Marc N. Busche

Autologous Fat Transplantation: Volumetric Tools for Estimation of Volume Survival. A Systematic Review

Autologous fat transplantation has gained great recognition in aesthetic and reconstructive surgery. Two main aspects are of predominant importance for progress control after autologous fat transplantation to the breast: quantitative information about the rate of fat survival in terms of effective volume persistence and qualitative information about the breast tissue to exclude potential complications of autologous fat transplantation. There are several tools available for use in evaluating the rate of volume survival. They are extensively compared in this review. The anthropometric method, thermoplastic casts, and Archimedes’ principle of water displacement are not up to date anymore because of major drawbacks, first and foremost being reduced reproducibility and exactness. They have been replaced by more exact and reproducible tools such as MRI volumetry or 3D body surface scans. For qualitative and quantitative progress control, MRI volumetry offers all the necessary information: evaluation of fat survival and diagnostically valuable imaging to exclude possible complications of autologous fat transplantation. For frequent follow-up, e.g., monthly volume analysis, repeated MRI exams would not be good for the patient and are not cost effective. In these cases, 3D surface imaging is a good tool and especially helpful in a private practice setting where fast data acquisition is needed. This tool also offers the possibility of simulating the results of autologous fat transplantation.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Acute effects of remote ischemic preconditioning on cutaneous microcirculation - a controlled prospective cohort study

BackgroundTherapeutic strategies aiming to reduce ischemia/reperfusion injury by conditioning tissue tolerance against ischemia appear attractive not only from a scientific perspective, but also in clinics. Although previous studies indicate that remote ischemic intermittent preconditioning (RIPC) is a systemic phenomenon, only a few studies have focused on the elucidation of its mechanisms of action especially in the clinical setting. Therefore, the aim of this study is to evaluate the acute microcirculatory effects of remote ischemic preconditioning on a distinct cutaneous location at the lower extremity which is typically used as a harvesting site for free flap reconstructive surgery in a human in-vivo setting.MethodsMicrocirculatory data of 27 healthy subjects (25 males, age 24 ± 4 years, BMI 23.3) were evaluated continuously at the anterolateral aspect of the left thigh during RIPC using combined Laser-Doppler and photospectrometry (Oxygen-to-see, Lea Medizintechnik, Germany). After baseline microcirculatory measurement, remote ischemia was induced using a tourniquet on the contralateral upper arm for three cycles of 5 min.ResultsAfter RIPC, tissue oxygen saturation and capillary blood flow increased up to 29% and 35% during the third reperfusion phase versus baseline measurement, respectively (both p = 0.001). Postcapillary venous filling pressure decreased statistically significant by 16% during second reperfusion phase (p = 0.028).ConclusionRemote intermittent ischemic preconditioning affects cutaneous tissue oxygen saturation, arterial capillary blood flow and postcapillary venous filling pressure at a remote cutaneous location of the lower extremity. To what extent remote preconditioning might ameliorate reperfusion injury in soft tissue trauma or free flap transplantation further clinical trials have to evaluate.Trial registrationClinicalTrials.gov: NCT01235286

Evaluation of Prophylactic Anticoagulation, Deep Venous Thrombosis, and Heparin-Induced Thrombocytopenia in 21 Burn Centers in Germany, Austria, and Switzerland

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication in intensive care settings. The timely diagnosis and management of HIT are challenging, and the incidences of HIT and deep venous thrombosis (DVT) may be related to prophylactic anticoagulation standards in burn units. We therefore evaluated, using a questionnaire, prophylactic anticoagulation, HIT management, and incidences of DVT and HIT in burn centers located in the German-speaking part of Europe. In the 21 responding burn centers, 1611 patients were treated and the overall incidences for clinically overt DVT and HIT in 2008 were 1.1% and 1.4%, respectively. Burn centers using low molecular weight heparin (LMWH) subcutaneous for all patients had a low rate of DVT (0.9%) and significantly lower rates of HIT (0.2%) relative to all other centers (P < 0.05). The highest rates of HIT (2.7%) and DVT (3.8%) were found in burn centers administering unfractionated heparin intravenous. While current HIT guidelines do not specify the administration of unfractionated heparin or LMWH for burn patients, these data warrant controlled prospective studies to confirm the advantage of LMWH administration in burn patients.

