Niklas Iblher

Negative pressure wound therapy reduces the ischaemia/reperfusion-associated inflammatory response in free muscle flaps☆

BACKGROUND We recently established negative pressure wound therapy (NPWT) as a safe postoperative care concept for free muscle flaps; however, the molecular effects of NPWT on free muscle flaps remain elusive. Here we investigated the effects of NPWT on pathological changes associated with ischaemia/reperfusion injury in free flap tissue. METHODS From July 2008 to September 2010, 30 patients receiving skin-grafted free muscle transfer for defect coverage were randomly assigned to two treatment groups: In one group the skin-grafted free flap was covered by a vacuum dressing (NPWT); in the second group, flaps were covered by conventional petroleum gauze dressings (conv). Biopsies were taken intra-operatively prior to clipping of the pedicle and on postoperative day 5. Samples were analysed by immunohistochemistry for infiltration of inflammatory cells, real-time polymerase chain reaction (RT-PCR) for the analysis of expression levels of interleukin-1β (IL-1β) and tumour necrosis factor (TNF)-alpha as markers of inflammation. Histological samples were also examined for interstitial oedema formation, and apoptosis was detected by a terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay. RESULTS NPWT leads to a significantly reduced tissue infiltration of CD68 + macrophages and reduced expression of the inflammatory cytokines IL-1β and TNFα. None of these parameters was significantly elevated in the pre-ischaemic biopsies. Furthermore, NPWT reduced the interstitial oedema formation and the number of apoptotic cells in free flap tissue. CONCLUSION NPWT of skin-grafted free muscle flaps leads to a reduced inflammatory response following ischaemia/reperfusion, resulting in reduced oedema formation improving the microcirculation and ultimately reduced tissue damage. We thereby deliver new insight into the effects of NPWT.

The aging lip: a comparative histological analysis of age-related changes in the upper lip complex.

Background: Upper lip rejuvenation is achieved by a large variety of different treatment approaches that clearly lack a unified theoretical background of the aging processes of the upper lip complex. In this study, the histological changes that occur in the aging upper lip were systematically evaluated for the first time. Methods: Histological cross-cuts of the upper lip complex of 20 individuals in two age groups, young (<40 years, n = 10) and old (>80 years, n = 10), were analyzed. The specimens were collected during the autopsies of individuals with no facial injuries. Hematoxylin-eosin and elastica van Gieson staining was performed, and the relevant anatomical structures were measured and compared using Students t test. Results: Histomorphometric analysis revealed statistically significant thinning of the cutis, thinning of the orbicularis oris muscle, and an increase of the orbicularis oris muscle angle defining the vermilion border in the old lip group. Elastic and collagen fibers in the cutis undergo degeneration processes during aging. The orbicularis oris muscle is not subject to fatty or fibroblastic degeneration, but shows signs of atrophy. Conclusions: The histomorphometric and histomorphological analyses shed light on the, so far, only unsystematically and episodically described process of upper lip aging on a histological level. The distinct changes add further evidence to the theory that the aged look is due to a loss of elasticity and resultant ptosis of the upper lip rather than to often-postulated but unproven total volume loss.

Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures.

BACKGROUND : Stable internal screw/plating systems for hand fractures have evolved during the last 20 years. The improved versatility leads to the increased use of these materials in open fractures, with the benefit of early mobilization. The aim of this retrospective study is to discern whether the broadening of the indications for these implants is accompanied by increased complication rates. METHODS : Data from 365 patients treated during the last 10 years at our department for metacarpal or phalangeal fractures with stable internal fixation by screw or plate were gathered and analyzed. RESULTS : Uneventful bony consolidation was observed in 91.2% (n = 333). The functional results were excellent to acceptable in 85.2%, whereas in 14.8% (n = 54), the result was unsatisfactory, the latter group presenting with concominant soft tissue injury. There was no statistically significant difference in infection and nonunion rates when comparing open and closed fractures. CONCLUSION : These results confirm that most patients with open metacarpal and phalangeal fractures can be treated by stable internal fixation.

Monitoring molecular changes induced by ischemia/reperfusion in human free muscle flap tissue samples.

