Wireless microcurrent stimulation improves blood flow in burn wounds

RATIONALE

Skin breakdown, as in wounds, leads to an electric potential, defined as current of injury with the intent of wound closure. Burn wounds are defined by different zones of perfusion having a direct influence on further therapy (e.g. conservative management or skin grafting). We studied immediate, quantifiable effects of electric stimulation on skin perfusion in burn wounds.

METHOD

Wireless Microcurrent Stimulation (WMCS) was utilised as an adjunct therapeutic modality in 10 patients with partial thickness burn wounds. Microcirculation in the skin was quantified with a Laser Doppler (LDI) before and after WMCS treatment. We included a control group of 10 healthy individuals.

RESULTS

A single application of WMCS significantly increased mean flow, velocity and subsequently, haemoglobin and oxygen saturation in partial thickness burn wounds. In healthy skin these parameters increased, but were far less pronounced than in thermally injured skin.

CONCLUSION

This study revealed, for the first time that non-contact WMCS improves blood flow in critically perfused partial thickness burn wounds without disturbing the wound or systemically affecting the patient and may represent a promising adjunct tool in burn treatment, with the potential of faster healing by enhanced perfusion of burn wounds and reduction of the zone of stasis.

LEVEL OF EVIDENCE

III.

Impact of scapholunate dissociation on human wrist kinematics

Neither the complex motions of the scapholunate joint, nor the kinematic changes that occur as a result of injury to it, are fully understood. We used electromagnetic tracking within affected bones to evaluate the physiologic motions in the planes of flexion and extension, and of radial and ulnar deviation of human cadaver wrists, before and after complete transection of the scapholunate ligaments. Despite individual variance between each wrist, we were able to establish a pattern in the changes that occurred after scapholunate ligament injury. During the motions examined, the scaphoid showed an increase in translational deviation in almost all motion axes. In contrast, the movement of the lunate seemed to be impaired, especially in radial-ulnar deviation.

Evaluation of facial blood flow using three-dimensional scanning

The Vectra X3 3-dimensional face scanner allows us to visualise the erythema of superficial layers of skin in addition to its regular scanning functions. The aim of our study was to find out whether changes we provoked in the circulation of the skin would be registered and displayed by the face scanner. We measured the circulation in the skin of the cheeks of 20 volunteers with a face scanner, a laser Doppler device, and a skin pigmentation analyser before and after the application of a nitric oxide cream. The results were compared in terms of grey tones, local concentrations of haemoglobin, and erythema. All methods showed significant changes (p<0.001) before and after application of the cream. The study proved that the Vectra X3 recognises changes in skin circulation and displays them in a simple and evident way.

Necrotizing fasciitis resulting in fatal lung aspergillosis: Uncommon pathogenesis. A case report

We present a fatal case of Aspergillus-associated lung failure in a patient with necrotizing fasciitis. The cause of the fasciitis was a retroperitoneal perforation of a colon carcinoma. Being already a rare condition, the fasciitis did not manifest as Fournier's gangrene like similar described cases illustrate, but instead travelled along the fasciae and subcutaneous fat tissue cranially into the thoracic cavity, ultimately leading to a disseminated infection of the lungs. The lethal outcome was thus caused by respiratory failure at a time when the primary focus was already successfully treated, contrary to typical cases of necrotizing fasciitis. This case report depicts the importance of acknowledging opportunistic fungal infections in the practice of emergency surgery. Contributing factors, pathogenesis and possible prevention measures are discussed.

[Registry Research Funding of the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and Research Funding Report 2015/2016]

In addition to the impact factor, research funding also plays a central role in evaluating the academic performance and quality of a researcher, a clinic or a surgical specialty. The scope and quality of research in Plastic Surgery are usually very little known, so that even large funding institutions do not get a full view of research funding in our specialty. Therefore, sometimes traditional structures are not adapted to new needs by the developing younger surgical fields. In peer review sometimes peers are not chosen from the same surgical specialty, but from a different surgical fields being peers in large field of surgery. By this a bias can easily be generated which would not be advantageous for subspecialties such Plastic Surgery. The goal of this paper is to establish an overview in the form of a registry of the German Society of Plastic Reconstructive and Aesthetic Surgeons (DGPRÄC) in order to make the joint academic achievements more visible in the future. At the same time, a research funding report is to be published for the years 2015 and 2016.

