Hugo B. Kitzinger

After massive weight loss: patients' expectations of body contouring surgery.

BackgroundMassive weight loss following bariatric surgery leads to excess skin with functional and aesthetic impairments. Surplus skin can then contribute to problems with additional weight loss or gain. The aims of the current study were to evaluate the frequency of massive soft tissue development in gastric bypass patients, to determine whether males and females experience similar post-bypass body changes, and to learn about the expectations and impairments related to body contouring surgery.MethodsA questionnaire addressing information on the satisfaction of body image, quality of life, and expectation of body contouring surgery following massive weight loss was mailed to 425 patients who had undergone gastric bypass surgery between 2003 and 2009. Of these 425 individuals, 252 (59%) patients completed the survey.ResultsNinety percent of women and 88% of men surveyed rated their appearance following massive weight loss as satisfactory, good, or very good. However, 96% of all patients developed surplus skin, which caused intertriginous dermatitis and itching. In addition, patients reported problems with physical activity (playing sports) and finding clothing that fit appropriately. Moreover, 75% of female and 68% of male patients reported desiring body contouring surgery. The most important expectation of body contouring surgery was improved appearance, followed by improved self-confidence and quality of life.ConclusionsSurplus skin resulting from gastric bypass surgery is a common issue that causes functional and aesthetic impairments in patients. Consequently, this increases the desire for body contouring surgery with high expectations for the aesthetic outcome as well as improved life satisfaction.

The Prevalence of Body Contouring Surgery After Gastric Bypass Surgery

BackgroundAs bariatric surgery has become more popular, more patients are undergoing body contouring surgery after massive weight loss. Many of the surgical procedures performed on the massive weight loss patient are complex and labor-intensive. Therefore, the plastic surgery unit needs to be prepared for a patients demand. Little literature is available on how frequently patients who have undergone gastric bypass surgery receive body contouring surgery.MethodsTwo hundred fifty-two subjects (out of 425 who were mailed the questionnaire) who had undergone gastric bypass surgery between 2003 and 2009 completed the questionnaire, which obtained information on body image satisfaction and frequency of body contouring surgery after massive weight loss.ResultsOf all patients, 74% desire a body contouring surgery after gastric bypass surgery. Fifty-three patients (21%) have undergone a total of 61 body contouring procedures. The most common were abdominoplasties (59%), followed by lower body lifts (20%). In contrast to a positive judgment of the general aspect of the body image satisfaction after massive weight loss, both genders are unsatisfied with body areas like abdomen/waist, breast, and thighs.ConclusionsParalleling the increasing use of bariatric surgery, there is a high demand for body contouring surgery. A huge disparity exists between the number of subjects who desire a body contouring surgery and those who actually received it.

The treatment of hand burns

In more than 80% of all burns, the hand is involved. Even if a burned hand does not play a major role for the survival of a patient, its function and aesthetic appearance are of utmost importance for the re-integration into society and professional life. Adequate treatment demands a number of major decisions: necessity of an escharotomy in the early post-traumatic phase, the timing of surgery and the type of wound coverage, as well as immobilization and rehabilitation. Rapid wound closure is of utmost importance, but infection control and the preservation of active and passive motion are also essential for optimal recovery of the injured hand. The treatment of hand burns requires the interdisciplinary teamwork of surgeons, physio- and occupational therapists, psychologists, motivated health care personnel and consequent treatment strategies.

Long-Term Outcomes of Web Creep, Scar Quality, and Function After Simple Syndactyly Surgical Treatment

PURPOSE Syndactyly is the second most common congenital malformation of the hand, and reports of the incidence of web creep after surgery vary. To evaluate our outcomes of simple syndactyly surgical release, we conducted a retrospective analysis of patients treated between January 1965 and December 2007. METHODS After matching for inclusion criteria, we recruited 19 patients with 26 affected web spaces for clinical examination. Outcomes evaluation included grading of web creep, Vancouver Scar Scale, assessment of complications and subjective patient analysis, range of motion, degree of finger abduction, power, and 2-point discrimination. Mean age at follow-up was 18 years (range, 6-50 y), with a mean age of 4.4 years (range, 7 mo to 15 y) at surgery and mean follow-up of 11.5 years (range, 5-35 y). Surgical management consisted of palmar and dorsal triangular skin flaps for creation of the new commissure, and multiple zigzag incisions for separation of digits. For tension-free closure, full-thickness skin grafts were harvested as needed. RESULTS We observed web creep up to the proximal third of the distance between palmar metacarpophalangeal and proximal interphalangeal joint crease in 2 web spaces. All other web spaces had either a soft web equivalent to the contralateral (unaffected) side (n = 13) or no web advancement with thickening of the interdigital space (n = 11). The scar quality as assessed with the Vancouver Scar Scale revealed a height below 2 mm in 24 of 26 web spaces, with close to normal to supple pliability in 20 of 26 web spaces. There were no considerable differences for range of motion, degree of finger abduction, power, or 2-point discrimination between the affected and unaffected sides. In 17 of 24 cases in which full-thickness skin grafts from the groin region were used, patients reported commissural hair growth in the grafted region. CONCLUSIONS Evaluation of the long-term outcomes of surgical treatment for simple syndactyly at our institution demonstrated a low incidence of web creep. When choosing the groin as a donor area for full thickness skin grafts, we recommend harvesting from the lateral third of the inguinal crease, to avoid esthetic compromise associated with the beginning of hair growth in puberty. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Ulnar Shortening Osteotomy With a Premounted Sliding-hole Plate

