Mareike Leffler

The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg

Soft tissue and bone defects of the lower leg, ankle, and heel region often require coverage by local or distant flaps. The authors successfully used the distally based peroneus brevis muscle flap for the treatment of 15 patients with osteomyelitis (n = 5), melanoma (n = 1), Achilles tendon defects (n = 6), posttraumatic bone defects (n = 2), and chronic diabetic heel ulcer (n = 1). The size of the defects ranged from 6 to 60 cm2. All defects were covered successfully without major complications by the muscle flap. The distally based peroneus brevis muscle represents a very reliable flap for coverage of small and moderate defects of the medial and lateral malleolus, the Achilles tendon, and the heel area. This flap offers a convincing alternative for covering defects in the distal leg region and is often preferable to the use of free flaps because the surgery is rapidly performed and does not require microsurgical expertise.

The use of the artificial dermis (Integra®) in combination with vacuum assisted closure for reconstruction of an extensive burn scar – A case report

The artificial dermis Integra (Ethicon, Johnson & Johnson Medical, Norderstedt, Germany) is widely used in the treatment of excessive burn injuries. It is also used in reconstructive surgery when large soft-tissue defects could not be covered with local or free flaps. In this article a 25-year old patient who presented with an early childhood burn of the trunk and lower extremity was treated with Integra in combination with the vacuum assisted closure (V.A.C., KCI, Texas, U.S.A.) and split thickness skin grafting. The combination of the artificial dermal substitute with negative pressure therapy has lead to a complete healing of Integra and the skin graft. During the whole treatment sterile wound conditions were present and time-consuming dressing changes could be prevented. Hospital stay was shortened because the patient could be treated as an outpatient with an ambulant vacuum assisted closure device.

Comparison between distally based peroneus brevis and sural flaps for reconstruction of foot, ankle and distal lower leg: An analysis of donor-site morbidity and clinical outcome

BACKGROUND Skin defects of the foot, ankle and distal lower leg often require coverage by local or distant flaps. We aimed to compare functional outcome and donor-site morbidity following transfer of distally based delayed sural (DSFs) or peroneus brevis flaps (PBFs). METHODS Between 2003 and 2006, 52 patients (24 DSFs and 28 PBFs) were included. For increased reliability, all extended sural flaps were delayed for 3-15 days. At the end of the follow-up period (minimum 12 months), patients were asked to fill out a modified foot and ankle score (Foot and Ankle Outcome Score (FAOS)) questionnaire. In addition, a chart review and a physical examination were performed. RESULTS Total hospital stay and total number of operations were significantly lower in the PBF group. Minor flap necrosis (<10%) was observed in 21% of the DSF and 7% of the PBF group, and partial (>10%) or total flap loss occurred in one and three patients from the DSF group, respectively. Patient satisfaction, FAOS results and range of motion were comparable in both groups. Defect aetiology and patient age did not influence surgical outcome. CONCLUSION Donor-site morbidity and functional outcome after DSF and PBF are comparable. A higher rate of complications was observed in the DSF group. Based on our findings, the PBF is recommended as first-line procedure for reconstruction of small- to medium-sized defects at the distal tibia, fibula, ankle and heel. The sural flap might be chosen for extended skin defects especially when a larger arc of rotation is required.

Coverage of Exposed Bones and Joints in Critically Ill Patients: Lower Extremity Salvage with Topical Negative Pressure Therapy

Background: Soft tissue defects of the limb with exposure of tendons and bones in critically ill patients usually lead to extremity amputation. A potential treatment with topical negative pressure may allow split-thickness skin grafting to the bone, which leads to limb salvage. Materials and Methods: We report on 21 multimorbid patients, 46 to 80 years of age, with severe lower limb soft tissue loss and infection with exposed bone following débridement with critical limb ischemia. Attempts to salvage the extremities were undertaken with repeated surgical débridement followed by vacuum-assisted closure therapy and subsequent split-thickness skin grafting procedures. Results: Infection control and limb salvage were achieved in all cases with multiple débridements, topical negative pressure therapy, and skin grafts. In all patients, the exposure of tendons and bones was reversible by this strategy without a free flap transfer. Discussion: The patients described in this study were severely compromised by systemic and vascular disorders, so extremity amputation had been considered owing to the overall condition and the exposure of tendons and bones. Since it was possible to salvage the affected limbs with this straightforward and simple procedure, this type of treatment should be considered as a last attempt to prevent amputation.