[Current Perceptions of Lipofilling on the Basis of the New Guideline on "Autologous Fat Grafting"]

Introduction: Autologous fat transfer has recently become an increasingly popular surgical procedure and comprises harvesting, processing and transplantation of adipose tissue, as well as professional follow-up care. This method, as a surgical procedure, can be utilised for trauma-, disease- or age-related soft tissue volume deficits and soft tissue augmentation. As usage is increasing, but the variables of fat harvest, specific indications and fashion of fat transfer are poorly defined, there is a great demand for development of a guideline in the field of reconstructive and aesthetic surgery. Methods: All relevant points were discussed within the scope of a consensus conference including a nominal group process of all societies involved in the procedure and ratified with a strong consensus (>95%). Literature from the standard medical databases over the last 10 years was retrieved, studied and specific guidelines were concluded. Results: Consensus was achieved among all professionals involved on the following points: 1. definition 2. indication/contraindication, 3. preoperative measures 4. donor sites 5. techniques of processing 6. transplantation 7. follow-up care 8. storage 9. efficacy 10. documentation 11. evaluation of patient safety. Conclusion: Definite indications and professional expertise are paramount for autologous fat tissue transfer. Successful transfers are based on the use of correct methods as well as specific instruments and materials. Autologous adipose tissue transplantation is considered to be a safe procedure in reconstructive and aesthetic surgery, due to the low rate of postoperative complications and sequelae.

Extensive burn injury caused by fundamental electronic cigarette design flaw

Currently, electronic cigarette (EC) devices are widely used as an alternative to conventional smoking. The underlying technical principle is an electric coil-based vaporizer unit, which vaporizes various solutions for inhalation purposes with a rechargeable lithium battery unit as power source. We report a case of extensive burn injury resulting from the thermal explosion of a battery unit within an EC device. Though internal thermal instabilities of lithium ion batteries are a known safety issue, the unique feature here is a pronounced amplification of the extent of burn injury due to an additional scalding burn mechanism that resulted from heating of the liquid reservoir adjacent to the battery. Thus, we demonstrate a relevant design flaw in various EC devices, which in the authors' opinion needs to be addressed both by manufacturers and safety regulations.

L-arginine and arginine ethyl ester enhance proliferation of endothelial cells and preadipocytes - how an arginine ethyl ester-releasing biomaterial could support endothelial cell growth in tissue engineering

Adipose tissue engineering is a promising solution for the reconstruction of soft tissue defects. An insufficient neovascularisation within the scaffolds that leads to necrosis and tissue loss is still a major shortcoming of current tissue engineering attempts. Biomaterials, which release angiogenic factors such as L-arginine, could overcome this challenge by supporting the neovascularisation of the constructs. L-arginine is insoluble in organic solvents and thus cannot be incorporated into commonly used polymers in contrast to its ethyl ester. Here, we compared the effects of arginine and its ethyl ester on endothelial cells and preadipocytes, and generated an arginine ethyl ester-releasing, angiogenic polymer. We cultivated adipose tissue-derived endothelial cells and preadipocytes in arginine-free medium supplemented with L-arginine or L-arginine ethyl ester and assayed the proliferation rate and the degree of adipogenic differentiation, respectively. Additionally, we prepared arginine ethyl ester-releasing poly(D,L-lactide) foils, and investigated their impact on endothelial cell proliferation. We could demonstrate that arginine ethyl ester like arginine significantly increased the proliferation of endothelial cells and preadipocytes without inhibiting an induced adipogenic conversion of the preadipocytes. Further, we could show that the arginine ethyl ester-releasing polymer significantly increased endothelial cell growth. The present data are helpful guidance for generating angiogenic biomaterials that promote endothelial cell growth, and thereby could support neovascularisation within tissue engineering approaches.

[Research Assessment in Plastic and Reconstructive Surgery on a National Level: A 5-Years Systematic Review of Research Activity in German University Hospitals]

BACKGROUND

In plastic surgery, a broad spectrum of research activity has been performed over the past decade. However, compared with other medical fields, there seems to be a lack of central coordination in the individual research areas. Also no comprehensive, periodical assessment has been undertaken to date. This study aims to provide an overview of German research activity in plastic surgery departments affiliated to medical universities.