Background:Ulnar shortening osteotomy represents a common procedure for various ulnar-sided wrist disorders but is still associated with complications like malrotation, angulation, or nonunion because of incomplete closure of the osteotomy gap. We describe the use of a newly developed palmarly placed sliding-hole dynamic compression plate that allows fixation of the ulna before the oblique osteotomy is carried out. Methods:We performed ulnar shortening osteotomy on 27 consecutive patients. The indication was ulnar impaction syndrome in 25 patients and symptomatic ulnar plus variance secondary to malunited distal radial fracture in 2 patients. The mean preoperative ulnar variance was +2.1 mm (range, +1 mm to +8 mm). All patients were evaluated before and after surgery and graded with the Disability of Arm-Shoulder-Hand (DASH) scoring system. Results:All 27 osteotomies healed uneventfully over an average of 9.2 ± 2.1 weeks. The mean postoperative ulnar variance was −2.1 mm (range, −3.1 mm to 0 mm). There were significant improvements in DASH score, pain, and grip strength at an average follow-up of 8.1 months. Six patients complained of plate irritation. Conclusion:Favorable results suggest that ulnar shortening osteotomy using an oblique osteotomy and a premounted sliding-hole compression plate avoids malrotation and angulation and is associated with satisfactory outcomes. This device does not require an assisting device, which minimizes the surgical exposure of the ulna. Palmar placement of the plate seems to reduce hardware irritation.

The surgical treatment of acute burns

ZusammenfassungGRUNDLAGEN: Infolge der optimierten Behandlungsstrategien richtet sich das Augenmerk bei der Verbrennungsbehandlung nicht mehr auf das Überleben allein; auch die wiederzuerlangende Lebensqualität spielt hier eine entscheidende Rolle. Ziel dieser Arbeit war es, einen aktuellen Behandlungsplan zu erheben und zu evaluieren. METHODIK: Der Inhalt dieser Arbeit beruht großteils auf unserer langjährigen Erfahrung bei der Verbrennungsbehandlung. ERGEBNISSE: Entscheidend für die Behandlung von Verbrennungen ist die exakte Tiefenbestimmung; auf ihr beruht die Entscheidung für ein konservatives oder operatives Vorgehen. Bei tiefen Verbrennungen (Grad 2b, Grad 3) ist eine frühzeitige Nekrosektomie und tiefenspezifische Deckung der Wunde anzustreben. Weiters kommt der richtigen Ernährung bei der Behandlung eine entscheidende Bedeutung zu. SCHLUSSFOLGERUNGEN: Diese Arbeit soll all jenen dienen, die lediglich geringe Erfahrung bei der Behandlung von Brandverletzen haben. Außerdem sollte sie dazu verwendet werden, Patienten herauszufiltern die nach einer adequaten Erstversorgung von dem Transfer und der Behandlung an einem Verbrennungszentrum profitieren.SummaryBACKGROUND: In the last decades, burn care has improved, so the trend in the current treatment extends beyond the preservation of life; the ultimate goal is the return of burn victims, as full members, back into their families and communities. This paper was prepared to consider the complex treatment of burns. METHODS: This paper is mainly based on our experience in treating patients suffering from burn injuries. RESULTS: One of the major problems that face any burn surgeon is the decision on the nature of treatment (conservative versus operative), so the key decision in the treatment is based on the exact determination of burn wound depth. In case of deep lesions early excision and suitable grafting and coverage should be performed whenever possible. Moreover, the adequate nutritional support is of utmost importance for the surgical treatment of burns. CONCLUSIONS: This paper is designed as a guideline and instruction manual to guide those with less experience through difficult situations in surgical burn care. Moreover it should be used as a guide to detect patients that require a referral to a burn centre after initial assessment.

