How to Treat a Cyclist's Nodule?-Introduction of a Novel, ICG-Assisted Approach

BACKGROUND

Perineal nodular induration (PNI) is a benign proliferation of the soft tissue in the perineal region that is associated with saddle sports, especially road cycling. The etiology has not been conclusively clarified; however, repeated microtrauma to the collagen and subcutaneous fat tissue by pressure, vibration and shear forces is considered a mechanical pathomechanism. In this context, chronic lymphedema resulting in the development of fibrous tissue has been suggested as an etiological pathway of PNI. The primary aim of this study was to introduce and elucidate a novel operative technique regarding PNI that is assisted by indocyanine green (ICG). In order to provide some context for this approach, we conducted a comprehensive review of the existing literature. This dual objective aimed to contribute to the existing body of knowledge while introducing an innovative surgical approach for managing PNI.

METHODS

We reviewed publications relating to PNI published between 1990 and 2023. In addition to the thorough review of the literature, we presented our novel surgical approach. We described how this elaborate approach for extensive cases of PNI involves surgical excision combined with tissue doubling and intraoperative ICG visualization for exact lymphatic vessel obliteration to minimize the risk of recurrence based on the presumed context of lymphatic congestion.

RESULTS

The literature research yielded 16 PubMed articles encompassing 23 cases of perineal nodular induration (PNI) or cyclist's nodule. Of these, 9 cases involved females, and 14 involved males. Conservative treatment was documented in 7 cases (30%), while surgical approaches were reported in 16 cases (70%). Notably, a limited number of articles focused on histopathological or radiological characteristics, with a shortage of structured reviews on surgical treatment options. Only two articles provided detailed insights into surgical techniques. Similarly to the two cases of surgical intervention identified in the literature research, the post-operative recovery in our ICG assisted surgical approach was prompt, meaning a return to cycling was possible six weeks after surgery. At the end of the observation period (twelve months after surgery), regular scar formation and no signs of recurrence were seen.

CONCLUSION

We hope that this article draws attention to the condition of PNI in times of increasing popularity of cycling as a sport. We aimed to contribute to the existing body of knowledge through our thorough review of the existing literature while introducing an innovative surgical approach for managing PNI. Due to the successful outcome, the combination of tissue doubling, intraoperative ICG visualization and postoperative negative wound therapy should be considered as a therapeutic strategy in cases of large PNI.

How Reliable Is Breast Volume Assessment When the Patient Is Lying Flat?-Volumetric Assessment of Breast Volume Using a Vectra H2 Handheld Device in Different Positions

(1) Background: Three-dimensional (3D) volumetric assessment is receiving increased recognition in breast surgery. It is commonly used for preoperative planning and postoperative control with the patient standing in an upright position. Recently, intraoperative use was evaluated with patients in the supine position. The aim of this prospective study was to evaluate the volumetric changes in 3D surface imaging depending on the patient's position. (2) Methods: 3D volumetric analysis was performed using a Vectra-H2 device with patients in standing, sitting, and supine positions. A total of 100 complete datasets of female breasts were included in the study. The measured volumes of each evaluated breast (n = 200) were compared between the three positions. (3) Results: The mean difference between the 3D volumetric assessments of the sitting and standing positions per breast was 7.15 cc and, thus, statistically insignificant (p = 0.28). However, the difference between supine and standing positions, at 120.31 cc, was significant (p < 0.01). (4) Conclusions: The 3D volumetric assessment of breasts in the supine position did not statistically correlate with the validated assessment of breast volume in the standing position while breast volume in the sitting position is reliable and correlates with the assessment of a standing patient. We conclude that intraoperative volumetric assessment should be performed with patients in an upright sitting position.

Evaluation of Intraoperative Volumetric Assessment of Breast Volume Using 3D Handheld Stereo Photogrammetric Device

Methods for assessing three-dimensional (3D) breast volume are becoming increasingly popular in breast surgery. However, the precision of intraoperative volumetric assessment is still unclear. Until now, only non-validated scanning systems have been used for intraoperative volumetric analyses. This study aimed to assess the feasibility, handling, and accuracy of a commercially available, validated, and portable device for intraoperative 3D volumetric evaluation. All patients who underwent breast surgery from 2020 to 2022 were identified from our institutional database. Intraoperative 3D volumetric assessments of 103 patients were included in this study. Standardized 3D volumetric measurements were obtained 3 months postoperatively to compare the intraoperatively generated volumetric assessment. All of the study participants were women with a mean age of 48.3 ± 14.7 years (range: 20-89). The mean time for intraoperative volumetric assessment was 8.7 ± 2.6 min. The postoperative 3D volumetric assessment, with a mean volume of 507.11 ± 206.29 cc, showed no significant difference from the intraoperative volumetric measurements of 504.24 ± 276.61 cc (p = 0.68). The mean absolute volume difference between the intraoperative simulations and postoperative results was 27.1 cc. Intraoperative 3D volumetric assessment using the VECTRA H2 imaging system seems to be a feasible, reliable, and accurate method for measuring breast volume. Based on this finding, we plan to investigate whether volumetric objective evaluations will help to improve breast symmetry in the future.

How Useful Is the SSN–Nipple Distance? An Analytical Questionnaire Survey on Anthropometric Measurements for the Aesthetically Ideal Positioning of the Nipple–Areolar Complex

Several studies have attempted to identify the optimal anthropometric measurement for the aesthetically ideal positioning of the nipple–areolar complex. However, no standardised solutions and measurements for planning surgical procedures have been reached. The aim of this study is to identify the optimal anthropometric measurement between the suprasternal notch (SSN)–nipple distance and mid-clavicle (MC)–nipple distance for the aesthetic position of the nipple–areola complex (NAC) on the breast. A detailed online survey was sent to 300 board-certified plastic surgeons and residents of plastic surgery departments of hospitals in German, Austrian, and Swiss. A similar survey was also provided to 100 patients who had planned or had already undergone breast surgery. All participants were asked to rank the attractiveness of a series of women’s breasts in images with different NAC position measurements. The images showed breasts from two different measurements and distances: all the breasts had equal dimensions and proportions and the same areola size. Complete datasets were obtained from 203 of the 300 board-certified plastic surgeons and residents of plastic surgery departments in German-speaking countries (recall 68%) and from 100 patients. The majority of doctors and patients find a symmetrical breast with a mirrored position of the nipple–areola complex more attractive than a non-symmetrical breast. In cases with minor measurement differences, such as 0.5 cm (SSN vs. MC), there is no relevant difference in the breast symmetry. However, at larger distances, the MC-to-nipple distance is superior for achieving aesthetically appealing symmetry compared with the SSN-to-nipple distance. Using the MC-to-nipple distance seems to be superior for correct nipple positioning than the SSN-to-nipple distance and is a valuable preoperative measurement option for breast symmetry with correct nipple height. Further studies on this topic involving a more general population should be conducted to confirm the improvements in perception with the preoperative measurements using the anatomical landmarks.

