Goetz A. Giessler

Soft tissue coverage in devastating hand injuries

Plastic surgical therapy of mutilating hand injuries represents a multifaceted task to the hand surgeon, where considerations about indication, timing, and structure of the soft tissue coverage play a major role in reconstruction. The concept of early primary reconstruction (including emergency procedures) and fast rehabilitation not only demands thoughtful tissue preparation but also mastering of a bandwidth of plastic surgical techniques. Systematic algorithms based on the reconstructive ladder help in decision making in the complexity of soft tissue coverage but have to be adjusted to the individual case profile. General considerations and strategic planning are explained and illustrated by three clinical cases.

Customized reconstruction with the free anterolateral thigh perforator flap

From April of 2003 through September of 2006, 70 free anterolateral thigh (ALT) flaps were transferred for reconstructing soft‐tissue defects. The overall success rate was 96%. Among 70 free ALT flaps, 11 were elevated as cutaneous ALT septocutaneous vessel flaps. Fifty‐seven were harvested as cutaneous ALT myocutaneous “true” perforator flaps. Two flaps were used as fasciocutaneous perforator flaps based on independent skin vessels. Fifty‐four ALT flaps were used for lower extremity reconstruction, 11 flaps were used for upper extremity reconstruction, 3 flaps were used for trunk reconstruction, and 1 flap was used for head and neck reconstruction. Total flap failure occurred in 3 patients (4.28% of the flaps), and partial failure occurred in 5 patients (7.14% of the flaps). The three flaps that failed completely were reconstructed with a free radial forearm flap, a latissimus dorsi flap and skin grafting, respectively. Among the five flaps that failed partially, three were reconstructed with skin grafting, one with a sural flap, and one with primary closure. The free ALT flap has become the workhorse for covering defects in most clinical situations in our center. It is a reliable flap with consistent anatomy and a long, constant pedicle diameter. Its versatility, in which thickness and volume can be adjusted, leads to a perfect match for customized reconstruction of complex defects.

Primary treatment of burn patients

ZusammenfassungIm notfallmedizinischen Krankengut sind Verbrennungen mit einem Anteil von nur ca. 1% der Einsätze relativ selten. Sie entstehen durch thermische, elektrische, chemische oder mechanische Einflüsse sowohl in Haushalt und Freizeit als auch im beruflichen Umfeld, wobei schwere, lebensbedrohliche Verletzungen noch deutlich seltener als Bagatellverletzungen sind. Für den Notarzt und weiterbehandelnde Kollegen in erstversorgenden Häusern können diese Umstände eine fehlende Routine im Umgang mit Brandverletzungen und ihren manchmal erheblichen systemischen Auswirkungen bedingen. Dies macht ein klar gegliedertes Behandlungskonzept für die erfolgreiche präklinische und klinische Notfallversorgung notwendig, durch die der entscheidende Grundstein für den weiteren Verlauf gelegt wird. Die aktuellen Therapieansätze werden ausgehend vom Geschehen am Unfallort über die Schockraumversorgung bis hin zur interdisziplinären Weiterbehandlung dargestellt. Die Behandlung der chemischen (Verätzungen) oder dermatologischen Notfälle (Epidermolysen) entspricht in vielen Aspekten der Versorgung Schwerbrandverletzter, sie muss im Einzelfall jedoch entsprechend modifiziert werden.AbstractBurn injuries can be caused by thermal, electrical, chemical, or mechanical trauma or radiation and are relatively rare, as they represent only about 1% of all emergencies. They are caused by accidents at home, during recreational activities, or in the occupational environment. Minor burn traumas are much more common than severe burn injuries with their systemic and potentially life-threatening effects. Altogether, these circumstances may result in a lack of routine for treating such injuries properly by physicians and their colleagues in the emergency room or intensive care unit. A clearly outlined concept for preclinical and clinical treatment can be the keystone of successful further clinical progress. The following article summarizes the current guidelines for first medical aid at the injury scene, burn stabilization and assessment in the emergency room, and the interdisciplinary approach for further clinical care. The treatment of dermatologic emergencies (acute epidermolytic syndromes) or caustic injuries by chemical agents is similar to the treatment of burn victims in many aspects but must be adapted in selected cases.Burn injuries can be caused by thermal, electrical, chemical, or mechanical trauma or radiation and are relatively rare, as they represent only about 1% of all emergencies. They are caused by accidents at home, during recreational activities, or in the occupational environment. Minor burn traumas are much more common than severe burn injuries with their systemic and potentially life-threatening effects. Altogether, these circumstances may result in a lack of routine for treating such injuries properly by physicians and their colleagues in the emergency room or intensive care unit. A clearly outlined concept for preclinical and clinical treatment can be the keystone of successful further clinical progress. The following article summarizes the current guidelines for first medical aid at the injury scene, burn stabilization and assessment in the emergency room, and the interdisciplinary approach for further clinical care. The treatment of dermatologic emergencies (acute epidermolytic syndromes) or caustic injuries by chemical agents is similar to the treatment of burn victims in many aspects but must be adapted in selected cases.

