Werner Haslik

Management of full-thickness skin defects in the hand and wrist region: first long-term experiences with the dermal matrix Matriderm.

The gold standard for the coverage of full-thickness skin defects is autologous skin grafts. However, poor skin quality and scar contracture are well-known problems in functional, highly strained regions. The use of dermal substitutes is an appropriate way to minimise scar contraction and, thereby, to optimise the quality of the reconstructed skin. The aim of this study was to evaluate the impact of the collagen-elastin matrix, Matriderm, for the single-step reconstruction of joint-associated defects of the upper extremity. Seventeen patients with full-thickness skin defects of the upper extremity were treated with the dermal substitute, Matriderm, and unmeshed skin graft in the functional critical region of the distal upper extremity in a single-step procedure. The take rate of the matrix-and-skin graft was 96%. Long-term follow-up revealed an overall Vancouver scar scale of 1.7. No limitation concerning hand function was observed; DASH-score analysis revealed excellent hand function in patients with burn injury and patients with a defect due to the harvest of a radial forearm flap achieved satisfying hand function. This matrix represents a viable alternative to other types of defect coverage and should therefore be considered in the treatment of skin injuries, especially in very delicate regions such as the joint regions. The possibility of performing a one-stage procedure is supposed to be a major advantage in comparison to a two-stage procedure.

Functional and morphometric evaluation of end-to-side neurorrhaphy for muscle reinnervation.

This study was undertaken to quantify the effect of motor collateral sprouting in an end-to-side repair model allowing end organ contact. Besides documentation of the functional outcome of muscle reinnervation by end-to-side neurorrhaphy, this experimental work was performed to determine possible downgrading effects to the donor nerve at end organ level. In 24 female New Zealand White rabbits, the motor nerve branch to the rectus femoris muscle of the right hindlimb was dissected, cut, and sutured end-to-side to the motor branch to the vastus medialis muscle after creating an epineural window. The 24 rabbits were divided into two groups of 12 each, with the second group receiving additional crush injury of the vastus branch. After a period of 8 months, maximum tetanic tension in the reinnervated rectus femoris and the vastus medialis muscles was determined. The contralateral healthy side served as control. The reinnervated rectus femoris muscle showed an average maximum tetanic force of 24.9 N (control 26.2 N, p = 0.7827), and the donor vastus medialis muscle 11.0 N (control 7.3 N, p = 0.0223). There were no statistically significant differences between the two experimental groups (p = 0.9914). The average number of regenerated myelinated nerve fibers in the rectus femoris motor branch was 1185 ± 342 (control, 806 ± 166), and the mean diameter was 4.6 ± 0.6 &mgr;m (control, 9.4 ± 1.0 &mgr;m). In the motor branch to the vastus medialis muscle, the mean fiber number proximal to the coaptation site was 1227 (±441), and decreased distal to the coaptation site to 795 (±270). The average difference of axon counts in the donor nerve proximal to distal regarding the repair site was 483.7 ± 264.2. In the contralateral motor branch to the vastus medialis muscle, 540 (±175) myelinated nerve fibers were counted. In nearly all cross-section specimens of the motor branch to the vastus medialis muscle, altered nerve fibers could be identified in one fascicle distal and proximal to the repair site. The results show a relevant functional reinnervation by end-to-side neurorrhaphy without functional impairment of the donor muscle. It seems to be evident that most axons in the attached segment were derived from collateral sprouts. Nonetheless, the present study confirms that end-to-side neurorrhaphy is a reliable method of reconstruction for damaged nerves, which should be applied clinically in a more extended manner. (Plast. Reconstr. Surg. 106: 383, 2000.)

Combined Hysterectomy/Salpingo-Oophorectomy and Mastectomy is a Safe and Valuable Procedure for Female-to-Male Transsexuals

INTRODUCTION Sex reassignment surgery is an important step for transsexuals, since it is known to help the patients to live more easily in their gender role and to significantly increase quality of life. AIMS To critically evaluate our experience with the combined procedure of hysterectomy, bilateral salpingo-oophorectomy, and bilateral mastectomy for female-to-male (FtM) transsexual patients. METHODS Thirty-two FtM transsexuals who underwent hysterectomy, bilateral salpingo-oophorectomy, and bilateral mastectomy in one single operative setting. MAIN OUTCOME MEASURES Operating time and complications, both intra-and postoperatively. RESULTS Patients were 30.0 ± 5.8 years of age, with a body mass index of 24.8 ± 3.5 kg/m(2). The majority of patients underwent hysterectomy and bilateral salpingo-oophorectomy by laparoscopy (31/32, 96.9%). The median operating time was 222.5 minutes (inter-quartile range [IQR] 190-270 minutes). The median postoperative stay was eight days (IQR, 7-9 days). Postoperative adverse events were found in five patients (15.6%), including breast hematomas as the most frequent complication (4/32, 12.5%). In one patient (1/32; 3.1%), conversion from laparoscopy to laparotomy was necessary, which was considered an adverse event. None of our patients required reoperation or readmission to the hospital. CONCLUSION Combined hysterectomy/salpingo-oophorectomy, and bilateral mastectomy in a single operating session seems a safe, feasible, and valuable procedure for FtM transsexuals.

