Gabriel Djedovic

Human skin dendritic cells can be targeted in situ by intradermal injection of antibodies against lectin receptors

Skin dendritic cells (DC) express C‐type lectin receptors for the recognition of pathogens. Langerhans cells (LC) express the receptor Langerin/CD207, whereas DEC‐205/CD205 is mainly expressed by dermal DC, but can also be detected at low levels on LC. In this study, we tested an ex vivo approach for targeting DC in situ with monoclonal antibodies (mAb) against Langerin and DEC‐205. The targeting mAb was injected intradermally into human skin biopsies or added to the medium during skin explant culture. Corresponding to the expression patterns of these lectin receptors on skin DC, Langerin mAb was detected merely in LC in the epidermis and DEC‐205 mainly in dermal DC in human skin explants, regardless of the application route. Migratory skin DC bound and carried targeting mAb from skin explants according to their lectin receptor expression profiles. In contrast to the very selective transport of Langerin mAb by LC, DEC‐205 mAb was more widely distributed on all CD1a+ skin DC subsets but almost absent in CD14+ dermal DC. As effective vaccination requires the addition of adjuvant, we co‐administered the toll‐like receptor (TLR)‐3 ligand poly I:C with the mAb. This adjuvant enhanced binding of DEC‐205 mAb to all skin DC subsets, whereas Langerin targeting efficacy remained unchanged. Our findings demonstrate that LC can be preferentially targeted by Langerin mAb. In contrast, DEC‐205 mAb can be bound by all CD1a+ skin DC subsets. The efficacy of DEC‐205 mAb targeting strategy can be boosted by addition of poly I:C underlining the potential of this combination for immunotherapeutical interventions.

Differences between patients and medical professionals in the evaluation of aesthetic outcome following breast reconstruction with implants.

BACKGROUND AND AIM Most studies on breast reconstruction evaluate different surgical techniques, types of implant or time of reconstruction. Moreover, evaluations are usually performed either by surgeons or by patients, but are rarely compared. We conducted a study on aesthetic outcome following breast reconstruction with implants comparing the evaluation by patients versus medical professionals. METHODS Forty-seven patients, who had a breast reconstruction with implants between 2001 and 2010 (median follow-up 71 months), underwent a clinical examination, standardized photo documentation and filled out a questionnaire to evaluate their aesthetic result (rate 1 very good to 5 very poor). Photo documentation was independently evaluated by 18 medical professionals using the same evaluation instrument and the results were compared. Gender and patient aspects were taken into account. RESULTS We found statistically significant differences between patients and medical professional ratings. The patient evaluation was better through all categories as compared to the evaluation by medical personnel. The degree of medical education or gender aspects did not significantly affect the professional ratings. Age at reconstruction, length of follow-up or primary versus secondary reconstruction did not seem to make a difference in the evaluations of the patients versus the medical professionals.. CONCLUSION The differences between patient and expert opinion in rating of aesthetic results indicate that patient satisfaction is influenced by multiple factors and not only by good aesthetic outcome. Patient evaluation should therefore be carefully considered in treatment and outcome studies of breast reconstruction..

Morphologic outcome of bimaxillary surgery--an anthropometric appraisal.

Objectives: To adequately perform orthognathic surgery procedures, it is from basic interest to understand the morphologic changes caused by orthognathic surgery. Anthropometric analyses of standardized frontal view and profile photographs could help to investigate and understand such changes. Study Design: We present a pre- to postoperative evaluation of orthognathic surgery results based on anthropometric indices described by Farkas and cephalometric measurements. 30 Class III patients undergoing maxillary advancement by Le Fort I Osteotomy and mandibular setback by bilateral sagittal split osteotomy were evaluated. Preoperative as well as three and nine months postoperative lateral cephalograms as well as standardized frontal view and profile photographs were taken. On the photographs 21 anthropometric indices given by Farkas were evaluated. In cephalograms SNA and SNB angle as well as Wits appraisal were investigated. Results: The investigated anthropometric indices showed a significant increase of the vertical height of the upper lip without changing the relation of the upper vermilion to the cutaneous upper lip. The lower vermilion height increased relatively to the cutaneous lower lip without vertical changes in the lower lip. Due to maxillary advancement the upper face height increased meanwhile the lower face height decreased due to mandibular setback. SNA and SNB angle and Wits appraisal showed typical changes related to surgery. Conclusions: The investigated photo-assisted anthropometric measurements presented reproducible results related to bimaxillary surgery. Key words:Orthognathic surgery, bimaxillary surgery, anthropometry, Class III.