Background:Our current knowledge of the pathophysiological sequelae of ischemia or reperfusion (I/R) injury in free tissue transfer in reconstructive surgery is based on data obtained in animal experiments. In this study, we investigated the histologic and molecular changes after 11 free microsurgical muscle transfers in human muscle tissue. Methods:Biopsies of free muscle flap tissue were taken immediately before clipping of the pedicle and 5 days after ischemia and successful microanastomosis and restoration of the blood flow. Samples were analyzed histologically for edema formation and by immunohistochemistry for infiltration of inflammatory cells and angiogenesis. Expression levels of the inflammatory marker proteins interleukin-1&bgr; and tumor necrosis factor &agr; and of complement component 3 as a major mediator of I/R injury were analyzed by real-time polymerase chain reaction. A TUNEL (terminal desoxynucleotidyl transferase–mediated-dUTP-nick-end-labeling) assay was used to assess apoptosis levels within the human muscle tissue. Results:I/R injury leads to a significant up-regulation of inflammatory parameters, infiltration of inflammatory cells, and angiogenesis. Increased complement component 3 deposition and apoptosis of cells were accompanied by interstitial edema as indication for a pronounced postischemic inflammatory reaction within the muscle tissue after free tissue transfer. Conclusions:Our findings of molecular changes induced by I/R injury in human striated muscle tissue validate data obtained in animal models of I/R injury. The parameters and inflammatory patterns defined in this study will allow for the monitoring of the success of novel pharmaceutical strategies in the future and will help to transfer data obtained in animal work to the in vivo setting in human beings.

A critical evaluation of the concomitant use of the implantable Doppler probe and the Vacuum Assisted Closure system in free tissue transfer

Introduction of the Vacuum‐Assisted Closure (V.A.C.) system has revolutionized the approach to a multitude of clinical settings. Yet, its use precludes adequate clinical monitoring of skin‐grafted free flaps, thus, making a reliable monitoring system essential if broad clinical application is aspired. In a clinical study, the usefulness of the combination of the V.A.C. and implantable Doppler probe was critically evaluated in patients with microsurgical lower extremity reconstruction. We retrospectively analyzed the usefulness of the implantable Doppler probe in five consecutive patients treated in our department from January to July 2007. Inclusion criteria were lower extremity reconstruction by means of skin‐grafted free tissue transfers with subsequent application of the V.A.C. device. Five consecutive patients (four males, one female) with a mean age of 37.8 years (range, 8–58 years) matched the criteria mentioned above. Of note, the two pediatric patients (8‐year‐old male and 12‐year‐old female) suffered from significant posttraumatic stress disorder necessitating concomitant psychological care by the Department of Psychiatry. All flaps healed uneventfully displaying no signs of vascular compromise. Interpretation of the Doppler signal was simple and well received by the nursing staff. The combination of V.A.C. and the implantable Doppler probe enhances patient comfort due to a reduction of the number of dressing changes while still allowing continuous free flap monitoring. Interpretation of the signal transmitted by the probe is simple and potentially reduces misinterpretations due to different levels of experience.

The Use of the Vacuum-Assisted Closure in Microsurgical Reconstruction Revisited: Application in the Reconstruction of the Posttraumatic Lower Extremity

Introduction of vacuum-assisted closure (VAC) system into clinical practice has revolutionized wound care. Despite its multiple advantages, however, the VAC is only rarely used in the setting of microsurgical reconstruction. Concerns have been the inability to clinically monitor the flap as well the possibility of flap compression by the device. The authors put their postoperative treatment concept of applying the VAC to free flaps to the test by reviewing their experience with this concept in patients undergoing microsurgical reconstruction of posttraumatic lower-extremity soft tissue defects. Twenty-six patients (22 male, 4 female) were included in this study. Use of the implantable Doppler probe allowed for postoperative flap monitoring. Two flap failures were observed, both in patients with peripheral vascular disease. In conclusion, using the VAC device in the setting of microsurgical reconstruction is safe and allows for increased patient comfort.