The treatment of deep dermal hand burns: How do we achieve better results? Should we use allogeneic keratinocytes or skin grafts?

The treatment of deep dermal burns has a broad spectrum and has been subject to discussion over the past years. The treatment of hand burns is challenging due to the high requirements to aesthetic and functional outcome. 27 patients, 7 women and 20 men with deep dermal hand burns with a mean age of 41.3+/-16.5 and a mean TBSA of 15%+/-19.6% were treated either with allogeneic cryopreserved keratinocytes or with split skin grafts. Long-term follow-up revealed no statistical significant differences between the two groups concerning Vancouver Scar Scale as well as hand function judged by the DASH score; however there was a tendency to higher VSS scores and impaired aesthetic results in the keratinocyte group. Allogeneic keratinocytes are a suitable armentarium for the treatment of deep dermal hand burns; and, if used correctly, they can produce a timely healing comparable to split-thickness skin grafts. Limited availability, high costs as well as the need for special skills are key factors, which render application of this technique outside specialist burn centres virtually impossible. In our opinion, the cultivation and use of keratinocytes should be reserved to these centres in order to facilitate a sensible application for a full range of indications. We recommend usage of allogeneic keratinocytes for deep dermal hand burns only in severely burned patients with a lack of donor sites. Patients with unrestricted availability of donor sites seem to profit from the application of split-thickness skin grafts according to our results.

The impact of a muscle target organ on nerve grafts with different lengths—A histomorphological analysis

The present study was done in order to evaluate the influence of a target muscle on the regenerative processes in long nerve grafts. In 21 rabbits the saphenous nerve was used as a nerve graft and coapted to the cut motor nerve of vastus medialis. The animals were separated into three groups with different graft lengths, namely 3, 5, and 7 cm. In a second stage the distal end of the graft (Graft.dist.) was coapted to the motor branch of rectus femoris. Cross sections of the normal vastus nerve and the Graft.dist. before and 7 months after the connection to rectus femoris were analyzed histomorphometrically. Before coaptation to the target organ mean fiber number in the Graft.dist. of the 3‐cm‐long grafts was 3380 and decreased to 2413 in the 7‐cm‐long grafts. Seven months after coaptation the results showed a statistically significant decrease of fibers in the Graft.dist. of group two and three and a distinct decrease of the fibers in group one. Summarizing, in a two‐stage nerve grafting procedure the reinnervation of the muscle target organ leads to a down‐regulation of fibers in the distal end of short and long nerve grafts.

Latissimus dorsi breast reconstruction: how much nerve resection is necessary to prevent postoperative muscle twitching?

Background: The latissimus dorsi muscle flap represents a valuable option in breast reconstruction but can result in postoperative twitching and retraction, discomfort, arm movement limitations, and breast deformation. These complications can be avoided by denervation of the thoracodorsal nerve; however, the optimal method of nerve management is unknown. This study presents the authors’ experience with the outcomes of latissimus dorsi flaps for breast reconstruction in the light of thoracodorsal nerve management strategies. Methods: The authors retrospectively collected data from 74 patients who underwent partial or total breast reconstruction with a latissimus dorsi flap alone or with an implant between January of 1999 and October of 2011. Follow-up data were collected at 12 and 24 months postoperatively. Results: In 56 patients (75.7 percent), the latissimus dorsi muscle was denervated at the time of surgery, whereas the thoracodorsal nerve remained intact in 18 patients (24.3 percent). No partial or total flap loss was observed. At 12 and 24 months’ follow-up, all patients with an intact thoracodorsal nerve showed twitching of the muscle, and 50 percent and 67.9 percent, respectively, of the denervated patients showed twitching (p < 0.001). No patient had twitching if more than 4 cm of nerve was excised at 12 or 24 months postoperatively, and the length of nerve resection was predictive of the presence of twitching. Conclusion: Denervation of the latissimus dorsi is a safe and reliable procedure that should be performed at the time of breast reconstruction and should include more than 4 cm to achieve a nontwitching breast with a stable volume and shape. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Indocyanine green video angiography predicts outcome of extravasation injuries.

