepersönlichkeitsstörung dar. Ein solches autoaggressives Verhalten kann in der Inkorporation von Fremdkörpern bestehen. Im Kopf-/Halsbereich führt dies zu primär oder sekundär entzündlichen Komplikationen mit sehr unterschiedlicher klinischer Manifestation. Diagnostik, Therapie und Verlauf eines solchen Falls werden im folgenden Bericht beschrieben und anhand einer Literaturauswertung kritisch diskutiert. Eine 24-jährige Patientin mit Borderlinepersönlichkeitsstörung stellte sich nach Auftreten einer infraaurikularen Schwellung in unserer Poliklinik vor. Nach antibiotischer Behandlung und persistierender Schwellung wurde eine lokale Revision mit Entfernung von 2 metallischen Fremdkörpern durchgeführt. Anschließende Röntgendiagnostik identifizierte multiple metallische Fremdkörper im Bereich des Kopfes, Halses und der Unterarme. Insgesamt 76 Fremdkörper wurden chirurgisch entfernt. Im postoperativen Verlauf inkorporierte die Patientin während der psychiatrischen Weiterbehandlung erneut Fremdkörper. Der geschilderte Fall stellt eine nach Durchsicht der Literatur ungewöhnliche, für Borderlinepatienten aber charakteristische perkutane Fremdkörperinkorporation dar. Diagnostik und Therapie machen ein unterschiedlich aufwändiges Konzept notwendig, welches nur in enger Zusammenarbeit mit den behandelnden Psychiatern umgesetzt werden sollte. Sekundärer Krankheitsgewinn durch chirurgische Diagnostik und Therapie sowie die Wahrscheinlichkeit eines autoaggressiven Rezidivs müssen in die therapeutischen Überlegungen einbezogen werden. Autoaggressive behaviour is one of the pathognomonic characteristics in patients with borderline personality disorder. Clinical symptoms of such behaviour can be the self-induced incorporation of foreign bodies. In the head and neck area, this form of autoaggressivity causes primary or secondary infectious complications with different clinical manifestations. Below follows a description of diagnosis, therapy and follow-up of such a case, comparing our own findings with the corresponding literature. A 24-year-old woman with manifest borderline personality disorder was referred to the Department of Maxillofacial Surgery after developing a swelling in the infra-auricular region. After antibiotic therapy failed to reduce inflammatory symptoms, local revision was performed including excision of two metallic foreign bodies. Comprehensive radiological evaluation identified multiple foreign bodies in the head and neck region and lower arms. A total of 76 metallic foreign bodies was removed surgically. During early surgical follow-up and subsequent psychiatric treatment, the patient incorporated new foreign bodies. The case reported represents a pattern of foreign body incorporation which is unusual based on review of the literature but characteristic for patients with borderline personality disorder. Diagnostics and therapy require an individual concept which only can be implemented in close co-operation with psychiatrists. Secondary clinical benefit derived from surgical diagnostics and therapy as well as the possibility of autoaggressive relapse have to be taken into consideration.

Incorporation of multiple foreign bodies due to borderline personality disorder

Selbst schädigende Verhaltensmuster stellen ein pathognomonisches Merkmal der Borderlinepersönlichkeitsstörung dar. Ein solches autoaggressives Verhalten kann in der Inkorporation von Fremdkörpern bestehen. Im Kopf-/Halsbereich führt dies zu primär oder sekundär entzündlichen Komplikationen mit sehr unterschiedlicher klinischer Manifestation. Diagnostik, Therapie und Verlauf eines solchen Falls werden im folgenden Bericht beschrieben und anhand einer Literaturauswertung kritisch diskutiert. Eine 24-jährige Patientin mit Borderlinepersönlichkeitsstörung stellte sich nach Auftreten einer infraaurikularen Schwellung in unserer Poliklinik vor. Nach antibiotischer Behandlung und persistierender Schwellung wurde eine lokale Revision mit Entfernung von 2 metallischen Fremdkörpern durchgeführt. Anschließende Röntgendiagnostik identifizierte multiple metallische Fremdkörper im Bereich des Kopfes, Halses und der Unterarme. Insgesamt 76 Fremdkörper wurden chirurgisch entfernt. Im postoperativen Verlauf inkorporierte die Patientin während der psychiatrischen Weiterbehandlung erneut Fremdkörper. Der geschilderte Fall stellt eine nach Durchsicht der Literatur ungewöhnliche, für Borderlinepatienten aber charakteristische perkutane Fremdkörperinkorporation dar. Diagnostik und Therapie machen ein unterschiedlich aufwändiges Konzept notwendig, welches nur in enger Zusammenarbeit mit den behandelnden Psychiatern umgesetzt werden sollte. Sekundärer Krankheitsgewinn durch chirurgische Diagnostik und Therapie sowie die Wahrscheinlichkeit eines autoaggressiven Rezidivs müssen in die therapeutischen Überlegungen einbezogen werden. Autoaggressive behaviour is one of the pathognomonic characteristics in patients with borderline personality disorder. Clinical symptoms of such behaviour can be the self-induced incorporation of foreign bodies. In the head and neck area, this form of autoaggressivity causes primary or secondary infectious complications with different clinical manifestations. Below follows a description of diagnosis, therapy and follow-up of such a case, comparing our own findings with the corresponding literature. A 24-year-old woman with manifest borderline personality disorder was referred to the Department of Maxillofacial Surgery after developing a swelling in the infra-auricular region. After antibiotic therapy failed to reduce inflammatory symptoms, local revision was performed including excision of two metallic foreign bodies. Comprehensive radiological evaluation identified multiple foreign bodies in the head and neck region and lower arms. A total of 76 metallic foreign bodies was removed surgically. During early surgical follow-up and subsequent psychiatric treatment, the patient incorporated new foreign bodies. The case reported represents a pattern of foreign body incorporation which is unusual based on review of the literature but characteristic for patients with borderline personality disorder. Diagnostics and therapy require an individual concept which only can be implemented in close co-operation with psychiatrists. Secondary clinical benefit derived from surgical diagnostics and therapy as well as the possibility of autoaggressive relapse have to be taken into consideration.