Improving symmetry of nipple-areola complex (NAC) position in reduction mammoplasty using laser level projection

BACKGROUND

Symmetrical height of the nipple-areola complex (NAC) is a key factor in the perception of breast symmetry. For preoperative markings, we mainly rely on conventional anthropometric measurements of distances in correlation to anatomical landmarks. In this study, we evaluated whether the use of a class 2 laser projection water level would lead to better symmetry of nipple height in reduction mammoplasty procedures when used for preoperative planning.

METHODS

We analysed 100 patients undergoing reduction mammoplasty with a supero-medial pedicle and wise-pattern skin resection. We compared the bilateral differences in nipple height of the last 50 reduction mammoplasty procedures before using the laser projection water level (group A; no laser) with the first 50 reduction mammoplasties after implementation of this device (group B; laser). The follow-up period was 12 months.

RESULTS

A total of 48 patients were included in group A and 44 patients in group B. Patient demographics, mean resection weight and complications did not differ statistically significantly. Nipple height differences were significantly lower in group B (laser), measuring 0.22 ± 0.20 cm (0-0.9; n = 44), than those in group A (no laser; p < 0.001), measuring 0.61 ± 0.28 cm (0.2-1.2; n = 49).

CONCLUSION

Using laser level projection helped improve nipple height symmetry in reduction mammoplasty. We consider a difference of more than 1 cm in nipple height to be unacceptable in aesthetic reduction mammoplasty. This simple tool facilitates preoperative markings, and we find it to be safe, quick to install and very helpful in daily practice.

Is there a need for postoperative monitoring after open carpal tunnel release under WALANT?

Open carpal tunnel release (OCTR) under wide-awake local anesthesia with no tourniquet (WALANT) is a common outpatient procedure in hand surgery worldwide. In our clinic, WALANT has replaced intravenous regional anesthesia with a tourniquet (IVRA, or 'Bier block') as standard practice in OCTR. We therefore wondered what the optimal postoperative setting after OCTR under WALANT is. In this study, we compared patient satisfaction in two postoperative settings: immediate discharge (ID) after the operation, or short postoperative monitoring (PM) period in the outpatient clinic. Our hypothesis was that older patients would prefer a brief postoperative surveillance. We retrospectively analyzed patient satisfaction with the two settings using an adjusted questionnaire based on the standard Swiss grading system. We also assessed postoperative pain, satisfaction with the perioperative preparations and the reasons for unscheduled postoperative consultations, as secondary outcomes. One hundred and nine patients (ID, n = 63; PM, n = 46) were included in this single-center retrospective observational study. Patients were highly satisfied with both postoperative settings (Mean: ID 5.1/6; PM 5.5/6; p = 0.07). Even patients aged ≥80 years reported extremely high satisfaction with both settings (ID 5.6/6; PM 6.0/6; p = 0.08). Fifteen patients (ID, n = 11 [17.5%]; PM, n = 4 [8.7%], p = 0.72) unexpectedly consulted a doctor after surgery. OCTR under WALANT as an outpatient procedure with immediate discharge was associated with high patient satisfaction. However, detailed postoperative monitoring could contribute to the patient's well-being and education on how to cope with the postoperative course, and help with any questions.

Prepectoral versus subpectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02/ PREPEC): a pragmatic, multicentre, randomised, superiority trial

INTRODUCTION

The emphasis on aesthetic outcomes and quality of life (QoL) has motivated surgeons to develop skin-sparing or nipple-sparing mastectomy (SSM/ NSM) for breast cancer treatment or prevention. During the same operation, a so-called immediate breast reconstruction is performed. The breast can be reconstructed by positioning of a breast implant above (prepectoral) or below (subpectoral) the pectoralis major muscle or by using the patients' own tissue (autologous reconstruction). The optimal positioning of the implant prepectoral or subpectoral is currently not clear. Subpectoral implant-based breast reconstruction (IBBR) is still standard care in many countries, but prepectoral IBBR is increasingly performed. This heterogeneity in breast reconstruction practice is calling for randomised clinical trials (RCTs) to guide treatment decisions.

METHODS AND ANALYSIS

International, pragmatic, multicentre, randomised, superiority trial. The primary objective of this trial is to test whether prepectoral IBBR provides better QoL with respect to long-term (24 months) physical well-being (chest) compared with subpectoral IBBR for patients undergoing SSM or NSM for prevention or treatment of breast cancer. Secondary objectives will compare prepectoral versus subpectoral IBBR in terms of safety, QoL and patient satisfaction, aesthetic outcomes and burden on patients. Total number of patients to be included: 372 (186 per arm).

ETHICS AND DISSEMINATION

This study will be conducted in compliance with the Declaration of Helsinki. Ethical approval has been obtained for the lead investigator's site by the Ethics Committee 'Ethikkommission Nordwest- und Zentralschweiz' (2020-00256, 26 March 2020). The results of this study will be published in a peer-reviewed medical journal, independent of the results, following the Consolidated Standards of Reporting Trials standards for RCTs and good publication practice. Metadata describing the type, size and content of the datasets will be shared along with the study protocol and case report forms on public repositories adhering to the FAIR (Findability, Accessibility, Interoperability, and Reuse) principles.

TRIAL REGISTRATION NUMBER

NCT04293146.

Open Carpal Tunnel Release Under WALANT – Suitable for All Ages?

Purpose

Wide-awake local anesthesia with no tourniquet (WALANT) as a walk-in procedure has become a standard technique in open carpal tunnel release (OCTR) and continues to replace the long-established intravenous regional anesthesia with a tourniquet (IVRA/”bier-block”) in our clinic. The aim of this study was to compare patient satisfaction with either WALANT or IVRA/”bier-block” and define subgroups that are particularly suited for either of the two procedures. We hypothesized that older patients would prefer IVRA because of a shorter period of postoperative surveillance.