Four-corner arthrodesis – Does the source of graft affect bony union rate? Iliac crest versus distal radius bone graft

Four-corner arthrodesis is an accepted surgical option for treatment of scapholunate advanced collapse, scaphoid non-union advanced collapse and midcarpal instability. A preferred source of bone graft for performing four-corner arthrodesis is the iliac crest. An alternative and more convenient donor site is the distal radius. The aim of this study was to investigate whether the union rate after four-corner arthrodesis is influenced by the source of bone graft, that is, iliac crest or distal radius. In a retrospective analysis, charts and radiographs of 180 patients were identified. In 109 patients, iliac crest bone grafts were used, whereas 71 patients received distal radius bone grafts. In the iliac crest bone graft group, 101 out of 109 patients obtained a solid radiographic union of the arthrodesis at an average of 10 weeks after surgery, and non-union in eight patients (7.3%). In the distal radius bone graft group, X-rays of 66 patients showed bone union after an average of 10 weeks after surgery as well and five patients with non-union (7.0%) respectively. There was no statistical difference in bone union. Our data show that distal radius bone graft compares equally to iliac crest bone graft in performing four-corner arthrodesis. The advantages of the distal radius bone graft include a minor surgical exposure and the avoidance of using a distant anatomic site with associated donor-site morbidity.

Proteomics and transcriptomics of peripheral nerve tissue and cells unravel new aspects of the human schwann cell repair phenotype

The remarkable feature of Schwann cells (SCs) to transform into a repair phenotype turned the spotlight on this powerful cell type. SCs provide the regenerative environment for axonal re‐growth after peripheral nerve injury (PNI) and play a vital role in differentiation of neuroblastic tumors into a benign subtype of neuroblastoma, a tumor originating from neural crest‐derived neuroblasts. Hence, understanding their mode‐of‐action is of utmost interest for new approaches in regenerative medicine, but also for neuroblastoma therapy. However, literature on human SCs is scarce and it is unknown to which extent human SC cultures reflect the SC repair phenotype developing after PNI in patients. We performed high‐resolution proteome profiling and RNA‐sequencing on highly enriched human SC and fibroblast cultures, control and ex vivo degenerated nerve explants to identify novel molecules and functional processes active in repair SCs. In fact, we found cultured SCs and degenerated nerves to share a similar repair SC‐associated expression signature, including the upregulation of JUN, as well as two prominent functions, i.e., myelin debris clearance and antigen presentation via MHCII. In addition to myelin degradation, cultured SCs were capable of actively taking up cell‐extrinsic components in functional phagocytosis and co‐cultivation assays. Moreover, in cultured SCs and degenerated nerve tissue MHCII was upregulated at the cellular level along with high expression of chemoattractants and co‐inhibitory rather than ‐stimulatory molecules. These results demonstrate human SC cultures to execute an inherent program of nerve repair and support two novel repair SC functions, debris clearance via phagocytosis‐related mechanisms and type II immune‐regulation. GLIA 2016;64:2133–2153

Middle age has a significant impact on gene expression during skin wound healing in male mice.

The vast majority of research on the impact of age on skin wound healing (WH) compares old animals to young ones. The middle age is often ignored in biogerontological research despite the fact that many functions that decline in an age-dependent manner have starting points in mid-life. With this in mind, we examined gene expression patterns during skin WH in late middle-aged versus young adult male mice, using the head and back punch models. The rationale behind this study was that the impact of age would first be detectable at the transcriptional level. We pinpointed several pathways which were over-activated in the middle-aged mice, both in the intact skin and during WH. Among them were various metabolic, immune-inflammatory and growth-promoting pathways. These transcriptional changes were much more pronounced in the head than in the back. In summary, the middle age has a significant impact on gene expression in intact and healing skin. It seems that the head punch model is more sensitive to the effect of age than the back model, and we suggest that it should be more widely applied in aging research on wound healing.

Prospective study on harvesting autologous bone grafts from the anterior iliac crest using a new specialized reamer.

AbstractThe iliac crest remains the most frequent donor site for bone harvesting. Despite the surgical access to the iliac crest being relatively simple and the operation being carried out regularly, there are frequent complications. Therefore, a new, manual iliac crest reamer (R group) was compared to the classical harvesting of a corticocancellous bone graft by means of an oscillating saw (Con group) in a prospective study on 80 consecutive patients having hand surgery. Follow-up time was 3 months. Operation time and incidence of hematomas, seromas, and paresthesias in the R group were significantly shorter and less, respectively, than in the Con group. Pain at harvest site measured with the visual analogue scale (VAS) at 5 days, 6 weeks, and 12 weeks postoperatively was significantly less in group R as well. The utilization of the iliac crest reamer allows bone graft harvest in a relatively quick and simple operation with relatively few complications but with the limitation in that the maximum diameter of a bone cylinder that it can harvest is 20 mm.