The Art of Skin Graft Inset in the Treatment of Full-Thickness Burns and Postburn Contractures in the Pediatric Palm

DOI: 10.1097/BCR.0b013e318248b410 Figure 1. Left palm of a 7-year-old boy presenting a palmar 30° MCP-joint scar flexion contracture with impaired MCP-joint extension of index, middle, and ring finger including impaired radial abduction of the thumb 4 years after conservative treatment of a contact burn injury in another institution. Table 1. Aspects to be considered in anticipating scar development in the pediatric patient

Plantar intermediate-thickness skin graft for palmar resurfacing: a valuable alternative with low morbidity.

To the Editor: We have read the article by Hashem with great interest and greatly appreciate his focus on anatomic palmar resurfacing. Extensive defect coverage of the palm and restoring its unique functional capacity is a challenge. The authors present their clinical results after the coverage of variable palmar soft-tissue defects with full-thickness skin grafts from the ulnar aspect of the hand. The ulnar border of the palm and hypothenar eminence can be regarded as an individual anatomic unit contributing to tactile gnosis and load bearing. Using glabrous skin from the ulnar aspect of the hand, any incision carried out palmar to a mediolateral line should be avoided to prevent flexion contractures. Any hypertrophic scarring may pose a major concern in the postoperative period. For reasons of anatomy and following these principles, dorsal donor partial glabrous skin will be harvested. A 14% rate of ulnar hypertrophic scarring, including color mismatch in 9%, is reported by the author. We are convinced that any further morbidity to an injured hand can be avoided with alternative procedures available. This is especially true for anatomic units of the palm with clinical and functional relevance. As briefly mentioned by the authors, another means to reestablish tissue stability, durability, appearance, and prehensile function are plantar glabrous instep skin grafts. Similarities between palmar and plantar skin of the instep region have been pointed out in the literature. We have applied intermediate-thickness plantar skin grafts (thickness 0.5 mm) for the coverage of moderate and extensive soft-tissue defects of the palm as well as in combination with fascial or muscle flap defect coverage. The instep donor site can be covered with semiocclusive dressings only. In the nonweight-bearing area of the foot, immediate ambulation is possible. We hardly see any indication for harvesting full-thickness plantar skin grafts for the purpose of palmar defect coverage. In contrast to the author, donor-site grafting may only be necessary, for example, after dissection of an fasciocutaneous medial plantar artery flap. In the literature, postoperative results not only have been excellent regarding texture and color match but also regarding scarring, range of motion, and sensation. Similar to lower extremity reconstruction, glabrous plantar skin grafts have been used widely for the treatment of smaller defects in the hand and digits. Its applications have yielded superior results with improved function, sensation, texture, and color match as well as increased durability. Donor-site morbidity after intermediate-thickness plantar skin or dermal grafting has been reported to be negligible. The same donor site may be even used several times after reepithelialization. In our opinion, color mismatch in palmar defect coverage is of esthetic concern. We refrain from using glabrous skin grafts for nonglabrous areas that are located dorsal to a mediolateral line. In these cases, we prefer conventional full-thickness skin grafts in children and fullor split-thickness skin grafts in adults. Defect analysis is crucial. The value of an intact glabrous donor region has to be considered carefully as well as sound inset of skin grafts according to principles in hand surgery. We agree with the author that, “Like should be reconstructed with like” which is particularly true in palmar resurfacing. As a contribution to his interesting work, intermediate-thickness (0.5 mm thickness) skin grafts from the instep region, should be regarded as a highly valuable alternative that may limit sequelae and further morbidity to an already injured hand.