Methods

In this retrospective study we evaluated patient satisfaction with either WALANT or IVRA using an adjusted questionnaire on a standard Swiss grading system (from 1 = insufficient/very strong pain to 6 = excellent/no pain). Secondary outcomes included postoperative pain or satisfaction with the tourniquet and quality of postoperative care.

Results

For the 176 patients (WALANT, n = 109; IVRA, n = 67) included in the study, there was high patient satisfaction with both procedures (WALANT, 5.5/6; IVRA, 5.5/6). Patients aged 80 years and older had significantly less postoperative pain after WALANT (WALANT, 5.8/6 vs IVRA, 4.9/6).

Conclusions

Patients aged 80 years and older had significantly less postoperative pain after WALANT than that after IVRA. Here, sarcopenia may have contributed to the prolonged discomfort after tourniquet application. Immediate postoperative discharge after WALANT did not negatively affect older patients.

Clinical relevance

For OCTR, WALANT as a walk-in procedure is a safe and comfortable alternative to IVRA, which is commonly planned with short postoperative surveillance. Both anesthesia techniques are suitable for all ages and sexes but based on this study we recommend WALANT as a tourniquet-free operation in older patients.

[Liposuction with consequences: what to consider when using prilocaine]

Aetiologically, prilocaine-induced methaemoglobinaemia is a rare form of acquired methaemoglobinaemia, which occurs rarely in the first place. The following report highlights a potentially dangerous complication arising after application of prilocaine during liposuction.A young female visited the Accident and Emergency Department following a pre-syncopal fall. As a consequence of her fall, she experienced debilitating wrist pain and exhibited a laceration on her chin. She had undergone liposuction of the lower extremity as an outpatient approximately 12 hours earlier and received regional anaesthesia in the process. A large volume of an anaesthetic solution containing prilocaine had been injected into the tissue.The patient was normotensive and slightly tachycardic and had oxygen saturations of 90 % on room air. She was cyanotic and her lips were pale. Initial arterial blood gas analysis showed a methaemoglobin fraction, which was increased significantly to 10.9 %. Conventional radiography confirmed the presence of a minimally dislocated distal radius fracture. Following subsequent oxygen therapy over a four-hour period, the patient's methaemoglobin level dropped to 6 %, her lip cyanosis abated and her vital parameters stabilised. The laceration of her chin was sutured and her wrist immobilised in a split plaster brace. After a 12-hour hospital stay, the patient was discharged. At her six-week follow-up appointment, the fracture had healed and both the functional and cosmetic aspects of her chin wound were adequate. We hope that this report draws the attention of emergency care personnel to the possible diagnosis of prilocaine-induced methaemoglobinaemia after liposuction and encourages more general discussions around the use of prilocaine.

Abstract OT-23-03: Pre- versus sub-pectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02 PREPEC): A pragmatic, multicenter, randomized, superiority trial

Background The emphasis on aesthetic outcomes and quality of life (QoL) has motivated surgeons to develop skin- and nipple-sparing mastectomy (SSM/NSM) for breast cancer (BC) treatment or prevention. Immediate breast reconstruction is based on implants or autologous tissue. The optimal positioning of the implant is not clear: While pre-pectoral positioning respects the anatomic position of the mammary gland and avoids surgery-induced alterations of the pectoralis major muscle, the lack of muscle coverage may increase the risk of additional surgical interventions due to major complications. The Oncoplastic Breast Consortium (OPBC) identified this knowledge gap as research priority in 2019.

Trial design International, multicenter study with a superiority trial design and two parallel groups with 1:1 random allocation to pre- or sub-pectoral implant-based breast reconstruction (IBBR). Following a pragmatic approach, randomly assigned IBBR will be performed according to the surgeons’ usual care by use of a one- or two-stage approach with or without adjunctive mesh. Follow-up visits are performed within routine care (visits at 10 days and at 1, 6, 12, 18 and 24 months after surgery). Oncological follow-up will be conducted annually for 10 years. ClinicalTrials.gov identifier: NCT04293146.

Eligibility We include women ≥ 18 years, with an indication for NSM or SSM and IBBR in the therapeutic or risk-reducing setting, the ability to complete QoL questionnaires and the adequateness of skin flap(s) for pre-pectoral IBBR (intraoperative decision of the surgeon).

Specific aims The primary objective is to test whether pre-pectoral IBBR provides better QoL with respect to long-term (24 months) physical well-being of the chest (BREAST-Q) compared to sub-pectoral IBBR for patients undergoing SSM or NSM for prevention or treatment of BC. Secondary endpoints include loss of expander or implant, complications, other BREAST-Q QoL and patient satisfaction domains, aesthetic outcomes and recurrence free survival. Interference of different dose distributions of radiation therapy and its consequences on the distribution of local tumor recurrences will be assessed.

Statistical methods The primary analysis will be performed on the full analysis set following the intention-to-treat principle. To test the primary hypothesis, a linear mixed model will be fitted with the BREAST-Q score as response variable and treatment assignment as independent variable. The analysis will be adjusted for baseline BREAST-Q score, stratification factors (i.e. uni- vs bilateral surgery and NSM vs SSM) and other potential confounders. A random intercept to account for the center effect will be included. As a sensitivity analysis, an unadjusted t-test will be performed on the BREAST-Q score change from baseline to compare the two treatment arms. The sample size was determined for the primary endpoint, with an expected mean score of 76 points for sub-pectoral and 80 points for pre-pectoral implants. The clinically relevant difference to be detected in this superiority design is 4 points, with an expected common standard deviation of 13 points. A sample size of 334 patients provides an 80% power for a two-sided t-test at level α = 0.05. Compensating for a 10% dropout rate, the total sample size was calculated to include 372 patients.

Present accrual and target accrual By June 2020, one study site (Basel) has been initiated. During a 21-month recruitment period, we plan to include 372 patients at 21 sites in Switzerland, USA, China, Austria, Germany, Hungary and Sweden.