Background Extravasation of cytotoxic drugs is a serious complication of systemic cancer treatment. Still, a reliable method for early assessment of tissue damage and outcome prediction is missing. Here, we demonstrate that the evaluation of blood flow by indocyanine green (ICG) angiography in the extravasation area predicts for the need of surgical intervention. Methods Twenty-nine patients were evaluated by ICG angiography after extravasation of vesicant or highly irritant cytotoxic drugs administered by peripheral i.v. infusion. Tissue perfusion as assessed by this standardized method was correlated with clinical outcome. Results The perfusion index at the site of extravasation differed significantly between patients with reversible tissue damage and thus healing under conservative management (N = 22) versus those who needed surgical intervention due to the development of necrosis (N = 7; P = 0.0001). Furthermore, in patients benefiting from conservative management, the perfusion index was significantly higher in the central extravasation area denoting hyperemia, when compared with the peripheral area (P = 0.0001). Conclusions In this patient cohort, ICG angiography as indicator of local perfusion within the extravasation area was of prognostic value for tissue damage. ICG angiography could thus be used for the early identification of patients at risk for irreversible tissue damage after extravasation of cytotoxic drugs.

Influence of brachial plexus blockade on oxygen balance during surgery.

The combined effects of anesthesia, motor blockade, and chemically induced sympathectomy after brachial plexus blockade can have a beneficial impact, when applied in selected, isolated diseased states of the upper limb. With the aim of using the prolonged effects of brachial plexus blockade for a future therapeutic application, we demonstrated a dependable methodology of venous blood gas monitoring and confirmed an improved oxygen balance of the blocked versus nonblocked upper extremity in a controlled, prospective study in healthy patients undergoing elective hand surgery.

Extraordinary Lymph Drainage in Cutaneous Malignant Melanoma and the Value of Hybrid Imaging: A Case Report

In melanoma patients, preoperative lymphoscintigraphy has become a gold standard. The role of single-photon emission computed tomography (SPECT) or its combination with computed tomography (SPECT-CT) as part of the standard sentinel scintigraphy protocol has yet to be determined. A 46-year-old female patient with melanoma of the trunk received preoperative lymphoscintigraphy and subsequent surgical excision. Planar imaging displayed two hot spots in the region of the primary lesion. No other lymphatic flow pathways could be appreciated. Two focal hot spots, one dorsal to the primary lesion near the left latissimus dorsi muscle and one just lateral to the primary lesion in the subcutaneous tissue, were appreciated with SPECT-CT imaging. The primary melanoma lesion, as well as the two additional lesions, which were detected by SPECT-CT, were excised and sent for histopathological examination. While the primary lesion was a superficial spreading melanoma, the lesions appreciated in SPECT-CT revealed four sentinel lymph nodes, each of which was negative for tumor cells. Melanomas, especially of the trunk, can demonstrate multiple lymphatic drain basins in a large percentage of patients. Given that without the detailed anatomical information provided by SPECT-CT it would be very difficult to locate the diverse lymphatic drain basins and their lymph nodes, we would suggest routinely implementing SPECT-CT in the standard planar sentinel imaging protocol.

Immediate breast reconstruction – a review of indications, techniques and results