METHODS

We performed a 5-year interval (01/2010-12/2014) survey of PubMed-listed publications of plastic surgery departments in German university hospitals. For each university (n=11), statistical analyses of the following parameters were performed: distribution of research fields, number of publications, annual cumulative impact sum (IS) and impact factor (IF).

RESULTS

For the above-mentioned period, a total of n=904 publications were analysed. Ranking among academic departments was as follows: number of publications: 1. Medizinische Hochschule Hannover 178 (annual average x̅=36/median x͂=34; 2. University Hospital of Erlangen 115 (x̅=23/x͂=23); 3. Bergmannsheil Bochum 90 (x̅=18/x͂=19). The annual impact sum (IS) averaged 33.51 (SD 11.088, p<0.05); separated IS: 1. Medizinische Hochschule Hannover x̅=74.66, x͂=62.22, 2. University Hospital of Erlangen x̅=53.24, x͂=50.84, 3. University Hospital RWTH Aachen x̅=46.12, x͂=44.67. The average impact factor per publication was: 1.98 (SD 0.31, p<0.05); separated IF: 1. University Hospital RWTH Aachen x̅=2.76, x͂=2.79; 2. University Hospital of Erlangen x̅=2.34, x͂=2.46; 3. Medizinische Hochschule Hannover x̅=2.08, x͂=2.05. The analysed publications were distributed as follows: 43% reviews, 20% cell biology/tissue engineering, 10% reconstruction, 27% others (including wound healing, vessel/nerve research, hand surgery, burn, aesthetics, oncology).

CONCLUSION

Based on this comprehensive analysis, it seems that a periodical assessment of current research activity would be useful for the future. Data assessments should be started on European and international levels and should also be applied to other surgical and medical disciplines.

[In Vitro and In Vivo Biocompatibility of a Novel, 3-Dimensional Cellulose Matrix Structure]

BACKGROUND

Biological and physical characteristics of matrices are one essential factor in creating bioartificial tissue. In this study, a new 3-dimensional cellulose matrix (Xellulin(®)) was tested in terms of biocompatibility and applicability for tissue engineering in vitro and in vivo.

MATERIALS AND METHODS

The tested matrix Xellulin(®) is a natural hydrological gel-matrix containing bacterial cellulose and water. To evaluate the cell biocompatibilty, cell adherence and proliferation characteristics in vitro, the matrix was cultured with human fibroblasts. Further in vivo studies were carried out by transplanting preadipocytes of 4- to 6-week-old Wistar rats with 3 different conditions: a) Xellulin(®) including 500 000 preadipocytes subcutaneous, b) Xellulin(®) including 500 000 preadipocytes within an in vivo bioreactor chamber, c) Xellulin(®) without cells subcutaneous as control. After explantation on day 14 histomorphological and immunohistochemical evaluations were performed.

RESULTS

In vitro study revealed an excellent biocompatibility with good cell adherence of the fibroblasts on the matrix and evidence of cell proliferation and creation of a 3-dimensional cell network. In vivo neocapillarisation could be shown in all groups with evidence of erythrocytes (H/E staining) and endothelial vascular cells (RECA-1-staining). A significantly higher vascular density was shown in vascularised bioreactor group (18.4 vessels/100 000 µm(2) (group b) vs. 8.1 (group a), p<0.05). Cell density was the highest in the vascularised group, but without significant values. No immunogenic reaction to the matrix was noticed.

DISCUSSION

The promising in vitro results concerning cell adherence and proliferation on the tested matrix could be confirmed in vivo with an evidence of 3-dimensional neocapillarisation. Cell survival was higher in the vascularised group, but without significance. Long-term tests (28-42 days) need to be carried out to evaluate long-term cell survival and the matrix stability. Furthermore, studies concerning the implementation of the matrix within anatomic structures as well as long-term biocompatibility are needed.