Contact information Prof. Dr. Walter Paul Weber, Chefarzt Brustchirurgie, Breast Surgeon SSO, Universitätsspital Basel, Spitalstrasse 21, CH-4031 Basel, Tel: +41 61 328 61 49, Walter.Weber@usb.ch

Citation Format: Walter Paul Weber, Elisabeth A Kappos, Meredith M Regan, Giusi Moffa, Yves Harder, Karin Ribi, Shelley Potter, Andrea Pusic, Mathias K Fehr, Lars G Hemkens, Thomas Holzbach, Jian Farhadi, Colin Simonson, Michael Knauer, Ralph Verstappen, Heiner Bucher, Daniel Zwahlen, Frank Zimmermann, Matthias Schwenkglenks, Rosine Mucklow, Vesna Bjelic-Radisic, Amelia Chiorescu, Yoon Chun, Subrina Farah, Xiasong Chen, Linda Nigard, Sherko Kümmel, Roland Reitsamer, Maik Hauschild, Ilario Fulco, Christoph Tausch, Thomas Fischer, Dimitri Sarlos, Mihai Constantinescu, Judith E Lupatsch, Florian Fitzal, Joerg Heil, Zoltán Mátrai, Jana de Boniface, Christian Kurzeder, Martin Haug, Alexandra Schulz. Pre- versus sub-pectoral implant-based breast reconstruction after skin-sparing mastectomy or nipple-sparing mastectomy (OPBC-02 PREPEC): A pragmatic, multicenter, randomized, superiority trial [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr OT-23-03.

[Herpetic whitlow - A neglected Diagnosis]

Mit einer akuten Paronychie werden Chirurg und Handchirurg regelmäßig konfrontiert. Zumeist erfolgt die Behandlung konservativ-antibiotisch, eine Abszedierung wird hingegen inzidiert. Gleichartig wird mit einem kutanen Panaritium verfahren. Im Abstrich findet man Staphylokokken, seltener Streptokokken und andere Keime. Die Routine verleitet schnell, in der Anamnese auf einen kurzen Fragenkatalog zu verzichten. Beginn, Symptomatik, Verlauf, sonstiger Körperbefall, Rückfall, Nebenerkrankungen, Familie, Beruf und Haustiere sollten kurz abgefragt werden. Eine solche Anamnese hätte unseren Fall vereinfacht.

Validation of a novel animal model for sciatic nerve repair with an adipose-derived stem cell loaded fibrin conduit

Despite the regenerative capabilities of peripheral nerves, severe injuries or neuronal trauma of critical size impose immense hurdles for proper restoration of neuro-muscular circuitry. Autologous nerve grafts improve re-establishment of connectivity, but also comprise substantial donor site morbidity. We developed a rat model which allows the testing of different cell applications, i.e., mesenchymal stem cells, to improve nerve regeneration in vivo. To mimic inaccurate alignment of autologous nerve grafts with the injured nerve, a 20 mm portion of the sciatic nerve was excised, and sutured back in place in reversed direction. To validate the feasibility of our novel model, a fibrin gel conduit containing autologous undifferentiated adipose-derived stem cells was applied around the coaptation sites and compared to autologous nerve grafts. After evaluating sciatic nerve function for 16 weeks postoperatively, animals were sacrificed, and gastrocnemius muscle weight was determined along with morphological parameters (g-ratio, axon density & diameter) of regenerating axons. Interestingly, the addition of undifferentiated adipose-derived stem cells resulted in a significantly improved re-myelination, axon ingrowth and functional outcome, when compared to animals without a cell seeded conduit. The presented model thus displays several intriguing features: it imitates a certain mismatch in size, distribution and orientation of axons within the nerve coaptation site. The fibrin conduit itself allows for an easy application of cells and, as a true critical-size defect model, any observed improvement relates directly to the performed intervention. Since fibrin and adipose-derived stem cells have been approved for human applications, the technique can theoretically be performed on humans. Thus, we suggest that the model is a powerful tool to investigate cell mediated assistance of peripheral nerve regeneration.

[Isolation and Characterization of Multipotent Precursor Cells from Murine Adipose Tissue using a Clinically Approved Cell Separation System]

INTRODUCTION

Recent studies underscored the clinical potential of adipose-derived multipotent stem-/precursor cells (ASPCs). One of the main hurdles en route to clinical application was to isolate cells without having to perform expansion cultures outside the OR. A new generation of clinically approved, commercially available cell separation systems claims to provide ASPCs ready for application without further expansion cultures. However, it is unclear if the new systems yield sufficient cells of adequate quality for the use in autologous murine models. The aim of this study was to isolate and characterize adipose-derived precursor cells taken from the inguinal fat pat of wistar rats using InGeneron's clinically approved ARC™-cell separation system.

MATERIALS AND METHODS

We isolated cells from the inguinal fat pad of 3 male Wistar rats according to the manufacturer's protocol. In order to reduce the influence of the atmospheric oxygen on the multipotent precursor cells, one half of the cell suspension was cultivated under hypoxia (2% O2) simulating physiological conditions for ASPCs. As a control, the other half of the cells were cultivated under normoxia (21% O2). Cell surface markers CD90, CD29, CD45 and CD11b/c were analyzed by FACS, and osteogenic and adipogenic differentiation of the ASPCs was performed. Finally, cellular growth characteristics were assessed by evaluation of the cumulative population doublings and CFU assay, and metabolic activity was evaluated by WST-1 assay.

RESULTS

Processing time was 90 (± 12) min. 1 g of adipose tissue yielded approximately 60 000 plastic adhering cells. Both groups showed a high expression of the mesenchymal stem cell markers CD90 and CD29 while they were negative for the leucocyte markers CD45 and CD11b/c. A strong osteogenic differentiation and a sufficient adipogenic differentiation potential was proven for all ASPCs. Under hypoxia, ASPCs showed increased proliferation characteristics and CFU efficiency as well as a significantly increased metabolic activity.

CONCLUSION

This study showed that sufficient multipotent ASPCs of appropriate quality can be isolated from the inguinal fat pad of Wistar rats using the ARC™-cell separation system. As shown in previous studies, cultivation of cells under hypoxic conditions increased their stemness. Our findings will enable future studies that focus on autologous transplantation of ASPCs in a rat model, which most closely resembles a possible clinical application.

[Interrater Reliability of Scapholunate Advanced Collapse (SLAC) Wrist Stage Classification and Influence of Diagnostic Wrist Arthroscopy]

AIM

Therapy of scapholunate advanced collapse (SLAC) wrist should be guided by the degree of arthritic changes within the radioscaphoid and midcarpal joints (stage 1-3 after Watson). Diagnostic investigations usually include X-ray imaging and wrist arthoscopy. In the present study, the interrater reliability of SLAC wrist stage classification by means of X-ray image analysis was evaluated between radiologists and hand surgeons. Ultimately, the influence of diagnostic wrist arthroscopy on the final stage classification was determined.