Gene expression analysis of ischaemia and reperfusion in human microsurgical free muscle tissue transfer

The aim of this study was to analyse various gene expression profiles of muscle tissue during normoxia, ischaemia and after reperfusion in human muscle free flaps, to gain an understanding of the occurring regulatory, inflammatory and apoptotic processes on a cellular and molecular basis. Eleven Caucasian patients with soft tissue defects needing coverage with microsurgical free muscle flaps were included in this study. In all patients, the muscle samples were taken from free myocutaneous flaps. The first sample was taken before induction of ischaemia in normoxia (I), another one after ischaemia (II), and the last one was taken after reperfusion (III). The samples were analysed using DNA‐microarray, real‐time‐quantitative‐PCR and immunohistochemistry. DNA‐microarray analysis detected multiple, differentially regulated genes when comparing the different groups (I–III) with statistical significance. Comparing ischaemia (II) versus normoxia (I) educed 13 genes and comparing reperfusion (III) versus ischaemia (II) educed 19 genes. The comparison of reperfusion (III) versus normoxia (I) yielded 100 differentially regulated genes. Real‐time‐quantitative‐PCR confirmed the results of the DNA‐microarrays for a subset of four genes (CASP8, IL8, PLAUR and S100A8). This study shows that ischaemia and reperfusion induces alterations on the gene expression level in human muscle free flaps. Data may suggest that the four genes CASP8, IL8, PLAUR and S100A8 are of great importance in this context. We could not confirm the DNA‐microarry and real‐time‐quantitative‐PCR results on the protein level. Finally, these findings correspond with the surgeon’s clinical experience that the accepted times of ischaemia, generally up to 90 min., are not sufficient to induce pathophysiological processes, which can ultimately lead to flap loss. When inflammatory and apoptotic proteins are expressed at high levels, flap damage might occur and flap loss is likely. The sole expression on mRNA level might explain why flap loss is unlikely.

Changes of anabolic processes at the cellular and molecular level in chronic wounds under topical negative pressure can be revealed by transcriptome analysis

Chronic wounds – as defined by the World Union of Wound Healing Societies (WUWHS) – are a considerable worldwide health care expense and impair quality of life. In order for chronic wounds to heal, these wounds must be transformed to a more acute state to begin the healing process. Topical negative pressure (TNP) with reticulated open cell foam (ROCF) is known to promote healing in certain types of chronic wounds. However, little is known about changes at the cellular or molecular level in wounds under various treatments, especially under the physical forces induced to tissue by TNP. In the current study, chronic wound samples were obtained during routine wound debridements prior to treatment and 7–12 days after initiating TNP with a continuous setting at –125 mmHg. Whole genome transcriptome microarray analyses were performed on samples to better understand how TNP with ROCF affects these types of wounds. It was found that more genes were expressed following TNP with ROCF as compared to before therapy and to normal, non‐wounded tissue. In this study, we show that TNP with ROCF transforms the chronic wound from its inflammation (non‐healing) state into more of a progressive, healing phenotype from a molecular point of view with expression of genes that are commonly associated with these terms.

Aesthetic correction of tuberous breast deformity: lessons learned with a single-stage procedure.

Abstract:  Tuberous breast deformity is a pathologic condition of the breast affecting teenage women. The aberration of breast shape in tuberous breast deformity consisting of a constricting ring at the breast base, breast tissue deficiency, and herniation of breast tissue into the nipple‐areola‐complex with areola enlargement and additional asymmetry makes the surgical correction challenging. In the present study, 15 patients were operated using a surgical procedure, which addresses all aspects of the deformity at a one‐stage operation. The described technique results in a periareolar scar only, and the use of tissue expanders or skin flaps is unnecessary. Minor periareolar scar revision surgery was necessary in eight of 15 patients (53%) because of hypertrophic or expanded scarring. In two patients, implant dislocation occurred and therefore surgical revision was necessary. In all cases, an excellent final aesthetic result with a high patient satisfaction was achieved.

Vessel transformation in chronic wounds under topical negative pressure therapy: an immunohistochemical analysis.

The underlying physiological mechanism of topical negative pressure (TNP) therapy is not yet completely understood. This prospective clinical study aims to clarify a potential influence of TNP therapy on vessel proliferation and hypoxia in chronic wounds. TNP was applied on chronic wounds of 16 patients (−125 mmHg) to prepare them for a plastic‐surgical reconstruction using free or pedicled flaps. Tissue biopsies were taken from the wound edge and wound bed at different time points. All samples were stained with haematoxylin and eosin, hypoxia‐induced factor‐1α and endothelial cell markers (CD31 and CD34) for the immunohistological analysis of inflammation, hypoxia and vessel proliferation. Between day 5 and day 8 of treatment, a considerable increase in blood vessel density could be observed, reaching a maximum of approximately 200% in contrast to the vessel density prior to treatment. In addition, the number of hypoxic and inflammatory cells was found to be increased at particular time points. This study demonstrates a stimulating effect on vessel proliferation under TNP treatment. TNP appears to support (neo‐) angiogenesis and transformation of chronic non‐healing wounds in a physiological wound healing process when combined with surgical debridement. This effect underlines the positive influence of TNP in the treatment of chronic wounds as shown by various clinical reports.