Is UV radiation beneficial in postburn wound healing

Currently strict ultraviolet (UV) light avoidance strategies and utilizing sunblock containing products are generally advocated during the reepithelialization process as well as after wound closure. These recommendations are guided by a common appreciation of UV radiation as a predominant cause of skin cancer development. It is possible however that the currently accepted practice of near continuous UV protection abrogates the normal cutaneous response to injury, with melanocyte redistribution and pigmentation creating hypopigmented scars. We hypothesize that judicious UV exposure might in fact be beneficial for wound healing and skin homeostasis. UV light should be investigated as a potential modulator of keratinocyte-melanocyte cross-talk in wound healing. In vitro studies will have to prove whether UV radiation induced melanocyte activation might have a stimulatory paracrine effect on keratinocyte proliferation which could beneficially affect wound healing. We further hypothesize that UV exposure to wounds might stimulate and restore normal melanocyte distribution and melanin content in reepithelialized wounds preventing hypopigmentation. Furthermore, exposure of reepithelialized wounds to UV light might exert a photo protective effect in the skin by the production of melanin. This in turn may protect the epidermis from UV-induced damage and carcinogenesis. It is therefore proposed that moderate UV exposure should be commenced early in the healing process of cutaneous wounds. At present, current practice and literature do not support the notion that UV-sun block is necessary in postburn scar management. Burn scars do not seem to exert an enhanced risk for melanomagenesis, the occurrence of which has only very rarely been reported in burn scars. Different mutations in susceptibility genes or in genes involved in the control of the cell cycle or maintenance of cellular integrity which are UV radiation independent are involved in the initiation and promotion steps of skin cancer.

Complete osteolysis of the dens with atlantoaxial luxation caused by infection with Staphylococcus aureus: a case report and review of the literature.

Study Design. Case report. Objectives. To present a case of complete osteolysis of the dens and accompanying luxation of the atlantoaxial joint, on the basis of a Staphylococcus aureus infection. Summary of Background Data. To date, complete osteolysis of the dens followed by atlantoaxial dislocation has only been reported as a rare complication in patients with tuberculosis but not as secondary to a Staphylococcus aureus infection. Methods. Because of emerging neurological complications in both upper extremities, we chose closed reduction and temporary Halo-fixation together with appropriate antibiotic coverage as primary treatment followed by an operative stabilization with Magerl fusion (Galli fusion combined with transarticular screw fixation of C1 and C2). Results. After the operative procedure (Magerl fusion), immediate pain relief was achieved as well as almost complete resolution of neurological deficits. Conclusions. To our knowledge, this presents the first reported case of a complete destruction of the dens, as a result of a purulent bacterial infection leading to atlantoaxial luxation. Our case demonstrates that infections of the atlantoaxial region are difficult to diagnose and are seen mostly in immunocompromised patients, such as patients with diabetes. Furthermore, it proves that other infections besides tuberculosis can lead to complete osteolytic destruction of the atlantoaxial joint.

Stress fracture of the hamate body and fourth metacarpal base following military style push-ups: an unusual trauma mechanism

We report the case of a 19-year-old male soldier, who sustained stress fractures of the hamate body and fourth metacarpal base due to his daily knuckle push-up routine in the military. We introduce repetitive microtrauma due to daily knuckle push-ups as an unusual, but potential trauma mechanism for metacarpal and carpal stress fractures.

Trauma mechanisms, patterns of injury, and outcomes in a retrospective study of 71 burns from civil gas explosions.

BACKGROUND Although explosion injuries caused by terror attacks or in war are evaluated in many studies, limited information about civil explosion injuries can be found in the literature. METHODS In a retrospective study of 71 civil gas explosion injuries treated in a single burn center during a 16-year period, we evaluated trauma mechanisms, patterns of injury, and clinical outcome. RESULTS More than 50% of all gas explosions injuries occurred in private households. The mortality correlated significantly with higher burned total body surface area (TBSA), higher abbreviated burn severity index (ABSI) score, accompanying inhalation injuries, and lung contusions. Although mean ABSI score and burned TBSA were similar in men and women (6 vs. 7 and 22% vs. 21%), the female mortality from gas explosions was noticeably higher, albeit not statistically significant due to small patient numbers (32% vs. 17%). Although mean burned TBSA, ABSI scores, and intensive care unit lengths of stay in patients with burns from gas explosions were comparable and not significantly different compared with all burn patients treated in our burn center (TBSA: 22% vs. 17%; ABSI: 6 vs. 6; and intensive care unit lengths of stay: 12 vs. 11 days), the mortality from gas explosions was significantly higher (21% vs. 12%, p = 0.04). CONCLUSIONS The mortality from gas explosion-related burns correlated significantly with burned TBSA, ABSI score, accompanying inhalation injuries, and lung contusions. Despite comparable ABSI scores, the mortality from gas explosion-related burns was significantly higher than the mortality for all burn victims.