Management, clinical outcomes, and complications of acute cannula-related peripheral vein phlebitis of the upper extremity: A retrospective study

OBJECTIVE

Acute phlebitis due to peripheral vein catheter use is frequently observed in clinical practice, and requires surgical therapy in severe cases. In this retrospective study, we aimed to increase awareness, evaluate current treatment options, and develop recommendations to optimize treatment outcomes.

METHODS

A total of 240 hospitalized patients with a diagnosis of upper extremity phlebitis from 2006 to 2011 were evaluated in terms of initial clinical features, parameters, co-morbidities and treatment regimes. Severity of phlebitis was graded according to the Baxter scale by assessing clinical symptoms such as pain, erythema, induration, swelling, or palpable venous cord (grade 0-5). Patients were divided in two subgroups: conservative (n = 132) and operative (n = 108) treatment.

RESULTS

Surgical intervention rates and severity were higher for cannula insertion in the cubital fossa region than for cannula insertion in the forearm and hand region (p < 0.05). Baxter scale grades were higher in the surgical treatment group than in the conservative treatment group (4.47 vs. 2.67, respectively).

CONCLUSIONS

The cubital fossa region is vulnerable to severe phlebitis and is not recommended as the first site of choice for cannulation. Phlebitis of Baxter scale grade 4 or 5 should be considered for early surgical intervention.

The lipo-facelift: merging the face-lift and liposculpture: eight years experience and a preliminary observational study

BACKGROUND

Since the introduction of the classic submucosal aponeurotic system (SMAS) face-lift, the surgical approach to improve the changes of an aging face has evolved, and significant technical improvements have been made. However, several problems still have not been solved satisfactorily. These problems include facial lipodystrophy and changes in skin and skin texture.

METHODS

The Lipo-Facelift procedure consists of facial liposculpturing performed simultaneously with a biplanar, bivectorial SMAS face-lift procedure. The authors analyzed pre- and postsurgical photographs of 12 patients with a Lipo-Facelift after 3 and 12 months and analyzed their charts for complications. Furthermore, O2C measurement was performed to assess improved microcirculation. The longest follow-up period was 8 years.

RESULTS

The Lipo-Facelift demonstrated very satisfying results. Initial swelling and bruising were seen as well as two cases of wound-healing disorders, but no surgical intervention or revision was needed. The findings show lasting improvement of skin quality and a youthful appearance.

CONCLUSION

The Lipo-Facelift corrects age-related skin and SMAS changes as well as age-related lipodystrophy, improves skin circulation and skin revitalization, and provides a lasting and natural result. The skin quality resulting from simultaneous lipofilling can be explained by improved angiogenesis due to transferred growth factors in the lipoaspirate. Also, differentiation of progenitor cells to fibroblasts and increased production of collagen contribute to firmer skin.

LEVEL OF EVIDENCE IV

This 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 .

A rare case of massive carpal osteoblastoma requiring complex reconstructive surgery

An osteoblastoma is a rare, commonly benign, osteoid-producing neoplasm of the bone with an incidence of 2% of all primary bone tumours. We present a case of a 54-year-old patient with persisting carpal pain and massive swelling of the hand for a period of 4 years. Incision biopsies revealed the histopathological finding of a carpal osteoblastoma. After complete tumour excision, including the carpal and, in parts, metacarpal bones, reconstructive surgery was performed with a free osteocutaneous iliac crest flap to obtain a natural hand contour and the best possible hand function. Follow-up revealed improvement of the hand function in terms of flexion, extension and strength without discomfort or further pain. Thus, ongoing carpal pain should lead to an intensive search with further diagnostic measures such as magnetic resonance imaging (MRI) scan as well as biopsies, if necessary, to obtain the correct diagnosis.

Micro-punch technique for treatment of Fordyce spots: a surgical approach for an unpleasant condition of the male genital

Fordyce spots are ectopic sebaceous glands, ranging between 2 and 3 mm in diameter. These benign lesions are most frequently located in the oral mucosa and the genital skin. Especially in the male genital region they can cause itching, discomfort during sexual activities and are aesthetically unpleasant. So far, a variety of therapeutic procedures have been reported with varying success and recurrence rates. In the present retrospective study (n = 23 patients between 2003 and 2011), we present our surgical approach by means of the micro-punch technique. Using this effective method, we achieved very satisfactory functional and cosmetic results. There were no signs of recurrence during postoperative observations from 12 up to 84 months (median = 51.3 months).

