Abstracts DGPRÄC

New insights into the anatomy at the palmodigital junction in Dupuytren’s disease: The Palmodigital Spiralling Sheet

(Abstract ID: 225)

A. Malsagova¹, R. Zwanenbrug², P. Werker²

¹Klinikum Nürnberg Süd

²Universitair Medisch Centrum Groningen

Background:

Knowledge of the normal fascial microanatomy of the hand is essential in understanding the origin and progression of pathological cords in Dupuytren Disease. Previous publications give various accounts of the microanatomy of the palmar and digital fascias, but the area of the palmodigital junction is relatively understudied, however clinically very relevant in surgical treatment of Dupuytren Disease.

Materials and methods:

To study the microanatomy of the palmodigital junction we dissected 26 cadaveric digits: 13 middle fingers and 13 ring fingers from 13 fresh frozen human cadaveric hands using microsurgical techniques. The dynamics of the different ligaments were studied in three hands preserved by Thiels method.

Results:

We have found a structure, which we have named the ‘Palmodigital Spiralling Sheet’ (PSS), and which to our knowledge has not previously been described. This structure has a spiralling course around the neurovascular bundle, as such giving rise to the neurovascular tunnel distally in the palm of the hand. It is fed proximally among others by fibres from the pretendinous band and by fibres originating from the intrinsic muscle fascias and is in the finger in continuity with Cleland’s and Grayson’s ligaments.

Conclusion:

PSS connects palmar and digital fascias. Through its spiralling course the PSS stabilises the neurovascular bundle in the healthy hand, but can also contribute to the development of spiral cords in Dupuytren Disease.

Note:

The research study has already been published in a similar form in the Journal of Hand Surgery - European Volume (Volume 44E I Issue 9 I November 2019 I ISSN 1753-1934) in November 2019.

Pedicled Anterolateral Thigh Flaps and Their Use in Abdominal Wall Reconstruction

(Abstract ID: 55)

I. Georgiou¹, M. Ghods¹, P. Kruppa¹

¹Klinikum Ernst von Bergmann, Potsdam

Background:

Large full-thickness abdominal wall defects pose a great challenge to the reconstructive surgeon. Multiple strategies for adequate soft tissue coverage have been described. This case series aims to present the pedicled Antero-Lateral Thigh (ALT) flap as a possible method of choice for reconstruction of full-thickness abdominal wall defects. After a retrospective review of our clinical records, three patients were selected who best describe our strategy. All operations were performed by the chief physician (MG) of the department. A classification of abdominal wall defects is presented for a standardized preoperative planning, as well as related advantages of the ALT flap.

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Use of a Total Leg Fillet Flap to Cover Multiple Pelvic Pressure Ulcers

(Abstract ID: 56)

I. Georgiou¹, M. Ghods¹, P. Kruppa¹

¹Klinikum Ernst von Bergmann, Potsdam

Background:

The authors present the surgical strategy in the treatment of a morbidly obese paraplegic patient with a massive sacral pressure ulcer as well as bilateral trochanteric ulcers in a 1-step leg-sacrificing procedure utilizing the "spare-part"concept. It is the intention of the authors to reinforce the use of fillet flaps as a last resort option in paraplegic patients with pressure sores. (Plast Reconstr SurgGlob Open 2019;7:e2084; doi: 10.1097/GOX.0000000000002084; Published online7 January 2019.)

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Secondary necrosis in TEN – patient after Gold-standard treatment

(Abstract ID: 250)

P. Mandal¹, T. Püski¹, B. Reichert¹

¹Klinikum Nürnberg - Standort Süd

Background:

The toxic epidermal necrolysis (TEN) is a severe and potential lethal side effect of different drugs including Allopurinol, Sildenafil and others. The patients usually need a specialized treatment center such as a burns unit or a dermatological ICU. The Gold Standard for the treatment of TEN is cyclosporin 3-5mg/kg BW, steroids and supportive therapy according to the affected organ systems. Although there is yet no hard evidence of the above-mentioned therapy, we had the experience that it might shorten the overall treatment duration.