Secondary Linburg-Comstock syndrome: a case report

Linburg-Comstock syndrome is characterized by an inability to flex the interphalangeal joint of the thumb without simultaneous flexion of the distal interphalangeal joint of the index finger due to hereditary interconnections between the flexor pollicis longus (FPL) and the index flexor digitorum profundus (iFDP) resulting in discomfort and symptoms of flexor tenosynovitis. In addition to this anatomic anomaly, our clinical findings suggest that the interconnection can also result secondarily as a consequence of tenosynovial hyperplasia producing adhesions from any cause including previous surgery or trauma using the example of forearm laceration with dissection of the two tendons.Level of Evidence: Level V, diagnostic study.

Phalloplasty in Female-to-Male Transsexuals by Gottlieb and Levine's Free Radial Forearm Flap Technique—A Long-Term Single-Center Experience Over More than Two Decades

Background The free radial forearm flap phalloplasty is the most utilized method for penile reconstruction. Among the techniques described in the literature, evidence for the flap design after Gottlieb and Levine is poor. Methods From January 1993 until December 2015, 402 phalloplasties were performed in our clinic. Among the 247 free radial forearm flap phalloplasties, 232 free radial forearm flap phalloplasties were performed after Gottlieb and Levine in 229 patients. Operation and patient‐specific characteristics were evaluated. Results This study presents the highest number of free radial forearm flap phalloplasties after Gottlieb and Levine. The rate of total flap failure was 3%; 46% of the patients were heavy smokers. Urinary fistulae and strictures are common. The revision rate for urinary fistulae and/or strictures was 1.3 per patient. The number of postoperative complications, such as bleeding (14.2%), thrombosis of the flap requiring revision (11.2%), or delayed wound healing (16.8%) was considering the high rate of nicotine abuse (45.9%) reasonable. Conclusion The free radial forearm phalloplasty in the design by Gottlieb and Levine is well established at our institution and has proven safe and reliable since 1993. The operative results are satisfactory for both patients and surgeons even in the presence of relevant comorbidities and heavy smoking. We acknowledge the long ordeal and psychological pressure that our patients suffer from, before presenting in our outpatient clinic.

Abdominal wall reconstruction after extensive abdominal wall necrosis resulting from chevron incision for liver transplant and subsequent Y-shaped incision for re-transplantation – Clinical experience and literature review

Extensive Abdominal wall necrosis is a devastating complication. In visceral transplant patients a quick and easy to perform reconstructive technique may be crucial for patient survival. Based on a clinical case a literature review is performed including a thorough analysis of abdominal wall perfusion and surgical options for defect closure are presented and critically appraised.

Negative pressure wound therapy with instillation: effects on healing of category 4 pressure ulcers

Aim: The use of negative pressure wound therapy (NPWT) is well established in the treatment of chronic wounds. NPWT with instillation (NPWTi) combines traditional NPWT with the application of a topical irrigation solution (in this case octenidine based octenilin® wound irrigation solution) within the wound bed. The purpose of the study was to investigate the impact of NPWTi on pressure ulcers (PUs). Methods: In total 13 patients with PUs in different locations were treated with negative pressure therapy combined with ocitenidine based instillation fluid after first surgical debridement. After 6 days the dressing was removed and wound closure using different local flaps was performed. Results: Normal wound healing without irritation was found 30 days post-debridement and after 90 days the wounds showed complete healing. No adverse incidents occurred and no toxic tissue reactions were documented. During the follow up period, there was no recurrence of the PU in any of the treated patients. Conclusion: It is generally recognised that for chronic wounds to heal, optimum wound bed preparation is of paramount importance. This helps prepare for secondary healing, skin grafting or coverage with flaps. Tests were performed in vitro simulating real clinical conditions using PU vacuum exudates. These tests quantified the antiseptic efficacy of octenilin® wound irrigation solution in the eradication of microorganisms. Further research is needed to establish the role of NPWTi with octenilin® in the management of category 4 PUs, but these initial results on 13 patients lead in the direction of developing an enhanced protocol for the treatment of chronic wounds.

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.