PATIENTS AND METHODS

Retrospectively, 38 SLAC wrists of 37 patients were included in this study. Conventional X-ray images in a dorso-palmar and lateral view were performed before diagnostic wrist arthroscopy. The degree of carpal collapse on X-rays was determined by 2 radiologists and 2 surgeons (1 board certified hand surgeon, 1 plastic surgeon, both experienced in hand surgery since years). After 14 days the stages were re-evaluated by the surgeons with the digital images from the wrist arthroscopies at hand.

RESULTS

While the interrater reliability turned out to be 'weak' amidst the radiologists, it was classified as 'light' among the surgeons. We found a 'weak' and a 'light' interrater reliability between the surgeons and the radiologists. Radiologists tended to assess the degree of severity higher than surgeons. The additional knowledge of the digital arthroscopy images led to a different classification in 55%. When X-rays were assessed in combination with the arthroscopy findings, both stage 1 and stage 3 were diagnosed less frequently.

CONCLUSIONS

Our study suggests that interpreting X-ray films alone is an unreliable method to assess the stage of SLAC wrist. We believe that additional diagnostic measures such as wrist arthroscopy are needed to accurately diagnose the SLAC wrist stage.

[Results after Arthroscopically Assisted Management of Intra-Articular Distal Radius Fractures]

Background/Goal: An arthroscopically assisted management of intra-articular distal radius fractures may improve the quality of reduction. Furthermore, concomitant ligament and triangular fibrocartilage complex injuries can be identified and treated. However, this approach increases the duration of surgery. If severe soft tissue lesions, such as SL-ligament disruptions are treated simultaneously, a longer post-operative immobilisation will be required. The aim of this study was to measure the clinical outcome one year after arthroscopically assisted treatment of intra-articular distal radius fractures.

PATIENTS AND METHODS

In a retrospective study from 2011 to 2013 we identified 27 patients with intra-articular distal radius fractures who were treated with volar fixed angle plates in an arthroscopically assisted fashion. The amount of associated injuries, the duration of surgery and the time of immobilisation were documented. One year postoperatively we evaluated 23 of these patients using several scores. Patient satisfaction, range of motion, visual analogue scale and grip strength were assessed using a standardised questionnaire.

RESULTS

The mean surgery time was 111 min (60-190 min). On average, we found 1.4 (0-3) associated injuries per patient. Seventy percent (19) of all patients had a triangular fibrocartilage complex lesion, 67% (16) had some degree of scapholunate ligament lesion. The mean number of interventions in addition to the plate fixation was 1.1 per patient (0-3). Among these were debridements of the triangular fibrocartilage complex in 11 cases (41%) and scapholunate ligament repairs in 4 cases (15%). The mean immobilisation time was 22 (0-42) days. At one year after surgery, the mean Mayo wrist score was 79 (65-95) and the DASH score was 12 (0-49).

CONCLUSION

The arthroscopically assisted management of intra-articular distal radius fractures helps to identify and treat associated injuries. However, it results in extended surgery and immobilisation time, especially if concomitant intra-articular lesions are treated. In our group of patients, the clinical outcome after one year was nonetheless very good.

Vascular endothelial growth factor gene therapy improves nerve regeneration in a model of obstetric brachial plexus palsy

The treatment of obstetric brachial plexus palsy has been limited to conservative therapies and surgical reconstruction of peripheral nerves. In addition to the damage of the brachial plexus itself, it also leads to a loss of the corresponding motoneurons in the spinal cord, which raises the need for supportive strategies that take the participation of the central nervous system into account. Based on the protective and regenerative effects of VEGF on neural tissue, our aim was to analyse the effect on nerve regeneration by adenoviral gene transfer of vascular endothelial growth factor (VEGF) in postpartum nerve injury of the brachial plexus in rats. In the present study, we induced a selective crush injury to the left spinal roots C5 and C6 in 18 rats within 24 hours after birth and examined the effect of VEGF-gene therapy on nerve regeneration. For gene transduction an adenoviral vector encoding for VEGF165 (AdCMV.VEGF165) was used. In a period of 11 weeks, starting 3 weeks post-operatively, functional regeneration was assessed weekly by behavioural analysis and force measurement of the upper limb. Morphometric evaluation was carried out 8 months post-operatively and consisted of a histological examination of the deltoid muscle and the brachial plexus according to defined criteria of degeneration. In addition, atrophy of the deltoid muscle was evaluated by weight determination comparing the left with the right side. VEGF expression in the brachial plexus was quantified by an enzyme-linked immunosorbent assay (ELISA). Furthermore the motoneurons of the spinal cord segment C5 were counted comparing the left with the right side. On the functional level, VEGF-treated animals showed faster nerve regeneration. It was found less degeneration and smaller mass reduction of the deltoid muscle in VEGF-treated animals. We observed significantly less degeneration of the brachial plexus and a greater number of surviving motoneurons (P < 0·05) in the VEGF group. The results of this study confirmed the positive effect of VEGF-gene therapy on regeneration and survival of nerve cells. We could demonstrate a significant improvement on the motor-functional as well as on the histomorphological level. However, increased vascularization of the nerve tissue caused by VEGF does not seem to be the major reason for these effects. The clinical use of adenoviral VEGF-gene therapy in the newborn cannot be justified so far.

Correction of asymmetric pectus excavatum using a virtually designed silicone implant

BACKGROUND

An extended asymmetric funnel chest deformity with the breast gland located in the thoracic mold can lead to a fictitious aplasia of the breast. The authors termed this condition "pseudo-Amazon syndrome" because the breast tissue and the pectoralis muscle are fully developed.

METHODS

This report presents a detailed technical approach to the fabrication of a precise-fitting custom-made silicone implant. The design of the implant was achieved using a computed tomography (CT) data set and rapid prototyping. The volumes of the "hidden" and the normal breasts measured preoperatively by processing the CT data were similar. These volumes were compared with the breast volumes measured by three-dimensional photography 4 years postoperatively to assess the predictability of the volume congruency. The silicone implant was surgically placed in the epicostal plane and extended almost over the right hemithorax.

RESULTS

The implantation was performed without the necessity of further trimming. Both the surgeon and the patient rated the aesthetic and functional long-term result as good in terms of symmetry and the possibility of exercise without restrictions. The final breast volume of the surgically treated side was 95 % of the volume of the normal contralateral breast.