Materials and methods:

Case Report:

We would like to present a Case from our own burn unit of a patient suffering from TEN after intake of Allopurinol for approximately two weeks before onset of symptoms. The patient hat nearly 80% of body surface affected with typical bullae and the trachea and the lungs were involved. No other organ system was affected. We treated the patient as mentioned above. The supportive therapy for the cutaneous lesions involved regular changes of the wound dressing, several split skin transplantations and the intense use of dermal replacement agents such as Epicite ®. To sufficiently maintain a safe airway the patient had been tracheal canuled and was on artificial ventilation until the airway was completely healed.

Results:

The initial very promising therapy of the cutaneous lesions was suddenly struck by the fact, that the patient developed secondary necrosis areas on the up to that point regularly healing body surface. These lesions were almost indistinguishable from regular healing skin. Our treatment in these areas, which were localized in a on the whole torso in a spotted manner, was primarily the tangential necrosectomy and secondary split skin transplantation. But since there was a lack of sufficient healthy skin available we tried a treatment alternative with skin replacement materials and more frequent changes of the wound dressing. We decided to use Epicite ® in combination with polyhexanide -gel on these secondary necrosis areas. After only 3–4 dressing changes, there was a severe improvement of the former necrotic areas and the skin started to grow in from the edges and after about 2.5 weeks of intensive treatment with the above mentioned protocol there was again a satisfactory healing of the wounds.

Conclusion:

This case demonstrates one of the pitfalls of TEN. Even though, treated with the Gold Standard, there must be close and critical monitoring of the skin to not miss secondary necrosis.

Late Onset of Lower Limb Infection Caused by Gluteal Augmentation with Polyalkylimide Gel (PAIG), a Case Report

(Abstract ID: 535)

A. Avila-Ferrufino¹, M. Spies¹, J. Zustin¹

¹Krankenhaus Barmherzige Brüder

Background:

Soft tissue augmentation with liquid injectibles are a common method for the treatment of lipodystrophy in HIV positive patients. Especially PAIG injections in small volumes have been used for this purpose and have been an established treatment. We report an unusual case of a complication 15 years after bilateral gluteoplasty by PAIG injection. PAIG as a volume replacement for aesthetic procedures as well as for the treatment of facial lipodystrophy has been used for a long time. A broad experience has been gained and few complications have been reported so far therefore it is an established and reliable procedure. Today’s plastic surgeon has a wide range of liquid injectibles and alternate procedures to choose from. Volume augmentation by hyaluronic acid, collagen and especially autologous fat grafting are more common in Europe and North America.

Materials and methods:

We present a case report of a patient treated in our department for lower limb infection due to a long term complication after bilateral gluteoplasty by polyalkylimde injection. Verbal consent was obtained from the patient.

Results:

We report an unusual case of a complication 15 years after bilateral gluteoplasty by PAIG injection. Our case reports a descending abscess on the left inferior member in a male patient of Asian descent. Typical silicone associated granulomas were absent. Histopathology revealed foreign body tissue reaction untypical for silicone. A second survey of the patient’s history indicated previous PAIG injections for gluteoplasty. A radical surgical approach was crucial for the cure.

Conclusion:

Our case shows that plastic surgeons have to be aware of alternate augmentation methods and procedures in patients of foreign descent especially Asia and its associated potential complications. Those might include unusual materials like PAIG or silicone and respective different injection areas, as well. Treating those patients means to consider material migration with unusual clinical presentation of the complication. Consideration of cultural particularities and thoroughly empathetic and perceptive history taking is a crucial condition for the correct diagnosis and consecutive therapy.