A New Evaluation Tool for Monitoring Devices and Its Application to Evaluate the Implantable Doppler Probe

Evaluation parameters for free flap monitoring devices are used inconsistently, leading to considerable confusion about the quality and applicability of these devices. A comparison of different systems and different clinical series is almost impossible. The ultimate questions that need to be answered are those regarding the efficiency and the effectiveness of the system. A new tool consisting of two simple parameters that sufficiently and comparably describe the quality of monitoring devices is developed. The flap failure reduction rate describes the percentage of saved flaps (effectiveness). The revision success rate describes the efficiency. Literature reevaluation shows inconsistent results, although all authors describe a positive experience. This shows the limited value of the classical parameters. Larger studies have flap failure reduction rates of 5 to 12% (5 to 12% of monitored flaps are saved). Revision success rates of 75 to 90% prove that the system is efficient enough in daily use. Reevaluation of the smaller reported series result in lower parameters, which shows that there is a significant learning curve for this device. The new parameters alleviate the confusion surrounding evaluation of monitoring systems by giving specific information about effectiveness and efficiency. The benefits of the implanted Doppler probe can now be clearly described. However, in several studies the benefit of the system is overrated.

The aging perioral region — do we really know what is happening

ObjectivesThe perioral region is subject to a myriad of different treatments for rejuvenation, many of which are applied without a clear understanding of the underlying physiological processes of perioral aging. The results of these procedures are therefore sometimes not optimal and do not achieve a natural youthful appearance. The aim of this study was to put the results of three investigations into the perioral aging process into relation to clinical application in aesthetic medicine.DesignThree different investigations were performed to evaluate the complex 3-dimensional changes during the perioral aging process. Perioral proportions of 182 standardized subject photographs were measured in a photomorphometric study and correlated to age. In cranial MRI scans of 30 women aged 20–35 and 30 women aged 65–80 relevant anatomical dimensions were measured. Histological cross cuts of the upper lip complex of 20 individuals in two age groups, young (< 40 years, n = 10) and old (> 80 years, n = 10), were analysed. The results were then set into relation to today’s lip rejuvenation procedures.ResultsAll studies showed a statistically significant lengthening of the aging upper lip. The photomorphometric study further showed an increase of prolabium skin at the cost of a decreasing visible upper lip vermilion. The MRI scans showed a decrease in thickness and redistribution towards a length increase but no total volume loss. Histomorphometric analysis revealed statistically significant thinning of the cutis, thickening of the subcutis and a degeneration of elastic and collagen fibers. The orbicularis oris muscle becomes thinner and shows a decrease of the forward curve defining the vermilion border. The results show that the main processes of lip aging are redistribution from thickness to length without total volume loss and a decrease of structural components of the lip, which leads to the decrease of pouting, an inversion of the vermilion and a ptosis of the lip.ConclusionA new and better understanding of the underlying physiological changes of perioral aging is essential and will lead to a better and more specific implementation of perioral rejuvenation procedures which will lead to more natural results.

Nipple Reconstruction: Evidence-Based Trials in the Plastic Surgical Literature

Although many technical descriptions of nipple reconstruction exist in the medical literature, insufficient evidence-based data are present about the outcome. This study aimed to identify randomized controlled trials (RCTs) and controlled clinical trials (CCTs) in the plastic surgical literature addressing nipple reconstruction, and to elucidate whether a hand search was superior to an extensive database search in retrieving all pertinent studies. The hand search included analysis of all “original articles” published in four of the leading plastic surgery journals from January 1990 to December 2005, with subsequent identification of RCTs and CCTs. Additionally, a computerized search was conducted including the following databases: PubMed, Web of Science, and Evidence-Based Medicine Reviews. From a total of 10,476 published original articles in four plastic surgery journals over a 16-year period, only one RCT was identified that addressed nipple reconstruction. The database search, however, retrieved two trials: the RCT identified by hand search and one CCT. The impact of nipple reconstruction is well described in the literature. However, it is astonishing that the plastic surgical literature lacks evidence-based trials addressing this issue. Clearly, more evidence-based trials are necessary to ensure that recommendations for a particular technique are based on solid scientific data.

Cupping treatment and associated burn risk: a plastic surgeon's perspective.

A recent clinical case at the Freiburg University Hospital, Germany, involving burn injuries sustained by cupping treatments is reviewed. The history of the cupping method, indications and contemporary use of this treatment, and the risks from the standpoint of the plastic surgeon are discussed.