CONCLUSION

The described method reduces the operation time and the operative trauma by primary implant fit. However, the method is rather elaborate and the production process is expensive. This in turn reduces the generation of proceeds to a minimum.

LEVEL OF EVIDENCE V

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 .

[Optimising care structures for severe hand trauma and replantation and chances of launching a national network]

Severe hand traumata have a significant impact on our health system and on insurance companies, respectively. It is estimated that 33% of all occupational injuries and 9% of all invalidity pensions are due to severe hand trauma. Unfortunately, these high numbers are not only due to the severity of the trauma but to organisational deficiencies. Usually, the patient is treated at the general surgical emergency in the first place and only then forwarded to a microsurgeon. This redirection increases the time that is required for the patient to finally arrive at an expert for hand surgery. On the one hand, this problem can be explained by the population's lack of awareness for distinguished experts for hand and microsurgery, on the other hand, the emergency network, or emergency doctors in particular are not well informed about where to take a patient with a severe hand trauma - clearly a problem of communication between the hospitals and the ambulance. It is possible to tackle this problem, but put participating hand trauma centres have to work hand in hand as a network and thus exploit synergy effects. The French system "FESUM" is a good example for such a network and even comprises centres in Belgium and Switzerland. To improve the treatment of severe hand trauma, a similar alliance was initiated in Germany just recently. The pilot project "Hand Trauma Alliance" (www.handverletzung.com) was started in April 2013 and currently comprises two hospitals within the region of upper Bavaria. The network provides hand trauma replantation service on a 24/7 basis and aims at shortening the way from the accident site to the fully qualified hand surgeon, to improve the therapy of severe hand injuries and to optimise acute patient care in general. In order to further increase the alliance's impact it is intended to extend the project's scope from regional to national coverage - nevertheless, such an endeavour can only be done in collaboration with the German Society for Hand Surgery (DGH). This article comprises 2 parts. First, the state-of-the-art of acute severe hand trauma care is summarised and explained. Subsequently, the above-mentioned pilot project is described in every detail, including positive effects but also barriers that still have to be overcome.

Protective effects of activated protein C (APC) on free groin flaps after secondary venous stasis in the rat model

BACKGROUND

The goal of this study was to determine whether the focused delivery of APC by rinsing of free adipocutaneous groin flaps shows protective effects on flap survival following a fatal secondary venous stasis in a rat model.

METHODS

36 Sprague Dawley rats were randomized to three groups and free microvascular groin flaps were transplanted to the neck in each animal. 20 hours postoperatively the flap pedicle was re-explored and the distal stump of the flap artery was catheterised. Animals in group I (n = 12) remained untreated, whereas animals of group II were treated with 1 ml of Ringer's solution. Those in group III received 1 ml of APC (2 mg/kg). Afterwards the flap vein was clamped for 35 minutes. The skin of the flaps and the native contralateral groin was examined by intravital video microscopy using FITC-Dextran and CFDA-SE-labelled thrombocytes.

RESULTS

APC-pretreatment significantly increased the functional capillary density (FCD) of the flaps. Flap viability was 8% in group I (n = 1/12), 9% in group II (n = 1/11) and 60% in group III (n = 6/10), respectively. No partial flap loss was detected.

CONCLUSIONS

The focused delivery of APC resulted in significantly improved flap salvage.

[Quality of life after brachial plexus lesions in adults]

Brachial plexus lesions are among the most severe injuries of the upper extremity. Despite intensive conservative and surgical treatment efforts, patients frequently suffer from serious impairments in the quality of life. This contribution presents the results of a retrospective clinical survey on the quality of life after brachial plexus injuries. Out of 38 treated patients, 25 patients could be included in the study. The disability of arm, shoulder and hand was evaluated by the DASH score and the quality of life by the FLZm, a questionnaire on life satisfaction. In addition, demographic data, work situation and mechanism and type of injury were recorded. The examined patients were mainly young males who were injured in traffic, in particular motorcycle accidents. The DASH score analysis revealed that plexus injuries are among the most disabling injuries of the upper extremity. The associated restrictions in the different sections of the quality of life involve not only the health-related section but also partnership, family and leisure time activities. A strong relation between the possibility to return to work and the quality of life was found. We recommend the use of the DASH score and the FLZm questionnaire on life satisfaction as routine tools for the evaluation of the therapeutic outcome after brachial plexus injuries.

The determination of tissue perfusion and collateralization in peripheral arterial disease with indocyanine green fluorescence angiography

PURPOSE

Indocyanine green (ICG) fluorescence angiography is used to evaluate tissue perfusion in many different medical fields. This study aims to evaluate the value of ICG angiography in the determination of tissue perfusion in the PAD lower extremities.

MATERIAL AND METHODS

In a prospective clinical study, ICG angiography was used to evaluate tissue perfusion and collateralization in 30 PAD patients. The perfusion index and maximum fluorescence intensity (MPI) were calculated as arterial perfusion parameters.

RESULTS

Significant differences in the perfusion index were found for the different PAD stages (p < 0.001). Poor collateralization was associated with a significantly lower perfusion index than good collateralization (p = 0.003). A ROC analysis for the perfusion index showed a positive likelihood ratio of 6.00 and a negative likelihood ratio of 0.00 with an area under the curve of 0.949 to discriminate critical and non-critical PAD.

CONCLUSION

ICG angiography is a promising diagnostic tool to quantify tissue perfusion and demonstrate critical limb ischemia and collateralization in lower extremities affected by PAD.

[3-dimensional imaging systems: first experience in planning and documentation of plastic surgery procedures]

A reproducible 3-dimensional photographic system enables plastic surgeons to perform preoperative planning and helps them to understand the patient's expectations. There are a few systems available that allow a reproducible 3-dimensional scans of the patient with direct simulation of the planned procedure. The Vectra Volumetric 3D Surface Imaging® by Canfield® provides such an option and helps the surgeons to document and compare postoperative changes at different time points. Since January 2011 we are digitally documenting all patients receiving form-modulating procedures in our plastic surgery unit. We present the spectrum of clinical implications and discuss advantages and disadvantages of the system. Furthermore, we have studied the accuracy of the system in comparison to direct measurement in 15 volunteers. The system is especially suited for planning and evaluation of breast augmentation, facial aesthetic and reconstructive surgery as well as volumetric measurements before and after liposuction and lipofilling. Computer-assisted measurements correlate with a median deviation of 2.3% with manually measured distances in the face. We found the user-friendly Vectra® system to be a reliable and reproducible device for planning plastic surgery therapies and for documenting postoperative results.