Using imaging technology to reduce the rate of fat necrosis in microsurgical breast reconstruction

(Abstract ID: 437)

A. Momeni¹

¹Stanford University Medical Center, Palo Alto

Background:

Fat necrosis following microsurgical breast reconstruction is common and problematic for patients and surgeons alike. Indocyanine green angiography provides a means of evaluating flap perfusion at the time of surgery to inform judicious excision of hypoperfused tissue. We hypothesized that incorporation of protocolized ICG-informed flap debridement at the time of surgery would decrease the incidence of fat necrosis.

Materials and methods:

A retrospective study of two cohorts was performed evaluating patients before and after implementation of protocolized ICG-guided flap excision. Variables included demographics, procedural details, and complications. Multivariable analysis was used to determine significant differences between the cohorts and evaluate for meaningful changes in fat necrosis.

Results:

Eighty patients were included, accounting for 137 flaps. Flap type was the only significant difference between the two groups with the ICG group more likely to be deep inferior epigastric perforator flaps, 43.1% vs. 25.3% p=0.038. The overall postoperative incidence of fat necrosis was 14.6% (20 of 137 flaps). Comparing by cohort, the standard debridement group showed 18 of 79 flaps with fat necrosis (22.8%), while the ICG-informed debridement group showed only 2 of 58 flaps with fat necrosis (3.4%), odds ratio 0.11 (95% CI 0.02-0.60, p-value=0.011). There were no other significant differences in complication profile.

Conclusion:

Intraoperative use of indocyanine green angiography was associated with significantly lower odds of fat necrosis. This technology may reduce additional revisionary operations and improve patient satisfaction. Additional studies are needed to determine whether this innovation is cost-effective and generalizable to the entire autologous breast reconstruction population.

Pre-mastectomy reduction/mastopexy – a method to increase the rate of nipple-areola-complex preservation in microsurgical breast reconstruction

(Abstract ID: 438)

A. Momeni¹

¹Stanford University Medical Center, Palo Alto

Background:

Nipple-sparing mastectomy has been associated with superior aesthetic outcomes and oncologic safety. However, traditional contraindications, e.g. breast ptosis/macromastia, have excluded a large number of patients. The purpose of this study was to determine if a staged approach would expand the indications for nipple- areolar-complex (NAC) preservation and permit greater control over NAC position and skin envelope following autologous reconstruction.

Materials and methods:

A retrospective analysis of female patients with a diagnosis of breast cancer or BRCA mutation with grade 2 or 3 ptosis and/or macromastia who underwent bilateral (oncoplastic) reduction/mastopexy (stage 1) followed by bilateral nipple-sparing mastectomy with immediate reconstruction with free abdominal flaps (stage 2) was conducted. We were specifically interested in the incidence of mastectomy skin necrosis, NAC necrosis, and NAC malposition following stage 2.

Results:

Sixty-one patients with a mean age of 45.1 years (range, 28 - 62 years) and mean BMI of 32.6 kg/m2 (range, 23.4 - 49.0 kg/m2) underwent reconstruction with 122 flaps. The mean interval between stage 1 and 2 was 16.9 weeks (range, 3 - 31 weeks). Clear margins were obtained in all cases of invasive cancer and in-situ disease following stage 1. Complications following stage 2 included partial NAC necrosis (N=5 [8.2%]), complete NAC necrosis (N=4 [6.6%]), NAC malposition (N=1 [1.6%]), and mastectomy skin necrosis (N=4 [6.6%]). No flap loss was noted in this series.

Conclusion:

Patients with moderate to severe breast ptosis and/or macromastia who wish to undergo mastectomy with reconstruction can be offered nipple-sparing approaches safely if a staged algorithm is implemented.

Treatment of upper-trunk defects using free style perforator flaps and introducing suprascapular artery perforator flap

(Abstract ID: 193)

I. Panchulidze¹

¹Elisabethklinik Berlin

Background:

Defects in the upper trunk region after radikalresection. Introduction of the suprascapular artery perforator (SSAP) flap.

Materials and methods:

Between 2017 and 2019, 10 patients with a mean age of 69 years (range, 59–82 years) underwent a flap procedure for reconstruction of upper trunk defects. Defect size varied from 3x4 to 12x9 cm.