[Extensive fibromata pendulantia. Hydrosurgery as a therapy option using the Versajet technique]

Fibromata pendulantia often appear as small filiform skin tags with a narrow pedicle in the neck, axilla and groin areas. Hitherto, extensive fibromata pendulantia were resected either surgically (curette, scissors, scalpel) or by laser. The present case study of an adipose patient with disseminated fibromata pendulantia in the axillary region in the setting of pseudoacanthosis nigricans introduces the Versajet hydrosurgery technique as an alternative method. It is able to remove tissue and rinse the wound simultaneously by means of a high-pressure water jet.

[Liposuction]

Liposuction is one of the most commonly performed procedures in aesthetic surgery. The primary aim is body contouring and not weight reduction. The vast amount of available methods for suctioning subcutaneous fat allows an optimal individual treatment plan, keeping in mind the correct indications. Although liposuction is often offered as a minor and harmless surgery, it is a complex procedure. A thorough training of the surgeon and in-depth knowledge about possible complications is essential. In addition to aesthetic indications liposuction is also a valuable tool in reconstructive surgery. For optimal patient selection the skin elasticity has to be considered during the preoperative assessment. Besides pure volume reduction through liposuction, the regenerative possibilities of adipose tissue are of great interest for basic research and clinical applications. Lipofilling or autologous fat transfer is used for a wide variety of aesthetic and reconstructive procedures. Of special interest is the regenerative and reconstructive potential of adipose-derived stem cells (ADSC).

Randomized controlled single center study comparing a polyhexanide containing bio-cellulose dressing with silver sulfadiazine cream in partial-thickness dermal burns

OBJECTIVE

A prospective, randomized, controlled single center study was designed to evaluate clinical efficacy of a polyhexanide containing bio-cellulose dressing (group B) compared to a silver-sulfadiazine cream (group A) in sixty partial-thickness burn patients.

PATIENTS AND METHODS

Local ethics committee approval was obtained and patients consented. Parameters were: pain reduction (VAS), healing time and wound bed condition, comparing day 0 (start) versus day 14 (end), as well as, ease of dressing use and treatment costs.

RESULTS

All completed the study (n=30/n=30) and were included in the ITT analysis, with a total of 72 burns (group A: n=38, group B: n=34). We noted no differences in healing time. Pain reduction was significantly faster and better in group B (p<0.01). There were fewer dressing changes in group B, compared to group A. Ease of use for the bio-cellulose dressing was rated better compared to group A. In group B, € 95.20 was saved for a 10 day treatment period, compared to group A.

CONCLUSION

Group B demonstrated a better and faster pain reduction in the treated partial-thickness burns, compared to group A. The results indicate the polyhexanide containing bio-cellulose dressing to be a safe and cost effective treatment for partial-thickness burns.

[Alloplastic cancellous bone replacement and fibrin glue in hand surgery]

INTRODUCTION

Alloplastic replacement of cancellous bone is being increasingly used in the clinical setting. The use in hand surgery, however, is only sparsely documented.

MATERIALS AND METHODS

We report about the use of micro- and macroporous biphasic calicium phosphate granulate (Tricos (®)) in combination with fibrin sealant (Tissucol (®)) in six patients undergoing surgery of the hand involving cancellous bone deficits. The indications ranged from carpal stabilisation to DIP athrodesis. Follow-up time was up to 15 months.

RESULTS

Because cancellous bone harvesting could be avoided, morbidity and the extent of surgery could be reduced in all patients. Healing was uneventful and the clinical course as documented by X-ray controls, toleration of physiotherapeutic exercises and stability was analogous to that of conventional surgery involving cancellous bone grafting.

CONCLUSION

These first results indicate that alloplastic replacement of spongiosa grafts, especially by micro- and macroporous biphasic calcium phosphate granulate can possibly be successfully used in surgery of the hand. The extent of bony remodelling still needs to be determined by further examination.