Die Akutversorgung von Brandverletzten

ZusammenfassungIm notfallmedizinischen Krankengut sind Verbrennungen mit einem Anteil von nur ca. 1% der Einsätze relativ selten. Sie entstehen durch thermische, elektrische, chemische oder mechanische Einflüsse sowohl in Haushalt und Freizeit als auch im beruflichen Umfeld, wobei schwere, lebensbedrohliche Verletzungen noch deutlich seltener als Bagatellverletzungen sind. Für den Notarzt und weiterbehandelnde Kollegen in erstversorgenden Häusern können diese Umstände eine fehlende Routine im Umgang mit Brandverletzungen und ihren manchmal erheblichen systemischen Auswirkungen bedingen. Dies macht ein klar gegliedertes Behandlungskonzept für die erfolgreiche präklinische und klinische Notfallversorgung notwendig, durch die der entscheidende Grundstein für den weiteren Verlauf gelegt wird. Die aktuellen Therapieansätze werden ausgehend vom Geschehen am Unfallort über die Schockraumversorgung bis hin zur interdisziplinären Weiterbehandlung dargestellt. Die Behandlung der chemischen (Verätzungen) oder dermatologischen Notfälle (Epidermolysen) entspricht in vielen Aspekten der Versorgung Schwerbrandverletzter, sie muss im Einzelfall jedoch entsprechend modifiziert werden.AbstractBurn injuries can be caused by thermal, electrical, chemical, or mechanical trauma or radiation and are relatively rare, as they represent only about 1% of all emergencies. They are caused by accidents at home, during recreational activities, or in the occupational environment. Minor burn traumas are much more common than severe burn injuries with their systemic and potentially life-threatening effects. Altogether, these circumstances may result in a lack of routine for treating such injuries properly by physicians and their colleagues in the emergency room or intensive care unit. A clearly outlined concept for preclinical and clinical treatment can be the keystone of successful further clinical progress. The following article summarizes the current guidelines for first medical aid at the injury scene, burn stabilization and assessment in the emergency room, and the interdisciplinary approach for further clinical care. The treatment of dermatologic emergencies (acute epidermolytic syndromes) or caustic injuries by chemical agents is similar to the treatment of burn victims in many aspects but must be adapted in selected cases.Burn injuries can be caused by thermal, electrical, chemical, or mechanical trauma or radiation and are relatively rare, as they represent only about 1% of all emergencies. They are caused by accidents at home, during recreational activities, or in the occupational environment. Minor burn traumas are much more common than severe burn injuries with their systemic and potentially life-threatening effects. Altogether, these circumstances may result in a lack of routine for treating such injuries properly by physicians and their colleagues in the emergency room or intensive care unit. A clearly outlined concept for preclinical and clinical treatment can be the keystone of successful further clinical progress. The following article summarizes the current guidelines for first medical aid at the injury scene, burn stabilization and assessment in the emergency room, and the interdisciplinary approach for further clinical care. The treatment of dermatologic emergencies (acute epidermolytic syndromes) or caustic injuries by chemical agents is similar to the treatment of burn victims in many aspects but must be adapted in selected cases.