ZusammenfassungGRUNDLAGEN: Erst im letzten Jahrzehnt wurde die sofortige Brustrekonstruktion als integrierter Bestandteil der Brustkrebstherapie in Österreich akzeptiert. Dennoch ist die Einbeziehung des plastischen Chirurgen in die Erstellung des Therapiekonzeptes zum Zeitpunkt der Diagnose Brustkrebs noch lange nicht Standard. Das Ziel dieses Übersichtsartikels ist die Verbreitung der wissenschaftlichen Information, dass die Sofortrekonstruktion der Brust eine Wahlmöglichkeit für die Mehrheit der mit Brustkrebs erkrankten Frauen ist, welche sich einer kompletten Mastektomie oder einer deformierenden Teilresektion der Brustdrüse unterziehen müssen, ohne dass dadurch ein negativer Einfluss auf den späteren onkologischen Verlauf hingenommen werden muss. METHODIK: Auf Basis eines Überblickes der internationalen Literatur und eigener Studien zur Brustrekonstruktion werden die aktuellen Indikationen und Kontraindikationenzur Sofortrekonstruktion der Brust herausgearbeitet. Anhand einer prospektiven Studie der Patientinnen mit Brustrekonstruktion an der Klinischen Abteilung für Plastische und Rekonstruktive Chirurgie an der Chirurgischen Universitätsklinik Wien während der letzten 15 Jahre wird die Evolution der Sofortrekonstruktion der Brust und ihrer operativen Techniken dargestellt. Besondere Aufmerksamkeit wird dabei der Biologie und dem Verlauf der Tumorerkrankung, der eventuellen Interferenz mit adjuvanten Therapieformen, dem Einfluss vom Alter der Patientin, und der Wahl der operativen Technik in Abhängigkeit von der individuellen Situation geschenkt. ERGEBNISSE: Alle größeren Langzeitstudien der Lokalrezidivrate oder des Überlebens haben jeden Verdacht über negative Einflüsse der Sofortrekonstruktion auf den onkologischen Verlauf beseitigt. Deshalb sollte jeder mit Brustkrebs erkrankten Frau, die mit einer Mastektomieodereiner größeren, deformierenden Resektion der Brustdrüse konfrontiert ist, die Möglichkeit der Sofortrekonstruktion zum Zeitpunkt der Krebsdiagnose angeboten werden. Diese Information muss das gesamte operative Spektrum der plastischen und rekonstruktiven Chirurgie beinhalten, sei es fürdie Teilrekonstruktion bei brusterhaltender Tumorresektion im Sinne einer lokalen glandulären Mammaplastik, einer Teilrekonstruktion mit myokutaner Latissimus dorsi – Lappenplastik, oder einer Teilrekonstruktion mit einem Brustimplantat, oder sei es bei Sofortrekonstruktion nach vollständiger Entfernung des Brustdrüsengewebes meist als hauterhaltende Mastektomie im Sinne einer Rekonstruktion mit autologem Gewebe durch einen freien Unterbauch-Perforator – Lappen (DIEP – Lappen), bzw. einen gestielten oder freien queren Unterbauchlappen (TRAM – Lappen) mit Mikrogefäßanastomosen bei großer Brust, durch eine erweiterte Latissimus dorsi – Lappenplastik bei kleinerer Brust, oder einer Rekonstruktion durch submuskuläre Implantation einer Brustprothese. Die Sofortrekonstruktion mit autologem Gewebe wurde zum Verfahren der ersten Wahl, da dadurch der Problematik einer eventuellen Anwendung postoperativer Strahlentherapie bei liegender Prothese in jedem Fall aus dem Weg gegangen wird. SCHLUSSFOLGERUNGEN: Patientinnen mit der Notwendigkeit einer vollständigen Entfernung der Brust oder einer deformierenden Resektion eines größeren Anteiles des Brustgewebes sollten zum Zeitpunkt der Diagnose Brustkrebs durch einen plastischen Chirurgen über das gesamte operative Spektrum der Brustrekonstruktion und besonders der Sofortrekonstruktion informiert werden, um ihnen bei Wunsch auch nicht die Möglichkeit der Sofortrekonstruktion zu verwehren.SummaryBACKGROUND: It has only been during the last decade that immediate breast reconstruction has become accepted as an integrated part of the treatment concept of breast cancer in Austria. The involvement of the plastic surgeon in the planning of treatment at the time of the diagnosis of breast cancer is still far from standard. The aim of this review article is to make it more widely known that immediate breast reconstruction is a choice for the majority of women undergoing complete breast removal or greater disfiguring resections of the breast gland and does not have any negative influence on the oncological late outcome. METHODS: On the basis of a review of the international literature and our own prospective studies on breast reconstruction, the actual indications and contraindications for immediate reconstruction are outlined. Having analysed patients of the Division of Plastic and Reconstructive Surgery at the Department of Surgery at the Medical University of Vienna for the last 15 years, the evolution of immediate breast reconstruction and of the methods applied is described. Special attention is paid to the biology and the course of the tumour disease, to the possible interference with adjuvant therapies, to the influence of age, and to the selection of the operative technique depending the individual situation. RESULTS: All major studies of local recurrence rate and survival rate after immediate breast reconstruction have ruled out any negative effect on the oncological course. Therefore information on the possibility of immediate breast reconstruction has to be passed on to every breast cancer patient at the time of diagnosis. This information has to include the whole range of techniques offered by plastic surgeons for breast preserving surgery, from the local glandular mammaplasty, the reduction mammaplasty for tumor resections in bigger breasts, the partial reconstruction with a myocutaneous latissimus dorsi flap to the reconstruction with a breast implant. In the case of a mastectomy, usually as skin-sparing mastectomy, again the whole spectrum of reconstructive approaches has to be discussed with the patient from the very beginning: the Deep Inferior Epigastric Perforator Flap (DIEP – flap), the Transverse Rectus Abdominis Myocutaneous Flap (TRAM – flap), and the extended latissimus dorsi myocutaneous flap for autologous breast reconstruction, or with the involvement of a breast implant. The immediate breast reconstruction with autologous tissue has become the procedure of first choice, because the disadvantages of the use of implants in the case of necessary postoperative irradiation therapy can be avoided. CONCLUSIONS: Information on all reconstructive possibilities should be passed on by the plastic surgeon to the patient needing a resection of the whole or a greater part of the breast because of breast cancer at the time of diagnosis so as not to miss the chance of immediate reconstruction if preferred by the patient.