[The impact of silicone spray on scar formation. A single-center placebo-controlled double-blind trial]

For more than two decades silicone has successfully been employed in the treatment and prevention of hypertrophic scars and keloids as a painless noninvasive modality with few side effects. In the present trial, after 3 months of treatment the Patient Scar Assessment Scale demonstrated that patient satisfaction with the silicone application was significantly higher compared to placebo. When treatment was stopped after 3 months, the topical silicone spray did not exhibit any lasting long-term impact on the objective results of scar formation. Due to the significant differences in patient satisfaction once treatment has ended and since the administration is safe and simple, any final decision on treatment indication should be tailored to the patient and include the psychological well-being of the patient as well as the temporary improvement in scar formation during treatment.

Tissue substitutes with improved angiogenic capabilities: an in vitro investigation with endothelial cells and endothelial progenitor cells

The use of implantable biomaterials, such as artificial skin substitutes used for dermal defects, remains limited by the low angiogenic potential of these products. The rapid in vivo degradation of growth factors contributes to the limiting of angiogenesis in biomaterials. Here, we report on collagen sponges in which vascular endothelial growth factor (VEGF) was immobilized through physical binding to heparin, covalently incorporated in the matrix via cross-linking with 1-ethyl-3-(3-dimethylaminopropyl)carbodiimide (EDC) and N-hydroxysuccinimide. The in vitro release of VEGF over time and endothelial cell proliferation were investigated in matrices modified at varying heparin to EDC ratios either nonloaded or loaded with VEGF. ELISA demonstrated a significantly slower in vitro release of VEGF over a period of 5 days from heparinized matrices as compared to their unmodified and cross-linked counterparts. The effects of these modifications on the proliferation of endothelial cells and endothelial progenitor cells were evaluated after 1, 3 and 5 days either according to the bromodeoxyuridine assay or total cell counting with a Neubauer chamber. The endothelial and endothelial progenitor cells cultured in contact with heparinized matrices loaded with VEGF revealed both the highest rate of DNA synthesis and the highest total cell count. Furthermore, these results show that the cross-linking of collagen matrices - both in the presence and absence of heparin - leads to increases of the proliferative activities. We can assume that these changes lead to matrices with increased angiogenic capabilities.

[Possibilities and limitations of plastic surgery]

Demographic changes of the industrialised modern society can be recognised throughout every medical specialisation. In the past plastic surgery had a main focus in the reconstruction of posttraumatic disorders but nowadays the typical disorders of the elderly and "civilization diseases" became a major part of reconstructive surgery. In this context the preservation of the lower extremity is a major concern of the plastic surgeon. Especially in patients with diabetes and its typical peripheral atherosclerosis we have to treat peripheral ulcers in an interdisciplinary setting including diabetologist, vascular and plastic surgeon to preserve the endangered extremity.

[Postbariatric plastic surgery]

Approximately 1.7 billion people around the world are defined as being overweight or obese. Various surgical options to treat obesity have quite recently been developed. Following efficient and lasting weight loss, up to one-third of the patients will require plastic and reconstructive surgery. Plastic surgery will thus be the final part of a modern bariatric treatment plan. Postbariatric plastic surgery interventions do not treat obesity but rather remove excess skin and restore the normal body contour and function of the bariatric patient. The presented work summarizes current concepts and limitations in modern plastic and reconstructive surgery of the bariatric patient population.

[Eccrine adenocarcinoma in a patient with familial breast carcinoma]

A 67-year-old patient developed a subcutaneous, non-tender nodule in her left groin over a period of about seven years. The patient underwent surgery and 4 procedures were required to obtain complete excision. The histopathologic findings showed eccrine adenocarcinoma, a member of the heterogeneous group of sweat gland tumors which occur primarily in adults with a peak of 50-60 years of age. Sweat gland carcinomas are extremely rare neoplasms of the skin and exhibit a slow growth rate with a rather high local recurrence rate. The tumor has a disposition to metastasize and shows a poor response rate to adjuvant therapy regimens. Therefore wide, deep surgical excision with an excision margin of 2-3 cm is the treatment of choice. Nevertheless there are some case reports on successful therapy of a metastasized sweat gland carcinoma with 5-fluorouracil and tamoxifen. Here further studies are needed to achieve a better survival rate for patients with metastatic disease.