[Microscope-integrated intraoperative indocyanine green angiography in plastic surgery]

The knowledge of tissue perfusion has not only a prognostic value in microvascular surgery but also the intraoperative detection of malperfusion can lead to a quick surgical intervention. Indocyanine green (ICG) angiography allows a topographic analysis of perfusion and is used to assess lymphatic drainage pathways and to analyse the depth of burn injuries. Integrating the technique into an operating microscope enables visualisation of the flow over microanastomoses and allows the assessment of the transit time of blood flow between arterial and venous anastomosis. Using this method we analysed 11 microsurgical free flaps (3 latissimus dorsi, 3 rectus abdominis, 1 gracilis muscle, 2 radial forearm, 1 ALT, and 1 DIEP flap). The topographic analysis was performed after the assessment of the microanastomoses. We observed no flap loss or partial flap necrosis. The transit time between arterial inflow and venous outflow was 32.8 s on average. Here we observed distinct differences between muscle flaps (27.7 s) on the one hand and fasciocutaneous and perforator flaps (47.5 s) on the other hand. We detected one venous thrombosis by ICG angiography in a case where the clinical patency test was not distinct. Revision was performed immediately. Particularly for intraoperative assessment, ICG angiography is a useful, reliable and safe technique. The integration into the operating microscope allows an "angiographic patency test" and the analysis of the transit time allows the evaluation of blood flow within the flap. Especially when planning perforator flaps the method of ICG angiography provides a new level of safety in flap design by quickly demonstrating the borders of perfusion.

[Phalloplasty with pedicled anterolateral thigh flap ("ALT-Flap")]

Phalloplasty in female-to-male transsexuals is a very demanding procedure concerning preoperative planning and surgical implementation and many operative techniques have been described in the past. Here we illustrate the phalloplasty by means of a pedicled anterolateral-thigh-flap ("ALT-flap") in a patient who underwent unsuccessful groin-flap-phalloplasty alio loco. The sensible innervation was constituted via coaptation to a branch of the pudendal nerve. The technique presented here shows an aesthetically appealing result 6 months postoperatively with a 2-point discrimination of 2.5 cm and ongoing reinnervation. The operative time was reasonable with 360 min. The benefit of a pedicled transposition vs. a free transplantation becomes obvious especially as a salvage procedure in a preoperated situs with altered vascular anatomy. Additionally the shortened operating time and the lack of possible complications of microvascular anastomoses bear advantages. In conclusion we consider this technique for phalloplasty concerning operating time and effort, complications, donor site morbidity and aesthetic result as an appropriate alternative to established methods in selected patients.

[High pressure injection injuries of the hand. Rare but often underestimated]

INTRODUCTION

Injection injuries of the hand are often underestimated because the full extent of the injury often only emerges after a delay. Flap coverage is often needed to avoid amputation.

CASE REPORT

In the case presented an epoxy resin injection trauma to the left index finger occurred. A critical blood circulation resulted and after demarcation of the injury a radical débridement was carried out. A heterodigital island flap was used to reconstruct the dorsum of the finger and 3 years after the trauma the patient has no impairments in daily activities.

DISCUSSION

The extent of the injury and the carcinogenic properties of the injected material are crucial for adequate treatment of injection injuries. Patients should be referred to specialized hand centers at an early stage.

Early postoperative detection of tissue necrosis in amputation stumps with indocyanine green fluorescence angiography

OBJECTIVE

Amputations of the lower extremity due to irreversible ischemic tissue loss are performed as distally as possible. Therefore, oftentimes wound-healing disorders develop, requiring additional surgical treatment.

METHODS

The amputations stumps of 10 patients with irreversible ischemic tissue loss due to arteriosclerosis were investigated within 72 hours postoperatively with indocyanine green (ICG) fluorescence.

RESULTS

For 6 of the investigated stumps, no perfusion deficit could be seen through fluorescence angiography. All stumps displayed primary healing. In the fluorescence angiography of 3 amputations, stump perfusions deficits predicted later tissue necrosis and had to be amputated again in a second operation. One amputation wound showed a small ICG perfusion deficit that represented a blood clot.

CONCLUSION

Indocyanine green fluorescence angiography allows a perfusion analysis of amputation stumps and therefore a prediction of the expected tissue necrosis. This tool may allow reliable prediction of amputation level.

Non-viral VEGF(165) gene therapy--magnetofection of acoustically active magnetic lipospheres ('magnetobubbles') increases tissue survival in an oversized skin flap model

Adenoviral transduction of the VEGF gene in an oversized skin flap increases flap survival and perfusion. In this study, we investigated the potential of magnetofection of magnetic lipospheres containing VEGF₁₆₅-cDNA on survival and perfusion of ischemic skin flaps and evaluated the method with respect to the significance of applied magnetic field and ultrasound. We prepared perfluoropropane-filled magnetic lipospheres (‘magnetobubbles’) from Tween60-coated magnetic nanoparticles, Metafectene, soybean-oil and cDNA and studied the effect in an oversized random-pattern-flap model in the rats (n= 46). VEGF-cDNA-magnetobubbles were administered under a magnetic field with simultaneously applied ultrasound, under magnetic field alone and with applied ultrasound alone. Therapy was conducted 7 days pre-operative. Flap survival and necrosis were measured 7 days post-operatively. Flap perfusion, VEGF-protein concentration in target and surrounding tissue, formation and appearance of new vessels were analysed additionally. Magnetofection with VEGF-cDNA-magnetobubbles presented an increased flap survival of 50% and increased flap perfusion (P < 0.05). Without ultrasound and without magnetic field, the effect is weakened. VEGF concentration in target tissue was elevated (P < 0.05), while underlying muscle was not affected. Our results demonstrate the successful VEGF gene therapy by means of magnetobubble magnetofection. Here, the method of magnetofection of magnetic lipospheres is equally efficient as adenoviral transduction, but has a presumable superior safety profile.

Angiogenese-Gentherapie mit AdVEGF165- Eine Art „Delay“ für Lappenplastiken?