Results:

All of the flaps survived completely

Conclusion:

The free style perforator flap approach in upper trunk reconstruction gives the patient an excellent contour and a satisfactory aesthetic result. Preliminary clinical application of the suprascapular artery perforator flap

The role of robotics in Plastic Surgery – is there a role?

(Abstract ID: 963)

M. Aitzetmüller¹, M.-L. Klietz², P. Wiebringhaus², C. Varnava², M. Raschke¹, T. Hirsch², M. Kückelhaus²

¹Sektion für Plastische Chirurgie, Münster

²Plastische, Rekonstruktive und Ästhetische Chirurgie, Münster

Background:

Robotics have been implemented in many surgical fields within the last decade. To date, many procedures are routinely performed via the DaVinci® system. However, despite case reports, the use of robotic systems has not found its way into Plastic Surgery practice. We are providing insight into current developments towards more customized systems for specific needs in Plastic Surgery.

Materials and methods:

We carefully analyzed case series, reviews, expert opinions and initial clinical trials from 1990 to 2019 concerning robotics and its use in Plastic Surgery. Moreover, the specific advantages and disadvantages of available and future robotic systems are evaluated.

Results:

Within the last years, the use of robots in Plastic Surgery has increased. New robotic systems that are customized towards microsurgery are emerging. These systems are also supposed to be less expensive and easier to manage in the operating room than the established systems.

Conclusion:

Although the use of robotics in Plastic Surgery is rarely described, it has tremendous potential. Future systems will help expanding indications and decrease costs. The implementation and refinement of these techniques require an active involvement of Plastic Surgeons. If the novel systems can successfully be introduced into clinical routine, there may be a promising future for robotics in Plastic Surgery.

Does an interaction exist between the inflammation process of the burn wound and enzymatic debridement? First explanatory approaches based on an in vitro model

(Abstract ID: 242)

L. Börner Valdez¹, A. Schulz², J. Schiefer², C. Opländer¹, C. Fuchs²

¹Universität Witten-Herdecke

²Kliniken der Stadt Köln - Krankenhaus Köln-Merheim

Background:

Previous studies found that burn eschar can be dissolved by enzymatic debridement with NexoBrid™ (NXB) selectively and efficiently. It was proven that vital tissue is preserved after treatment with NXB. However, a detailed cell-based scientific explanation is missing so far. The current study intends to close this gap. In an in vitro model, the impact of NXB on vital skin and inflammatory cells was investigated. Furthermore, the mutual influence between the inflammation process of the burn wound and the enzyme activity of NXB was analyzed.

Materials and methods:

Human keratinocytes, fibroblasts, and macrophages were treated with NXB (10-5 - 10 mg/ml) for four hours. Viability of the treated cells was determined 24 hours later by a resazurin-based assay and microscopy. Additionally, enzyme activity of NXB was investigated in the presence of activated macrophages or hydrogen peroxide (0.01 - 1 mM H2O2) via spectrophotometric analysis and a new established assay. Finally, NXB was pretreated with H2O2. Human dermal fibroblasts were treated with the modified NXB solution and cell viability was again measured the following day.

Results:

While keratinocytes and fibroblasts showed no viability after treatment with NXB, macrophages remained viable and metabolically active after the same treatment. Enzyme activity of NXB was inhibited by H2O2 in a dose-dependent manner. The supplant of activated macrophages did not inhibit NXB enzyme activity. Treated fibroblasts only showed viability when NXB was previously modified with H2O2.

Conclusion:

Toxicity of NXB for human skin cells was shown in this study. Therefore, previously assumed selectivity of NXB needs to be questioned. However, inflammatory cells showed a better survival rate after treatment with NXB which could be due to a different cell structure or their released substances. H2O2 is such a substance released by inflammatory cells and contributes to the oxidative stress in the inflamed burn wound. In this study, H2O2 inhibited NXB dose-dependently and showed a protective effect on the cell survival when treated with NXB. Consequently, a mutual interaction and inhibition between the inflammatory processes of the burn wound and the enzyme activity is more likely than a sole, attributed selectivity of NXB.