Wiederherstellung der verbrannten Extremität durch Transplantation freier Lappenplastiken

Free tissue transplantation in burn reconstruction presents a major challenge to reconstructive surgeons. The results of a retrospective analysis of 68 free flaps in 55 patients are reported. This experience facilitated the establishment of reconstructive principles and a decision-making algorithm for primary and secondary reconstruction of burned extremities. Fourty-two free flaps were used for primary reconstruction. The indications were predominantly extremity salvage.The safety of the microsurgical procedures is correlated with the timing of the reconstruction. The failure rate of the free flaps was 24% in primary reconstruction. Due to an increased post-traumatic thrombogenicity, the period between 5 and 21 days had the highest risk of flap failure (40%).Twenty-six flaps were used for secondary reconstruction, with a success rate of 100%. Due to their elasticity, adipo- and fasciocutaneous flaps provide a useful option for the release of contractures. The large variability demonstrated by the use of 19 different types of free flaps showed that the reconstruction of burned extremities requires a reconstructive concept individualized to each patient as well as sophisticated microsurgical techniques. This clearly demonstrates the importance of a close link between primary burn treatment and reconstructive plastic surgery.

Patient-specific reconstruction plates are the missing link in computer-assisted mandibular reconstruction: A showcase for technical description

INTRODUCTION Preoperative planning of mandibular reconstruction has moved from mechanical simulation by dental model casts or stereolithographic models into an almost completely virtual environment. CAD/CAM applications allow a high level of accuracy by providing a custom template-assisted contouring approach for bone flaps. However, the clinical accuracy of CAD reconstruction is limited by the use of prebent reconstruction plates, an analogue step in an otherwise digital workstream. TECHNICAL REPORT In this paper the integration of computerized, numerically-controlled (CNC) milled, patient-specific mandibular plates (PSMP) within the virtual workflow of computer-assisted mandibular free fibula flap reconstruction is illustrated in a clinical case. Intraoperatively, the bone segments as well as the plate arms showed a very good fit. Postoperative CT imaging demonstrated close approximation of the PSMP and fibular segments, and good alignment of native mandible and fibular segments and intersegmentally. Over a follow-up period of 12 months, there was an uneventful course of healing with good bony consolidation. CONCLUSION The virtual design and automated fabrication of patient-specific mandibular reconstruction plates provide the missing link in the virtual workflow of computer-assisted mandibular free fibula flap reconstruction.

Early Free Active Versus Dynamic Extension Splinting After Extensor Indicis Proprius Tendon Transfer to Restore Thumb Extension: A Prospective Randomized Study

PURPOSE Transfer of the extensor indicis proprius tendon to the distal extensor pollicis longus (EPL) tendon is a standard operation to restore thumb extension. However, several postoperative hand therapy regimens exist. The previously described early dynamic extension splinting protocol has become our standard, and we now compare it with an early active protocol in a prospective randomized study. METHODS Twenty-one patients with a closed EPL tendon rupture in zones T4 and T5 were treated with an extensor indicis proprius tendon transfer and were randomly divided into 2 postoperative physical therapy regimens: one group (DY) was treated with a dynamic protocol using a rubber-band system, and the other group (AC) was allowed an early active thumb extension with limited flexion. All patients were evaluated for active range of motion (ROM) of the thumb and for grip and tip-pinch strength 3, 4, 6, and 8 weeks postoperatively. Long-term outcomes were not evaluated. RESULTS Three weeks postoperatively, DY group patients demonstrated a significantly better active ROM in the interphalangeal joint than that of the AC group patients. DY group patients achieved 72% of contralateral joint active ROM compared with 49% of contralateral joint active ROM achieved in the AC group. However, no significant difference was found during further course of study resulting in a final mean interphalangeal joint active ROM of 69 degrees (range, 45 degrees to 110 degrees) in group DY and of 58 degrees (range, 40 degrees to 75 degrees) in group AC. The mean grip strength and tip-pinch strength did not differ significantly after 8 weeks with patients achieving 66% and 73%, respectively, of the contralateral side in group DY and 63% and 71%, respectively, of the contralateral side in group AC. Three complications--one due to rupture (DY group), one due to adhesion, and one due to inadequate joint motion secondary to poor tendon tensioning at the time of initial surgery (both AC group)--occurred during a 1-year follow-up. CONCLUSIONS Considering the small group sizes, both regimens (dynamic vs early active) achieved comparable clinical results. The early active protocol does not have a notably higher complication rate but fails to accelerate rehabilitation. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