A regular tissue functioning requires the adequate supply of oxygen and nutrient via blood vessels. The sequences of formation and maturation of vessels are initiated and maintained by different growth factors. The VEGF growth factor plays an exceptional role in these mechanisms. The creation of sublethal ischemia as an angiogenic stimulus known as "Delay" is a well established procedure in plastic surgery, although the underlying molecular biological mechanisms still remain unknown. The important role of VEGF and its regulation depending on oxygen pressure suggest a strong connection between this growth factor and the delay phenomenon. The VEGF concentration in skin and underlying muscle was measured in overdimensioned random pattern flaps on 32 male Sprague-Dawley rats after either VEGF gene therapy or circumcision without elevation of the flap and compared to controls. Additional random pattern flaps were raised seven days post gene therapy or delay. The effect on the flap perfusion was measured postoperatively using Indocyanine green Laser Fluoroscopy and the size of the surviving and necrotic areas of the flaps were analysed. The skin of the random pattern flaps showed both in the Delay group and in the VEGF gene therapy group a significantly elevated VEGF concentration compared to the controls. The underlying rectus abdominis muscle showed no significant differences in VEGF concentration between the groups. The flap perfusion postoperatively was significantly increased solely in the VEGF gene therapy group. The analysis of the surviving area of the flaps showed a significant increase over the controls in the gene therapy group. The Delay procedure results in a significantly and locally raised concentration of the VEGF growth factor. The gene therapeutical use of this growth factor allows us to raise flap perfusion and to reduce necrosis. Both VEGF gene therapy and Delay seem to promote similar mechanisms whereas the gene therapy produced superior results in this setting.

Evaluation der Perfusion von Lappenplastiken mittels Laserfluoreszenz von Indocyaningrün

Prediction of necrosis in critically perfused skin flaps is difficult and rarely precise. An early detection of insufficiently perfused skin is highly desirable since it may lead to surgical decisions such as operative flap revision or early resection. The application of laser-induced indocyanine green (ICG) fluoroscopy allows an objective quantification of skin perfusion and a high topographical resolution. Aim of the present study is to determine a threshold value for flap perfusion under well-defined experimental conditions and test the validity of the results in the clinical application. Twenty overdimensioned random pattern flaps with a length to width ratio of 4 : 1 (8 x 2 cm) were dissected at the anterior abdominal wall of 20 male Sprague-Dawley rats weighing 365 g on average. ICG fluorescence was performed at the end of the operation by intravenous injection of 1 g ICG/kg bodyweight into a tail vein and digital recording. On the seventh postoperative day, both the necrotic and surviving areas of the flaps were measured and the ICG-fluorescence was analysed in the areas that had undergone necrosis. 41 flaps with areas of critical perfusion (18 skin flaps, 13 muscle flaps, 8 replantations) were analysed in 39 patients. The surviving part of the flap had a mean perfusion index of 62 % compared to reference skin. The distal parts of the flap that necrotized during the experiment showed an average perfusion index of 19 % postoperatively. Differences were statistically significant (p < 0.001). In clinical application, a number of 13 flaps were found to have a perfusion index less than 25 % in a region of critical perfusion. Eleven of these developed a partial necrosis in that region, one flap underwent total necrosis. Indocyanine green fluoroscopy allows a detailed topographical analysis of flap perfusion and the prediction of necrosis. Experimental findings presented a threshold value for the perfusion index of 25 % which could be confirmed in clinical application.

Prediction of flap necrosis with laser induced indocyanine green fluorescence in a rat model

Prediction of necrosis has a clinical relevance in all fields of plastic surgery. The new application of indocyanine green (ICG) fluoroscopy in plastic surgery allows an objective quantification of skin perfusion and a high topographical resolution. The aim of the present study is to determine threshold values for flap perfusion under well-defined experimental conditions. Twenty random pattern flaps with a length to width ratio of 4:1 (8 x 2 cm(2)) were dissected on the anterior abdominal wall of 20 male Sprague-Dawley rats. ICG fluoroscopy was performed at the end of the operation. The animals were sacrificed at the seventh postoperative day with a reliable necrosis of the distal part of the flaps. Postoperative ICG fluoroscopy then was analysed both in regions that will survive and undergo necrosis. At day 7 a mean area of 5.5 cm(2) (57% of the total flap area) survived and a mean of 3.8 cm(2) (43%) became necrotic. The surviving part of the flap had a mean perfusion index of 62% compared to reference skin. The distal parts of the flap that necrotised showed an average perfusion index of only 19% postoperatively. Differences were statistically highly significant (p<0.001). Indocyanine green fluoroscopy is a useful tool to evaluate perfusion topographically and predict necrosis. From a statistical point of view a perfusion index of less than 25% of the reference skin can be considered as a sign of developing flap necrosis.

AdVEGF165gene transfer increases survival in overdimensioned skin flaps

BACKGROUND

Vascular endothelial growth factor (VEGF) is a key regulator of angiogenesis. VEGF A also plays an important role in wound healing of the skin by promoting angiogenesis and by stimulating blood vessel growth. Therefore we tested the hypothesis that flap survival could be increased by the preoperative injection of AdVEGF(165).

METHODS

We studied the effect of AdVEGF(165) in an overdimensioned ischemic random-pattern-flap model in the rat (n = 50) with a length-to-width ratio of 4 : 1. VEGF cDNA was administered in two concentrations of 5 x 10(8) plaque-forming units (pfU) and 1 x 10(9) pfU using a recombinant adenoviral vector. Recombinant virus was injected subdermally 7, 3 or 0 days prior to flap harvest for the lower concentration and 7 days prior for the higher concentration. Flap survival and necrosis were observed at day 7, the day the animals were sacrificed.

RESULTS

Adenoviral gene transfer with VEGF(165) 3 and 7 days before flap harvest showed a significantly increased flap survival of 50% together with a significantly reduced necrosis (p < 0.01). Injection using a titer of 1 x 10(9) pfU 7 days prior to surgery increased flap survival even more, though failing to reach statistical significance compared to the lower concentration. VEGF protein concentration in the injected skin was significantly higher than in controls (p < 0.01). Flap perfusion was increased as well, demonstrated by indocyanine green (ICG) fluoroscopy (p < 0.001).

CONCLUSIONS

Our results confirm the important role of VEGF(165) on angiogenesis in ischemic flaps. Indeed by injecting VEGF(165) at 3 to 7 days preoperatively in a concentration of 1 x 10(9) pfU our data show that length-to-width ratio for random-pattern-flaps could be increased from 2 : 1 to 3 : 1 and therefore may allow a wider range of applications of this simple flap technique.