The ABSI is dead, long live the ABSI – reliable prediction of survival in burns with a modified Abbreviated Burns Severity Index

(Abstract ID: 508)

P. Bartels¹, O. Thamm², J. Elrod¹, K. Reinshagen³, I. Königs¹

¹Altonaer Kinderkrankenhaus, Hamburg

²Helios Klinikum Berlin-Buch

³Universitätsklinikum Hamburg-Eppendorf

Background:

The Abbreviated Burn Severity Index (ABSI), developed in 1982, is a widely used and simple score to predict mortality after burn injuries. Due to demographic changes and improvements in the treatment of burn injuries it is questionable if the ABSI still accurately predicts mortality.

Materials and methods:

Data of 15,559 patients from the German Burn Registry (VR-DGV-Project-ID: 2018-001) from 2015 - 2018 were analysed to re-evaluate the variables included in the ABSI score, identify discrepancies between the predicted probability of survival and the observed survival. Descriptive statistics, univariate analysis and binary logistic regression were used to test the variables impact and to establish a modified score.

Results:

Data of 15,559 patients from the German Burn Registry (VR-DGV-Project-ID: 2018-001) from 2015 - 2018 were analysed to re-evaluate the variables included in the ABSI score, identify discrepancies between the predicted probability of survival and the observed survival. Descriptive statistics, univariate analysis and binary logistic regression were used to test the variables impact and to establish a modified score.

Conclusion:

The results of this study show that the Abbreviated Burn Severity Index does not accurately predict the probability of survival. Especially for severely burned patients it overestimates the mortality. We developed a modified version based on our statistical findings that accurately predicts the probability of survival of our data.

The treatment of partial thickness to deep dermal burn wounds with Platelet Rich Fibrin (PRF) after enzymatic debridement

(Abstract ID: 659)

A. Schulz¹, W. Heitzmann¹, J. L. Schiefer¹, P. C. Fuchs¹, C. Haiek Kanho¹

¹Krankenhaus Merheim - Kliniken der Stadt Köln gGmbH

Background:

Enzymatic debridement was found to remove burn eschar selectively. Thus, vital tissue can be preserved and burn wounds can heal spontaneously in many cases. However, healing time can be significantly prolonged depending on burn depth and extend. It is therefore questionable, whether the application of Platelet Rich Fibrin (PRF) can shorten the wound healing time and thus improve long term scar quality.

Materials and methods:

In a single-centre clinical trial we treated patients with partial thickness to deep dermal burns by enzymatic debridement followed by PRF application. All patients wear compression clothing over 6 months. After 8 and 12 months, the aesthetics and function of the scar were assessed objectively (Mexameter, Cutometer, O2C, Tewameter) and subjectively (VSS, POSAS).

Results:

34 patients (23 hands and 11 faces) with a mean age of 42 years (min15 years, max 71 years; 32 males, 2 females) were involved in the study. The mean total TBSA was 13,22% (min 1%, max 37%). The mean TBSA treated was 3,63% (min1%, max 22%). After min 1 and max 2 enzymatic debridements (mean 1.17 treatments) only 2 atients needed skin transplantation. All other wounds healed spontanously under PRF and Suprathel dressing. The mean healing time was 16,6 days (min 12 days, max 28 days). In faces mean healing was 16 days and in hands 17 days. After 8 and 12 months, 6 out of 22 different objective variables showed that the scars were more perfused, less flexible and more red than untreated skin. The other variables were equal. Subjectively, physicians and patients judged scar quality good. However, they found that scars were more red after spontanous healing.

Conclusion:

In sum, the study found that by combining enzymatic debridement with PRF, healing time of partial thickness to deep dermal burn wounds can be reduced compared to previous studies with the same study design but without PRF. Therefore, this treatment might be suitable to improve wound healing, scar quality and the functionality of the hand after burn injury. The treatment is easy to handle and patients tolerate the treatment well.

