Timm O. Engelhardt

World Experience After More Than a Decade of Clinical Hand Transplantation: Update on the Innsbruck Program

Patients who have lost a hand or upper extremity face many challenges in everyday life. For some patients, reconstructive hand transplantation represents a reasonable option for anatomic reconstruction, restoring prehensile function with sensation and allowing them to regain daily living independence. The first clinical case of bilateral hand transplantation at University Hospital Innsbruck was realized on March 17th, 2000. A decade later, a total of 7 hands and forearms were transplanted in 4 patients. This article review the clinical courses of 3 bilateral hand transplant recipients and highlights psychological aspects on reconstructive hand transplantation with special regard to unilateral/bilateral transplantation.

Adipokine Profile and Insulin Sensitivity in Formerly Obese Women Subjected to Bariatric Surgery or Diet-Induced Long-term Caloric Restriction

To better understand the contribution of the fat mass to the effects of long-term caloric restriction in humans, we compared adipokine profile and insulin sensitivity in long-term calorically restricted formerly obese women (CRW) subjected to different interventions, bariatric surgery, or reducing diet, with age- and BMI-matched obese (OW) and normal-weight women (NW) eating ad libitum. Our key findings are that despite a considerably stronger weight loss induced by bariatric surgery, both long-term caloric restriction interventions improved insulin sensitivity to the same degree and led to significantly lower retinol-binding protein-4 and interleukin-6 serum levels than in OW, suggesting that lowering of these two adipokines contributes to the improved insulin sensitivity. Moreover, serum leptin was considerably lower in CRW than in OW as well as in NW, suggesting that CRW develop hypoleptinemia.

The psychological assessment of candidates for reconstructive hand transplantation

Standardized psychological assessment of candidates for reconstructive hand transplantation (RHT) is a new approach in transplantation medicine. Currently, international guidelines and standardized criteria for the evaluation are not established. Patients suffering from the loss of a hand or an upper extremity have to cope with multiple challenges. For a selected group of patients, RHT represents an option for restoring natural function and for regaining daily living independence. The identification of at‐risk patients and those requiring ongoing counseling due to poor coping or limited psychological resources are the primary focus of the psychological assessment. We have developed the ‘Innsbruck Psychological Screening Program for Reconstructive Transplantation (iRT‐PSP)’ which utilizes a semi‐structured interview and standardized psychological screening procedures and continuous follow‐up ratings. Between January 2011 and October 2011, four candidates were evaluated using the iRT‐PSP. Psychological impairments including social withdrawal, embarrassment, reduced self‐esteem, and a depressive coping style were identified and poor quality of life was reported. The motivation for transplantation was diverse, depending on many factors such as bi‐ or unilateral impairment, native or accidental loss of hand, and social integration.

How Reconstructive Transplantation Is Different From Organ Transplantation—and How It Is Not

An evolution of understanding and knowledge gained over more than 100 years in the field of solid organ transplantation (SOT) led to the first successful clinical cases of composite tissue allotransplantation. In many ways reconstructive transplantation (RT) is similar to SOT; however, certain characteristics make this novel type of transplantation unique, interesting, and challenging for both clinicians/scientists and patients. Currently, RT is a rapidly advancing multidisciplinary clinical reality. With over 100 clinical cases performed over the past 12 years, and encouraging early to midterm results, the relevance of RT for treatment of congenital and acquired tissue defects unsalvageable by conventional reconstruction is significant and holds great potential for the future. We herein report the extraordinary progress in this field with particular discussion of a comparative analysis of the similarities and differences regarding indications, end point, failure, patient and graft survival, and side effects between SOT and RT.

Functional resurfacing of the palm: flap selection based on defect analysis.

Extensive defect coverage of the palm and anatomical reconstruction of its unique functional capacity remains difficult. In manual laborers, reconstruction of sensation, range of motion, grip strength but also mechanical stability is required. Sensate musculo‐/fasciocutaneous flaps bear disadvantages of tissue mobility with shifting/bulkiness under stress. Thin muscle and fascial flaps show adherence but preclude sensory nerve coaptation. The purpose of this review is to present our algorithm for reliable selection of the most appropriate procedure based on defect analysis. Defect analysis focusing on units of tactile gnosis provides information to weigh needs for sensation or soft tissue stability. We distinguish radial unit (r)‐thenar, ulnar unit (u)‐hypothenar and unit (c)‐central plus distal palm. Individual parameters need similar consideration to choose adequate treatment. Unit (r) and unit (u) are regions of secondary touch demanding protective sensation. Restoration of sensation using neurovascular, fasciocutaneous flaps is recommended. In unit (c), tactile gnosis is of less, mechanical resistance of greater value. Reconstruction of soft tissue resistance is suggested first in this unit. In laborers, free fascial‐ or muscle flaps with plantar instep skin grafts may achieve near to anatomical reconstruction with minimal sensation. Combined defects involving unit (c) require correlation with individual parameters for optimal flap selection. Defect coverage of the palm should not consist of merely providing sensate vascularized tissue. The most appropriate procedure should be derived from careful defect analysis to achieve near to anatomical reconstruction. In laborers, defect related demands need close correlation with sensation and mechanical stability to be expected.

Familial congenital symmastia: ultrastructurally abnormal breast tissue.