Plastische Deckung von Hautdefekten

Hautdefekte von oberflachlichen Erosionen bis hin zu komplexen Verlusten des Integuments sind ein ernst zu nehmendes Problem in allen medizinischen Bereichen, v. a. aber den operativen Disziplinen. Die Rekonstruktion solcher Defekte verlangt eine individuelle, dem Patienten angepasste Therapie. Vielfach sind ausgefeilte plastisch-rekonstruktive Masnahmen notwendig, um beste funktionelle und kosmetische Ergebnisse zu erzielen. Der vorliegende Beitrag stellt die aktuellen Therapiekonzepte der plastisch-chirurgischen Wiederherstellung des Integuments dar und beschreibt ?Algorithmen zur Entscheidungsfindung bei der Vielfalt zur Verfugung stehender Moglichkeiten zur Defektdeckung.

Reconstruction of burned extremities by free flap transplantation

Free tissue transplantation in burn reconstruction presents a major challenge to reconstructive surgeons. The results of a retrospective analysis of 68 free flaps in 55 patients are reported. This experience facilitated the establishment of reconstructive principles and a decision-making algorithm for primary and secondary reconstruction of burned extremities. Fourty-two free flaps were used for primary reconstruction. The indications were predominantly extremity salvage.The safety of the microsurgical procedures is correlated with the timing of the reconstruction. The failure rate of the free flaps was 24% in primary reconstruction. Due to an increased post-traumatic thrombogenicity, the period between 5 and 21 days had the highest risk of flap failure (40%).Twenty-six flaps were used for secondary reconstruction, with a success rate of 100%. Due to their elasticity, adipo- and fasciocutaneous flaps provide a useful option for the release of contractures. The large variability demonstrated by the use of 19 different types of free flaps showed that the reconstruction of burned extremities requires a reconstructive concept individualized to each patient as well as sophisticated microsurgical techniques. This clearly demonstrates the importance of a close link between primary burn treatment and reconstructive plastic surgery.

Macroscopic and microangiographic anatomy of the teres major muscle: a new free functional muscle flap?

Background: The teres major can be seen as an additional head of the latissimus dorsi muscle for three-dimensional movement of the arm. It gained importance in pedicled muscle transfers for the treatment of plexus palsies and shoulder instability. Its supplying vessels belong to the subscapular system. According to the literature, the muscle was transferred only once as a free microvascular but nonfunctional graft. Methods: Eleven flaps from fresh cadavers were dissected and perfused with radiopaque media. The detailed macroscopic and microangiographic anatomy was investigated to determine its potential use as a free functional muscle flap. Results: Three different access routes are possible. The mean length of the flap was 158 mm, and the distal and proximal tendinous widths were 24 mm and 52 mm, respectively. A Taylor type 1 nerve and Mathes type 2 vessel distribution was found in all specimens. The main pedicle is situated in the middle third of the superomedial border of the flap and derives almost exclusively from the circumflex scapular artery. Radioangiograms indicate possible splitting of the muscle in the transverse and longitudinal directions. The nerve could always be isolated to a considerable length (66 mm) before reaching the posterior cord. Conclusions: This anatomical study indicates that the teres major can be seen as a separate entity in the subscapular system and can be transferred as a free flap either alone or in combination. According to what is known from pedicled transfers, the donor-site morbidity should be low if the latissimus dorsi is left intact.