Using artificial intelligence for more evidence? Predictive accuracy of length of hospitalization in pediatric burn patients

(Abstract ID: 863)

J. Elrod¹, R. Wolff², C. Mohr¹, K. Reinshagen¹, I. Königs¹

¹Altonaer Kinderkrankenhaus, Hamburg

²Neoglia LTD, London

Background:

Prediction of length of stay (LOS) is of great importance in burn patients. This study aims at investigating the prediction accuracy of complex models and a linear regression-based approach. The heuristic expecting a 1 day of stay per % total body surface area (TBSA) commonly applied as a rule of thumb in burn care is used as the performance benchmark.

Materials and methods:

The study is based on a pediatric burn patient data sets provided by the German Society for Burn Treatment (DGV) with N=8542. Mean absolute and standard error (MAE resp. MSE) are calculated for each prediction model (rule of thumb, linear regression and random forest) and the level of significance is investigated. To test the statistical difference between the selected estimators 20-fold cross validation is performed. In addition, the relationship between TBSA and the residual error is analyzed and factors contributing to a prolonged stay are determined.

Results:

The present analysis indicates prediction accuracy (MAE, MSE) of the two methods of interest to be statistically significantly superior to the rule of thumb (p < 0.01). Furthermore, the residual error rises as TBSA increases for all three methods. Factors associated with a prolonged LOS are % TBSA by degree, inhalation trauma and scald.

Conclusion:

More complex models lead to a moderate increase in prediction accuracy in this cohort. Our work indicates that improving the predictive power of such machine learning systems will require recording more details about each burn incident. Generally speaking, the use of artificial intelligence for the purpose of data analysis could lead to more evidence in medicine.

E-cigarette explosion-related burn injuries

(Abstract ID: 1017)

A. Kaltenborn¹, P. M. Vogt¹, N. Krezdorn¹

¹Medizinische Hochschule Hannover

Background:

Since their introduction as a substitute for smoking tobacco, e-cigarettes have a growing popularity. Recently, there is an increasing number of reports in scientific as well as popular media on exploding e-cigarettes and concomitant burn injuries. The rechargeable batteries are assumed to be the culprit for overheating a subsequent combustion of the e-cigarette device resulting in a specific injury pattern, which is predominantly affecting the hand, groin and facial area. In the literature even two accounts of fatal injuries are reported. There is currently no data from the German population available.

Materials and methods:

In this retrospective observational study 46 patients with E-cigarette explosion-related injuries were included, which were consecutively treated from July 2016 at a German severe burn injury unit. The patient profile, injury patterns and severity, treatment as well as outcome are analyzed. All patients were interviewed via telephone regarding the outcome, smoking habits as well as details on the device, which caused the injury.

Results:

All included patients have had burn injuries grade 2a. Moreover, 39 patients experienced a grade 2b-injury, and 8 patients also showed grade 3 burn injuries. Significantly more man between the age of 18 and 25 years were affected. In 69% of the patients, the groin region was injured solely, another 25% showed a concomitant injury of the hand. Only 3 patients were treated for burn injuries to the face. 13 patients reported that they have had altered their device to prolong battery power by their own. More than 79% of the exploded devices were bought via internet. Significant risk factors for the onset of wound infections the injury’s depth as well as the occurrence of penetrating injuries from clothing or the device itself. Most patients must be treated operatively, in 19% a hydrotherapy debridement were performed. 28 patients underwent a tangential excision and subsequent skin grafting. Furthermore, synthetic polyactic-dressing was applied in 31 cases. 18 patients suffered from a wound infection. Surprisingly, only 62% of patients reported that they quit e-cigarette smoking after the injury.

Conclusion:

In summary, exploding e-cigarettes can lead to serious injuries requiring intensive, expensive and sophisticated treatment. Injury patterns are characterized by burns and associated penetrating shrapnel to the groin, hand and face.