How to prevent overlooking cervical spine injuries: pitfalls in spinal diagnostics.

Many patients with a cervical spine injury do not show clinical signs of the injury. Therefore, cervical spine trauma may not be recognized, especially in unconscious and multiply injured patients. Due to proximity to the spinal cord, neurological deficits inclusive of complete tetraplegia are possible. Since cervical spine injuries are typically associated with injuries at other spinal levels, accurate knowledge of the trauma mechanism is essential. Even mild clinical symptoms need to be carefully evaluated in a standardized fashion with clinical and radiological examinations including plane X-rays and possibly CT scans.

Evaluation of infrastructure, equipment and training of 28 burn units/burn centers in Germany, Austria and Switzerland.

Treatment of burn patients requires special training and skills, and an adequate infrastructure. In the United States, burn center referral criteria and requirements of burn centers are defined by the American Burn Association (ABA) in the Guidelines for the Operation of Burn Centers, and in Germany, by the German Society for Burn Treatment (DGV). The European Burn centers in Austria and the German-speaking part of Switzerland share the standards in the setting of the German-speaking Association for Burn Therapy (DAV) with some modifications. The aim of this study was to evaluate the current infrastructure of burn centers in the three German-speaking countries with respect to the existing guidelines. Therefore, guidelines for burn center referral criteria and burn center requirements were compared between the USA (ABA) and Germany (DGV). In addition, a questionnaire was sent to all burn centers in Germany, Austria and the German-speaking part of Switzerland, in order to collect current information regarding the architectural and medical infrastructure, available equipment and care-providing personnel. The comparison of guidelines for the USA and Germany revealed similar burn center referral criteria for both countries. With respect to burn center requirements, both the USA and Germany have similar requirements, albeit with different focus points. In Germany, the main focus lies on the infrastructural requirements for burn centers, while in the US, the main focus lies on the requirements for medical and nursing personnel. Critical review of the responses from the burn centers of German-speaking countries revealed that the biggest infrastructural differences among centers were observed in burn units providing pediatric care, as compared to adult burn centers. In summary, the DGV guidelines for German-speaking countries reflect an overall adoption of the ABA guidelines, and the burn centers included in this study met those requirements. As a result of the positive experience and effective treatment of burn patients in German-speaking countries, we recommend an adoption of the ABA guidelines to those countries and societies that are in need of appropriate standards of burn care.

Impact of diabetes and peripheral arterial occlusive disease on the functional microcirculation at the plantar foot.

Background: Plastic and reconstructive surgeons are commonly faced with chronic ulcerations and consecutive wound infections of the feet as complications in patients with diabetes and/or peripheral arterial occlusive disease (PAOD). Microcirculatory changes seem to play an important role. However, the evaluation of functional changes in the soft tissue microcirculation at the plantar foot using combined Laser-Doppler and Photospectrometry System has not yet been performed in patients with DM or PAOD. Methods: A prospective, controlled cohort study was designed consisting of a total of 107 subjects allocated to 1 of 3 groups—group A: healthy subjects (57% males, 63.3 y); group B: patients with diabetes mellitus (DM) (53% males, 59.4 y); and group C: patients with PAOD (81% males, 66.1 y). Microcirculatory data were assessed using a combined Laser-Doppler and Photospectrometry System. Results: Global cutaneous oxygen saturation microcirculation at the plantar foot of healthy individuals was 8.4% higher than in patients with DM and 8.1% higher than in patients with PAOD (both P = 0.033). Patients with diabetes did not show significant differences in global cutaneous blood flow when compared with either healthy subjects or patients suffering from PAOD. Conclusions: Functional microcirculation at the plantar foot differs between healthy subjects and patients suffering from diabetes or PAOD of the same age. Patients with either diabetes or PAOD demonstrate deteriorated cutaneous oxygen saturation with equivalent blood perfusion at the plantar foot. More clinical studies have to be conducted to evaluate therapeutical methods that might ameliorate cutaneous oxygen saturation within diabetic foot disease and PAOD.