Reports about congenital symmastia and its surgical treatment are few. We report two patients – a mother and daughter – with congenital symmastia in whom breast and fatty tissue was found to be mobile adhering poorly to the chest wall. Although histological examination showed no abnormality of the tissue bridge between the breasts, ultrastructural investigation of breast tissue (including Coopers ligaments) showed an abnormal arrangement of collagen fibres. Satisfying aesthetic results were achieved by resection of excess soft tissue in the cleavage area through a submammary incision and fixation of the skin with subcutaneous interrupted sutures to the sternal periosteum.

Stabilization of microvascular pedicles in intricate locations using fibrin glue

In reconstructive microsurgery, it is occasionally advantageous to use long recipient or donor vessels for optimal flap inset. These long vessels are prone to kinking or torsion along their longitudinal axis from vessel distension during blood inflow and rising blood pressure. More often than arteries, the veins can also be compressed by overlying tissue sutured under tension or by developing edema. Reanastomosis can no longer be feasible or desirable for several reasons, and the elongated vessels may have to be shifted to a curved course. To avoid detrimental kinking or torsion, fibrin glue can be administered along this new vessel course in order to ensure stabilization. In 20 such cases, we successfully avoided complications when the danger of kinking, torsion, or vein compression was evident after successful anastomosis. On the basis of this experience, we recommend the use of fibrin glue in microsurgical procedures, especially for vessels in intricate geometrical locations.

The Art of Skin Graft Inset in the Treatment of Full-Thickness Burns and Postburn Contractures in the Pediatric Palm

DOI: 10.1097/BCR.0b013e318248b410 Figure 1. Left palm of a 7-year-old boy presenting a palmar 30° MCP-joint scar flexion contracture with impaired MCP-joint extension of index, middle, and ring finger including impaired radial abduction of the thumb 4 years after conservative treatment of a contact burn injury in another institution. Table 1. Aspects to be considered in anticipating scar development in the pediatric patient

Plantar intermediate-thickness skin graft for palmar resurfacing: a valuable alternative with low morbidity.

To the Editor: We have read the article by Hashem with great interest and greatly appreciate his focus on anatomic palmar resurfacing. Extensive defect coverage of the palm and restoring its unique functional capacity is a challenge. The authors present their clinical results after the coverage of variable palmar soft-tissue defects with full-thickness skin grafts from the ulnar aspect of the hand. The ulnar border of the palm and hypothenar eminence can be regarded as an individual anatomic unit contributing to tactile gnosis and load bearing. Using glabrous skin from the ulnar aspect of the hand, any incision carried out palmar to a mediolateral line should be avoided to prevent flexion contractures. Any hypertrophic scarring may pose a major concern in the postoperative period. For reasons of anatomy and following these principles, dorsal donor partial glabrous skin will be harvested. A 14% rate of ulnar hypertrophic scarring, including color mismatch in 9%, is reported by the author. We are convinced that any further morbidity to an injured hand can be avoided with alternative procedures available. This is especially true for anatomic units of the palm with clinical and functional relevance. As briefly mentioned by the authors, another means to reestablish tissue stability, durability, appearance, and prehensile function are plantar glabrous instep skin grafts. Similarities between palmar and plantar skin of the instep region have been pointed out in the literature. We have applied intermediate-thickness plantar skin grafts (thickness 0.5 mm) for the coverage of moderate and extensive soft-tissue defects of the palm as well as in combination with fascial or muscle flap defect coverage. The instep donor site can be covered with semiocclusive dressings only. In the nonweight-bearing area of the foot, immediate ambulation is possible. We hardly see any indication for harvesting full-thickness plantar skin grafts for the purpose of palmar defect coverage. In contrast to the author, donor-site grafting may only be necessary, for example, after dissection of an fasciocutaneous medial plantar artery flap. In the literature, postoperative results not only have been excellent regarding texture and color match but also regarding scarring, range of motion, and sensation. Similar to lower extremity reconstruction, glabrous plantar skin grafts have been used widely for the treatment of smaller defects in the hand and digits. Its applications have yielded superior results with improved function, sensation, texture, and color match as well as increased durability. Donor-site morbidity after intermediate-thickness plantar skin or dermal grafting has been reported to be negligible. The same donor site may be even used several times after reepithelialization. In our opinion, color mismatch in palmar defect coverage is of esthetic concern. We refrain from using glabrous skin grafts for nonglabrous areas that are located dorsal to a mediolateral line. In these cases, we prefer conventional full-thickness skin grafts in children and fullor split-thickness skin grafts in adults. Defect analysis is crucial. The value of an intact glabrous donor region has to be considered carefully as well as sound inset of skin grafts according to principles in hand surgery. We agree with the author that, “Like should be reconstructed with like” which is particularly true in palmar resurfacing. As a contribution to his interesting work, intermediate-thickness (0.5 mm thickness) skin grafts from the instep region, should be regarded as a highly valuable alternative that may limit sequelae and further morbidity to an already injured hand.

Abdominal wall reconstruction after extensive abdominal wall necrosis resulting from chevron incision for liver transplant and subsequent Y-shaped incision for re-transplantation – Clinical experience and literature review

Extensive Abdominal wall necrosis is a devastating complication. In visceral transplant patients a quick and easy to perform reconstructive technique may be crucial for patient survival. Based on a clinical case a literature review is performed including a thorough analysis of abdominal wall perfusion and surgical options for defect closure are presented and critically appraised.